Alpha 1-acid glycoprotein is upregulated in severe COVID-19 patients and decreases neutrophil NETs in SARS-CoV-2 infection.

Orosomucoid, or alpha-1 acid glycoprotein (AGP), is a major acute-phase protein expressed in response to systemic injury and inflammation. AGP has been described as an inhibitor of neutrophil migration on sepsis, particularly its immunomodulation effects. AGP's biological functions in coronavirus disease 2019 (COVID-19) are not understood. We sought to investigate the role of AGP in severe COVID-19 infection patients and neutrophils infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Epidemiological data, AGP levels, and other laboratory parameters were measured in blood samples from 56 subjects hospitalized in the ICU with SARS-CoV-2 infection. To evaluate the role of AGP in NETosis in neutrophils, blood samples from health patients were collected, and neutrophils were separated and infected with SARS-CoV-2. Those neutrophils were treated with AGP or vehicle, and NETosis was analyzed by flow cytometry. AGP was upregulated in severe COVID-19 patients (p<0.05). AGP level was positively correlated with IL-6 and C-reactive protein (respectively, p=0.005, p=0.002) and negatively correlated with lactate (p=0.004). AGP treatment downregulated early and late NETosis (respectively, 35.7% and 43.5%) in neutrophils infected with SARS-CoV-2 and up-regulated IL-6 supernatant culture expression (p<0.0001). Our data showed increased AGP in COVID-19 infection and contributed to NETosis regulation and increased IL-6 production, possibly related to the Cytokine storm in COVID-19.

Incidence of hospital acquired pressure injury in critically ill patients with COVID-19 in prone position admitted to the intensive care unit.

Critical patients have conditions that may favor the occurrence of hospital-acquired pressure injury (HAPI). The objective of this study was to identify the incidence and factors associated with the occurrence of HAPI in patients with coronavirus disease 2019 admitted to the intensive care unit (ICU) who used the prone position. Retrospective cohort study carried out in an ICU of a tertiary university hospital. Two hundred four patients with positive real-time polymerase chain reactions were evaluated, of which 84 were placed in the prone position. All patients were sedated and submitted to invasive mechanical ventilation. Of the prone patients, 52 (62%) developed some type of HAPI during hospitalization. The main place of occurrence of HAPI was the sacral region, followed by the gluteus and thorax. Of the patients who developed HAPI, 26 (50%) had this event in places possibly associated with the prone position. The factors associated with the occurrence of HAPI in patients prone to coronavirus disease 2019 were the Braden Scale and the length of stay in the ICU. The incidence of HAPI in prone patients was extremely high (62%), which denotes the need to implement protocols in order to prevent the occurrence of these events.

Assessment of physicians' knowledge about brain death and organ donation and associated factors.

Precocity and assertiveness when diagnosing brain death are essential for identifying potential donors. To assess the knowledge of physicians about brain death and organ donation, cross-sectional web-based survey was carried out with physicians from different specialties. The knowledge about brain death and organ donation was assessed by a questionnaire with 12 multiple-choice or multiple-answer questions (possible range from 0 to 12). The nonparametric Mann-Whitney and Kruskal-Wallis tests were performed to verify the association between the physicians' knowledge and others variables. The project was approved by the Research Ethics Committee of the Hospital das Clínicas, Faculty of Medicine of Ribeirão Preto, University of São Paulo, under number 4.022.657, and all patients agreed to participate and provided free prior-informed consent. Three hundred sixty physicians were included in this study, most of them have postgraduate (55%) and 59.2% were intensive care physicians. The median of responses was 5 (obtained range from 0 to 10). The participants were classified in 2 groups: with satisfactory knowledge (scores above 5) or without satisfactory knowledge (scores equal/below 5). There was better performance among participants who: completed graduation between 6 and 10 years (P < .012); were intensive care physicians (P < .002); had participated in training courses (P < .001); and those who had worked in intensive care unit (ICU) from 6 to 10 years (P < .023); had performed over 10 brain death protocols (P < .001), and felt safe to talk to family members about brain death (P < .001). The results showed that the participants had low knowledge about diagnosis of brain death and organ donation protocols despite the majority working in ICUs. Be an intensive care physician, had large time experience in ICU, and had performed brain death protocols were associated with unsatisfactory knowledge concerning the subject.

Factors associated with the use of personal protective equipment among Brazilian physicians during the COVID-19 pandemic.

INTRODUCTION: The objective was to analyze the factors associated with use of Personal Protective Equipment (PPE) among Brazilian physicians during the COVID-19 pandemic. METHODOLOGY: An analytical cross-sectional study was conducted from October to December 2020 with 1298 Brazilian physicians. The respondent driven sampling technique was used by sharing the survey through social media. RESULTS: Factors associated with the use of PPE while caring for COVID-19 patients were: being female (AOR = 1.57; 95% CI: 1.24-1.98; p ≤ 0.001); working in Intensive Care Unit (ICU) (AOR = 2.78; 95% CI: 2.06-3.75; p ≤ 0.001); training (AOR = 1.62; 95% CI: 1.25-2.09; p ≤ 0.001); access to sufficient PPE (AOR = 2.22; 95% CI: 1.27-3.90; p = 0.0050), and PPE of good quality (AOR = 1.84; 95% CI: 1.16-2.92; p = 0.009). The following factors were associated with the use of recommended PPE during procedures that generate aerosols in the context of COVID-19: working in the ICU (ORA=2.73; 95% CI: 2.06-3.62; p < 0.01); working in a field hospital (AOR = 1.37; 95% CI: 1.06-1.79; p = 0.018;) training (AOR = 1.72 95% CI: 1.32-2.24; p < 0.01); access to sufficient PPE (AOR = 1.63; 95% CI: 0.91-2.92; p < 0.01), PPE of good quality (AOR = 2.07; 95% CI: 1.28-3.35; p = 0.003). CONCLUSIONS: The factors associated with the use of necessary PPE with COVID-19 patients and for procedures that generate aerosols were identified. Educational interventions for professionals and managers must be implemented to direct them towards protecting themselves and others.

Critical care nursing service costs: Comparison of the top-down versus bottom-up micro-costing approach in Brazil.

AIM: To estimate the nursing service costs using a top-down micro-costing approach and to compare it with a bottom-up micro-costing approach. BACKGROUND: Accurate data of nursing cost can contribute to reliable resource management. METHOD: We employed a retrospective cohort design in an adult intensive care unit in São Paulo. A total of 286 patient records were included. Micro-costing analysis was conducted in two stages: a top-down approach, whereby nursing costs were allocated to patients through apportionment, and a bottom-up approach, considering actual nursing care hours estimated by the Nursing Activities Score (NAS). RESULTS: The total mean cost by the top-down approach was US$1,640.4 ± 1,484.2/patient. The bottom-up approach based on a total mean NAS of 833 ± 776 points (equivalent to 200 ± 86 hr of nursing care) yielded a mean cost of US$1,487.2 ± 1,385.7/patient. In the 268 patients for whom the top-down approach estimated higher costs than the bottom-up approach, the total cost discrepancy was US$4,427.3, while for those costed higher based on NAS, the total discrepancy was US$436.9. The top-down methodology overestimated costs for patients requiring lower intensity of care, while it underestimated costs for patients requiring higher intensity of care (NAS >100). CONCLUSIONS: The top-down approach may yield higher estimated ICU costs compared with a NAS-based bottom-up approach. IMPLICATIONS FOR NURSING MANAGEMENT: These findings can contribute to an evidence-based approach to budgeting through reliable costing methods based on actual nursing workload, and to efficient resource allocation and cost management.

Omission of nursing care, professional practice environment and workload in intensive care units.

AIM: The present study aimed to characterize the omission of nursing care according to the nurses' perception, the professional practice environment and the nursing workload of intensive care units (ICU) in Brazil. Additionally, the influence of the practice environment and nursing workload on such omission was assessed, as well as the type of care omitted regarding priority classification. BACKGROUND: In order to ensure patient safety and quality of care, it is necessary to invest in improvements in nursing care practices. METHOD: The present cross-sectional study was performed in three large ICU in Brazil. The omission of nursing care was identified using the MISSCARE-BRASIL instrument, and the environment and duration of professional nursing practice were analysed using the Practice Environment Scale (PES) and Nursing Activities Score (NAS), respectively. RESULTS: "Ambulation three times a day or as prescribed" was the form of care reported as the most omitted in the three studied units. The reasons for not performing care included the following: inadequate number of staff, inadequate physical blueprint of the unit/sector and the professional having more than one employment relationship. Upon characterizing the work environment in the ICU according to the PES, ICU 1 and 3 were considered "mixed" environments, whereas ICU 2 was considered a "favourable" environment. CONCLUSION: The professional practice environment, as well as the workload, may constitute predictive factors for the omission of care. IMPLICATIONS FOR NURSING MANAGEMENT: The nursing workload and practice environment influence the omission of care. Moreover, the establishment of criteria for the prioritization of care when faced with adverse work conditions is necessary.

Urgent need for standardised guidelines for reporting healthcare costs in ICUs - Results of an integrative review of costing methodologies.

OBJECTIVES: Diverse costing methodologies in critical care have produced discrepant results. We aimed to critically review studies addressing critical care patients' costs, to estimate total costs and cost categories and to delineate methodologies used and relevant limitations. METHODS: Integrative review based on key-word searches of electronic databases targeting primary studies that report estimates of patient cost, in the last 21 years. We assessed the level transparency of reporting and the quality of the studies, by the SIGN tool. RESULTS: Overall, 12 research articles were included, of which eight studies mentioned the specific approach used to identify the elements of cost. Most studies employed a micro-costing and one study a macro-costing approach. With regard to approaches to valuation of cost components, only one study identified the bottom-up approach. The total patient cost ranged from US$ 487 to US$ 39,300 and human resources was identified as the cost category mostly driving total costs. CONCLUSIONS: Although valid methodologies to evaluate critical care patients' costs, such as micro-costing, are employed more frequently, a variety of non-standardized methods are still used. There is a pressing need to develop standardised guidelines for reporting of observational studies of cost in healthcare, with particular considerations for critical care.

Fatores associados à carga de trabalho de enfermagem em unidade de terapia intensiva: revisão integrativa / Factores asociados con la carga de trabajo de enfermería en la unidad de cuidados intensivos: revisión integradora / Factors associated with nursing workload in the intensive care units: integrative review

RESUMO Objetivo: Identificar as evidências disponíveis na literatura nacional e internacional sobre fatores associados à carga de trabalho de enfermagem em Unidade de Terapia Intensiva. Método: Trata-se de uma Revisão Integra tiva da Literatura realizada no período de janeiro de 2003 a dezembro de 2013. O levantamento dos estudos foi realizado nas bases de dados Literatura Latino-Americana e do Caribe em Ciências da Saúde e Medical Literature Analysis and Retrieval System Online. Resultados: A amostra final consistiu de 16 artigos. A análise evidenciou que as variáveis que mais foram citadas como preditoras de maior carga de trabalho em Unidade de Terapia Intensiva foram o tempo de permanência na unidade, gravidade e desfecho. A idade do paciente não teve impacto na carga de trabalho na maioria dos estudos. Conclusão: Esta revisão possibilitou conhecer as va riáveis que tem sido objeto de investigação enquanto influência sobre carga de trabalho em Unidade de Terapia Intensiva sem, entretanto possibilitar que se afirme tal relação, necessitando novos estudos.

ABSTRACT Objective: This study aimed to evaluate the evidence available in the national and international literature on the factors associated with nursing workload in the Intensive Care Unit. Method: This is an Integrative Literature Review conducted from January 2003 to December 2013. The survey of studies was conducted on the basis of Latin American and Caribbean Literature Data on Health Sciences and Medical Literature Analysis and Retriev al System Online. Results: The final sample consisted of 16 items. The analysis of these showed that the variables that were mosly cited as predictors of increased workload in the Intensive Care Unit were the length of stay in the unit, severity and outcome. Patient age had no impact on the workload in most studies. Conclusion: This review has helped understand the variables that have received attention as influence on nursing workload in the Intensive Care Unit, although such relationship cannot be confirmed therefore further studies are needed.

RESUMEN Objetivo: Identificar la evidencia disponible en la literatura nacional e internacional sobre los factores asociados con la carga de trabajo de enfermería en Unidades de Cuidados Intensivos. Método: Se trata de una revisión integradora de la literatura realizada en el período enero de 2003 a diciembre de 2013. La búsqueda de estudios se realizó en las bases de datos de Literatura Latinoamericana y del Caribe en Ciencias de la Salud y en Medical Literature Analysis and Retrieval System Online. Resultados: La muestra final estuvo compuesta por 16 artícu los. El análisis mostró que las variables que más se citaron como predictoras de mayor carga de trabajo en las Unidades de Cuidados Intensivos fueron la duración de la estadía en la unidad, la gravedad y el resultado. La edad del paciente no tuvo impacto en la carga de trabajo en la mayoría de los estudios. Conclusión: La revisión permitió conocer las variables que han sido objeto de investigación en relación a la influencia en la carga de trabajo en Unidades de Cuidados Intensivos, pero sin permitir afirmar esta relación, lo que requiere estudios adicionales.