Exploring the Association of Metabolic Syndrome with In-Hospital Survival of Older Patients Hospitalized with COVID-19: Beyond Chronological Age.

BACKGROUND: Despite the variability and complexity of geriatric conditions, few COVID-19 reports of clinical characteristic prognostication provide data specific to oldest-old adults (over age 85), and instead generally report broadly as 65 and older. OBJECTIVE: To examine metabolic syndrome criteria in adults across 25 hospitals with variation in chronological age. DESIGN AND PARTICIPANTS: This cohort study examined 39,564 hospitalizations of patients aged 18 or older with COVID-19 who received inpatient care between March 13, 2020, and February 28, 2022. EXPOSURE: ICU admission and/or in-hospital mortality. MAIN MEASURES: Metabolic syndrome criteria and patient demographics were examined as risk factors. The main outcomes were admission to ICU and hospital mortality. KEY RESULTS: Oldest old patients (≥ 85 years) hospitalized with COVID-19 accounted for 7.0% (2758/39,564) of all adult hospitalizations. They had shorter ICU length of stay, similar overall hospitalization duration, and higher rates of discharge destinations providing healthcare services (i.e., home health, skilled nursing facility) compared to independent care. Chronic conditions varied by age group, with lower proportions of diabetes and uncontrolled diabetes in the oldest-old cohort compared with young-old (65-74 years) and middle-old (75-84 years) groups. Evaluations of the effect of metabolic syndrome and patient demographics (i.e., age, sex, race) on ICU admission demonstrate minimal change in the magnitude of effect for metabolic syndrome on ICU admission across the different models. CONCLUSIONS: Metabolic syndrome measures are important individual predictors of COVID-19 outcomes. Building on prior examinations that metabolic syndrome is associated with death and ARDS across all ages, this analysis supports that metabolic syndrome criteria may be more relevant than chronological age as risk factors for poor outcomes attributed to COVID-19.

Driving among individuals with chronic conditions: A systematic review of applied research using kinematic driving sensors.

BACKGROUND: Kinematic driving data studies are a novel methodology relevant to health care, but prior studies have considerable variance in their methods, populations, and findings suggesting a need for critical analysis and appraisal for feasibility and methodological guidelines. METHODS: We assessed kinematic driving studies of adults with chronic conditions for study feasibility, characteristics, and key findings, to generate recommendations for future study designs, and to identify promising directions for applications of kinematic driving data. PRISMA was used to guide the review and searches included PubMed, CINAHL, and Compendex. Of 379 abstract/titles screened, 49 full-text articles were reviewed, and 29 articles met inclusion criteria of analyzing trip-level kinematic driving data from adult drivers with chronic conditions. RESULTS: The predominant chronic conditions studied were Alzheimer's disease and related Dementias, obstructive sleep apnea, and diabetes mellitus. Study objectives included feasibility testing of kinematic driving data collection in the context of chronic conditions, comparisons of simulation with real-world kinematic driving behavior, assessments of driving behavior effects associated with chronic conditions, and prognostication or disease classification drawn from kinematic driving data. Across the studies, there was no consensus on devices, measures, or sampling parameters; however, studies showed evidence that driving behavior could reliably differentiate between adults with chronic conditions and healthy controls. CONCLUSIONS: Vehicle sensors can provide driver-specific measures relevant to clinical assessment and interventions. Using kinematic driving data to assess and address driving measures of individuals with multiple chronic conditions is positioned to amplify a functional outcome measure that matters to patients.

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

A systematic review of the facilitators and barriers to rapid response team activation.

BACKGROUND: Outcomes associated with rapid response teams (RRTs) are inconsistent. This may be due to underlying facilitators and barriers to RRT activation that are affected by team leaders and health systems. AIMS: The aim of this study was to synthesize the published research about facilitators and barriers to nurse-led RRT activation in the United States (U.S.). METHODS: A systematic review was conducted. Four databases were searched from January 2000 to June 2023 for peer-reviewed quantitative, qualitative, and mixed methods studies reporting facilitators and barriers to RRT activation. Studies conducted outside the U.S. or with physician-led teams were excluded. RESULTS: Twenty-five studies met criteria representing 240,140 participants that included clinicians and hospitalized adults. Three domains of facilitators and barriers to RRT activation were identified: (1) hospital infrastructure, (2) clinician culture, and (3) nurses' beliefs, attributes, and knowledge. Categories were identified within each domain. The categories of perceived benefits and positive beliefs about RRTs, knowing when to activate the RRT, and hospital-wide policies and practices most facilitated activation, whereas the categories of negative perceptions and concerns about RRTs and uncertainties surrounding RRT activation were the dominant barriers. LINKING EVIDENCE TO ACTION: Facilitators and barriers to RRT activation were interrelated. Some facilitators like hospital leader and physician support of RRTs became barriers when absent. Intradisciplinary communication and collaboration between nurses can positively and negatively impact RRT activation. The expertise of RRT nurses should be further studied.

Understanding and Managing Anxiety Sensitivity During Critical Illness and Long-Term Recovery.

Anxiety sensitivity is a fear of symptoms associated with anxiety (eg, rapid respiration and heart rate, perspiration), also known as "fear of fear." This fear is a misinterpretation of nonthreatening symptoms as threatening across 3 domains: physical ("When my heart rate increases, I'm afraid I may have a heart attack"), social ("If people see me perspire, I fear they will negatively evaluate me"), and cognitive ("When I feel these symptoms, I fear it means I'm going crazy or will lose control and do something dangerous like disconnect my IV"). These thoughts stimulate the sympathetic nervous system, resulting in stronger sensations and further catastrophic misinterpretations, which may spiral into a panic attack. Strategies to address anxiety sensitivity include pharmacologic and nonpharmacologic interventions. In intensive care unit settings, anxiety sensitivity may be related to common monitoring and interventional procedures (eg, oxygen therapy, repositioning, use of urine collection systems). Anxiety sensitivity can be a barrier to weaning from mechanical ventilation when patients are uncomfortable following instructions to perform awakening or breathing trials. Fortunately, anxiety sensitivity is a malleable trait with evidence-based intervention options. However, few health care providers are aware of this psychological construct and available treatment. This article describes the nature of anxiety sensitivity, its potential impact on intensive care, how to assess and interpret scores from validated instruments such as the Anxiety Sensitivity Index, and treatment approaches across the critical care trajectory, including long-term recovery. Implications for critical care practice and future directions are also addressed.

Driving decisions after critical illness: Qualitative analysis of patient-provider reviews during ICU recovery clinic assessments.

BACKGROUND: Driving a vehicle is a functional task requiring a threshold of physical, behavioral and cognitive skills. OBJECTIVE: To report patient-provider evaluations of driving status and driving safety assessments after critical illness. DESIGN: Qualitative secondary analysis of driving-related dialog drawn from a two-arm pilot study evaluating telemedicine delivery of Intensive Care Unit Recovery Clinic assessments. Multidisciplinary providers assessed physical, psychological, and cognitive recovery during one-hour telemedicine ICU-RC assessments. Qualitative secondary analysis of patient-provider dialog specific to driving practices after critical illness. SETTING AND PATIENTS: Multidisciplinary Intensive Care Unit Recovery clinic assessment dialog between 17 patients and their providers during 3-week and/or 12-week follow-up assessments at a tertiary academic medical center in the Southeastern United States. MAIN MEASURES AND KEY RESULTS: Thematic content analysis was performed to describe and classify driving safety discussion, driving status and driving practices after critical illness. Driving-related discussions occurred with 15 of 17 participants and were clinician-initiated. When assessed, driving status varied with participants reporting independent decisions to resume driving, delay driving and cease driving after critical illness. Patient-reported driving practices after critical illness included modifications to limit driving to medical appointments, self-assessments of trip durations, and inclusion of care partners as a safety measure for new onset fatigue while driving. CONCLUSION: We found that patients are largely self-navigating this stage of recovery, making subjective decisions on driving resumption and overall driving status. These results highlight that driving status changes are an often underrecognized yet salient social cost of critical illness. TRIAL REGISTRATION: Clinicaltrials.gov: NCT03926533.

Return to Driving After Critical Illness.

This cross-sectional study examines the postintensive care syndrome in patients who had vs patients who had not resumed driving 1 month after hospitalization for a critical illness.

Analysis of Silver Alert Reporting System Activations for Missing Adults With Dementia in Texas, 2017 to 2022.

This cross-sectional study analyzes data from Silver Alert activations in Texas from 2017 to 2022 to identify temporal, geographic, and wandering characteristics of missing adults with dementia.

Medication Discussions With Patients With Cardiovascular Disease in the Emergency Department: An Opportunity for Emergency Nurses to Engage Patients to Support Medication Reconciliation.

INTRODUCTION: This study aimed to investigate the level of patient involvement in medication reconciliation processes and factors associated with that involvement in patients with cardiovascular disease presenting to the emergency department. METHODS: An observational and cross-sectional design was used. Patients with cardiovascular disease presenting to the adult emergency department of an academic medical center completed a structured survey inclusive of patient demographics and measures related to the study concepts. Data abstracted from the electronic health record included the patient's medical history and emergency department visit data. Our multivariable model adjusted for age, gender, education, difficulty paying bills, health status, numeracy, health literacy, and medication knowledge and evaluated patient involvement in medication discussions as an outcome. RESULTS: Participants' (N = 93) median age was 59 years (interquartile range 51-67), 80.6% were white, 96.8% were not Hispanic, and 49.5% were married or living with a partner. Approximately 41% reported being employed and 36.9% reported an annual household income of <$25,000. Almost half (n = 44, 47.3%) reported difficulty paying monthly bills. Patients reported moderate medication knowledge (median 3.8, interquartile range 3.4-4.2) and perceived involvement in their care (41.8 [SD = 9.1]). After controlling for patient characteristics, only difficulty paying monthly bills (b = 0.36, P = .005) and medication knowledge (b = 0.30, P = .009) were associated with involvement in medication discussions. DISCUSSION: Some patients presenting to the emergency department demonstrated moderate medication knowledge and involvement in medication discussions, but more work is needed to engage patients.

Symptom Clusters Seen in Adult COVID-19 Recovery Clinic Care Seekers.

BACKGROUND: COVID-19 symptom reports describe varying levels of disease severity with differing periods of recovery and symptom trajectories. Thus, there are a multitude of disease and symptom characteristics clinicians must navigate and interpret to guide care. OBJECTIVE: To find natural groups of patients with similar constellations of post-acute sequelae of COVID-19 (PASC) symptoms. DESIGN: Cohort SETTING: Outpatient COVID-19 recovery clinic with patient referrals from 160 primary care clinics serving 36 counties in Texas. PATIENTS: Adult patients seeking COVID-19 recovery clinic care between November 15, 2020, and July 31, 2021, with laboratory-confirmed mild (not hospitalized), moderate (hospitalized), or severe (hospitalized with critical care) COVID-19. MAIN MEASURES: Demographics, COVID illness onset, and duration of persistent PASC symptoms via semi-structured medical assessments. KEY RESULTS: Four hundred forty-one patients (mean age 51.5 years; 295 [66.9%] women; 99 [22%] Hispanic, and 170 [38.5%] non-White, racial minority) met inclusion criteria. Using a k-medoids algorithm, we found that PASC symptoms cluster into two distinct groups: neuropsychiatric (N = 186) (e.g., subjective cognitive dysfunction) and pulmonary (N = 255) (e.g., dyspnea, cough). The neuropsychiatric cluster had significantly higher incidences of otolaryngologic (X2 = 14.3, p < 0.001), gastrointestinal (X2 = 6.90, p = 0.009), neurologic (X2 = 441, p < 0.001), and psychiatric sequelae (X2 = 40.6, p < 0.001) with more female (X2 = 5.44, p = 0.020) and younger age (t = 2.39, p = 0.017) patients experiencing longer durations of PASC symptoms before seeking care (t = 2.44, p = 0.015). Patients in the pulmonary cluster were more often hospitalized for COVID-19 (X2 = 3.98, p = 0.046) and had significantly higher comorbidity burden (U = 20800, p = 0.019) and pulmonary sequelae (X2 = 13.2, p < 0.001). CONCLUSIONS: Health services clinic data from a large integrated health system offers insights into the post-COVID symptoms associated with care seeking for sequelae that are not adequately managed by usual care pathways (self-management and primary care clinic visits). These findings can inform machine learning algorithms, primary care management, and selection of patients for earlier COVID-19 recovery referral. TRIAL REGISTRATION: N/A.

Multidisciplinary ICU Recovery Clinic Visits: A Qualitative Analysis of Patient-Provider Dialogues.

BACKGROUND: Research confirms the heterogeneous nature of patient challenges during recovery from the ICU and supports the need for modifying care experiences, but few data are available to guide clinicians seeking to support patients' individual recovery trajectories. RESEARCH QUESTION: What is the content of patient-provider dialogues in a telemedicine multidisciplinary ICU recovery clinic (ICU-RC)? STUDY DESIGN AND METHODS: We conducted a qualitative descriptive study in a telemedicine multidisciplinary ICU-RC at a tertiary academic medical center in the southeastern United States. The sample included 19 patients and 13 caregivers (≥ 18 years of age) attending a telemedicine ICU-RC visit after critical illness resulting from septic shock or ARDS. Patients and caregivers met with an ICU pharmacist, ICU physician, and a psychologist via a secure web-conferencing platform for 33 ICU-RC visits within 12 weeks of hospital discharge. Telemedicine ICU-RC visits were audio-recorded and transcribed verbatim for analysis. A coding system was developed using iterative inductive and deductive approaches. RESULTS: Two themes were identified from the patient-provider dialogue: (1) problem identification and (2) problem-solving strategies. We identified five subthemes that capture the types of problems identified: health status, mental health and cognition, medication management, health-care access and navigation, and quality of life. Problem-solving subthemes included facilitating care coordination and transitions, providing education, and giving constructive feedback and guidance. INTERPRETATION: Patients surviving a critical illness experience a complexity of problems that may be addressed best by a multidisciplinary ICU-RC. Through analysis of our telemedicine ICU-RC dialogues, we were able to identify problems and solutions to address challenges during a critical transitional phase of ICU recovery. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03926533; URL: www. CLINICALTRIALS: gov.

Evidence-Based Practice Knowledge Retention Among Nurse Practitioner Students.

ABSTRACT: The mastery of clinical scholarship and analytic methods for evidence-based practice (EBP) is a published essential for nurse practitioner (NP) education; however, retention of EBP-related knowledge during NP education remains unknown. We assessed EBP knowledge during a first-semester research course and again during the last semester using an item response model. We found that changes depended on the exam item, with performance dropping on a third of the items. Our findings suggest a need to integrate EBP concepts across curricula (e.g., feedback loops in courses other than the research course) to retain these essential skills.

Daily Oxygenation Support for Patients Hospitalized With SARS-CoV-2 in an Integrated Health System.

BACKGROUND: Many COVID-19 studies are constructed to report hospitalization outcomes, with few large multi-center population-based reports on the time course of intra-hospitalization characteristics, including daily oxygenation support requirements. Comprehensive epidemiologic profiles of oxygenation methods used by day and by week during hospitalization across all severities are important to illustrate the clinical and economic burden of COVID-19 hospitalizations. METHODS: This was a retrospective, multi-center observational cohort study of 15,361 consecutive hospitalizations of patients with COVID-19 at 25 adult acute care hospitals in Texas participating in the Society of Critical Care Medicine Discovery Viral Respiratory Illness Universal Study COVID-19 registry. RESULTS: At initial hospitalization, the majority required nasal cannula (44.0%), with an increasing proportion of invasive mechanical ventilation in the first week and particularly the weeks to follow. After 4 weeks of acute illness, 69.9% of adults hospitalized with COVID-19 required intermediate (eg, high-flow nasal cannula, noninvasive ventilation) or advanced respiratory support (ie, invasive mechanical ventilation), with similar proportions that extended to hospitalizations that lasted ≥ 6 weeks. CONCLUSIONS: Data representation of intra-hospital processes of care drawn from hospitals with varied size, teaching and trauma designations is important to presenting a balanced perspective of care delivery mechanisms employed, such as daily oxygen method utilization.

Factors Influencing Engagement with in-Person Intensive Care Unit Recovery Clinic Services.

Background: Intensive Care Unit recovery clinics (ICU-RC), are multidisciplinary outpatient clinics designed to identify and treat post-intensive care syndrome impairments unique to each survivor of critical illness. Engagement is limited, thus we aimed to describe patient- and hospitalization-related sociodemographic factors associated with scheduling and attending in-person ICU-RC visits. Design: Consecutive case series of prospectively collected ICU-RC referral data. Setting: Data was collected over a 9-year period (2012-2020) for patients referred to an ICU-RC from ICUs at an academic medical center in the southeast United States. Participants: 251 adults admitted to a medical, surgical, burn, or trauma ICU referred to the ICU-RC and eligible to be scheduled for a visit. Main Outcome and Measures: The main study outcome was scheduling and completing an ICU-RC visit. Independent variables included patient demographics, ICU visit characteristics (eg, diagnosis, ventilator days), severity of illness, discharge disposition, ICU-RC referral criteria (eg, shock, delirium), and clinic scheduling administrative data (eg, referral date, clinic visit date). Results: Of 251 ICU-RC referrals eligible for a visit, 128 were scheduled, and 91 completed a visit. In univariate models older age, unspecified shock, and distance from the clinic location were associated with decreased in-person ICU-RC engagement. In a multivariable logistic regression using the same predictors and interactions, older age, unspecified shock, and home-to-clinic distance remained as factors decreasing the likelihood of ICU-RC engagement. There was a decreasing likelihood of scheduling and attending an ICU-RC visit for every additional mile of distance the patient lived from the ICU-RC. Male sex was a strong predictor of completing an ICU-RC visit. Conclusions: Older ICU survivors and those who live farther from the clinic site are less likely to engage in an in-person ICU-RC. Innovation and telemedicine strategies are needed to improve access to ICU recovery care for these populations.

SARS-CoV-2 With Concurrent Respiratory Viral Infection as a Risk Factor for a Higher Level of Care in Hospitalized Pediatric Patients.

OBJECTIVE: As of early 2021, there have been over 3.5 million pediatric cases of SARS-CoV-2, including 292 pediatric deaths in the United States. Although most pediatric patients present with mild disease, they are still at risk for developing significant morbidity requiring hospitalization and intensive care unit (ICU) level of care. This study was performed to evaluate if the presence of concurrent respiratory viral infections in pediatric patients admitted to the hospital with SARS-CoV-2 was associated with an increased rate of ICU level of care. DESIGN: A multicenter, international, noninterventional, cross-sectional study using data provided through The Society of Critical Care Medicine Discovery Network Viral Infection and Respiratory Illness Universal Study database. SETTING: The medical ward and ICU of 67 participating hospitals. PATIENTS: Pediatric patients younger than 18 years hospitalized with SARS-CoV-2. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 922 patients were included. Among these patients, 391 required ICU level care and 31 had concurrent non-SARS-CoV-2 viral coinfection. In a multivariate analysis, after accounting for age, positive blood culture, positive sputum culture, preexisting chronic medical conditions, the presence of a viral respiratory coinfection was associated with need for ICU care (odds ratio, 3.6; 95% confidence interval, 1.6-9.4; P < 0.01). CONCLUSIONS: This study demonstrates an association between concurrent SARS-CoV-2 infection with viral respiratory coinfection and the need for ICU care. Further research is needed to identify other risk factors that can be used to derive and validate a risk-stratification tool for disease severity in pediatric patients with SARS-CoV-2.