Evaluation of the Impact of ABCDEF Bundle Compliance Rates on Postintensive Care Syndrome: A Secondary Analysis Study.

OBJECTIVES: This study aimed to examine the association between ABCDEF bundles and long-term postintensive care syndrome (PICS)-related outcomes. DESIGN: Secondary analysis of the J-PICS study. SETTING: This study was simultaneously conducted in 14 centers and 16 ICUs in Japan between April 1, 2019, and September 30, 2019. PATIENTS: Adult ICU patients who were expected to be on a ventilator for at least 48 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Bundle compliance for the last 24 hours was recorded using a checklist at 8:00 am The bundle compliance rate was defined as the 3-day average of the number of bundles performed each day divided by the total number of bundles. The relationship between the bundle compliance rate and PICS prevalence (defined by the 36-item Short Form Physical Component Scale, Mental Component Scale, and Short Memory Questionnaire) was examined. A total of 191 patients were included in this study. Of these, 33 patients (17.3%) died in-hospital and 48 (25.1%) died within 6 months. Of the 96 patients with 6-month outcome data, 61 patients (63.5%) had PICS and 35 (36.5%) were non-PICS. The total bundle compliance rate was 69.8%; the rate was significantly lower in the 6-month mortality group (66.6% vs 71.6%, p = 0.031). Bundle compliance rates in patients with and without PICS were 71.3% and 69.9%, respectively ( p = 0.61). After adjusting for confounding variables, bundle compliance rates were not significantly different in the context of PICS prevalence ( p = 0.56). A strong negative correlation between the bundle compliance rate and PICS prevalence ( r = -0.84, R 2 = 0.71, p = 0.035) was observed in high-volume centers. CONCLUSIONS: The bundle compliance rate was not associated with PICS prevalence. However, 6-month mortality was lower with a higher bundle compliance rate. A trend toward a lower PICS prevalence was associated with higher bundle compliance in high-volume centers.

Prevalence of bacterial contamination of touchscreens and posterior surfaces of smartphones owned by healthcare workers: a cross-sectional study.

BACKGROUND: Mobile phones used by healthcare workers (HCWs) are contaminated with bacteria, but the posterior surface of smartphones has rarely been studied. The aim of this study was to compare the prevalence of microbial contamination of touchscreens and posterior surfaces of smartphones owned by HCWs. METHODS: A cross-sectional study of smartphones used by HCWs employed at two intensive care units at a Japanese tertiary care hospital was performed. Bacteria on each surface of the smartphones were isolated separately. The primary outcomes were the prevalence of microbial contamination on each surface of smartphones and associated bacterial species. Fisher's exact test was used to compare dichotomous outcomes. RESULTS: Eighty-four HCWs participated in this study. The touchscreen and posterior surface were contaminated in 27 (32.1%) and 39 (46.4%) smartphones, respectively, indicating that the posterior surface was more frequently contaminated (p = 0.041). Bacillus species and coagulase-negative staphylococci were isolated from each surface of the smartphones. CONCLUSIONS: The posterior surface of a smartphone was more significantly contaminated with bacteria than the touchscreen, regardless of having a cover. Therefore, routine cleaning of the posterior surface of a smartphone is recommended.

Usefulness of ß-lactam and macrolide combination therapy for treating community-acquired pneumonia patients hospitalized in the intensive care unit: Propensity score analysis of a prospective cohort study.

INTRODUCTION: Whether ß-lactam and macrolide combination therapy reduces mortality in severe community-acquired pneumonia (SCAP) patients hospitalized in the intensive care unit (ICU) is controversial. The aim of the present study was to evaluate the usefulness of ß-lactam and macrolide combination therapy for SCAP patients hospitalized in the ICU. METHODS: A prospective, observational, cohort study of hospitalized pneumonia patients was performed. Hospitalized SCAP patients admitted to the ICU within 24 h between October 2010 and October 2017 were included for analysis. The primary outcome was 30-day mortality, and secondary outcomes were 14-day mortality and ICU mortality. Inverse probability of treatment weighting (IPTW) analysis as a propensity score analysis was used to reduce biases, including six covariates: age, sex, C-reactive protein, albumin, Pneumonia Severity Index score, and APACHE II score. RESULTS: A total of 78 patients were included, with 48 patients in the non-macrolide-containing ß-lactam therapy group and 30 patients in the macrolide combination therapy group. ß-lactam and macrolide combination therapy significantly decreased 30-day mortality (16.7% vs. 43.8%; P = 0.015) and 14-day mortality (6.7% vs. 31.3%; P = 0.020), but not ICU mortality (10% vs 27.1%, P = 0.08) compared with non-macrolide-containing ß-lactam therapy. After adjusting by IPTW, macrolide combination therapy also decreased 30-day mortality (odds ratio, 0.29; 95%CI, 0.09-0.96; P = 0.04) and 14-day mortality (odds ratio, 0.19; 95%CI, 0.04-0.92; P = 0.04), but not ICU mortality (odds ratio, 0.34; 95%CI, 0.08-1.36; P = 0.13). CONCLUSIONS: Combination therapy with ß-lactam and macrolides significantly improved the prognosis of SCAP patients hospitalized in the ICU compared with a non-macrolide-containing ß-lactam regimen.

Conventional risk prediction models fail to accurately predict mortality risk among patients with coronavirus disease 2019 in intensive care units: a difficult time to assess clinical severity and quality of care.

Since the start of the coronavirus disease 2019 (COVID-19) pandemic, it has remained unknown whether conventional risk prediction tools used in intensive care units are applicable to patients with COVID-19. Therefore, we assessed the performance of established risk prediction models using the Japanese Intensive Care database. Discrimination and calibration of the models were poor. Revised risk prediction models are needed to assess the clinical severity of COVID-19 patients and monitor healthcare quality in ICUs overwhelmed by patients with COVID-19.

Body Mass Index and Ventilator Dependence in Critically Ill Subjects in Japan: A Cohort Study Using a Nationwide Database.

BACKGROUND: Body mass index (BMI) can be an important indicator for health outcomes among critically ill patients. However, the association between BMI and ventilator dependence at ICU discharge among these patients remains unknown. We aimed to evaluate the association between BMI at ICU admission and ventilator dependence at the time of ICU discharge. As secondary outcomes, we used ICU mortality, hospital mortality, and implementation of tracheostomy during ICU stay. METHODS: This is a retrospective cohort study. The data were derived from The Japanese Intensive Care Patient Database, a nationwide ICU database in Japan. We included all patients in the registry who were ≥ 16 y old, received mechanical ventilation, and were admitted to an ICU between April 2018 and March 2019. On the basis of their BMI at ICU admission, subjects were classified as underweight (< 18.5 kg/m2); normal weight (≥ 18.5 kg/m2 to < 23 kg/m2); overweight (≥ 23 kg/m2 to < 27.5 kg/m2); or obese (≥ 27.5 kg/m2). RESULTS: Among 11,801 analyzed subjects, 388 (3.3%) subjects were ventilator-dependent at ICU discharge. Compared with normal-weight subjects, the risk for ventilator dependence at ICU discharge increased among underweight subjects even after adjusting for potential confounders and inter-ICU variance in 2-level multivariable logistic regression analysis (odds ratio 1.46 [95% CI 1.18-1.79]). Although obesity was also associated with a higher risk of ventilator dependence, the association was less clear (odds ratio 1.10 [95% CI 0.99-1.22]). The risk of ICU mortality, hospital mortality, and implementation of tracheostomy also increased in underweight subjects. CONCLUSIONS: Critically ill underweight subjects had a higher risk of ventilator dependence at ICU discharge compared to normal-weight subjects, even after adjusting for potential confounders and inter-ICU variance. The association between BMI and ventilator dependence should be examined using information on subjects' nutritional status and frailty in further studies.

Development and validation of the predictive risk of death model for adult patients admitted to intensive care units in Japan: an approach to improve the accuracy of healthcare quality measures.

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) III-j model is widely used to predict mortality in Japanese intensive care units (ICUs). Although the model's discrimination is excellent, its calibration is poor. APACHE III-j overestimates the risk of death, making its evaluation of healthcare quality inaccurate. This study aimed to improve the calibration of the model and develop a Japan Risk of Death (JROD) model for benchmarking purposes. METHODS: A retrospective analysis was conducted using a national clinical registry of ICU patients in Japan. Adult patients admitted to an ICU between April 1, 2018, and March 31, 2019, were included. The APACHE III-j model was recalibrated with the following models: Model 1, predicting mortality with an offset variable for the linear predictor of the APACHE III-j model using a generalized linear model; model 2, predicting mortality with the linear predictor of the APACHE III-j model using a generalized linear model; and model 3, predicting mortality with the linear predictor of the APACHE III-j model using a hierarchical generalized additive model. Model performance was assessed with the area under the receiver operating characteristic curve (AUROC), the Brier score, and the modified Hosmer-Lemeshow test. To confirm model applicability to evaluating quality of care, funnel plots of the standardized mortality ratio and exponentially weighted moving average (EWMA) charts for mortality were drawn. RESULTS: In total, 33,557 patients from 44 ICUs were included in the study population. ICU mortality was 3.8%, and hospital mortality was 8.1%. The AUROC, Brier score, and modified Hosmer-Lemeshow p value of the original model and models 1, 2, and 3 were 0.915, 0.062, and < .001; 0.915, 0.047, and < .001; 0.915, 0.047, and .002; and 0.917, 0.047, and .84, respectively. Except for model 3, the funnel plots showed overdispersion. The validity of the EWMA charts for the recalibrated models was determined by visual inspection. CONCLUSIONS: Model 3 showed good performance and can be adopted as the JROD model for monitoring quality of care in an ICU, although further investigation of the clinical validity of outlier detection is required. This update method may also be useful in other settings.

Prevalence of post-intensive care syndrome among Japanese intensive care unit patients: a prospective, multicenter, observational J-PICS study.

BACKGROUND: Many studies have compared quality of life of post-intensive care syndrome (PICS) patients with age-matched population-based controls. Many studies on PICS used the 36-item Short Form (SF-36) health survey questionnaire version 2, but lack the data for SF-36 values before and after intensive care unit (ICU) admission. Thus, clinically important changes in the parameters of SF-36 are unknown. Therefore, we determined the frequency of co-occurrence of PICS impairments at 6 months after ICU admission. We also evaluated the changes in SF-36 subscales and interpreted the patients' subjective significance of impairment. METHODS: A prospective, multicenter, observational cohort study was conducted in 16 ICUs across 14 hospitals in Japan. Adult ICU patients expected to receive mechanical ventilation for > 48 h were enrolled, and their 6-month outcome was assessed using the questionnaires. PICS definition was based on the physical status, indicated by the change in SF-36 physical component score (PCS) ≥ 10 points; mental status, indicated by the change in SF-36 mental component score (MCS) ≥ 10 points; and cognitive function, indicated by the worsening of Short-Memory Questionnaire (SMQ) score and SMQ score at 6 months < 40. Multivariate logistic regression model was used to identify the factors associated with PICS occurrence. The patients' subjective significance of physical and mental symptoms was assessed using the 7-scale Global Assessment Rating to evaluate minimal clinically important difference (MCID). RESULTS: Among 192 patients, 48 (25%) died at 6 months. Among the survivors at 6 months, 96 patients responded to the questionnaire; ≥ 1 PICS impairment occurred in 61 (63.5%) patients, and ≥ 2 occurred in 17 (17.8%) patients. Physical, mental, and cognitive impairments occurred in 32.3%, 14.6% and 37.5% patients, respectively. Population with only mandatory education was associated with PICS occurrence (odds ratio: 4.0, 95% CI 1.1-18.8, P = 0.029). The MCID of PCS and MCS scores was 6.5 and 8.0, respectively. CONCLUSIONS: Among the survivors who received mechanical ventilation, 64% had PICS at 6 months; co-occurrence of PICS impairments occurred in 20%. PICS was associated with population with only mandatory education. Future studies elucidating the MCID of SF-36 scores among ICU patients and standardizing the PICS definition are required. Trial registration UMIN000034072.

Extracorporeal membrane oxygenation in Stenotrophomonas maltophilia pneumonia during acute myeloid leukemia: A case report.

Stenotrophomonas maltophilia (S. maltophilia) is a Gram-negative, multidrug-resistant organism that both opportunistically infects the bloodstream and leads to pneumonia in immunosuppressed patients, including those with hematologic malignancies. In patients with severe respiratory failure, venovenous extracorporeal membrane oxygenation (VV ECMO) can stabilize the respiratory status. However, whether ECMO in patients with hematologic malignancies improves the clinical outcomes is still controversial because ECMO increases the risk of the exacerbation of sepsis and bleeding. We report a case of a 46-year-old man with Stenotrophomonas maltophilia hemorrhagic pneumonia acquired during consolidation chemotherapy for acute myeloid leukemia in whom VV ECMO lead to a good clinical outcome. The stabilization of his respiratory status achieved with VV ECMO allowed time for trimethoprim-sulfamethoxazole antibiotic therapy to improve the pneumonia. We suggest the background of patients, including comorbidities and general conditions, should be taken into account when considering the clinical indications of ECMO.

The Japanese Intensive care PAtient Database (JIPAD): A national intensive care unit registry in Japan.

PURPOSE: The Japanese Intensive care PAtient Database (JIPAD) was established to construct a high-quality Japanese intensive care unit (ICU) database. MATERIALS AND METHODS: A data collection structure for consecutive ICU admissions in adults (≥16 years) and children (≤15 years) has been established in Japan since 2014. We herein report a current summary of the data in JIPAD for admissions between April 2015 and March 2017. RESULTS: There were 21,617 ICU admissions from 21 ICUs (217 beds) including 8416 (38.9%) for postoperative or procedural monitoring, defined as adult admissions following elective surgery or for procedures and discharged alive within 24 h, 11,755 (54.4%) critically ill adults other than monitoring, and 1446 (6.7%) children. The standardized mortality ratios (SMRs) based on the Acute Physiology and Chronic Health Evaluation (APACHE) III-j, APACHE II, and Simplified Acute Physiology Score II scores in adults ranged from 0.387 to 0.534, whereas the SMR based on the Paediatric Index of Mortality 2 in children was 0.867. CONCLUSION: The data revealed that the SMRs based on general severity scores in adults were low because of high proportions of elective and monitoring admission. The development of a new mortality prediction model for Japanese ICU patients is needed.

Reducing unnecessary urethral catheter use in Japanese intensive care units: A multicenter interventional study.

We conducted a preintervention-postintervention study to assess the effectiveness of a multimodal approach to reduce unnecessary urethral catheters in 5 Japanese intensive care units. After the intervention urethral catheter point prevalence decreased by 18%, from 79% preintervention to 61% postintervention, and catheter appropriateness increased by 28%, from 57% preintervention to 85% postintervention.

Outcomes of patients on dual antiplatelet therapy post-coronary stenting following emergency noncardiac surgery.

BACKGROUND: The outcomes of patients on dual antiplatelet therapy (DAPT) post-coronary stenting following emergency noncardiac surgery remain unclear. METHODS: This retrospective cohort study included patients on DAPT post-coronary stenting who underwent emergency noncardiac surgery within 24 hours of diagnosis from April 2007 to March 2018 where DAPT was discontinued within <5 days for aspirin and 7 days for P2Y12 inhibitors. Our primary outcome was 180-day mortality in these patients. We investigated factors associated with bleeding within 180 days after surgery as our secondary outcome and exploratorily examined factors affecting 180-day mortality. RESULTS: Of 62,528 patients who underwent any surgery under general anaesthesia during the 11-year study period, 133 patients (0.22% of all and 1.41% of emergency surgical patients) were analysed. Among the eligible patients, 180-day mortality was 9.8% (13/133). Eighteen patients (13.5%) developed bleeding within 180 days after surgery, which was the most common post-operative complication. Restarting antiplatelet agents <2 days post-operatively (OR, 4.51; 95% CI, 1.56-13.0; P = 0.005) and stent implantation at bifurcation lesions before surgery (OR, 3.28; 95% CI, 1.07-10.1; P = 0.04) were associated with post-operative bleeding. Patients on haemodialysis had the worse prognosis (hazard ratio, 5.73; 95% CI, 1.87-17.5; P = 0.002) in terms of 180-day mortality. CONCLUSION: The 180-day mortality following emergency noncardiac surgery was approximately 10% in patients on DAPT post-coronary stenting. Restarting antiplatelet agents earlier than 2 days post-operatively and coronary stenting at bifurcation lesions were associated with bleeding within 180 days after surgery.

Prognostic factors in critically ill patients with hematological malignancy admitted to the general intensive care unit: a single-center experience in Japan.

PURPOSE: This study aims to identify prognostic factors related to short-term and long-term outcomes of patients with hematological malignancy (HM) admitted to the intensive care unit (ICU) in Japan during ICU stay and after discharge from ICU. METHODS: We conducted a retrospective, observational study of 169 patients with HM admitted to the general ICU from January 2009 to December 2016. We examined prognostic factors affecting outcome during ICU stay and at 180 days after ICU discharge using logistic regression analysis. RESULTS: During ICU stay, 57 patients (33.7%) died. Invasive mechanical ventilation (OR 8.96, 95% CI 3.67-21.9; P < 0.001, the same hereinafter), the Sequential Organ Failure Assessment (SOFA) score within the first 24 h of ICU admission (1.25, 1.11-1.40; P < 0.001), and malignant lymphoma (0.30, 0.11-0.78; P = 0.014) were detected as factors associated with ICU outcome. Of 112 ICU survivors, 46 (41.1%) died within 180 days after ICU discharge. Duration of ICU stay (1.07, 1.01-1.13; P = 0.027) and the SOFA score at ICU discharge (1.24, 1.04-1.48; P = 0.016) were related to poor outcome at 180 days after ICU discharge. CONCLUSIONS: In critically ill patients with HM, the use of invasive mechanical ventilation, a high SOFA score within the first 24 h of ICU admission, and malignant lymphoma as primary HM affected short-term ICU outcome. Increased duration of ICU stay and SOFA score at ICU discharge influenced long-term outcome at 180 days after ICU discharge.

Prevalence and Appropriateness of Urinary Catheters in Japanese Intensive Care Units: Results From a Multicenter Point Prevalence Study.

BACKGROUND: Catheter-associated urinary tract infection is a common and costly problem throughout the world. As limited data from Asia exist regarding the prevalence and appropriateness of urinary catheters in critically ill patients, we sought to assess both prevalence and appropriateness of urinary catheters in Japan. METHODS: Using independent observers, we evaluated the prevalence and clinical necessity of indwelling urinary catheters in 7 Japanese intensive care units. RESULTS: Data were collected on 1289 catheter-days and 1706 patient days in the 7 participating intensive care units between August 2015 and May 2016. Urinary catheter prevalence was 76% (range, 49%-94%). The observers deemed that only 54% of the catheters met an appropriate indication for use (range, 40%-74%). The most common appropriate indications for urinary catheter use were (1) the need for accurate input and output monitoring in critically ill patients; (2) perioperative use; and (3) prolonged immobilization. The use of monitoring accurate input and output in critically ill patients, however, may be overused as bedside nurses used this indication in 27% more patients than the objective observer deemed necessary. CONCLUSIONS: Urinary catheters were frequently used in the 7 participating Japanese intensive care units and almost half did not meet an appropriate indication for use. Overusing catheters for monitoring accurate input and output was especially notable. Multimodal interventions may be needed to limit inappropriate urinary catheter use.