Safety Outcomes of Direct Discharge Home From ICUs: An Updated Systematic Review and Meta-Analysis (Direct From ICU Sent Home Study).

OBJECTIVE: To evaluate the impact of direct discharge home (DDH) from ICUs compared with ward transfer on safety outcomes of readmissions, emergency department (ED) visits, and mortality. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature from inception until March 28, 2022. STUDY SELECTION: Randomized and nonrandomized studies of DDH patients compared with ward transfer were eligible. DATA EXTRACTION: We screened and extracted studies independently and in duplicate. We assessed risk of bias using the Newcastle-Ottawa Scale for observational studies. A random-effects meta-analysis model and heterogeneity assessment was performed using pooled data (inverse variance) for propensity-matched and unadjusted cohorts. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS: Of 10,228 citations identified, we included six studies. Of these, three high-quality studies, which enrolled 49,376 patients in propensity-matched cohorts, could be pooled using meta-analysis. For DDH from ICU, compared with ward transfers, there was no difference in the risk of ED visits at 30-day (22.4% vs 22.7%; relative risk [RR], 0.99; 95% CI, 0.95-1.02; p = 0.39; low certainty); hospital readmissions at 30-day (9.8% vs 9.6%; RR, 1.02; 95% CI, 0.91-1.15; p = 0.71; very low-to-low certainty); or 90-day mortality (2.8% vs 2.6%; RR, 1.06; 95% CI, 0.95-1.18; p = 0.29; very low-to-low certainty). There were no important differences in the unmatched cohorts or across subgroup analyses. CONCLUSIONS: Very low-to-low certainty evidence from observational studies suggests that DDH from ICU may have no difference in safety outcomes compared with ward transfer of selected ICU patients. In the future, this research question could be further examined by randomized control trials to provide higher certainty data.

After-Hours/Nighttime Transfers Out of the Intensive Care Unit and Patient Outcomes: A Systematic Review and Meta-Analysis.

PURPOSE: We evaluated the effects of after-hours/nighttime patient transfers out of the ICU on patient outcomes, by performing a systematic review and meta-analysis (PROSPERO CRD 42017074082). DATA SOURCES: MEDLINE, PubMed, EMBASE, Google Scholar, CINAHL, and the Cochrane Library from 1987-November 2019. Conference abstracts from the Society of Critical Care Medicine, American Thoracic Society, CHEST, Critical Care Canada Forum, and European Society of Intensive Care Medicine from 2011-2019. DATA EXTRACTION: Observational or randomized studies of adult ICU patients were selected if they compared after-hours transfer out of the ICU to daytime transfer on patient outcomes. Case reports, case series, letters, and reviews were excluded. Study year, country, design, co-variates for adjustment, definitions of after-hours, mortality rates, ICU readmission rates, and hospital length of stay (LOS) were extracted. DATA SYNTHESIS: We identified 3,398 studies. Thirty-one observational studies (1,418,924 patients) were selected for the systematic review and meta-analysis. Included studies had varying definitions of after-hours, with the after-hours period starting anytime between 16:00-22:00 and ending between 06:00-09:00. Approximately 16% of transfers occurred after-hours. After-hours transfers were associated with increased in-hospital mortality for both unadjusted (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.30-1.75, I2 = 96%, number of studies [n] = 26, P < 0.001, low certainty) and adjusted (OR 1.32, 95% CI 1.25-1.38, I 2 = 33%, n = 10, P < 0.001, low certainty) data, compared to daytime transfers. They were also associated with increased ICU readmission (pooled unadjusted OR 1.28, 95% CI 1.18-1.38, I2 = 85%, n = 17, P < 0.001, low certainty) and longer hospital LOS (standardized mean difference 0.13, 95% CI 0.09-0.18, I 2 = 93%, n = 9, P < 0.001, low certainty), compared to daytime transfers. CONCLUSIONS: After-hours transfers out of the ICU are associated with increased in-hospital mortality, ICU readmission, and hospital LOS, across many settings. While the certainty of evidence is low, future research is needed to reduce the number and effects of after-hours transfers.

Long-term Safety of Directly Discharging Patients Home from the ICU Compared to Ward Transfer.

Purpose: To evaluate the long-term safety of directly discharging intensive care unit (ICU) survivors to their home. Methods: A retrospective observational cohort of 341 ICU survivors who were directly discharged home from the ICU ("direct discharge") or discharged home ≤72 hours after ICU transfer to the ward ("ward transfer") was conducted in Regina, Saskatchewan ICUs between September 1, 2016 and September 30, 2018. The primary outcome was 90-day hospital readmission. Secondary outcomes included 30-day, 90-day, and 365-day emergency department (ED) visits, 30-day and 365-day hospital readmissions, and 365-day mortality. All outcomes were evaluated by multivariable Cox regression after adjustment for demographic and clinical characteristics. Results: Of 341 survivors (25.5% of total ICU visits), 148 (43.4%) patients were direct discharges and 193 (56.6%) were ward transfers. The median age was 46 years (interquartile range, 34-62), 38.4% were female, and 61.8% resided in Regina. Compared to the ward transfer cohort, more patients in the direct discharge cohort had at least one 90-day hospital readmission (30.4% versus 17.1% of patients, adjusted hazard ratio 2.09, 95% confidence interval 1.28-3.40, P = .003), after adjustment. Additionally, there were more 90-day ED visits (P = .045), and 30-day (P = .049) and 365-day hospital readmissions (P = .03), after adjustment. Conclusions: In Saskatchewan, direct discharge compared to ward transfer was associated with an increase in 90-day hospital readmissions, and potentially other clinical outcomes. Further study is necessary.

Moxifloxacin-Induced Immune-Mediated Thrombocytopenia in a Chronic Kidney Disease Patient Receiving Hemodialysis.

OBJECTIVE: To alert clinicians to a serious complication from a commonly prescribed medication, moxifloxacin. CASE SUMMARY: A 65-year-old male, septic, hemodialysis patient developed thrombocytopenia following exposure to vancomycin, ceftazidime, and moxifloxacin. Drug-specific immunoglobulin testing showed positive autoantibodies against only moxifloxacin, and the probability stratification proposed by Naranjo et al would give this case a score of 7-a probable association between moxifloxacin and the adverse event. DISCUSSION: Idiopathic thrombocytopenic purpura (ITP) results in immune-mediated platelet destruction, with bleeding risk frequently manifested by purpuric skin and mucosal lesions. Although many drugs are associated with ITP, moxifloxacin has only been characterized in 2 previous case reports. This is the first case report where specific immunoglobulin antibody testing showed a positive association between ITP and moxifloxacin. CONCLUSIONS: Moxifloxacin is a commonly prescribed medication because of its wide spectrum of activity, high bioavailability, and convenient dose schedule. Clinicians need to be aware of this little-known side effect of this commonly prescribed antibiotic.

Evaluating service needs for veno-venous extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome in Saskatchewan.

To determine the number of patients with acute respiratory distress syndrome (ARDS) who would be eligible to receive veno-venous extracorporeal membrane oxygenation (VV-ECMO). We conducted a retrospective observational study of ARDS patients admitted to Regina General Hospital Intensive Care Unit (ICU). VV-ECMO eligibility was assessed using selection criteria from the Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Syndrome trial (EOLIA), the Extracorporeal Life Support Organization (ELSO), New South Wales (NSW), Critical Care Services Ontario (CCSO) and a Regina-restrictive criteria. Of 415 patients admitted between October 16, 2018, and January 21, 2021, 103 (25%) had mild, 175 (42%) had moderate, and 64 (15%) had severe ARDS. Of the cohort, 144 (35%) had bacterial pneumonia, 86 (21%) had viral pneumonia (including COVID-19), and 72 (17%) had aspiration pneumonia. Using the EOLIA, ELSO, NSW, CCSO and Regina-restrictive criteria, 7/415 (1.7%), 6/415 (1.5%), 19/415 (4.6%), 26/415 (6.3%) and 12/415 (2.9%) were eligible for VV-ECMO, respectively. Of all ECMO-eligible patients, only one (2.4%) actually received VV-ECMO, 20/42 (48%) received prone positioning and 21/42 (50%) received neuromuscular blockade. There is potential for service expansion of VV-ECMO in Regina; however, there is still a need to improve the delivery of evidence-based ARDS therapies.

Treatments and Outcomes of Critically Ill Patients with Candida spp. Colonization of the Lower Respiratory Tract in Regina, Saskatchewan.

Background: Among critically ill patients receiving mechanical ventilation, Candida spp. are commonly detected in the lower respiratory tract (LRT). This is generally considered to represent colonization. Objective: To evaluate the use of antifungal treatments and the clinical outcomes of patients with Candida colonization of the LRT. Methods: This retrospective analysis involved consecutive patients admitted to the intensive care unit between April 2016 and May 2021with positive results on Candida spp. testing of LRT samples. Data related to antifungal treatment and clinical outcomes were analyzed descriptively, and multivariable logistic regression was performed. Results: Of 200 patients initially identified, 160 (80%) died in hospital. Antifungal therapy was given to 103 (51.5%) of the patients, with treatment being more likely among those with shock and those who received parenteral nutrition. Mortality was high among patients with positive Candida results on LRT culture, regardless of treatment. Multivariable logistic regression, with adjustment for age, sex, comorbidities, and sequential organ failure assessment (SOFA) score, showed that antifungal treatment was associated with lower odds of death (odds ratio 0.39, 95% confidence interval 0.17-0.87) compared with no treatment (p = 0.021). Conclusions: This study showed higher mortality rates than have been reported previously. Further investigation into the role of antifungal therapy among critically ill patients with Candida spp. colonization is required.

Contexte: Chez les patients gravement malades recevant une ventilation mécanique, les Candida spp. sont fréquemment détectées dans les voies respiratoires inférieures (VRI) ­ une situation généralement considérée comme une colonisation. Objectif: Évaluer l'utilisation d'un traitement antifongique et les résultats cliniques chez les patients présentant une colonisation par Candida dans les VRI. Méthodes: Cette analyse rétrospective portait sur des patients consécutifs de l'unité de soins intensifs ayant obtenu un résultat positif au test de Candida sur les isolats des VRI entre avril 2016 et mai 2021. Les données relatives au traitement antifongique et aux résultats cliniques ont été analysées de manière descriptive, et une régression logistique multivariable a été effectuée. Résultats: Parmi les 200 patients initialement recensés, 160 (80 %) sont décédés à l'hôpital. Une thérapie antifongique a été administrée à 103 (51,5 %) des patients, et le traitement était plus probable chez ceux en état de choc et ceux ayant reçu une nutrition parentérale. Les patients ayant été déclarés positifs pour la Candida dans la culture des VRI présentaient un taux de mortalité élevé, indépendamment du traitement. Une régression logistique multivariable, avec ajustement pour l'âge, le sexe, les comorbidités et le score SOFA (sequential organ failure assessment), a montré que le traitement antifongique était associé à une probabilité de décès réduite (rapport de cotes 0,39; intervalle de confiance à 95 % 0,17­0,87), par rapport à l'absence de traitement (p = 0,021). Conclusions: Cette étude a révélé des taux de mortalité plus élevés que ce qui avait été rapporté précédemment. Une enquête plus approfondie sur le rôle de la thérapie antifongique chez les patients gravement malades présentant une colonisation par Candida spp. est nécessaire.

External validation of the hospital frailty risk score among older adults receiving mechanical ventilation.

To externally validate the Hospital Frailty Risk Score (HFRS) in critically ill patients. We selected older adult (≥ 75 years old) hospitalizations receiving mechanical ventilation, using the Nationwide Readmissions Database (January 1, 2016-November 30, 2018). Frailty risk was subcategorized into low-risk (HFRS score < 5), intermediate-risk (score 5-15), and high-risk (score > 15). We evaluated the HFRS to predict in-hospital mortality, prolonged hospitalization, and 30-day readmissions, using multivariable logistic regression, adjusting for patient and hospital characteristics. Model performance was assessed using the c-statistic, Brier score, and calibration plots. Among 649,330 weighted hospitalizations, 9.5%, 68.3%, and 22.2% were subcategorized as low-, intermediate-, and high-risk for frailty, respectively. After adjustment, high-risk patient hospitalizations were associated with increased risks of prolonged hospitalization (adjusted odds ratio [aOR] 5.59 [95% confidence interval [CI] 5.24-5.97], c-statistic 0.694, Brier 0.216) and 30-day readmissions (aOR 1.20 [95% CI 1.13-1.27], c-statistic 0.595, Brier 0.162), compared to low-risk hospitalizations. Conversely, high-risk hospitalizations were inversely associated with in-hospital mortality (aOR 0.46 [95% CI 0.45-0.48], c-statistic 0.712, Brier 0.214). The HFRS was not successfully validated to predict in-hospital mortality in critically ill older adults. While it may predict other outcomes, its use should be avoided in the critically ill.

Trends and outcomes of mechanically ventilated cirrhotic patients in the United States from 2005-2014.

Purpose: Cirrhotic patients in organ failure are frequently admitted to intensive care units (ICUs) to receive invasive mechanical ventilation (IMV). We evaluated the trends of hospitalizations, in-hospital mortality, hospital costs, and hospital length of stay (LOS) of IMV patients with cirrhosis. Methods: We analyzed the United States National Inpatient Sample from 2005-2014. We selected discharges of IMV adult (≥18 years) patients with cirrhosis using the International Classification of Diseases, 9th Edition, Clinical Modification codes. Trends were assessed using linear regression and joinpoint regression. Results: Between 2005 and 2014, there were approximately 9,441,605 hospitalizations of IMV adult patients, of which 4.7% had cirrhosis. There was an increasing trend in the total number of IMV cirrhotic patient hospitalizations (annual percent change [APC] 7.0%, 95% confidence interval [CI] 6.4%; 7.6%, Ptrend < 0.001). The in-hospital case-fatality ratio declined between 2005-2011 (APC -2.9%, 95% CI, -3.4%; -2.4%, Ptrend < 0.001); however, it remained similar between 2011-2014 (Ptrend = 0.58). The total annual hospital costs of all IMV cirrhotic patients increased from approximately $1.2 billion USD in 2005 to $2.7 billion USD in 2014 (Ptrend < 0.001). The mean hospital costs per patient and mean LOS declined between 2005 and 2014 (Ptrend < 0.001 and Ptrend = 0.01 respectively). Conclusions: The total number of hospitalizations and total annual costs of IMV patients with cirrhosis have been increasing over time. However, past hesitancy around admitting cirrhotic patients to the ICU may need to be tempered by the improving mortality trends in this patient population.

Identification of Staphylococci by Polymerase Chain Reaction Directly from a Positive Blood Culture and Effect on Patient Care.

BACKGROUND: As one of the most common bloodstream infections worldwide, Staphylococcus aureus bacteremia places a major burden on health care. Implementation of a rapid, genetic-based diagnostic test may have important implications in the clinical management of patients with S. aureus bacteremia. OBJECTIVES: The primary objective was to assess concordance between testing based on polymerase chain reaction (PCR) and the current gold standard, culture and sensitivity testing; the secondary objective was to assess the impact of this technology on patient care. METHODS: A pre-post intervention retrospective chart review was used to document the hospital course of patients with a diagnosis of S. aureus bacteremia before and after implementation of the PCR-based diagnostic system. Laboratory results from all patient samples subjected to PCR-based analysis following implementation of this system were compared with culture and sensitivity data for the same samples to determine accuracy of the new system. In addition, time to optimal therapy for each patient was calculated as the interval between the initiation of empiric and terminal therapies. The appropriateness of antimicrobial treatment was characterized as guideline-concordant, nonconcordant with the guidelines, or nonconcordant yet still clinically appropriate. RESULTS: In total, 98 and 99 patients met the inclusion criteria before and after implementation of the PCR-based diagnostic system, respectively. PCR-based results displayed 99.8% concordance (440/441 total samples) with results from culture and sensitivity testing. The time to optimal therapy was significantly shorter after implementation, by a mean of 22.8 h (p < 0.001). Overall, 97% of empiric and 99% of terminal antimicrobial regimens were either guideline-concordant or clinically appropriate for treatment of S. aureus bacteremia; 3% of empiric and 1% of terminal antimicrobial regimens were nonconcordant with clinical guidelines without any explanation based on other clinical considerations. CONCLUSIONS: The study findings support the utility of using a direct-from-positive-blood-culture PCR-based diagnostic tool as the primary method of identifying S. aureus bacteremia in patients, as well as the acceptance of and acting upon the new assay's results by our local clinicians. PCR-based assays can help reduce the time to optimal terminal therapy for patients with bacteremia.

CONTEXTE: La bactériémie à Staphylococcus aureus (BAC-SA), qui est l'une des infections du sang les plus répandues dans le monde, fait peser une lourde charge sur les soins de santé. La mise en place d'un test diagnostique génétique rapide pourrait avoir des retombées importantes sur la gestion clinique des patients présentant une BAC-SA. OBJECTIFS: L'objectif principal consistait à évaluer la concordance entre les tests basés sur la réaction en chaîne par polymérase (PCR) et le test de sensibilité et de culture, qui est la référence absolue actuelle; l'objectif secondaire consistait à évaluer l'impact de cette technologie sur les soins des patients. MÉTHODES: Un examen rétrospectif des dossiers pré-et post-intervention a servi à décrire le séjour à l'hôpital des patients ayant reçu un diagnostic de BAC-SA avant et après la mise en place du système de diagnostic de la PCR. Les résultats de laboratoire de tous les échantillons des patients soumis à une analyse de la PCR à la suite de la mise en place de ce système ont été comparés avec les données relatives à la culture et à la sensibilité de ces mêmes échantillons afin de déterminer la précision du nouveau système. De plus, l'évaluation du délai d'atteinte du traitement optimal de chaque patient repose sur le calcul de l'intervalle entre le début des thérapies empiriques et terminales. La pertinence du traitement antimicrobien était caractérisée comme suit : concordance avec les lignes directrices, non-concordance avec les lignes directrices ou non-concordance mais encore approprié d'un point de vue clinique. RÉSULTATS: Au total, 98 et 99 patients ont satisfait au critère d'inclusion respectivement avant et après la mise en place du système de diagnostic de la PCR. Les résultats basés sur la PCR affichaient une concordance de 99,8 % (440/441 échantillons au total) avec les résultats des tests de sensibilité et de culture. La diminution du délai d'atteinte du traitement optimal était importante après la mise en place du système, puisqu'elle atteignait en moyenne 22,8 h (p < 0,001). De manière générale, 97 % des régimes antimicrobiens empiriques et 99 % des régimes antimicrobiens terminaux concordaient avec les lignes directrices ou étaient cliniquement appropriés pour le traitement de la BAC-SA; 3 % des régimes antimicrobiens empiriques et 1 % des régimes antimicrobiens terminaux n'étaient pas conformes aux lignes directrices cliniques sans qu'aucune explication basée sur d'autres considérations cliniques n'ait été donnée. CONCLUSIONS: Les résultats de l'étude confirment la nécessité d'utiliser un outil diagnostique basé sur la PCR directement de l'hémoculture positive en guise de méthode principale pour déterminer la présence de BAC-SA chez les patients ainsi que l'acceptation et l'utilisation des nouveaux résultats du test par nos cliniciens locaux. Les tests basés sur la PCR peuvent aider à réduire le délai d'attente du traitement optimal pour les patients atteints de BAC-SA.