Patient Trajectories Among Persons Hospitalized for COVID-19 : A Cohort Study.

BACKGROUND: Risk factors for progression of coronavirus disease 2019 (COVID-19) to severe disease or death are underexplored in U.S. cohorts. OBJECTIVE: To determine the factors on hospital admission that are predictive of severe disease or death from COVID-19. DESIGN: Retrospective cohort analysis. SETTING: Five hospitals in the Maryland and Washington, DC, area. PATIENTS: 832 consecutive COVID-19 admissions from 4 March to 24 April 2020, with follow-up through 27 June 2020. MEASUREMENTS: Patient trajectories and outcomes, categorized by using the World Health Organization COVID-19 disease severity scale. Primary outcomes were death and a composite of severe disease or death. RESULTS: Median patient age was 64 years (range, 1 to 108 years); 47% were women, 40% were Black, 16% were Latinx, and 21% were nursing home residents. Among all patients, 131 (16%) died and 694 (83%) were discharged (523 [63%] had mild to moderate disease and 171 [20%] had severe disease). Of deaths, 66 (50%) were nursing home residents. Of 787 patients admitted with mild to moderate disease, 302 (38%) progressed to severe disease or death: 181 (60%) by day 2 and 238 (79%) by day 4. Patients had markedly different probabilities of disease progression on the basis of age, nursing home residence, comorbid conditions, obesity, respiratory symptoms, respiratory rate, fever, absolute lymphocyte count, hypoalbuminemia, troponin level, and C-reactive protein level and the interactions among these factors. Using only factors present on admission, a model to predict in-hospital disease progression had an area under the curve of 0.85, 0.79, and 0.79 at days 2, 4, and 7, respectively. LIMITATION: The study was done in a single health care system. CONCLUSION: A combination of demographic and clinical variables is strongly associated with severe COVID-19 disease or death and their early onset. The COVID-19 Inpatient Risk Calculator (CIRC), using factors present on admission, can inform clinical and resource allocation decisions. PRIMARY FUNDING SOURCE: Hopkins inHealth and COVID-19 Administrative Supplement for the HHS Region 3 Treatment Center from the Office of the Assistant Secretary for Preparedness and Response.

The application of human engineering interventions reduces ventilator-associated pneumonia in trauma patients.

BACKGROUND: Ventilator-associated pneumonia (VAP) increases mortality and length of stay and escalates the cost of care. Our institution embarked on a project to eradicate VAP. METHODS: We compared the outcome of trauma patients admitted in period 1 (P1) (January 2005 to December 2006) and period 2 (P2) (January 2006 to December 2009). Team building, culture change, and the ventilator bundle were introduced and modified during P1 and were fully implemented in P2. Outcome data were calculated for both periods. The Center for Disease Control VAP definition was used. The VAP rate was calculated as VAP/1,000 ventilator days. Chi-square and t test statistics were used as appropriate. Data were considered statistically significant if p ≤ 0.05. RESULTS: In total, 299 trauma patients were admitted in P1 and 655 in P2. The two groups were identical in age, Injury Severity Score, mortality, and non-VAP. There was a trend toward a shorter length of stay in P2 (p = 0.06). The days on ventilator was significantly shorter in P2 compared with P1 (p = 0.05). The VAP rate dropped significantly from 7.9/1,000 in P1 to 1.0/1,000 in P2 (p = 0.04). The Appropriate Care Measure score increased from 45% in early P1 to 91% in late P2 (p = 0.0001). CONCLUSION: The application of the VAP bundle, a checklist, and the multidisciplinary team approach resulted in significant improvement of VAP in all trauma patients admitted to the shock trauma unit and to the decrease in days on ventilator in the trauma patients. This intervention did not affect mortality or the rate of non-VAP in the trauma patients. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Mannequin simulation identifies common surgical intensive care unit teamwork errors long after introduction of sepsis guidelines.

INTRODUCTION: Groups of evidence-based guidelines were developed into a comprehensive treatment bundle as part of an international-based Surviving Sepsis Campaign to improve treatment of severe sepsis and septic shock. Conventional educational strategies of this sepsis treatment "bundle" may not ensure acceptable knowledge or completion of these specific tasks and may overlook other dynamic factors present during critical moments of a crisis. Simulation using multidisciplinary teams of clinicians through mannequin-based simulations (MDMS) may improve "bundle" compliance by identifying sepsis guideline errors, reinforcing knowledge, and exposing other potential causes of poor performance. METHODS: Seventy-four clinicians participated in the MDMS 14 months after hospital-wide introduction of the sepsis bundle. Additionally, each team was given a sepsis treatment-learning packet before the training session. Twelve teams underwent a MDMS of a patient in septic shock. Two evaluators recorded completed sepsis guideline tasks in real time. Sessions were videotaped and reviewed with the team in a postscenario debriefing session. Pre/posttests were also administered. RESULTS: Individual participants' pretest scores averaged 64.6% correct. Despite all but one team having at least one knowledgeable member with a pretest score of at least 80%, team task completion averaged only 60.4%. Team mean pretest scores and proportion of tasks completed were significantly correlated (P = 0.007), but correlations between specific tasks and related questions showed no relationship to knowledge. CONCLUSION: Inadequate completion of the sepsis guideline tasks during the MDMS could not be explained by inadequate pretest knowledge alone. MDMS may be a useful tool in identifying and exploring these unknown factors.

Midlevel practitioner workforce analysis at a university-affiliated teaching hospital.

OBJECTIVE: To quantify midlevel practitioner (MLP) staffing requirements based on the volume and complexity of patient care and the duty-hour constraints of the Accreditation Council for Graduate Medical Education 80-hour workweek. DESIGN: Data extracted from Eclipsys Sunrise Decision Support Manager, the hospital financial budget, and census reports; and MLP, resident, and subspecialty fellow clinical, operative, and on-call schedules, and educational curriculum. Fiscal year 2005 patient census and hours of required care were defined by attending physician service and/or patient care location. Volume of patient care activity for MLPs, residents, and subspecialty fellows were established by verified self-reporting methodology. SETTING: Urban teaching hospital with 867 beds, of which 116 are surgical beds (which include 36 intensive care unit beds and 12 step-down beds). PARTICIPANTS: Attending physicians, MLPs, residents, and subspecialty fellows. MAIN OUTCOME MEASURES: Coverage index (available staffing hours [residents, subspecialty fellows, and MLPs] divided by the clinical coverage schedule), and the workload staffing efficiency index (number of clinical hours of patient care activities divided by the hours of available staff for a specific clinical service). RESULTS: The workload staffing efficiency index and the coverage index identified 4 services that benefited from the addition of new MLPs. CONCLUSION: We developed a quantitative MLP staffing methodology based on patient volume and the type and complexity of direct and indirect patient care activities, encompassing the roles and availability of residents, subspecialty fellows, and MLPs.

The impact of re-engineering a multi-institutional residency program on resident perceptions of the individual institutions.

PURPOSE: We report on the development of a survey tool used to assess resident perceptions of support and educational quality among multiple institutions in an integrated surgical residency, as well as its use in measuring the impact of re-engineering on that program. METHODS: The University of Connecticut Integrated General Surgical Residency (UCIGSR) is a multisite program that was placed on probation by the Residency Review Committee in Surgery (RRC) in November 1998. This led to a re-evaluation and a re-engineering of the program. In order to better assess the residents' evaluation of the program, we serially examined their attitudes with a survey of 65 questions. A 4-point grading scale (1 = Poor, 4 = Excellent) was used, and each resident was required to complete a survey beginning shortly after RRC probation was announced and at 6-month intervals. Seven global questions in the survey, directed at residency program support and educational quality, were asked for each of the 4 individual adult hospitals, for a total of 28 questions. Statistical analysis of the data was performed using the Jonckhere-Terpstra and the Mann-Whitney U tests. RESULTS: The results demonstrated significant improvement for all 7 questions in all 4 hospitals between November 1998 (S1) and November 1999 (S3). Average scores for all 7 questions, Hospital Support (HS), Departmental Support (DS), Hospital Teaching (HT), Outpatient Teaching (OTC), Operating Room Teaching (ORT), Grand Rounds (GR), and Morbidity and Mortality Conferences (MM), improved in every hospital by 16-28%. In S1, 1 out of 28 questions received an average score greater than or equal to 3, whereas on the most recent survey, 17 of 28 scored greater than or equal to 3 and 78.5% of the questions demonstrated statistically significant improvement (p < 0.05). Three of the 4 hospitals now have a combined overall average score greater than or equal to 3 for all 7 questions. Areas of strength in each hospital had the least amount of improvement yet remained highly rated. CONCLUSIONS: The survey was able to detect weaknesses and variation in program support and educational quality among institutions in our surgical program. Over time, a re-engineering of the process of educating surgical residents demonstrated a positive effect on all of the institutions. While raising the overall satisfaction level of the residents throughout, the greatest improvement occurred in the lowest rated hospitals. Despite barriers of different institutional cultures and geographic locations, a multi-institutional residency program can institute positive change uniformly, and quantitatively monitor that change.