RESUMO
BACKGROUND: Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. METHODS: A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. RESULTS: A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. CONCLUSION: Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures. LEVEL OF EVIDENCE: Epidemiologic/prognostic, level III.
Assuntos
Manuseio das Vias Aéreas , Competência Clínica/normas , Cuidados Críticos/métodos , Equipe de Respostas Rápidas de Hospitais , Traqueostomia , Centros Médicos Acadêmicos/estatística & dados numéricos , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/normas , Assistência Integral à Saúde/métodos , Assistência Integral à Saúde/estatística & dados numéricos , Emergências/epidemiologia , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Equipe de Respostas Rápidas de Hospitais/organização & administração , Equipe de Respostas Rápidas de Hospitais/normas , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação das Necessidades , Equipe de Assistência ao Paciente/organização & administração , Pericardiocentese/estatística & dados numéricos , Tempo para o Tratamento , Traqueostomia/efeitos adversos , Traqueostomia/métodos , Traqueostomia/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To determine if socioeconomic disadvantage impacts perioperative outcomes after tracheostomy. METHODS: We performed a retrospective case series of children who underwent tracheostomy. Children were divided into less and more disadvantaged groups based on their community's Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure. Primary outcomes were the length of stay, total cost, in-hospital mortality, and 30-day all-cause readmission after tracheostomy placement. Length of stay was further analyzed using parametric survival analysis. RESULTS: A total of 239 patients met inclusion criteria, with 153 (64%) residing in more disadvantaged communities. Children from more disadvantaged communities were less likely to be White (42% vs. 26%, P = .009) and more likely to have Medicaid coverage (90% vs. 62%, P < .001). The two groups had similar medical complexity and comorbidities. The main outcome measures showed differences in median total length of stay (113 vs. 79 days, P = .04) and median total cost ($461 000 vs. $279 000, P = .01). Children with tracheostomies who were from more disadvantaged communities also had increased risk of prolonged hospitalizations (HR = 0.63, 95% CI = 0.48-0.83, P = .001). Readmissions, mortality rates, and quality of life scores were similar between groups. CONCLUSIONS: Community disadvantage was associated with differences in hospitalization length and costs after pediatric tracheostomy placement. Further research should continue to describe how health disparities impact children's safe and efficient care with tracheostomies. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2603-2609, 2021.
Assuntos
Disparidades nos Níveis de Saúde , Complicações Pós-Operatórias/epidemiologia , Fatores Socioeconômicos , Traqueostomia/efeitos adversos , Criança , Pré-Escolar , Comorbidade , Feminino , Mortalidade Hospitalar , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Qualidade de Vida , Estudos Retrospectivos , Centros de Atenção Terciária/estatística & dados numéricos , Traqueostomia/estatística & dados numéricosRESUMO
OBJECTIVES/HYPOTHESIS: To compare perioperative outcomes after pediatric tracheostomy placement based on patient complexity. STUDY DESIGN: Retrospective case series. METHODS: All patients that underwent tracheostomy placement at a tertiary children's hospital between 2015 and 2019 were followed. Children with a history of major cardiac surgery, sepsis, or total parental nutrition (TPN) were grouped as complex. Admission length, tracheostomy-related complications, in-hospital mortality, and 30-day readmissions were recorded among complex and non-complex patients. RESULTS: A total of 238 children were included. Mean age at tracheostomy was 39.9 months (SD: 61.3), 51% were male and 51% were complex. Complex patients were younger at admission (29.9 vs. 46.8 months, P = .03), more likely to have respiratory failure (81% vs. 53%, P < .001) and more often required mechanical ventilation at discharge (86% vs. 67%, P < .001). An additional 33 days after placement was required for complex children (95% CI: 14-51, P = .001) and this group had more deaths (8% vs. 1%, P = .02); however, both groups had similar complication and readmission rates (P > .05). Total charges were higher among complex patients ($700,267 vs. $338,937, P < .001). Parametric survival analysis identified mechanical ventilation and patient complexity interacting to predict post-tracheostomy admission length. CONCLUSIONS: Hospital discharge after pediatric tracheostomy was associated with patient complexity and further influenced by mechanical ventilation. Recognition that cardiac surgery, sepsis, or TPN can predict poorer perioperative outcomes can provide quality improvement strategies for these vulnerable children. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2469-E2474, 2021.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Nutrição Parenteral Total/efeitos adversos , Período Perioperatório/estatística & dados numéricos , Sepse/complicações , Traqueostomia/efeitos adversos , Criança , Pré-Escolar , Feminino , Mortalidade Hospitalar/tendências , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Segurança do Paciente , Período Perioperatório/economia , Complicações Pós-Operatórias/epidemiologia , Melhoria de Qualidade , Respiração Artificial/métodos , Respiração Artificial/mortalidade , Insuficiência Respiratória/complicações , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Traqueostomia/economia , Traqueostomia/estatística & dados numéricosRESUMO
Background There are limited contemporary data prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI). Methods and Results Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000-2017) were evaluated for in-hospital AIS. Outcomes of interest included in-hospital mortality, hospitalization costs, length of stay, discharge disposition, and use of tracheostomy and percutaneous endoscopic gastrostomy. The discharge destination was used to classify survivors into good and poor outcomes. Of a total 11 622 528 AMI admissions, 183 896 (1.6%) had concomitant AIS. As compared with 2000, in 2017, AIS rates increased slightly among ST-segment-elevation AMI (adjusted odds ratio, 1.10 [95% CI, 1.04-1.15]) and decreased in non-ST-segment-elevation AMI (adjusted odds ratio, 0.47 [95% CI, 0.46-0.49]) admissions (P<0.001). Compared with those without, the AIS cohort was on average older, female, of non-White race, with greater comorbidities, and higher rates of arrhythmias. The AMI-AIS admissions received less frequent coronary angiography (46.9% versus 63.8%) and percutaneous coronary intervention (22.7% versus 41.8%) (P<0.001). The AIS cohort had higher in-hospital mortality (16.4% versus 6.0%; adjusted odds ratio, 1.75 [95% CI, 1.72-1.78]; P<0.001), longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and percutaneous endoscopic gastrostomy, and less frequent discharges to home (all P<0.001). Among AMI-AIS survivors (N=153 318), 57.3% had a poor functional outcome at discharge with relatively stable temporal trends. Conclusions AIS is associated with significantly higher in-hospital mortality and poor functional outcomes in AMI admissions.
Assuntos
Mortalidade Hospitalar/tendências , Hospitalização/estatística & dados numéricos , AVC Isquêmico , Infarto do Miocárdio , Causalidade , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Estado Funcional , Gastrostomia/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Humanos , AVC Isquêmico/etiologia , AVC Isquêmico/mortalidade , AVC Isquêmico/terapia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/classificação , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde , Prevalência , Traqueostomia/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES/HYPOTHESIS: Little data exists regarding the relationship between socioeconomic and demographic factors and tracheostomy outcomes. The goal of this study was to determine associations between socioeconomic status (SES), demographic factors, and insurance status with hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality following tracheostomy. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective analysis of all patients who underwent tracheostomy at an urban tertiary-care academic hospital from 2016 to 2017 was performed. Patients were aggregated into low-, middle-, and high-income brackets. Other variables included age, sex, race, ethnicity, body mass index, and Charlson Comorbidity Index (CCI). Outcomes included hospital and ICU LOS, in-hospital mortality, and 30-day mortality following tracheostomy. Outcomes were compared using Kruskal-Wallis tests for continuous variables and χ2 or Fisher exact tests for categorical variables. The α level was set to .05. RESULTS: In total, 523 patients were included in the study. Patients from high-income areas were more likely to be male (P < .01), white (P < .01), and had lower body mass index (P = .04). On multiple regression analysis, Hispanic or Latino ethnicity was associated with an increased odds of 30-day mortality (odds ratio [OR]: 4.43, P = .020). CCI was also associated with increased odds of 30-day mortality (OR: 1.12, P = .039). CONCLUSIONS: Lower SES was not associated with increased morbidity or mortality after tracheostomy. Although Hispanic patients tended to have a lower CCI score, they had increased 30-day mortality, suggesting there are factors specific to this population that may influence outcomes, and future targeted studies are warranted to study these relationships. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1463-1467, 2021.
Assuntos
Renda/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Traqueostomia/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Povo Asiático/estatística & dados numéricos , População Negra/estatística & dados numéricos , Índice de Massa Corporal , Feminino , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Cobertura do Seguro/economia , Seguro Saúde/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Traqueostomia/economia , Traqueostomia/estatística & dados numéricos , Resultado do Tratamento , População Branca/estatística & dados numéricosRESUMO
BACKGROUND: Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited. OBJECTIVE: We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity. STUDY DESIGN: This cohort study used data on all births at ≥20 weeks gestation in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women. RESULTS: Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19-1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20-1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11-1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21-1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups. CONCLUSION: In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.
Assuntos
Entorno do Parto/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Hospitais/estatística & dados numéricos , Complicações do Trabalho de Parto/etnologia , Complicações na Gravidez/etnologia , Transtornos Puerperais/etnologia , Adulto , Negro ou Afro-Americano , Asiático , Transfusão de Sangue/estatística & dados numéricos , California/epidemiologia , Transtornos Cerebrovasculares/etnologia , Eclampsia/etnologia , Emigrantes e Imigrantes , Feminino , Idade Gestacional , Equidade em Saúde , Insuficiência Cardíaca/etnologia , Hispânico ou Latino , Hospitais Privados/estatística & dados numéricos , Hospitais Públicos/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Humanos , Histerectomia/estatística & dados numéricos , Indígenas Norte-Americanos , Povos Indígenas , Modelos Logísticos , Pessoa de Meia-Idade , Havaiano Nativo ou Outro Ilhéu do Pacífico , Obesidade Materna , Gravidez , Cuidado Pré-Natal , Edema Pulmonar/etnologia , Respiração Artificial/estatística & dados numéricos , Sepse/etnologia , Índice de Gravidade de Doença , Choque/etnologia , Traqueostomia/estatística & dados numéricos , População Branca , Adulto JovemRESUMO
BACKGROUND: Ethnicity may be associated with important aspects of end-of-life care, such as what treatments are received, access to palliative care and where people die. However, most studies have focused on end-of-life care of white, Hispanic and black patients. We sought to compare end-of-life care delivered to people of Chinese and South Asian ethnicity with that delivered to others from the general population, in Ontario, Canada. METHODS: In this population-based cohort study, we included all people who died in Ontario, Canada, between Apr. 1, 2004, and Mar. 31, 2015. People were identified as having Chinese or South Asian ethnicity on the basis of a validated surname algorithm. We used modified Poisson regression analyses to assess location of death and care received in the last 6 months of life. RESULTS: We analyzed 967 339 decedents, including 18 959 (2.0%) of Chinese and 11 406 (1.2%) of South Asian ethnicity. Chinese (13.6%) and South Asian (18.5%) decedents were more likely than decedents from the general population (10.1%) to die in the intensive care unit (ICU). The adjusted relative risk of dying in intensive care was 1.21 (95% confidence interval [CI] 1.15 to 1.27) for Chinese and 1.25 (95% CI 1.20 to 1.30) for South Asian decedents. In their last 6 months of life, decedents of Chinese and South Asian ethnicity experienced significantly more ICU admission, hospital admission, mechanical ventilation, dialysis, percutaneous feeding tube placement, tracheostomy and cardiopulmonary resuscitation than the general population. INTERPRETATION: Decedents of Chinese and South Asian ethnicity in Ontario were more likely than decedents from the general population to receive aggressive care and to die in an ICU. These findings may be due to communication difficulties between patients and clinicians, differences in preferences about end-of-life care or differences in access to palliative care services.
Assuntos
Povo Asiático/etnologia , Assistência Terminal/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Ásia/etnologia , Reanimação Cardiopulmonar/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Emigração e Imigração , Nutrição Enteral/estatística & dados numéricos , Utilização de Instalações e Serviços , Acessibilidade aos Serviços de Saúde , Hospitalização/estatística & dados numéricos , Humanos , Ontário/epidemiologia , Cuidados Paliativos/psicologia , Cuidados Paliativos/estatística & dados numéricos , Preferência do Paciente , Diálise Renal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Assistência Terminal/psicologia , Traqueostomia/estatística & dados numéricosAssuntos
Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/terapia , Ruptura Aórtica/economia , Ruptura Aórtica/terapia , Cuidados Paliativos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/epidemiologia , Ruptura Aórtica/epidemiologia , Reanimação Cardiopulmonar/estatística & dados numéricos , Comorbidade , Procedimentos Endovasculares/estatística & dados numéricos , Feminino , Preços Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Diálise Renal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto JovemAssuntos
Broncoscopia/estatística & dados numéricos , Imperícia/estatística & dados numéricos , Toracentese/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Formulário de Reclamação de Seguro/estatística & dados numéricos , Responsabilidade Legal , Masculino , Imperícia/economia , Pessoa de Meia-Idade , Análise de Regressão , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Although pulmonary and/or critical care (P/CC) physicians perform percutaneous tracheostomy in mechanically ventilated patients, the trends, timing, and outcomes of this procedure have not been well described. This study aims to describe the trends, timing, and outcomes of this procedure. METHODS: Using 5% medicare data, we retrospectively examined a cohort who had tracheostomy performed after initiation of mechanical ventilation during acute hospitalization to describe the timing of tracheostomy placement by pulmonary and/or critical care (P/CC) physicians and associated outcomes. RESULTS: There were 4864 participants in the study cohort from 2007 to 2014. We examined the timing of tracheostomy (in days from initiation of mechanical ventilation), length of hospital stay, in-hospital death, and death within 30 days after hospital discharge. The percentage of tracheostomies performed by P/CC physicians increased significantly, from 7.2% in 2007 to 14.1% in 2014 (Cochran-Armitage test for trend, P = .001). Tracheostomies performed by P/CC physicians were more common in larger hospitals and major academic medical centers. After adjustment for baseline characteristics, the following parameters did not differ by provider: time to tracheostomy, length of hospital stay (days), in-hospital death, and death within 30 days after discharge. A tracheostomy was more likely to be performed by a P/CC physician at a larger (≥500 beds) hospital (adjusted odds ratio: 1.85, 95% confidence interval: 1.47-2.34). CONCLUSIONS: Tracheostomies are increasingly performed by P/CC physicians with similar outcomes, likely related to patient selection.
Assuntos
Cuidados Críticos/estatística & dados numéricos , Médicos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Fatores de Tempo , Traqueostomia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/métodos , Resultados de Cuidados Críticos , Feminino , Humanos , Masculino , Medicare , Pneumologistas/estatística & dados numéricos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Traqueostomia/métodos , Estados UnidosRESUMO
BACKGROUND: The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma health care (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the intensive care unit to discharge. METHODS: Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n = 60) to those in the first full year following implementation (n = 70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Scale score less than 8 on postinjury Day 2, all paraplegic and quadriplegic patients, and patients older than 55 years with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality. RESULTS: The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. Thirty-day readmission and mortality rates remained unchanged. A cost savings of US $11,238 per index hospitalization was observed. CONCLUSION: In the year following the initiation of the mPATH team, we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared with our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.
Assuntos
Lesões Encefálicas Traumáticas/terapia , Tempo de Internação/estatística & dados numéricos , Equipe de Assistência ao Paciente/organização & administração , Traumatismos da Medula Espinal/terapia , Traqueostomia/estatística & dados numéricos , Centros de Traumatologia/organização & administração , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/economia , Lesões Encefálicas Traumáticas/mortalidade , Redução de Custos , Feminino , Implementação de Plano de Saúde , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente/economia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/economia , Traumatismos da Medula Espinal/mortalidade , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Traqueostomia/economia , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND/OBJECTIVE: Mild obesity is associated with a survival benefit in cardiovascular and cerebrovascular disease. Only a few studies have analyzed the effect of obesity on outcomes after spontaneous intracerebral hemorrhage (ICH), and none have used a national US database. We sought to determine whether or not obesity was associated with outcomes and in-hospital complications following ICH. METHODS: The Nationwide Inpatient Sample was used to identify patients with ICH in the USA who were discharged between 2002 and 2011. The presence of obesity (body mass index [BMI] 30-39.9) or morbid obesity (BMI ≥ 40) was noted. The primary outcome of interest was in-hospital mortality, and secondary outcomes included non-routine discharge disposition, tracheostomy or gastrostomy placement, length of stay (LOS), inflation-adjusted hospital charges, and in-hospital complications. RESULTS: A total of 123,415 patients with ICH met the inclusion criteria, and the 10-year overall incidence of obesity was 4.5%. Between 2002 and 2011, the incidence of obesity increased from 1.9 to 4.4% and the incidence of morbid obesity increased from 0.7 to 3.2%. Both obese (OR 0.62, 95% CI 0.56-0.69) and morbidly obese (OR 0.76, 95% CI 0.66-0.88) patients had lower odds of inpatient mortality. Obese (OR 0.85, 95% CI 0.78-0.93) but not morbidly obese patients had lower odds of non-routine discharge. Morbidly obese patients were twice as likely to require a tracheostomy than non-obese patients (OR 2.07, 95% CI 1.62-2.66). Both obese and morbidly obese patients had higher total hospital charges and rates of pulmonary, renal, and venous thromboembolic complications. There was no difference in LOS according to body habitus. CONCLUSIONS: In patients with spontaneous ICH, obesity is associated with decreased in-hospital mortality but higher rates of in-hospital complications and greater total hospital charges. Non-morbid obesity carries lower odds of non-routine hospital discharge.
Assuntos
Hemorragia Cerebral/epidemiologia , Mortalidade Hospitalar , Obesidade/epidemiologia , Adolescente , Adulto , Idoso , Comorbidade , Feminino , Gastrostomia/estatística & dados numéricos , Preços Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/epidemiologia , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Traqueostomia/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: We hypothesize that if both energy expenditure and oxygenation are optimized (EEOO) toward ventilator tolerance, this would provide patients with the best condition to be liberated from the ventilator. We defined ventilator tolerance as having a respiratory quotient value between 0.7 and 1.0 while maintaining saturations above 98% with FIO2 70% or less and a normal respiratory rate without causing disturbances to the patient's pH. METHODS: This is a single-institution prospective cohort study of ventilator dependent patients within a closed trauma intensive care unit (ICU). The study period was over 52 months. A total of 1,090 patients were part of the primary analysis. The test group (EEOO) was compared to a historical cohort, comparing 26 months in each study group. The primary outcome of this study was number of ventilator days. Secondary outcomes included in-hospital mortality, ICU length of stay (LOS), overall hospital length of stay, tracheostomy rates, reintubation rates, and in-hospital complication rates, such as pneumonia and Acute Respiratory Distress Syndrome (ARDS) ARDS. Both descriptive and multivariable regression analyses were performed to compare the effects of the EEOO protocol with our standard protocols alone. RESULTS: The primary outcome of number of ventilator days was significantly shorter the EEOO cohort by nearly 3 days. This was significant even after adjustment for age, sex, race, comorbidities, nutrition type, and injury severity, (4.3 days vs. 7.2 days, p = 0.0001). The EEOO cohort also had significantly lower ICU days, hospital days, and overall complications rates. CONCLUSION: Optimizing the patient's nutritional regimen to ventilator tolerance and optimizing oxygenation by means of targeted pulmonary mechanics and inspired FIO2 may be associated with lower ventilator and ICU days, as well as overall complication rates. LEVEL OF EVIDENCE: Therapeutic, Level IV.
Assuntos
Metabolismo Energético , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Respiração Artificial/métodos , Desmame do Respirador/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/administração & dosagem , Estudos Prospectivos , Respiração Artificial/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia , Adulto JovemRESUMO
OBJECTIVES: To investigate national and regional variations in pediatric tracheostomy rates, epidemiology, and outcomes from 2000 to 2012. STUDY DESIGN: Retrospective cohort analysis. SETTING: Previous research with the 1997 edition of the Kids' Inpatient Database (KID), a national database of pediatric hospital discharge data, demonstrated that rates and outcomes of pediatric tracheostomy vary among US geographic regions. The KID has since been released an additional 5 times, increasing in size with successive editions. SUBJECTS AND METHODS: Patients ≤18 years old with procedure codes for permanent or temporary tracheostomy from 2000 to 2012 were included. Primary outcome was a weighted population-based rate of tracheostomy stratified by year. Secondary analysis included epidemiologic characteristics and outcomes stratified by year and geographic region. RESULTS: A weighted total of 24,354 cases was analyzed. Population-based tracheostomy rates decreased from 6.8 ± 0.2 (mean ± SD) tracheostomies per 100,000 child-years in 2000 to 6.0 ± 0.2 in 2012. Minorities increased from 53.3% in 2000 to 56.4% in 2012. Patients experienced increased procedures, diagnoses, length of stay, and hospital charges with time. From 2000 to 2012, rates and outcomes varied by US geographic region. Mortality during hospitalization (8%) did not vary by year, patient age, region, or sex. CONCLUSIONS: Pediatric tracheostomy is associated with variation in incidence, epidemiology, and hospitalization outcomes in the United States from 2000 to 2012. While rates of pediatric tracheostomy decreased, patients became increasingly medically complicated and ethnically diverse with outcomes varying according to geographic region.
Assuntos
Preços Hospitalares/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Tempo de Internação/economia , Traqueostomia/estatística & dados numéricos , Fatores Etários , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Razão de Chances , Pediatria , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Traqueostomia/métodos , Estados UnidosRESUMO
OBJECTIVES: To investigate variability in pediatric tracheostomy tube care practice patterns and access to resources across Canada. METHODS: Canadian pediatric otolaryngologists-head & neck surgeons reported their own practice patterns for children with chronic tracheostomy tubes using a web-based, 29-item multiple choice and short answer questionnaire. Domains investigated included tracheostomy team membership, inpatient care practices, caregiver education, homecare resources, speech and communication, and completeness of emergency tracheostomy kits. RESULTS: The response rate was 86.4% (38/44). Most respondents care for children with tracheostomy tubes as part of an inter-professional team (25/36; 69.4%) and arrange routine follow-up with a speech and language pathologist (22/36; 61.1%). However, the majority (23/34; 67.6%) of respondents do not formally reassess caregiver competencies (i.e. cardiopulmonary resuscitation, emergency tracheostomy care). Notably, respondents were also unsure 36.1% (13/36) of how frequently Shiley tracheostomy tubes should be washed and reused with the majority (15/36; 41.7%) reporting never. Most (15/36; 41.7%) respondents were also unsure of reuse recommendations for Bivona tracheostomy tubes. One third (12/36; 33.3%) of respondents were unsure about government-funded homecare services being provided in their community to children with tracheostomy tubes. CONCLUSION: There is much variability in pediatric tracheostomy tube care practice patterns across Canada. Results suggest that an evidence-based Canadian clinical practice guideline may help to streamline care provided to Canadian children with tracheostomy tubes.
Assuntos
Otorrinolaringologistas/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Canadá , Cuidadores/estatística & dados numéricos , Criança , Estudos Transversais , Atenção à Saúde , Tratamento de Emergência , Feminino , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Hospitalização , Humanos , Masculino , Cirurgiões/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. METHODS: This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. RESULTS: Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy during their ICU stay. Patients from high-income European countries (n = 198/1263) more frequently underwent tracheostomy compared to patients from non-European high-income countries (n = 63/649) or patients from middle-income countries (n = 48/465). Only 86/309 (27.8%) underwent tracheostomy on or before day 7, while the median timing of tracheostomy was 14 (Q1-Q3, 7-21) days after onset of ARDS. In the subsample matched by propensity score, ICU and hospital stay were longer in patients with tracheostomy. While patients with tracheostomy had the highest survival probability, there was no difference in 60-day or 90-day mortality in either the patient subgroup that survived for at least 5 days in ICU, or in the propensity-matched subsample. CONCLUSIONS: Most patients that receive tracheostomy do so after the first week of critical illness. Tracheostomy may prolong patient survival but does not reduce 60-day or 90-day mortality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02010073 . Registered on 12 December 2013.
Assuntos
Síndrome do Desconforto Respiratório/terapia , Traqueostomia/estatística & dados numéricos , Idoso , Estudos de Coortes , Estado Terminal/epidemiologia , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Prospectivos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Síndrome do Desconforto Respiratório/epidemiologia , Índice de Gravidade de Doença , Traqueostomia/métodosRESUMO
RATIONALE: In the intensive care unit (ICU), studies involving specialized palliative care services have shown decreases in the use of nonbeneficial life-sustaining therapies and ICU length of stay for patients. However, whether widespread availability of hospital-based palliative care is associated with less frequent use of high intensity care is unknown. OBJECTIVES: To determine whether availability of hospital-based palliative care is associated with decreased markers of treatment intensity for ICU patients. METHODS: Retrospective cohort study of adult ICU patients in New York State hospitals, 2008-2014. Multilevel regression was used to assess the relationship between availability of hospital-based palliative care during the year of admission and hospital length of stay, use of mechanical ventilation, dialysis and artificial nutrition, placement of a tracheostomy or gastrostomy tube, days in ICU and discharge to hospice. RESULTS: Of 1,025,503 ICU patients in 151 hospitals, 814,794 (79.5%) received care in a hospital with a palliative care program. Hospital length of stay was similar for patients in hospitals with and without palliative care programs (6 d [interquartile range, 3-12] vs. 6 d [interquartile range, 3-11]; adjusted rate ratio, 1.04 [95% confidence interval 1.03-1.05]; P < 0.001), as were other healthcare use outcomes. However, patients in hospitals with palliative care programs were 46% more likely to be discharged to hospice than those in hospitals without palliative care programs (1.7% vs. 1.4%; adjusted odds ratio, 1.46 [95% confidence interval 1.30-1.64]; P < 0.001). CONCLUSIONS: The availability of hospital-based palliative care was not associated with differences in in-hospital treatment intensity, but it was associated with significantly increased hospice use for ICU patients. Currently, the measurable benefit of palliative care programs for critically ill patients may be the increased use of hospice facilities, as opposed to decreased healthcare use during an ICU-associated hospitalization.
Assuntos
Estado Terminal/terapia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Hospitais , Cuidados Paliativos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Nutrição Enteral/estatística & dados numéricos , Feminino , Gastrostomia/estatística & dados numéricos , Hospitais para Doentes Terminais , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise Multinível , New York , Razão de Chances , Nutrição Parenteral/estatística & dados numéricos , Alta do Paciente , Diálise Renal/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Traqueostomia/estatística & dados numéricos , Adulto JovemRESUMO
INTRODUCTION: Tracheostomy is a commonly performed procedure. The aim of this study was to assess professional practice, describe patient characteristics and examine short and long-term outcomes. METHODS: All patients with CCAM GEPA004 code were retrospectively included. RESULTS: Two hundred and fourteen (7%) patients who were mecanically ventilated had a tracheostomy performed in intensive care unit (ICU). Median time to tracheostomy was 22 (14-28) days. In total, 95.3% of tracheostomy procedures were surgical. Median age was 58 (48-67) years. Eighty-three (38.8%) tracheostomies were performed for respiratory reasons. Twenty-eight-day and 90-day mortality were 4.2% and 35.5%. One-year mortality was 52.4%. Patients with tracheostomies performed for weaning from mechanical ventilation had a higher mortality rate. After ICU discharge, mortality rate was 29.8% and was higher in non-decannulated patients. Patient characteristics, timing, technique, indication and outcomes were stable over the years. CONCLUSION: Young patients weaning from mechanical ventilation were more likely to receive a tracheostomy. More than half died during the first year. Patients discharged from ICU with a tracheostomy tube in place had higher mortality rate.
Assuntos
Cuidados Críticos/métodos , Cuidados Críticos/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Traqueostomia/estatística & dados numéricos , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Desmame do Respirador/estatística & dados numéricosRESUMO
Care coordination programs are important in caring for medically complex pediatric patients, particularly for children with special health care needs. This study is a retrospective financial analysis of a hospital-based care coordination program involving one procedural subgroup of children with special health care needs: those receiving pediatric tracheostomy. Hospital records were reviewed for patients who received a tracheostomy at a large Midwestern U.S. hospital from 1999 through 2015. The population was divided into two subgroups: patients who received a tracheostomy before the development of a care coordination program and patients who received a tracheostomy after enrollment in the care coordination program. Patient records were reviewed for length of stay, readmissions related to respiratory and tracheostomy management, and total hospital charges. Enrollment in a care coordination program for the pediatric tracheostomy patient resulted in a decrease in mean length of stay and reduced hospital charges and a slight increase in readmissions. Further analysis using larger sample sizes and multiple centers is necessary to determine whether such outcomes are the direct result of enrollment in a care coordination program.
Assuntos
Continuidade da Assistência ao Paciente/economia , Hospitais Pediátricos/economia , Tempo de Internação/economia , Assistência Centrada no Paciente/economia , Doenças Respiratórias/terapia , Traqueostomia , Criança , Pré-Escolar , Crianças com Deficiência , Feminino , Grupos Focais , Custos de Cuidados de Saúde , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Meio-Oeste dos Estados Unidos , Avaliação de Programas e Projetos de Saúde , Doenças Respiratórias/economia , Estudos Retrospectivos , Traqueostomia/economia , Traqueostomia/estatística & dados numéricosRESUMO
Importance: More than 80% of older patients die or are seriously impaired within 1 year after severe traumatic brain injury (TBI). Given their poor survival, information about end-of-life care is a relevant marker of high-value trauma care for these patients. In-hospital mortality is commonly used to measure quality of trauma care; however, it is not known what type of end-of-life care hospitals with the best survival outcomes provide to those who die. Objective: To determine whether end-of-life care for older patients with TBI is correlated with in-hospital mortality. Design, Setting, and Participants: A retrospective cohort study using 2005-2011 national Medicare claims from acute care hospitals was conducted. Medicare beneficiaries aged 65 years or older who were admitted with serious or severe TBI were included. Transferred patients, those treated at low-volume hospitals, and those who died on the date of admission were excluded. Low-mortality hospitals were those in the lowest quartile for in-hospital mortality using standardized mortality rates adjusting for age, sex, race/ethnicity, comorbidity, and injury severity. Patients at low-mortality hospitals were compared with patients at all other hospitals. The study was conducted from January 2005 to December 2011. Data analysis was conducted between August 2016 and February 2017. Main Outcomes and Measures: End-of-life care outcomes for patients who died in hospital or 30 days or less after discharge included gastrostomy and tracheostomy placement during the TBI admission and enrollment in hospice. Results: Of 363 hospitals included in the analysis, 91 (25.1%) were designated as low-mortality. The cohort included 34â¯691 patients (median age, 79 years; interquartile range, 72-84 years; 40.8% women). Of these patients, 55.8% of those at low-mortality hospitals and 62.5% at all other hospitals died in the hospital or 30 days or less after discharge (P < .01). Among patients who died in the hospital (n = 16â¯994), end-of-life care was similar at low-mortality hospitals and all other hospitals. For patients who survived the TBI admission and died 30 days or less after discharge (n = 4027), those at low-mortality hospitals underwent fewer gastrostomy (15.9% vs 24.0%; adjusted OR, 0.61; 95% CI, 0.52-0.72) or tracheostomy (18.2% vs 24.9%; adjusted OR, 0.71; 95% CI, 0.60-0.83) procedures and received more hospice care (66.3% vs 52.5%; adjusted OR, 1.72; 95% CI, 1.50-1.96). Conclusions and Relevance: For older patients with serious or severe TBI, hospitals with the lowest in-hospital mortality perform fewer high-intensity treatments at the end of life and enroll more patients in hospice without increasing cumulative mortality 30 days or less after discharge.