Venous Thromboembolism Prophylaxis in Neurocritical Care Patients: Are Current Practices, Best Practices?

BACKGROUND/OBJECTIVES: Venous thromboembolism (VTE) is a leading cause of preventable, in-hospital deaths; critically ill patients have a higher risk. Effective and efficient strategies to prevent VTE exist; however, neurocritical care patients present unique challenges due to competing risk of bleeding. The objective of this study was to examine current VTE prophylaxis practices among neurocritical care patients, concordance with guideline-recommended care, and the association with clinical outcomes. METHODS: This retrospective cohort study of patients admitted to ten adult, medical-surgical and neurological intensive care units (ICUs) in nine hospitals between 2014 and 2017 using administrative and clinical data. Neurocritical care patients were classified based on the primary admission diagnosis. Concordance with guideline-recommended care was evaluated using recommendations from recent guidelines. RESULTS: 20.0% of 23,191 patients were classified as neurocritical care. Among neurocritical care patients, pharmacological VTE prophylaxis was administered on 60.9% of all ICU days, mechanical VTE prophylaxis on 46.9%, and no VTE prophylaxis on 12.2% of all ICU days. Type of VTE prophylaxis was associated with sex, neurological diagnosis, and invasive neurological monitoring. Fifty-six percentage of ICU days were guideline concordant but concordance varied by recommendation (range 6-100%) and by type of VTE prophylaxis recommended (p = 0.05); among patients where guidelines recommended use of pharmacologic prophylaxis, care was concordant 26.6% of ICU days, whereas for mechanical prophylaxis it was concordant 80.5% of ICU days. There was an overall improvement in guideline concordance on 2.3% of ICU days after the publication of the Society of Neurocritical Care guideline (p = 0.005). CONCLUSIONS: Neurocritical care patients commonly receive mechanical VTE prophylaxis despite guidelines recommending the use of pharmacological VTE prophylaxis. Our findings suggest uncertainty around best VTE prophylaxis practices for neurocritical care patients remains.

The association between paramedic service system hospital offload time and response time.

OBJECTIVE: To address an important care issue in Canada, we tested the association between paramedic system hospital offload and response time, while considering the impact of other system-level factors. METHODS: Data from Calgary, Alberta (2014-2017), included median offload (exposure) and response (outcome) time aggregated by hour, with covariates paramedic system episodes of care-dispatch and arrival of a response unit-and hospital transport arrivals (collectively called volume), time of day, and season. Analyses used linear regression and modified Poisson models. RESULTS: 301,105 EMS episodes of care over 26,193 1-h periods were included. For any given 1-h period, the median (IQR) across all episodes of care for offload time, response time, episodes of care, and hospital transport arrivals were 55.3 (45.7, 66.3) min, 8.6 (7.6, 9.8) min, 12 (8, 16) episodes, and 8 (5, 10) hospital arrivals, respectively. Multivariable modelling revealed a complex association differing over levels of exposure and covariates, requiring description using "light stress" and "heavy stress" system scenarios. The light scenario was defined as median offload of 30 min and volume < 10th percentile (six episodes and four hospital arrivals), in the summer, and the heavy scenario as median offload of 90 min and volume > 90th percentile (17 episodes and 13 hospital arrivals), in the winter. An increase is reported in minutes:seconds for median hourly response time between scenarios by time of day: 1:04-4:16 (0000-0559 h.), 0:42-2:05 (0600-1159 h.), 0:57-3:01 (1200-1759 h.), and 0:18-2:21 (1800-2359 h.). CONCLUSIONS: Increasing offload is associated with increased response time; however the relationship is complex, with a greater impact on response time noted in select situations such as high volume in the winter. These observations illustrate the interdependence of paramedic, ED, and inpatient systems and provide high-yield targets for polices to mitigate the risk to community availability of paramedic resources at times of high offload delay/system stress.

ABSTRAIT: OBJECTIF: Afin de régler un problème important de soins au Canada, nous avons testé l'association entre le déchargement du système paramédical et le temps de réponse, tout en tenant compte de l'incidence d'autres facteurs au niveau du système. MéTHODES: Les données de Calgary, en Alberta (2014-2017) incluent le temps médian de déchargement (exposition) et de réponse (résultat) agrégé par heure, qui s'agit co-variables épisodes de soins du système paramédical - répartition et arrivée d'une unité d'intervention - et arrivées de transport hospitalier (collectivement appelé volume), l'heure et la saison. Les analyses ont utilisé la régression linéaire et des modèles de Poisson modifiés. RéSULTATS: 301105 épisodes de soins médicaux d'urgence sur 26193 périodes d'une heure ont été inclus. Pour une période d'une heure donnée, la médiane (QRI) pour tous les épisodes de soins pour le temps de déchargement, le temps de réponse, les épisodes de soins et les arrivées par transport à l'hôpital était de 55,3 (45,7, 66,3) minutes, 8,6 (7,6, 9,8) minutes, 12 (8, 16) épisodes et 8 (5, 10) arrivées à l'hôpital, respectivement. La modélisation multi-variable a révélé une association complexe qui varie selon les niveaux d'exposition et les co-variables, et qui nécessite une description à l'aide de scénarios de systèmes de « stress léger ¼ et de « stress lourd ¼. Le scénario léger a été défini comme un déchargement médian de 30 minutes, volume inférieur au 10e percentile (six épisodes et quatre arrivées à l'hôpital), pendant l'été. Le scénario lourd comme déchargement médian de 90 minutes, volume > 90e percentile (17 épisodes et 13 arrivées à l'hôpital), en hiver. Une augmentation est rapportée en minutes: secondes pour le temps de réponse horaire médian entre des scénarios par heure du jour : 1:04-4:16 (0000-0559 h.), 0:42-2:05 (0600-1159 h.), 0:57-3:01 (1200-1759 h.), et 0:18-2:21 (1800-2359 h.). CONCLUSIONS: L'augmentation du déchargement est associée à une augmentation du temps de réponse, mais la relation est complexe, avec un impact plus important sur le temps de réponse noté dans certaines situations, comme un volume élevé en hiver. Ces observations illustrent l'interdépendance des systèmes paramédicaux, des services d'urgence et des services aux patients hospitalisés et fournissent des cibles à haut rendement pour les politiques afin d'atténuer le risque pour la disponibilité des ressources paramédicales dans la collectivité en période de retard élevé ou de stress systémique.

Culturing rate and the surveillance of bloodstream infections: a population-based assessment.

OBJECTIVES: Diagnosis of a bloodstream infection (BSI) requires a positive blood culture. However, low culturing rates will underestimate the true incidence of BSI and high rates may increase the risk of false-positive results. We sought to investigate the relationship between culturing rates and the incidence of BSI at the population level. METHODS: Population-based surveillance was conducted in the western interior of British Columbia, Canada, between 1 April 2010 and 31 March 2017. RESULTS: Among 60 243 blood culture sets drawn, 5591 isolates were obtained, of which 2303 were incident, 1929 were repeat positive and 1359 were contaminants. Overall annual rates of culturing, incident, repeat positive and contaminant isolates were 4832, 185, 155 and 109 per 100 000 population, respectively. During the 84-month study, there was an increase in the culturing rate that reached a plateau at 48 months (5403 cultures per 100 000 per year). The rate of both repeat isolates and contaminants increased linearly with an increasing culturing rate. However, the incident isolate rate reached an inflection point at a rate of approximately 5550 per 100 000 annually, at which point the increase in incident isolates per culture sample was diminished. At a culturing rate above 6123 per 100 000 per year, the number of repeat isolates exceeded that of incident isolates. CONCLUSIONS: The determined incidence of BSI will increase with increased culturing in a population. Further studies are needed to explore optimal BSI culturing rates in other populations.

Cost and outcomes of nosocomial bloodstream infections complicating major traumatic injury.

The objective of this study was to assess the incidence, outcomes, and costs of trauma-related nosocomial bloodstream infection (BSI). This was a 3:1 matched cohort study in patients with severe trauma [defined by an injury severity score (ISS)≥12] admitted to adult or paediatric regional trauma centres over a four-year period. Case patients with nosocomial BSI were matched to controls without a BSI based on predetermined criteria. Outcomes of interest included mortality, length of stay (LOS), and cost attributable to nosocomial BSI. Fifty-seven cases were identified, among whom 51 were successfully matched to three controls. The mean ISS among cases was 30.3, and Staphylococcus aureus was the most commonly isolated pathogen (27%). Being a case was accompanied by a 27% relative increase in the hospital LOS (P=0.02). The odds ratio for 30 day mortality associated with being a case was 5.8 (95% confidence interval (CI): 1.1-30.8; P=0.04). Among survivor-matched groups, being a case was associated with 53% relative increase in the geometric mean total hospital cost [$97,993 (95% CI: $70,143-136,899) for cases and $62,297 (95% CI: $52,155-74,411) for controls, P<0.0001]. This is the first study to show that nosocomial BSI complicating severe trauma is associated with a substantial increase in hospital LOS and in total hospital cost. Our data provide justification to support efforts to reduce the adverse impact of BSI in trauma victims.