Past, present, and future of sustainable intensive care: narrative review and a large hospital system experience.

Healthcare systems are large contributors to global emissions, and intensive care units (ICUs) are a complex and resource-intensive component of these systems. Recent global movements in sustainability initiatives, led mostly by Europe and Oceania, have tried to mitigate ICUs' notable environmental impact with varying success. However, there exists a significant gap in the U.S. knowledge and published literature related to sustainability in the ICU. After a narrative review of the literature and related industry standards, we share our experience with a Green ICU initiative at a large hospital system in Texas. Our process has led to a 3-step pathway to inform similar initiatives for sustainable (green) critical care. This pathway involves (1) establishing a baseline by quantifying the status quo carbon footprint of the affected ICU as well as the cumulative footprint of all the ICUs in the healthcare system; (2) forming alliances and partnerships to target each major source of these pollutants and implement specific intervention programs that reduce the ICU-related greenhouse gas emissions and solid waste; and (3) finally to implement a systemwide Green ICU which requires the creation of multiple parallel pathways that marshal the resources at the grass-roots level to engage the ICU staff and institutionalize a mindset that recognizes and respects the impact of ICU functions on our environment. It is expected that such a systems-based multi-stakeholder approach would pave the way for improved sustainability in critical care.

Quality of hospital care and clinical outcomes: a comparison between the Lombardy Region and the Italian national data.

Background: Improving the quality and effectiveness of healthcare is a key priority in health policy. The emergence of the COVID-19 pandemic has exerted considerable pressure on hospital networks, requiring unprecedented reorganization and restructuring actions. This study analyzed data from the Italian National Outcomes Program to compare some volumes and outcomes of public and private accredited hospitals in the Lombardy Region with national data. Study design: Observational study. Methods: A thorough examination of hospital outcomes between 2019 and 2021 was conducted, considering 45 volume indicators and 48 process and outcome indicators, comparing Lombardy with other Italian regions and public versus private accredited hospitals. Results: In 2020, Italy and Lombardy experienced a considerable reduction in overall hospital admissions, with Lombardy showing a deeper decline (21.3% compared with 16.0% in Italy). In 2021, both experienced a partial recovery, especially marked in the Lombardy region (+7.3%, compared with national data). Focusing specifically on the private sector in Lombardy, a recovery of +9.3% in hospitalization was observed. In the analysis of clinical outcomes, Lombardy outperformed the national average for 63% of the indicators in 2020 and 83.3% in 2021. Conclusions: The study shows the continuing decline in volumes compared to 2019 (pre-COVID), the excellent performance of hospitals in Lombardy and a relevant contribution for the volumes and the quality of outcomes of private accredited hospitals.

Changes in In-Hospital Survival and Long-Term Neurodevelopmental Outcomes of Extremely Preterm Infants: A Retrospective Study of a Japanese Tertiary Center.

OBJECTIVES: The objective of this study was to elucidate whether the survival and long-term neurodevelopmental outcomes of extremely preterm infants have improved in a Japanese tertiary center with an active treatment policy for infants born at 22-23 weeks of gestation. STUDY DESIGN: This single-centered retrospective cohort study enrolled extremely preterm infants treated at Saitama Medical Center, Saitama Medical University, from 2003 to 2014. Patients with major congenital abnormalities were excluded. Primary outcomes were in-hospital survival and severe neurodevelopmental impairment (NDI) at 6 years of age, which was defined as having severe cerebral palsy, severe cognitive impairment, severe visual impairment, or deafness. We assessed the changes in primary outcomes between the first (period 1; 2003-2008) and the second half (period 2; 2009-2014) of the study period and evaluated the association between birth-year and primary outcomes using multivariate logistic regression models. RESULTS: Of the 403 eligible patients, 340 (84%) survived to discharge. Among 248 patients available at 6 years of age, 43 (14%) were classified as having severe NDI. Between the 2 periods, in-hospital survival improved from 155 of 198 (78%) to 185 of 205 (90%), but severe NDI increased from 11 of 108 (10%) to 32 of 140 (23%). In multivariate logistic regression models adjusted for gestational age, birthweight, sex, singleton birth, and antenatal corticosteroids, the aOR (95% CI) of birth-year for in-hospital survival and severe NDI was 1.2 (1.1-1.3) and 1.1 (1.0-1.3), respectively. CONCLUSION: Mortality among extremely preterm infants has improved over the past 12 years; nevertheless, no significant improvement was observed in the long-term neurodevelopmental outcomes.

Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019.

Importance: Approximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking. Objectives: To describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non-mental health hospitalizations, and to characterize variation in utilization across hospitals. Design, Setting, and Participants: Retrospective analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age. Exposures: Hospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types. Main Outcomes and Measures: Measures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non-mental health hospitalizations; and variation in these measures across hospitals. Results: Of 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non-mental health hospitalizations. Conclusions and Relevance: Between 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.

Racial Disparities in Stroke Readmissions Reduced in Hospitals With Better Nurse Staffing.

BACKGROUND: Racial minorities are disproportionately affected by stroke, with Black patients experiencing worse poststroke outcomes than White patients. A modifiable aspect of acute stroke care delivery not yet examined is whether disparities in stroke outcomes are related to hospital nurse staffing levels. OBJECTIVES: The aim of this study was to determine whether 7- and 30-day readmission disparities between Black and White patients were associated with nurse staffing levels. METHODS: We conducted a secondary analysis of 542 hospitals in four states. Risk-adjusted, logistic regression models were used to determine the association of nurse staffing with 7- and 30-day all-cause readmissions for Black and White ischemic stroke patients. RESULTS: Our sample included 98,150 ischemic stroke patients (87% White, 13% Black). Thirty-day readmission rates were 10.4% (12.7% for Black patients, 10.0% for White patients). In models accounting for hospital and patient characteristics, the odds of 30-day readmissions were higher for Black than White patients. A significant interaction was found between race and nurse staffing, with Black patients experiencing higher odds of 30- and 7-day readmissions for each additional patient cared for by a nurse. In the best-staffed hospitals (less than three patients per nurse), Black and White stroke patients' disparities were no longer significant. DISCUSSION: Disparities in readmissions between Black and White stroke patients may be linked to the level of nurse staffing in the hospitals where they receive care. Tailoring nurse staffing levels to meet the needs of Black ischemic stroke patients represents a promising intervention to address systemic inequities linked to readmission disparities among minority stroke patients.

Hospital-specific Template Matching for Benchmarking Performance in a Diverse Multihospital System.

BACKGROUND: Hospital-specific template matching is a newer method of hospital performance measurement that may be fairer than regression-based benchmarking. However, it has been tested in only limited research settings. OBJECTIVE: The objective of this study was to test the feasibility of hospital-specific template matching assessments in the Veterans Affairs (VA) health care system and determine power to detect greater-than-expected 30-day mortality. RESEARCH DESIGN: Observational cohort study with hospital-specific template matching assessment. For each VA hospital, the 30-day mortality of a representative subset of hospitalizations was compared with the pooled mortality from matched hospitalizations at a set of comparison VA hospitals treating sufficiently similar patients. The simulation was used to determine power to detect greater-than-expected mortality. SUBJECTS: A total of 556,266 hospitalizations at 122 VA hospitals in 2017. MEASURES: A number of comparison hospitals identified per hospital; 30-day mortality. RESULTS: Each hospital had a median of 38 comparison hospitals (interquartile range: 33, 44) identified, and 116 (95.1%) had at least 20 comparison hospitals. In total, 8 hospitals (6.6%) had a significantly lower 30-day mortality than their benchmark, 5 hospitals (4.1%) had a significantly higher 30-day mortality, and the remaining 109 hospitals (89.3%) were similar to their benchmark. Power to detect a standardized mortality ratio of 2.0 ranged from 72.5% to 79.4% for a hospital with the fewest (6) versus most (64) comparison hospitals. CONCLUSIONS: Hospital-specific template matching may be feasible for assessing hospital performance in the diverse VA health care system, but further refinements are needed to optimize the approach before operational use. Our findings are likely applicable to other large and diverse multihospital systems.

Between-centre differences in care for in-hospital cardiac arrest: a prospective cohort study.

BACKGROUND: Survival after in-hospital cardiac arrest is poor, but current literature shows substantial heterogeneity in reported survival rates. This study aims to evaluate care for patients suffering in-hospital cardiac arrest (IHCA) in the Netherlands by assessing between-hospital heterogeneity in outcomes and to explain this heterogeneity stemming from differences in case-mix or differences in quality of care. METHODS: A prospective multicentre study was conducted comprising 14 centres. All IHCA patients were included. The adjusted variation in structure and process indicators of quality of care and outcomes (in-hospital mortality and cerebral performance category [CPC] scale) was assessed with mixed effects regression with centre as random intercept. Variation was quantified using the median odds ratio (MOR), representing the expected odds ratio for poor outcome between two randomly picked centres. RESULTS: After excluding centres with less than 10 inclusions (2 centres), 701 patients were included of whom, 218 (32%) survived to hospital discharge. The unadjusted and case-mix adjusted MOR for mortality was 1.19 and 1.05, respectively. The unadjusted and adjusted MOR for CPC score was 1.24 and 1.19, respectively. In hospitals where personnel received cardiopulmonary resuscitation (CPR) training twice per year, 183 (64.7%) versus 290 (71.4%) patients died or were in a vegetative state, and 59 (20.8%) versus 68 (16.7%) patients showed full recovery (p < 0.001). CONCLUSION: In the Netherlands, survival after IHCA is relatively high and between-centre differences in outcomes are small. The existing differences in survival are mainly attributable to differences in case-mix. Variation in neurological outcome is less attributable to case-mix.

National survey on sedation for gastrointestinal endoscopy in 2758 Chinese hospitals.

BACKGROUND: Although sedation during gastrointestinal endoscopy is widely used in China, the characteristics of sedation use, including regional distribution, personnel composition, equipment used, and drug selection, remain unclear. The present study aimed to provide insights into the current practice and regional distribution of sedation for gastrointestinal endoscopy in China. METHODS: A questionnaire consisting of 19 items was distributed to directors of anaesthesiology departments and anaesthesiologists in charge of endoscopic sedation units in mainland China through WeChat. RESULTS: The results from 2758 participating hospitals (36.7% of the total) showed that 9 808 182 gastroscopies (69.3%) and 4 353 950 colonoscopies (30.7%), with a gastroscopy-to-colonoscopy ratio of 2.3, were conducted from January to December 2016. Sedation was used with 4 696 648 gastroscopies (47.9%) and 2 148 316 colonoscopies (49.3%), for a ratio of 2.2. The most commonly used sedative was propofol (61.0% for gastroscopies and 60.4% for colonoscopies). Haemoglobin oxygen saturation (SpO2) was monitored in most patients (96.1%). Supplemental oxygen was routinely administered, but the availability of other equipment was variable (anaesthesia machine in 64.9%, physiological monitor in 84.4%, suction device in 72.3%, airway equipment in 75.5%, defibrillator in 32.7%, emergency kit in 57.0%, and difficult airway kit in 20.8% of centres responding). CONCLUSIONS: The sedation rate for gastrointestinal endoscopy is much lower in China than in the USA and in Europe. The most commonly used combination of sedatives was propofol plus an opioid (either fentanyl or sufentanil). Emergency support devices, such as difficult airway devices and defibrillators, were not usually available.

Hospitalizations for Acute on Chronic Liver Failure at Academic Compared to Non-academic Centers Have Higher Mortality.

BACKGROUND AND AIM: Acute on chronic liver failure (ACLF) in patients with cirrhosis has high short-term mortality. Data comparing ACLF admissions to academic centers (AC) and non-academic centers (NAC) are scanty. METHODS: National Inpatient Sample (2006-2014) was queried for admissions with cirrhosis and ACLF using the ICD-09 codes, and was stratified to AC or NAC. RESULTS: Of 1,928,764 admissions with cirrhosis (2006-2014), 112,174 (5. 9%) had ACLF. 6.7% of 1,018,568 cirrhosis admissions to AC had ACLF versus 5% of 910,196 admissions to NAC, P < 0.0001. Proportion of ACLF admissions to AC increased from 49% during 2006-2008 to 59% during 2012-2014. In a cohort of 73,630 ACLF admissions (36,615 each to AC and NAC) matched for patient demographics, cirrhosis etiology, number of comorbidities, elective versus emergent admission, ACLF grade, and type of organ failure. In-hospital mortality declined by 7% over the study period, but remained higher in AC (46% vs. 42%, P < 0.001), with 11% increased odds for in-hospital mortality compared to admission to NAC. Further admissions to AC versus NAC had higher median (IQR) length of stay at 13 (6-25) versus 11 (5-20) days, with higher median (IQR) hospital charges: 138,239 (66,772-275,603) versus 116,209 (55,767-232,699) USD, P < 0.001 for both. CONCLUSION: Patients with ACLF have high in-hospital mortality. Further, this is higher among admissions to AC. Although the in-hospital mortality is improving, strategies are needed on early identification of patients with futility of care for early discussion on goals of care, and optimal utilization of hospital resources among admissions with ACLF.

Temporal Trends in Critical Care Outcomes in U.S. Minority-Serving Hospitals.

Rationale: Whether critical care improvements over the last 10 years extend to all hospitals has not been described.Objectives: To examine the temporal trends of critical care outcomes in minority and non-minority-serving hospitals using an inception cohort of critically ill patients.Measurements and Main Results: Using the Philips Health Care electronic ICU Research Institute Database, we identified minority-serving hospitals as those with an African American or Hispanic ICU census more than twice its regional mean. We examined almost 1.1 million critical illness admissions among 208 ICUs from across the United States admitted between 2006 and 2016. Adjusted hospital mortality (primary) and length of hospitalization (secondary) were the main outcomes. Large pluralities of African American (25%, n = 27,242) and Hispanic individuals (48%, n = 26,743) were cared for in minority-serving hospitals, compared with only 5.2% (n = 42,941) of white individuals. Over the last 10 years, although the risk of critical illness mortality steadily decreased by 2% per year (95% confidence interval [CI], 0.97-0.98) in non-minority-serving hospitals, outcomes within minority-serving hospitals did not improve comparably. This disparity in temporal trends was particularly noticeable among African American individuals, where each additional calendar year was associated with a 3% (95% CI, 0.96-0.97) lower adjusted critical illness mortality within a non-minority-serving hospital, but no change within minority-serving hospitals (hazard ratio, 0.99; 95% CI, 0.97-1.01). Similarly, although ICU and hospital lengths of stay decreased by 0.08 (95% CI, -0.08 to -0.07) and 0.16 (95% CI, -0.16 to -0.15) days per additional calendar year, respectively, in non-minority-serving hospitals, there was little temporal change for African American individuals in minority-serving hospitals.Conclusions: Critically ill African American individuals are disproportionately cared for in minority-serving hospitals, which have shown significantly less improvement than non-minority-serving hospitals over the last 10 years.

A Glimpse Into the Magnet® Program Office: The High-Performing Senior Magnet® Program Analyst Team.

The Magnet Recognition Program® has a dedicated team of RNs and non-RNs who are committed to advancing nursing and supporting healthcare organizations on their Magnet® journeys. Healthcare organizations who are either Magnet-designated or applicants for Magnet designation regularly communicate with the various members of the Magnet program office team. This perspective will highlight the roles of the senior Magnet program analysts and the assistant director of Magnet program operations.

Preparation for the next major incident: are we ready? Comparing major trauma centres and other hospitals.

OBJECTIVES: A major incident is any emergency requiring special arrangements by the emergency services. All hospitals are required by law to keep a major incident plan (MIP) detailing the response to such events. In 2006 and 2019, we assessed the preparedness and knowledge of key individuals in hospitals across England and found a substantial gap in responding to the MIP. In this report, we compare responses from doctors at major trauma centres (MTCs) and other hospitals (non-MTCs). METHODS: We identified trusts in England that received over 30 000 patients through the ED in the fourth quarter of 2016/2017. We contacted the on-call anaesthetic, emergency, general surgery and trauma and orthopaedic registrar at each location and asked three questions assessing their confidence in using their hospital's MIP: (1) Have you read your hospital's MIP? (2) Do you know where you can access your hospital's MIP guidelines? (3) Do you know what role you would play if an MIP came into effect while you are on call?We compared data from MTCs and non-MTCs using multinomial mixed proportional odds models. RESULTS: There was a modest difference between responses from individuals at MTCs and non-MTCs for question 2 (OR=2.43, CI=1.03 to 5.73, p=0.04) but no evidence of a difference between question 1 (OR=1.41, CI=0.55 to 3.63, p=0.47) and question 3 (OR=1.78, CI=0.86 to 3.69, p=0.12). Emergency medicine and anaesthetic registrars showed significantly higher preparedness and knowledge across all domains. No evidence of a systematic difference in specialty response by MTC or otherwise was identified. CONCLUSIONS: Confidence in using MIPs among specialty registrars in England remains low. Doctors at MTCs tended to be better prepared and more knowledgeable, but this effect was only marginally significant. We make several recommendations to improve education on major incidents.

Harnessing the Power of Hospitalists in Operational Disaster Planning: COVID-19.

Hospitalists are well poised to serve in key leadership roles and in frontline care in particular when facing a pandemic such as the SARS-CoV-2 (COVID-19) infection. Much of the disaster planning in hospitals around the country addresses overcrowded emergency departments and decompressing these locations; however, in the case of COVID-19, intensive care units, emergency departments, and medical wards ran the risk of being overwhelmed by a large influx of patients needing high-level medical care. In a matter of days, our Division of Hospital Medicine, in partnership with our hospital, health system, and academic institution, was able to modify and deploy existing disaster plans to quickly care for an influx of medically complex patients. We describe a scaled approach to managing hospitalist clinical operations during the COVID-19 pandemic.

Effect of regionalization of endometrial cancer care on site of care and patient travel.

BACKGROUND: Complex oncologic surgeries, including those for endometrial cancer, increasingly have been concentrated to greater-volume centers, owing to previous research that has demonstrated associations between greater surgical volume and improved outcomes. There is a potential for concentration of care to have unwanted consequences, including cost burden, delayed treatment, patient dissatisfaction, and possibly worse clinical outcomes, especially for more vulnerable populations. OBJECTIVE: To describe changes in site of care for patients with endometrial cancer in New York State and to determine whether the distance women traveled for hysterectomy has changed over time. STUDY DESIGN: We used the New York Statewide Planning and Research Cooperative System to identify women with endometrial cancer who underwent hysterectomy from 2000 to 2014. Demographic and clinical data as well as hospital data were collected. Trends in travel distance (straight-line distance) were analyzed within all hospital referral regions and differences in travel distance over times and across sociodemographic characteristics analyzed. RESULTS: We identified 41,179 subjects. The number of hospitals and surgeons performing hysterectomy decreased across all hospital referral regions over time. The decline in the number of hospitals caring for women with endometrial cancer ranged from -16.7% in Syracuse (12 to 10 hospitals) to -76.5% in Rochester (17 to 4 hospitals). Similarly, the percentage of surgeons within a given hospital referral region operating on women declined from -45.2% in Buffalo (84-46 surgeons) to -77.8% in Albany (72 to 16 surgeons). The median distance to the index hospital for patients increased in all Hospital Referral Regions. For residents in Binghamton, median travel distance increased by 46.9 miles (95% confidence interval, 33.8-60.0) whereas distance increased in Elmira by 19.7 miles (95% confidence interval, 7.3-32.1) and by 12.4 miles (95% confidence interval, 6.4-18.4) in Albany. For residents of Binghamton and Albany, there was a greater than 100% increase in distance traveled over the 15-year time period, with increases of 551.8% (46.9 miles; 95% confidence interval, 33.8-60.0 miles) and 102.5% (12.4 miles; 95% confidence interval, 6.4-18.4 miles), respectively. Travel distance increased for all races and regardless of insurance status but was greatest for white patients and those with private insurance (P<.0001 for both). CONCLUSION: The number of surgeons and hospitals caring for women with endometrial cancer in New York State has decreased, whereas the distance that patients travel to receive care has increased over time.

Do hospitals respond to decreasing prices by supplying more services?

Regulated prices are common in markets for medical care. We estimate the effect of changes in regulated reimbursement prices on volume of hospital care based on a reform of hospital financing in Germany. Uniquely, this reform changed the overall level of reimbursement-with increasing prices for some hospitals and decreasing prices for others-without directly affecting the relative prices for different groups of patients or types of treatment. Based on administrative data, we find that hospitals react to increasing prices by decreasing the service supply and to decreasing prices by increasing the service supply. Moreover, we find some evidence that volume changes for hospitals with different price changes are nonlinear. We interpret our findings as evidence for a negative income effect of prices on volume of care.

Delivery Hospital Characteristics and Postpartum Maternal Mortality: A National Case-Control Study in France.

BACKGROUND: The variability in resources for managing critical events among maternity hospitals may impact maternal safety. Our main objective was to assess the risk of postpartum maternal death according to hospitals' organizational characteristics. A secondary objective aimed to assess the specific risk of death due to postpartum hemorrhage (PPH). METHODS: This national population-based case-control study included all 2007-2009 postpartum maternal deaths from the national confidential enquiry (n = 147 cases) and a 2010 national representative sample of parturients (n = 14,639 controls). To adjust for referral bias, cases were classified by time when the condition/complication responsible for the death occurred: postpartum maternal deaths due to conditions present before delivery (n = 66) or during or after delivery (n = 81). Characteristics of delivery hospitals included 24/7 on-site availability of an anesthesiologist and an obstetrician, level of perinatal care, number of deliveries annually, and their teaching and profit status. In teaching and other nonprofit hospitals in France, obstetric care is organized on the principle of collective team-based management, while in for-profit hospitals, this organization is based mostly on that of "one woman-one doctor." Logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for postpartum maternal death. RESULTS: The risk of maternal death from prepartum conditions was lower for women who gave birth in for-profit compared with teaching hospitals (aOR, 0.3; 95% CI, 0.1-0.8; P = .02) and in hospitals with <1500 vs ≥1500 annual deliveries (aOR, 0.4; 95% CI, 0.1-0.9; P = .02). Conversely, the risk of postpartum maternal death from complications occurring during or after delivery was higher for women who delivered in for-profit compared with teaching hospitals (aOR, 2.8; 95% CI, 1.3-6.0; P = .009), as was the risk of death from PPH in for-profit versus nonprofit hospitals (aOR, 2.8; 95% CI, 1.2-6.5; P = .019). CONCLUSIONS: After adjustment for the referral bias related to prepartum morbidity, the risk of postpartum maternal mortality in France differs according to the hospital's organizational characteristics.

Trends and molecular characteristics of carbapenemase-producing Enterobacteriaceae in Japanese hospital from 2006 to 2015.

BACKGROUND: The increasing number of carbapenemase-producing Enterobacteriaceae (CPE) has become a global problem. Most carbapenemases detected in Japan are imipenemase, which is an imipenem-degrading enzyme with low ability; thus, CPE could have been overlooked. Therefore, this study aimed to detect and analyze CPE, without overlooking CPE showing the low minimum inhibitory concentration phenotype. METHODS: CPE screening was conducted on 531 ceftazidime-resistant Enterobacteriaceae isolated from Kitasato University Hospital during 2006-2015. We confirmed the presence of the carbapenemase genes (blaIMP, blaVIM, blaKPC, blaNDM, and blaOXA-48) by multiplex polymerase chain reaction. The detected CPE strains were analyzed by antimicrobial susceptibility testing, multilocus sequence typing, conjugal experiments, replicon typing, and plasmid profiling by restriction enzyme treatment. RESULTS: The CPE detection rate in Kitasato University Hospital within the past 10 years was 0.0003% (nine CPE strains). These nine CPE strains were identified to harbor 8 blaIMP-1 or 1 blaNDM-5. The CPE strains consisted of five species including Klebsiella pneumoniae and Citrobacter freundii. Six of eight blaIMP-1 were coded by IncHI2 plasmid, and the other two were coded by IncA/C plasmid. Plasmid profiling revealed that K. pneumoniae and C. freundii isolated from the same patient harbored the same plasmid. CONCLUSION: The CPE detection rate in this study was significantly lower than those previously reported in Japan. In one case, IncA/C plasmid transmission through different bacterial species within the body was speculated. Although the number of CPE detected was low, these results indicated that the resistance plasmid could spread to other bacterial species.

The impact of revised diagnostic criteria on hospital trends in gestational diabetes mellitus rates in a high income country.

OBJECTIVE: In 2010, national guidelines were published in Ireland recommending more sensitive criteria for the diagnosis of Gestational Diabetes Mellitus (GDM). The criteria were based on the 2008 Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) Study and were endorsed subsequently by the World Health Organization (WHO). Screening nationally is selective based on risk factors. We examined the impact of the new criteria on hospital trends nationally for GDM over the 10 years 2008-17. RESEARCH DESIGN AND METHODS: Data from three national databases, the Hospital Inpatient Enquiry System (HIPE), National Perinatal Reporting System (NPRS) and the Irish Maternity Indicator System (IMIS), were analyzed using descriptive statistics, analysis of variance, and Poisson loglinear modelling. RESULTS: The overall incidence of GDM nationally increased almost five-fold from 3.1% in 2008 to 14.8% in 2017 (p ≤ 0.001). The incidence varied widely across maternity units. In 2008, the incidence varied from 0.4 to 5.9% and in 2017 it varied from 1.9 to 29.4%. There were increased obstetric interventions among women with GDM over the decade, specifically women with GDM having increased cesarean sections (CS) and induction of labor (IOL) (p ≤ 0.001). These trends were significant in large and mid-sized maternity hospitals (p ≤ 0.001). The increase in GDM diagnosis could not be explained by an increase in maternal age nationally over the decade. The data did not include information on other risk factors such as obesity. The increased incidence in GDM diagnosis was accompanied by a decrease in high birthweight ≥ 4.5 kg nationally. CONCLUSIONS: We found adoption of the new criteria for diagnosis of GDM resulted in a major increase in the incidence of GDM rates. Inter-hospital variations increased over the decade, which may be explained by variations in the implementation of the new national guidelines in different maternity units. It is likely to escalate further as compliance with national guidelines improves at all maternity hospitals, with implications for provision and configuration of maternity services. We observed trends that may indicate improvements for women and their offspring, but more research is required to understand patterns of guideline implementation across hospitals and to demonstrate how increased GDM diagnosis will improve clinical outcomes.

Canadian spontaneous coronary artery dissection cohort study: in-hospital and 30-day outcomes.

AIMS: Spontaneous coronary artery dissection (SCAD) was underdiagnosed and poorly understood for decades. It is increasingly recognized as an important cause of myocardial infarction (MI) in women. We aimed to assess the natural history of SCAD, which has not been adequately explored. METHODS AND RESULTS: We performed a multicentre, prospective, observational study of patients with non-atherosclerotic SCAD presenting acutely from 22 centres in North America. Institutional ethics approval and patient consents were obtained. We recorded baseline demographics, in-hospital characteristics, precipitating/predisposing conditions, angiographic features (assessed by core laboratory), in-hospital major adverse events (MAE), and 30-day major adverse cardiovascular events (MACE). We prospectively enrolled 750 SCAD patients from June 2014 to June 2018. Mean age was 51.8 ± 10.2 years, 88.5% were women (55.0% postmenopausal), 87.7% were Caucasian, and 33.9% had no cardiac risk factors. Emotional stress was reported in 50.3%, and physical stress in 28.9% (9.8% lifting >50 pounds). Predisposing conditions included fibromuscular dysplasia 31.1% (45.2% had no/incomplete screening), systemic inflammatory diseases 4.7%, peripartum 4.5%, and connective tissue disorders 3.6%. Most were treated conservatively (84.3%), but 14.1% underwent percutaneous coronary intervention and 0.7% coronary artery bypass surgery. In-hospital composite MAE was 8.8%; peripartum SCAD patients had higher in-hospital MAE (20.6% vs. 8.2%, P = 0.023). Overall 30-day MACE was 8.8%. Peripartum SCAD and connective tissue disease were independent predictors of 30-day MACE. CONCLUSION: Spontaneous coronary artery dissection predominantly affects women and presents with MI. Despite majority of patients being treated conservatively, survival was good. However, significant cardiovascular complications occurred within 30 days. Long-term follow-up and further investigations on management are warranted.

Early Management of Transient Ischemic Attack in Emergency Departments in France.

INTRODUCTION: Emergency departments play a key role in the diagnosis and treatment of transient ischemic attacks, but limited data are available about the early management of such patients in emergency wards. Therefore, we aimed to evaluate emergency physicians' management of transient ischemic attack and analyze variations factors. METHODS: A multicenter survey among emergency physicians of the Grand Est region network (Est-RESCUE) was conducted from January 28th to March 28th, 2019. Medical and administrative data were collected by the same network and the national directory of medical resources. RESULTS: Among 542 emergency physicians recipients, 78 answered (14%) and 71 were finally included, practicing in 25 public hospitals homogeneously distributed across the territory, including 3 university hospitals. A cerebral magnetic resonance imaging was obtained for 75%-100% of patients by 4.3% of responders, 36.4% of which were performed within more than 24 hours. A cardiac monitoring was prescribed in 75%-100% of cases by 32.4% of responders. A neurologic consultation was routinely requested by 84.6% of responders practicing in a university hospital and 36.8% of responders practicing in a community hospital (P = .02). Patients were hospitalized in a neurovascular unit in 75%-100% of cases by 17.4% of responders, which happened more likely in university hospitals (P < .001). CONCLUSIONS: Transient ischemic attack suffers from management disparities across territories, due to limited access to technical facilities and neurologic consultations. Therefore, international recommendations are too often not followed. Implementation of territorial neurovascular tracks may help to standardize the management of these patients.