Screening Testing for SARS-CoV-2 upon Admission to Rehabilitation Hospitals in a High COVID-19 Prevalence Community.

BACKGROUND: While planning for the care of coronavirus disease 2019 (COVID-19) patients during the pandemic crisis has dominated the focus of leaders of inpatient rehabilitation facilities (IRFs), patients with injuries/illnesses unrelated to COVID-19 continue to need inpatient rehabilitation admission. To maintain a safe environment for all patients and staff, we established an admission screening plan of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to determine the presence of asymptomatic patients who were infected with the virus upon admission. OBJECTIVE: To determine the prevalence of patients who test positive for SARS-CoV-2 but were presumed to be COVID-19 negative at the time of admission to IRF in New Jersey. DESIGN: Retrospective analysis of SARS-CoV-2 testing results. SETTING: Four freestanding IRFs in New Jersey operated as one system. PATIENTS: All (N = 103) patients sequentially admitted from 4 to 27 April 2020 with no symptoms or evidence of COVID-19 disease at the time of transfer from the acute hospital. INTERVENTIONS: Specimens were collected for SARS-CoV-2 analysis at the time of admission to the IRF and patients were monitored for subsequent symptom development over the next 14 days. MAIN OUTCOME MEASURES: Results of SARS-CoV-2 testing upon admission and evidence of development of clinical signs or symptoms of COVID-19. RESULTS: Seven asymptomatic persons (6.8% of admissions) without clinical signs/symptoms of COVID-19 tested positive on admission. Of these, five developed symptoms of COVID-19, with a mean onset of 3.2 (range of 2-5) days. Five additional patients became symptomatic and tested positive within the next 3 to 10 days (mean of 5.2 days). Overall, 11.6% of admissions (12/103) had a positive test within 14 days of admission. CONCLUSIONS: Admission testing to postacute centers for SARS-CoV-2 can help identify presymptomatic or asymptomatic individuals, especially in areas where COVID-19 is prevalent. Negative results, however, do not preclude COVID-19 and should not be used as the sole basis for patient management decisions.

Risk factors for delirium in older trauma patients admitted to the surgical intensive care unit.

BACKGROUND: Adults (age > 50 years) admitted to the surgical intensive care unit (SICU) are at high risk for delirium. Little is known about the role traumatic injury plays in the development of delirium because these patients have often been excluded from studies. Identification of specific risk factors for delirium among older adults following injury would be useful to guide prevention strategies. We attempted to identify modifiable factors that would predict delirium in an older trauma population admitted to the SICU. METHODS: Data were collected prospectively from July 2012 to August 2013 at a Level I trauma center on consecutive trauma patients, older than 50 years, admitted to the SICU. Patients who died in the SICU were excluded. Delirium was assessed every 12 hours using the Confusion Assessment Method for the ICU scale. Demographic, injury, social, and clinical variables were reviewed. Bivariate analysis determined significant factors associated with delirium. A multivariate logistic regression model was used to predict delirium risk. After preliminary results, additional analysis compared patients with chest injury (defined as chest Abbreviated Injury Scale [AIS] score ≥ 3) with those without. RESULTS: A total of 115 patients met criteria, with a mean age of 67 years, Injury Severity Score (ISS) of 19, and Glasgow Coma Scale (GCS) score of 14. The incidence of delirium was 61%. Variables present on admission, which were positive predictors of delirium, were as follows: age, ISS greater than 17, GCS score less than 15, substance abuse, and traumatic brain injury (defined as head AIS score ≥ 3). Chest injury (defined as chest AIS score ≥ 3) was a negative predictor of delirium. Significant risk factors influenced by clinical treatment included doses of opioids and propofol, restraint use, and hours deeply sedated (Richmond Agitation Sedation Scale [RASS] score ≤ -3). Clinical treatments with negative predictability were ventilator-free days/30 (vent-free), benzodiazepine-free days/30 (benzo-free), and restraint-free days/30. In a regression model considering age, vent-free days, chest injury, traumatic brain injury, GCS score, benzo-free days, and hours sedated, only age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.01-1.1; p = 0.03) was a predictor of delirium, while vent-free days (OR, 0.79; 95% CI, 0.65-0.96; p = 0.02) and chest injury (OR, 0.3; 95% CI, 0.09-0.83; p = 0.02) were significant negative predictors of delirium. Patients with chest injury had lower delirium incidence (44%) versus those without (75%) (p = 0.002) despite similar GCS score, ISS, and clinical variables. CONCLUSION: Delirium is common in older trauma patients admitted to the SICU, and for every year for those older than 50 years, the chance of delirium increases by 10%. While higher ISS increases delirium risk, we identified several modifiable treatment variables including days patients were deeply sedated, mechanically ventilated, and physically restrained. Interestingly, patients with chest injury experienced less delirium, despite similar injury severity and clinical variables, perhaps owing to frequent health care provider interactions. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Delirium prevention program in the surgical intensive care unit improved the outcomes of older adults.

BACKGROUND: Hospital-acquired delirium is a known risk factor for negative outcomes in patients admitted to the surgical intensive care unit (SICU). Outcomes worsen as the duration of delirium increases. The purpose of this study was to evaluate the efficacy of a delirium prevention program and determine whether it decreased the incidence and duration of hospital-acquired delirium in older adults (age>50 y) admitted to the SICU. METHODS: A prospective pre- or post-intervention cohort study was done at an academic level I trauma center. Older adults admitted to the SICU were enrolled in a delirium prevention program. Those with traumatic brain injury, dementia, or 0 d of obtainable delirium status were excluded from analysis. The intervention consisted of multidisciplinary education, a pharmacologic protocol to limit medications associated with delirium, and a nonpharmacologic sleep enhancement protocol. Primary outcomes were incidence of delirium and delirium-free days/30. Secondary outcomes were ventilator-free days/30, SICU length of stay (LOS), daily and cumulative doses of opioids (milligram, morphine equivalents) and benzodiazepines (milligram, lorazepam equivalents), and time spent in severe pain (greater than or equal to 6 on a scale of 1-10). Delirium was measured using the Confusion Assessment Method for the ICU. Data were analyzed using Chi-squared and Wilcoxon rank sum analysis. RESULTS: Of 624 patients admitted to the SICU, 123 met inclusion criteria: 57 preintervention (3/12-6/12) and 66 postintervention (7/12-3/13). Cohorts were similar in age, gender, ratio of trauma patients, and Injury Severity Score. Postintervention, older adults experienced delirium at the same incidence (pre 47% versus 58%, P=0.26), but for a significantly decreased duration as indicated by an increase in delirium-free days/30 (pre 24 versus 27, P=0.002). After intervention, older adults with delirium had more vent-free days (pre 21 versus 25, P=0.03), shorter SICU LOS (pre 13 [median 12] versus 7 [median 6], P=0.01) and were less likely to be treated with benzodiazepines (pre 85% versus 63%, P=0.05) with a lower daily dose when prescribed (pre 5.7 versus 3.6 mg, P=0.04). After intervention, all older adults spent less time in pain (pre 4.7 versus 3.1 h, P=0.02), received less total opioids (pre 401 versus 260 mg, P=0.01), and had shorter SICU LOS (pre 9 [median 5] versus 6 [median 4], P=0.04). CONCLUSIONS: Although delirium prevention continues to be a challenge, this study successfully decreased the duration of delirium for older adults admitted to the SICU. Our simple, cost-effective program led to improved pain and sedation outcomes. Older adults with delirium spent less time on the ventilator and all patients spent less time in the SICU.

Unrelenting violence: an analysis of 6,322 gunshot wound patients at a Level I trauma center.

BACKGROUND: Perceptions of violence are too often driven by individual sensational events, yet "routine" gunshot wound (GSW) injuries are largely underreported. Previous studies have mostly focused on fatal GSW. To illuminate this public health problem, we studied the health care burden of interpersonal GSW at a Level I trauma center. METHODS: Retrospective analysis of GSW injuries (excluding self and law enforcement) treated from January 2000 to December 2011. Data collected included body regions injured, number of wounds per patient, and mortality. Costs were calculated using Medicare cost-charge modifiers. Geographic information system mapping of the incident location and home addresses were determined to identify hot spot locations and the characterization of those neighborhoods. RESULTS: A total of 6,322 patients were treated. There were significant increases in patients with three or more wounds (13-22%, p < 0.0001) and three or more body regions injured (6-16%, p < 0.0001). Mortality increased from 9% to 14% (p < 0.0001). Nineteen percent of the patients were never seen by the trauma service. Geographic information system mapping revealed significant clustering of GSWs. Five cities accounted for 85% of the GSWs, with rates per 100,000 ranging from 19 to 108 compared with a national rate of 20. Only 19% of the census tracts had no GSWs during the period, and 39% of the census tracts had at least one GSW per year for 12 years. Fifteen percent of the census tracts accounted for 50% of the GSWs. Seventy percent of the patients were shot in their home city, 25% within 168 m, and 55% within 1,600 m of their home. Total inpatient cost was $115 million, with cost per patient increasing more than three times over the course of the study; 75% were unreimbursed. CONCLUSION: GSW violence remains a significant public health problem, with escalating mortality and health costs. Relying on trauma registry data seriously underestimates GSW numbers. In contrast to episodic mass casualties, routine GSW violence is geographically restricted and not random. To combat this problem, policy makers must understand that the determinants of firearm violence reside at the community level. LEVEL OF EVIDENCE: Epidemiologic study, level II.