Changes in diagnostic patterns and resource utilisation in Swiss adult ICUs during the first two COVID-19 waves: an exploratory study.

BACKGROUND AND AIM: The coronavirus disease 2019 (COVID-19) outbreak deeply affected intensive care units (ICUs). We aimed to explore the main changes in the distribution and characteristics of Swiss ICU patients during the first two COVID-19 waves and to relate these figures with those of the preceding two years. METHODS: Using the national ICU registry, we conducted an exploratory study to assess the number of ICU admissions in Switzerland and their changes over time, characteristics of the admissions, the length of stay (LOS) and its trend over time, ICU mortality and changes in therapeutic nursing workload and hospital resources in 2020 and compare them with the average figures in 2018 and 2019. RESULTS: After analysing 242,935 patient records from all 84 certified Swiss ICUs, we found a significant decrease in admissions (-9.6%, corresponding to -8005 patients) in 2020 compared to 2018/2019, with an increase in the proportion of men admitted (61.3% vs 59.6%; p <0.001). This reduction occurred in all Swiss regions except Ticino. Planned admissions decreased from 25,020 to 22,021 in 2020 and mainly affected the neurological/neurosurgical (-14.9%), gastrointestinal (-13.9%) and cardiovascular (-9.3%) pathologies. Unplanned admissions due to respiratory diagnoses increased by 1971 (+25.2%), and those of patients with acute respiratory distress syndrome (ARDS) requiring isolation reached 9973 (+109.9%). The LOS increased by 20.8% from 2.55 ± 4.92 days (median 1.05) in 2018/2019 to 3.08 ± 5.87 days (median 1.11 days; p <0.001), resulting in an additional 19,753 inpatient days. The nine equivalents of nursing manpower use score (NEMS) of the first nursing shift (21.6 ± 9.0 vs 20.8 ± 9.4; p <0.001), the total NEMS per patient (251.0 ± 526.8 vs 198.9 ± 413.8; p <0.01) and mortality (5.7% vs 4.7%; p <0.001) increased in 2020. The number of ICU beds increased from 979 to 1012 (+3.4%), as did the number of beds equipped with mechanical ventilators (from 773 to 821; +6.2%). CONCLUSIONS: Based on a comprehensive national data set, our report describes the profound changes triggered by COVID-19 over one year in Swiss ICUs. We observed an overall decrease in admissions and a shift in admission types, with fewer planned hospitalisations, suggesting the loss of approximately 3000 elective interventions. We found a substantial increase in unplanned admissions due to respiratory diagnoses, a doubling of ARDS cases requiring isolation, an increase in ICU LOS associated with substantial nationwide growth in ICU days, an augmented need for life-sustaining therapies and specific therapeutic resources and worse outcomes.

Contribution margin per hour of operating room to reallocate unutilized operating room time: a cost-effectiveness analysis

Abstract Background and objectives: Contribution margin per hour (CMH) has been proposed in healthcare systems to increase the profitability of operating suites. The aim of our study is to propose a simple and reproducible model to calculate CMH and to increase cost-effectiveness. Methods: For the ten most commonly performed surgical procedures at our Institution, we prospectively collected their diagnosis-related group (DRG) reimbursement, variable costs and mean procedural time. We quantified the portion of total staffed operating room time to be reallocated with a minimal risk of overrun. Moreover, we calculated the total CMH with a random reallocation on a first come-first served basis. Finally, prioritizing procedures with higher CMH, we ran a simulation by calculating the total CMH. Results: Over a two-months period, we identified 14.5 hours of unutilized operating room to reallocate. In the case of a random ''first come -first serve'' basis, the total earnings were 87,117 United States dollars (USD). Conversely, with a reallocation which prioritized procedures with a high CMH, it was possible to earn 140,444 USD (p < 0.001). Conclusion: Surgical activity may be one of the most profitable activities for hospitals, but a cost-effective management requires a comprehension of its cost profile. Reallocation of unused operating room time according to CMH may represent a simple, reproducible and reliable tool for elective cases on a waiting list. In our experience, it helped improving the operating suite cost-effectiveness.

Contribution margin per hour of operating room to reallocate unutilized operating room time: a cost-effectiveness analysis.

BACKGROUND AND OBJECTIVES: Contribution margin per hour (CMH) has been proposed in healthcare systems to increase the profitability of operating suites. The aim of our study is to propose a simple and reproducible model to calculate CMH and to increase cost-effectiveness. METHODS: For the ten most commonly performed surgical procedures at our Institution, we prospectively collected their diagnosis-related group (DRG) reimbursement, variable costs and mean procedural time. We quantified the portion of total staffed operating room time to be reallocated with a minimal risk of overrun. Moreover, we calculated the total CMH with a random reallocation on a first come-first served basis. Finally, prioritizing procedures with higher CMH, we ran a simulation by calculating the total CMH. RESULTS: Over a two-months period, we identified 14.5 hours of unutilized operating room to reallocate. In the case of a random "first come-first serve" basis, the total earnings were 87,117 United States dollars (USD). Conversely, with a reallocation which prioritized procedures with a high CMH, it was possible to earn 140,444 USD (p < 0.001). CONCLUSION: Surgical activity may be one of the most profitable activities for hospitals, but a cost-effective management requires a comprehension of its cost profile. Reallocation of unused operating room time according to CMH may represent a simple, reproducible and reliable tool for elective cases on a waiting list. In our experience, it helped improving the operating suite cost-effectiveness.

Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations.

Aim: This systematic review aimed to investigate the drugs used and their potential effect on noninvasive ventilation (NIV). Background: NIV is used increasingly in acute respiratory failure (ARF). Sedation and analgesia are potentially beneficial in NIV, but they can have a deleterious impact. Proper guidelines to specifically address this issue and the recommendations for or against it are scarce in the literature. In the most recent guidelines published in 2017 by the European Respiratory Society/American Thoracic Society (ERS/ATS) relating to NIV use in patients having ARF, the well-defined recommendation on the selective use of sedation and analgesia is missing. Nevertheless, some national guidelines suggested using sedation for agitation. Methods: Electronic databases (PubMed/Medline, Google Scholar, and Cochrane library) from January 1999 to December 2019 were searched systematically for research articles related to sedation and analgosedation in NIV. A brief review of the existing literature related to sedation and analgesia was also done. Review results: Sixteen articles (five randomized trials) were analyzed. Other trials, guidelines, and reviews published over the last two decades were also discussed. The present review analysis suggests dexmedetomidine as the emerging sedative agent of choice based on the most recent trials because of better efficacy with an improved and predictable cardiorespiratory profile. Conclusion: Current evidence suggests that sedation has a potentially beneficial role in patients at risk of NIV failure due to interface intolerance, anxiety, and pain. However, more randomized controlled trials are needed to comment on this issue and formulate strong evidence-based recommendations. How to cite this article: Karim HMR, Sarc I, Calandra C, Spadaro S, Mina B, Ciobanu LD, et al. Role of Sedation and Analgesia during Noninvasive Ventilation: Systematic Review of Recent Evidence and Recommendations. Indian J Crit Care Med 2022;26(8):938-948.

Dissemination of patient blood management practices in Swiss intensive care units: a cross-sectional survey.

BACKGROUND: Patient blood management (PBM) promotes the routine detection and treatment of anaemia before surgery, optimising the management of bleeding disorders, thus minimising iatrogenic blood loss and pre-empting allogeneic blood utilisation. PBM programmes have expanded from the elective surgical setting to nonsurgical patients, including those in intensive care units (ICUs), but their dissemination in a whole country is unknown. METHODS: We performed a cross-sectional, anonymous survey (10 October 2018 to 13 March 2019) of all ordinary medical members of the Swiss Society of Intensive Care Medicine and the registered ICU nurses from the 77 certified adult Swiss ICUs. We analysed PBM-related interventions adopted in Swiss ICUs and related them to the spread of PBM in Swiss hospitals. We explored blood test ordering policies, blood-sparing strategies and red blood cell-related transfusion practices in ICUs. RESULTS: A total of 115 medical doctors and 624 nurses (response rates 27% and 30%, respectively) completed the surveys. Hospitals had implemented a PBM programme according to 42% of physicians, more commonly in Switzerland's German-speaking regions (Odds Ratio [OR] 3.39, 95% confidence interval [CI] 1.23-9.35; p = 0.018) and in hospitals with more than 500 beds (OR 3.91, 95% CI 1.48-10.4; p = 0.006). The PBM programmes targeted the detection and correction of anaemia before surgery (79%), minimising perioperative blood loss (94%) and optimising anaemia tolerance (98%). Laboratory tests were ordered in 70.4% by the intensivist during morning rounds; the nurses performed arterial blood gas analyses autonomously in 48.4%. Blood-sparing techniques were used by only 42.1% of nurses (263 of 624, missing: 6) and 47.0% of physicians (54 of 115). Approximately 60% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin threshold for the nonbleeding ICU population was 70 g/l and, therefore, was at the lower limit of current guidelines. CONCLUSIONS: Based on this survey, the estimated proportion of the intensivists working in hospitals with a PBM initiative is 42%, with significant variability between regions and hospitals of various sizes. The risk of iatrogenic anaemia is relevant due to liberal blood sample collection practices and the underuse of blood-sparing techniques. The reported transfusion threshold suggests excellent adherence to current international ICU-specific transfusion guidelines.

High-Flow Nasal Oxygen Therapy in Acute Hypoxemic Respiratory Failure: Concise Review on Technology and Initial Methodology.

High-flow nasal cannula oxygen therapy (HFNCOT) system consists of an air/oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 80 L/min. The system includes a blender, active humidifier, single heated tube, and nasal cannula. HFNCOT has many physiological advantages compared with other standard oxygen therapies, such as anatomical dead space washout, more constant fraction of inspired oxygen, positive end-expiratory (PEEP) effect, supplement of adequate humidification and maintenance of muco-ciliary function. HFNCOT is mostly used for hypoxemic acute respiratory failure, although it also has other indications. HFNCOT is a common choice of physicians as its technology makes it more silent and comfortable. Though HFNCOT is used in many clinical settings, there is a lack of publications addressing devices and initial settings. We present a review on HFNCOT, with focus on device and application methodology.

Severity-Adjusted ICU Mortality Only Tells Half the Truth-The Impact of Treatment Limitation in a Nationwide Database.

OBJECTIVES: The influence of different forms of treatment limitation on mortality rate in the ICU is not known despite the common use of the latter as a quality indicator. The aim of the present study was to assess the prevalence of treatment limitation and its influence on ICU mortality rate. Primary outcomes were prevalence of treatment limitation and its influence on severity-adjusted ICU mortality rate. Secondary outcomes included the association of limitation with age, sex, type of admission, diagnostic group, treatment intensity, and length of ICU stay. DESIGN: Retrospective, observational study. SETTING: All Swiss adult ICUs. INTERVENTIONS: None. PATIENTS: A total of 166,764 patients were admitted to an ICU in 2016 and 2017. Of these, 9139 were excluded because of readmission or invalid coding. MEASUREMENTS AND MAIN RESULTS: Of 157,625 ICU patients, 20,916 (13.3%) had a fully defined treatment limitation. Among this group, treatment limitation was defined upon ICU admission in 12,854 (61%), the decision to limit treatment was based on the patient's advance directives in 9,951 (48%), and in 15,341 (73%), there was a decision to deliberately withhold certain treatment modalities. The mortality odds ratio for the group with a treatment limitation, considering relevant cofactors, was 18.1 (95% CI 16.8-19.4). CONCLUSIONS: Every seventh patient in a Swiss ICU has some kind of treatment limitation, and this most probably affects the severity-adjusted mortality rate. Thus, mortality data as a quality indicator or benchmark in intensive care can only meaningfully be interpreted if existence, grade, cause, and time of treatment limitation are taken into account.

Non-invasive ventilation during surgery under neuraxial anaesthesia: a pathophysiological perspective on application and benefits and a systematic literature review.

Unlike general anaesthesia, neuraxial anaesthesia (NA) reduces the burden and risk of respiratory adverse events in the post-operative period. However, both patients affected by chronic obstructive pulmonary disease (COPD) and chest wall disorders and/or neuromuscular diseases may experience the development or the worsening of respiratory failure, even during surgery performed under NA; this latter negatively affects the function of accessory respiratory muscles, resulting in a blunted central response to hypercapnia and possibly in an exacerbation of cardiac dysfunction (NA-induced relative hypovolemia). According to European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines, non-invasive ventilation (NIV) is effective in the post-operative period for the treatment of both impaired pulmonary gas exchange and ventilation, while the intra-operative use of NIV in association with NA is just anecdotally reported in the literature. Whilst NIV does not assure a protected patent airway and requires the patient's cooperation, it is a handy tool during surgery under NA: NIV is reported to be successful for treatment of acute respiratory failure; it may be delivered through the patient's home ventilator, may reverse hypoventilation induced by sedatives or inadvertent spread of anaesthetic up to cervical dermatomes, and allow the avoidance of intubation in patients affected by chronic respiratory failure, prolonging the time of non-invasiveness of respiratory support (i.e., neuromuscular patients needing surgery). All these advantages could make NIV preferable to oxygen in carefully selected patients.

Effect of postoperative haemoglobin variation on major cardiopulmonary complications in high cardiac risk patients undergoing anatomical lung resections.

OBJECTIVES: Recent evidence shows that permissive anaemia strategies are safe in different surgical settings. However, effects of variations in haemoglobin (Hb) levels could have a negative impact in high-risk patients. We investigated the combined effect of postoperative Hb concentration and cardiac risk status on major cardiopulmonary complications after anatomical lung resections. METHODS: We retrospectively analysed the records, collected in a prospective clinical database, of 154 consecutive patients undergoing anatomical lung resections at our institution (February 2017-February 2019). Hb levels were displayed as preoperative concentration, nadir Hb level before onset of complications and delta Hb (ΔHb). Cardiac risk was stratified according to the Thoracic Revised Cardiac Risk Index (ThRCRI). Univariable and multivariable logistic regression analyses were used to test the associations between patients, surgical variables and cardiopulmonary complications according to the European Society of Thoracic Surgeons definitions. RESULTS: Cardiopulmonary complications occurred in 63 patients (17%). In the fully adjusted multivariable model, higher values of ΔHb were associated with increased risk of complications [odds ratio (OR) 1.07; P < 0.001], along with higher ThRCRI classes (classes A-B versus C-D: OR 0.09; P < 0.001). Interaction terms with transfusion were not statistically significant, indicating that the harmful effect of ΔHb was independent. According to receiver operating characteristic curve analysis, a ΔHb of 29 g/l was found to be the best cut-off value for predicting complications. CONCLUSIONS: In our series, ΔHb, rather than nadir Hb, was associated with an increased risk of complications, particularly in patients with higher cardiac risk. Restrictive transfusion strategies should be carefully applied in patients undergoing lung resections and balanced according to individual clinical status.

Non-invasive ventilation in palliative care: a systematic review.

INTRODUCTION: An ageing population and steady increase in the rates of neoplasms and chronic degenerative diseases poses a challenge for societies and their healthcare systems. Because of the recent and continued advances in therapies, such as the development and widespread use of non-invasive ventilation (NIV), survival rates have increased for these pathologies. For patients with end-stage chronic respiratory diseases, the use of NIV following the onset of acute or severe chronic respiratory failure is a valid option when intubation has been excluded. EVIDENCE ACQUISITION: The following electronic databases were searched from their inception to January 2000 to December 2017: MEDLINE, EMBASE, CINHAIL, CENTRAL (Cochrane Central register of Controlled Trials), DARE (Database of Abstracts of Reviews of Effectiveness), the Cochrane Database of Systematic Reviews, ACP Journal Club database. EVIDENCE SYNTHESIS: The available evidence strongly supports the use of NIV in patients presenting with an exacerbation of chronic obstructive pulmonary disease, as well end-stage neuromuscular disease. Few studies support the use of NIV in end-stage interstitial lung disease and in morbid obesity patients. In patients with cancer has been recommend offering NIV as palliative care to improve dyspnea. CONCLUSIONS: The decision regarding the treatment should be made by the patient, ideally before reaching the terminal stage and after having a frank dialogue with healthcare professionals and family members.

Persistent postdischarge pain and chronic postoperative pain after breast cancer surgery under general anesthesia and single-shot paravertebral block: incidence, characteristics and impact on quality of life and healthcare costs.

Introduction: Breast surgery is associated with persistent postsurgical pain; usually related to poorly treated acute pain. Paravertebral block has been successfully employed in analgesic protocols for breast surgery; its impact on postdischarge pain (PDP) has not been investigated. The aim of this study was to assess characteristics of PDP after breast surgery, the development of chronic postoperative pain (CPP) and its impact on health care costs. Methods: We conducted a retrospective, observational study on a continuous cohort of adult female patients undergoing local breast cancer surgery under combined anesthesia. All patients were interviewed 6 months after hospital discharge. The survey was specifically conceived to assess incidence, features and duration of PDP. The overall cost of additional healthcare resources consumed with a specific relationship to persistent PDP was estimated. Results: A database of 244 patients was preliminarily analyzed. Of these, 188 were included in the following statistical analysis; 123 patients (65.2%) reported significant PDP, with a median intensity on NRS of 6 (IQR=2), more frequently described as burning and associated with paresthesia and/or hyperalgesia (87 patients, 46%). One hundred and six patients (56.5%) reported this pain as interfering with their normal daily activities, work and sleep. In 26.8% of cases (50 patients) symptoms lasted more than 1 month and in 28 patients (15.0%) pain became chronic. The majority of patients self-treated their pain with non-steroideal anti-inflammatory drugs, but in 50 patients (26.8%) this therapy was reported as ineffective. This additional consumption of healthcare resources led to a significant economical impact. Conclusion: PDP and CPP seem to be common complications after breast cancer surgery, even if a combined anesthesia technique with a thoracic paravertebral block is performed, leading to severe consequences on patients' quality of life and increasing consumption of healthcare resources after discharge. Trial number: NCT03618459 (www.clinicaltrials.gov).

A novel method to assess data quality in large medical registries and databases.

BACKGROUND: There is no gold standard to assess data quality in large medical registries. Data auditing may be impeded by data protection regulations. OBJECTIVE: To explore the applicability and usefulness of funnel plots as a novel tool for data quality control in critical care registries. METHOD: The Swiss ICU-Registry from all 77 certified adult Swiss ICUs (2014 and 2015) was subjected to quality assessment (completeness/accuracy). For the analysis of accuracy, a list of logical rules and cross-checks was developed. Type and number of errors (true coding errors or implausible data) were calculated for each ICU, along with noticeable error rates (>mean + 3 SD in the variable's summary measure, or >99.8% CI in the respective funnel-plot). RESULTS: We investigated 164 415 patient records with 31 items each (37 items: trauma diagnosis). Data completeness was excellent; trauma was the only incomplete item in 1495 of 9871 records (0.1%, 0.0%-0.6% [median, IQR]). In 15 572 patients records (9.5%), we found 3121 coding errors and 31 265 implausible situations; the latter primarily due to non-specific information on patients' provenance/diagnosis or supposed incoherence between diagnosis and treatments. Together, the error rate was 7.6% (5.9%-11%; median, IQR). CONCLUSIONS: The Swiss ICU-Registry is almost complete and data quality seems to be adequate. We propose funnel plots as suitable, easy to implement instrument to assist in quality assurance of such a registry. Based on our analysis, specific feedback to ICUs with special-cause variation is possible and may promote such ICUs to improve the quality of their data.

Does spinal chloroprocaine pharmacokinetic profile actually translate into a clinical advantage in terms of clinical outcomes when compared to low-dose spinal bupivacaine? A systematic review and meta-analysis.

STUDY OBJECTIVE: Spinal anesthesia is well suited for day-care surgery, however a persisting motor block after surgery can delay discharge. Among the new drugs available, chloroprocaine has been associated with a short onset time, and motor block duration and a quicker discharge. However, it is not clear if those outcomes are clinically significantly superior compared to those associated with the use of low-dose hyperbaric bupivacaine. DESIGN: Aim of the study was to determine if spinal 2-chloroprocaine was superior to low-dose spinal bupivacaine regarding the following outcomes: onset time, block duration, time to ambulation and time to discharge. PATIENTS/INTERVENTIONS: We performed a systematic literature search of the last 30 years using PubMed Embase and the Cochrane Controlled Trials Register. We included only blinded, prospective trials comparing chloroprocaine with a low dose of bupivacaine for spinal anesthesia. Low dose bupivacaine was defined as a dose of 10 mg or less. Outcomes of interest were time to motor block regression (primary outcome), time to ambulation and time to discharge (secondary outcomes), as indirect indicators of a complete recovery after spinal anesthesia. MAIN RESULTS: Compared to a low dose bupivacaine, spinal 2-chloroprocaine was associated with significantly faster motor and sensory block regression (pMD = -57 min-140.3 min; P = 0.015 and <0.001 respectively), a significantly shorter time to ambulation and an earlier discharge (pMD = -84.6 min; P < 0.001 and pMD = -88.6 min and <0.001 respectively). Onset time did not differ between the two drugs (pMD = -1.1 min; P = 0.118). CONCLUSIONS: Spinal 2-chloroprocaine has a shorter motor block duration, a significantly quicker time to ambulation and time to discharge compared to low dose hyperbaric bupivacaine and may be advantageous when spinal anesthesia is performed for day case surgery.

Sharing intimacy in "open" intensive care units.

PURPOSE: Opening intensive care units (ICUs) is particularly relevant because of a new Swiss law granting the relatives of patients without decision-making capability a central role in medical decisions. The main objectives of the study were to assess how the presence of relatives is viewed by patients, health care providers, and relatives themselves and to evaluate the perception of the level of intrusiveness into the personal sphere during admission. MATERIAL AND METHODS: In a longitudinal and prospective design, qualitative questionnaires were submitted concomitantly to patients, relatives, and health care providers consecutively over a 6-month period. The study was conducted in the 4 ICUs of the public hospitals of Canton Ticino (Switzerland). RESULTS: The questionnaires collected from patients, relatives, and health care providers were 176, 173, and 134, respectively. The analysis of the answers of 120 patient-relative pairs showed consistent results (P < .0001), whereas those of health care providers were significantly different (P < .0001), regarding both the usefulness of opening ICUs to patient relatives and what was stressful during admission. CONCLUSIONS: Relatives in these "open" ICUs share a great deal of intimacy with the patients. Their presence and the deriving benefits were seen as very positive by patients and relatives themselves. Skepticism, instead, prevailed among health care providers.