Increasing Frequency of Interpreting Services is Associated With Shorter Peri-operative Length of Stay.

BACKGROUND: Patients with limited English proficiency have barriers to accessing care. Rather than a binary use or no use, this study uses granular data on frequency of interpreting services to determine if this frequency is associated with differences in peri-operative length of stay for patients with limited English proficiency. MATERIALS AND METHODS: This is a cross sectional study on length of stay for peri-operative admissions of at least one night during 2018, for patients who used medical interpreting services in an academic medical center in Boston, Massachusetts. The participants are split into quartiles of ascending number of interpreting events per day. The exposure for the primary outcome is the frequency of interpreting events per day during peri-operative admission. The primary study outcome measurement is peri-operative length of stay in days. RESULTS: There was a statistically significant decrease in length of stay for patients in the highest two quartiles of interpreting service frequency, compared to the lowest quartile: quartile 2 trended shorter by 1.4 d (95% CI -4.5 to 1.7, P = 0.37), quartile 3 was 4.2 d shorter (95% CI -7.6 to -0.7, P = 0.02), and quartile 4 was 4.6 d shorter (95% CI -8.1 to -1.1, P = 0.01). CONCLUSIONS: More frequent interpreting services per day during peri-operative admission are associated with shorter length of stay in adjusted analysis. The findings merit further study in an intervention to increase use of interpreting services for surgical patients with limited English proficiency to study the impact of increased frequency of culturally competent care.

Continuous renal replacement therapy: individualization of the prescription.

PURPOSE OF REVIEW: Continuous renal replacement therapy (CRRT) is now the mainstay of renal organ support in the critically ill. As our understanding of CRRT delivery and its impact on patient outcomes improves there is a focus on researching the potential benefits of tailored, patient-specific treatments to meet dynamic needs. RECENT FINDINGS: The most up-to-date studies investigating aspects of CRRT prescription that can be individualized: CRRT dose, timing, fluid management, membrane selection, anticoagulation and vascular access are reviewed. The use of different doses of CRRT lack conventional high-quality evidence and importantly studies reveal variation in assessment of dose delivery. Research reveals conflicting evidence for clinicians in distinguishing which patients will benefit from 'watchful waiting' vs. early initiation of CRRT. Both dynamic CRRT dosing and precision fluid management using CRRT are difficult to investigate and currently only observational data supports individualization of prescriptions. Similarly, individualization of membrane choice is largely experimental. SUMMARY: Clinicians have limited evidence to individualize the prescription of CRRT. To develop this, we need to understand the requirements for renal support for individual patients, such as electrolyte imbalance, fluid overload or clearance of systemic inflammatory mediators to allow us to target these abnormalities in appropriately designed randomized trials.

Incidence, aetiology and outcome of community-acquired acute kidney injury in medical admissions in Malawi.

BACKGROUND: Epidemiological data on Acute Kidney Injury (AKI) from low-income countries is sparse. The aim of this study was to establish the incidence, severity, aetiology, and outcomes of community-acquired AKI in Malawi. METHODS: We conducted a prospective observational study of general medical admissions to a tertiary hospital in Blantyre between 27th April and 17th July 2015. All patients were screened on admission with a serum creatinine; those with creatinine above laboratory reference range were managed by the nephrology team. Hospital outcome was recorded in all patients. RESULTS: Eight hundred ninety-two patients were included; 188 (21 · 1%) had kidney disease on admission, including 153 (17 · 2%) with AKI (median age 41 years; 58 · 8% HIV seropositive). 60 · 8% of AKI was stage 3. The primary causes of AKI were sepsis and hypovolaemia in 133 (86 · 9%) cases, most commonly gastroenteritis (n = 29; 19 · 0%) and tuberculosis (n = 18; 11 · 8%). AKI was multifactorial in 117 (76 · 5%) patients; nephrotoxins were implicated in 110 (71 · 9%). Inpatient mortality was 44 · 4% in patients with AKI and 13 · 9% if no kidney disease (p <0.0001). 63 · 2% of patients who recovered kidney function left hospital with persistent kidney injury. CONCLUSION: AKI incidence is 17 · 2% in medical admissions in Malawi, the majority is severe, and AKI leads to significantly increased in-hospital mortality. The predominant causes are infection and toxin related, both potentially avoidable and treatable relatively simply. Effective interventions are urgently required to reduce preventable young deaths from AKI in this part of the world.

Implementation of a Simplified Regional Citrate Anticoagulation Protocol for Post-Dilution Continuous Hemofiltration Using a Bicarbonate Buffered, Calcium Containing Replacement Solution.

BACKGROUND/AIMS: Recent updates to the Nikkiso Aquarius continuous renal replacement therapy (CRRT) platform allowed us to develop a post-dilution protocol for regional citrate anticoagulation (RCA) using standard bicarbonate buffered, calcium containing replacement solution with acid citrate dextrose formula-A as a citrate source. Our objective was to demonstrate that the protocol was safe and effective. METHODS: Prospective audit of consecutive patients receiving RCA for CRRT within intensive care unit, who were either contraindicated to heparin or had poor filter lifespan (<12 h for 2 consecutive filters) on heparin. RESULTS: We present the first 29 patients who used 98 filters. After excluding 'non-clot' filter loss, 50% had a duration of >27 h. Calcium supplementation was required for 30 (30%) filter circuits, in 17 of 29 (58%) patients. One patient discontinued the treatment due to metabolic alkalosis, but there were no adverse bleeding events. CONCLUSION: Post-dilution RCA system is effective and simple to use on the Aquarius platform and results in comparable filter life for patients relatively contraindicated to heparin.

Anti-Xa activity supports using a simple dosing algorithm for tinzaparin for anticoagulation in hemodialysis.

BACKGROUND: Unfractionated heparin has been traditionally used for anticoagulation during hemodialysis (HD), but more recently low-molecular-weight heparin (LMWH) is being used as an alternative. Anti-Xa activity can be measured as a surrogate of LMWH efficacy. We present 52 patients treated with tinzaparin anticoagulation on HD, confirming that fixed dosing is safe and efficacious with sound pharmacodynamic reason in relation to anti-Xa profiling. METHODS: We undertook a prospective audit in a single dialysis unit. All patients were established on a simple anticoagulation protocol for at least 1 month prior to the audit. Blood anti-Xa activity was measured at time 0, 30, 60 and 120 min into and at the end of HD. Efficacy and safety data were collected on the study day and the two sessions before and after it. RESULTS: Fifty-two patients were included in the efficacy and safety analysis with 43 patients undergoing anti-Xa analysis (9 sampling errors). Using current consensus (an end-HD anti-Xa activity of <0.4 IU/ml), our fixed-dose protocol resulted in satisfactory safety in all patients tested. Of 260 HD sessions, 10 (4%) had reduced tinzaparin efficacy. During 105 dialysis sessions (21 patients) using an arteriovenous fistula, 4 patients had one episode of minor bleeding and there were 6 episodes (2 patients) of post-needle-compression time greater than 15 min. CONCLUSION: Tinzaparin administered thrice weekly as a fixed dose has good efficacy and is well tolerated as an anticoagulant during HD when used according to our protocol.

Anticoagulation prescription among atrial fibrillation patients managed with and without an anticoagulant initiation pathway: a cohort study.

BACKGROUND AND IMPORTANCE: The Canadian Association of Emergency Physicians atrial fibrillation (AF) checklist advises that emergency physicians initiate anticoagulation therapy for patients with AF or flutter who are CHADS65 positive. OBJECTIVES: The aim was to compare anticoagulation initiation rates between patients treated with and without an anticoagulation assessment pathway (the SAFE pathway). DESIGN: This was a retrospective cohort study. SETTINGS AND PARTICIPANTS: All emergency department patients were discharged home with a diagnosis of AF between June 2018 and May 2020 at two Canadian emergency departments. INTERVENTION: The SAFE pathway is a hard copy form which allows emergency physicians to document contraindications to anticoagulation, the positive components of the CHADS65 score, and details how to prescribe anticoagulation. OUTCOME MEASURES AND ANALYSIS: Trained researchers abstracted data on the use of the SAFE pathway by the presence or absence of the completed, scanned pathway in the electronic medical chart. The exposure of interest was use of this pathway. Patients were followed forward in time for 90 days by electronic medical record review to document stroke, transient ischemic attack, arterial embolism and major bleeding events. All events were independently adjudicated. Adjusted odds ratios were calculated to compare outcomes between those managed with and without the SAFE pathway. RESULTS: In total, 766 patients were included, of whom 264 were already taking anticoagulation, 166 were CHADS65 negative and 65 had a contraindication to anticoagulation, leaving 271 patients eligible for anticoagulation prescription. Among the 271 eligible patients, 137/166 managed with the SAFE pathway were initiated on anticoagulation and 24/105 managed without the SAFE pathway started anticoagulation (adjusted odds ratio 25.9; 13.1-51.2). There was no statistically significant difference in the 90-day rate of stroke or bleeding. CONCLUSION: Use of the SAFE pathway was associated with a higher rate of anticoagulation prescription.

Addressing virtual care disparities for patients with limited English proficiency.

During a surge of COVID-19 cases, the majority of care delivery at a large academic medical center moved to virtual care. Due to COVID-19-associated regulatory changes, virtual care is now delivered through telephone and videoconferencing platforms. Although virtual platforms allow patients to access care while socially distancing, patients with limited English proficiency (LEP) face structural barriers to these platforms, including lack of access to technology, need for medical interpreters, unfriendly patient portals, and increased privacy concerns. Strategies for increasing access to virtual platforms and technology for patients with LEP included offering patient education in multiple languages, reducing barriers to patient portal enrollment, and addressing the technology literacy gap through the use of tablets and bilingual interns. Strategies for addressing privacy concerns for patients with LEP included developing a low-literacy script and other actions that address patient concerns about Immigration and Customs Enforcement and mitigate perceived risk, as well as identifying a virtual platform that meets privacy regulations and does not require a patient to download an application to their phone or computer to join. Strategies for integrating medical interpreters into virtual visits included assessing existing virtual platforms for the ability to host a third party, changing the electronic health record software (Epic) interface, and convening directors of interpreter departments at each site to ensure comprehensive system rollout. Health care organizations that rely heavily on virtual visits to provide patient care will need to take all these challenges into consideration for patients with LEP.

Filter life span in postoperative cardiovascular surgery patients requiring continuous renal replacement therapy, using a postdilution regional citrate anticoagulation continuous hemofiltration circuit.

BACKGROUND: Regional citrate anticoagulation (RCA) is the recommended standard for continuous renal replacement therapy (CRRT). This study assesses its efficacy in patients admitted to critical care following cardiovascular surgery and the influence of standard antithrombotic agents routinely used in this specific group. METHODS: Consecutive cardiovascular surgery patients treated with postdilution hemofiltration with RCA were included in this prospective observational study. The primary outcome of the study was CRRT circuit life-span adjusted for reasons other than clotting. The secondary outcome evaluated the influence of standard antithrombotic agents (acetylsalicylic acid [ASA], low molecular weight heparin [LMWH] or fondaparinux as thromboprophylaxis or treatment dose with or without ASA) on filter life. RESULTS: Fifty-two patients underwent 193 sessions of continous veno-venous hemofiltration, after exclusion of 15 sessions where unfractionated heparin was administered. The median filter life span was 58 hours. Filter life span was significantly longer in patients receiving therapeutic dose of LMWH or fondaparinux (79 h [2-110]), in comparison to patients treated with prophylactic dose of LMWH or fondaparinux (51 h [7-117], p < 0.001), and patients without antithrombotic prophylaxis (42 h [2-91], p < 0.0001). 12 bleeding episodes were observed; 8 occurred in patients receiving treatment dose anticoagulation, 3 in patients receiving prophylactic dose anticoagulation and 1 in a patient with no antithrombotic prophylaxis. CONCLUSIONS: A postdilution hemofiltration with RCA provides prolonged filter life span when adjusted for reasons other than clotting. Patients receiving treatment dose anticoagulation had a significantly longer filter life span than those who were on prophylactic doses or ASA alone.

Acute kidney injury in COVID-19: multicentre prospective analysis of registry data.

BACKGROUND: Acute kidney injury (AKI) is a common and important complication of coronavirus disease 2019 (COVID-19). Further characterization is required to reduce both short- and long-term adverse outcomes. METHODS: We examined registry data including adults with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to five London Hospitals from 1 January to 14 May 2020. Prior end-stage kidney disease was excluded. Early AKI was defined by Kidney Disease: Improving Global Outcomes creatinine criteria within 7 days of admission. Independent associations of AKI and survival were examined in multivariable analysis. Results are given as odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals. RESULTS: Among 1855 admissions, 455 patients (24.5%) developed early AKI: 200 (44.0%) Stage 1, 90 (19.8%) Stage 2 and 165 (36.3%) Stage 3 (74 receiving renal replacement therapy). The strongest risk factor for AKI was high C-reactive protein [OR 3.35 (2.53-4.47), P < 0.001]. Death within 30 days occurred in 242 (53.2%) with AKI compared with 255 (18.2%) without. In multivariable analysis, increasing severity of AKI was incrementally associated with higher mortality: Stage 3 [HR 3.93 (3.04-5.08), P < 0.001]. In 333 patients with AKI surviving to Day 7, 134 (40.2%) recovered, 47 (14.1%) recovered then relapsed and 152 (45.6%) had persistent AKI at Day 7; an additional 105 (8.2%) patients developed AKI after Day 7. Persistent AKI was strongly associated with adjusted mortality at 90 days [OR 7.57 (4.50-12.89), P < 0.001]. CONCLUSIONS: AKI affected one in four hospital in-patients with COVID-19 and significantly increased mortality. Timing and recovery of COVID-19 AKI is a key determinant of outcome.

Treating Posttransplant Anemia With Erythropoietin Improves Quality of Life but Does Not Affect Progression of Chronic Kidney Disease.

OBJECTIVES: Posttransplant anemia affects 30% to 45% of kidney transplant recipients and is associated with increased morbidity. However, there is lack of evidence about safe hemoglobin levels after erythropoietin treatment. Studies are needed to better understand the potential benefits and risks, as well as to define safe target hemoglobin ranges in these patients. MATERIALS AND METHODS: In this single-center exploratory, open-label randomized controlled trial, kidney trans-plant recipients with anemia 3 months posttransplant were either treated with epoetin beta to a hemoglobin target level of 11.5 to 13.5 g/dL (n = 28) or given no treatment (n = 27). Treatment effects on graft function and health quality of life were assessed. RESULTS: After 2 years, hemoglobin concentrations were significantly higher in the epoetin beta treatment group than in the no treatment group (12.3 ± 0.18 vs 9.99 ± 0.22 g/dL; P < .0001). Estimated glomerular filtration rate, calculated by Modified Diet in Renal Disease 7, declined by 1.7 mL/min (interquartile range, -6 to 4.24) in the epoetin treatment group and by 4.16 mL/min (interquartile range, -12.42 to 2.78) in the no treatment group (P = .32). Rate of progression, determined by estimated glomerular filtration rate slope, was not significantly different between groups (-0.09 ± 0.1 vs -0.12 ± 0.15 mL/min for treated vs not treated; P = .78). Moreover, we observed no significant differences in proteinuria and blood pressure. Treated patients had greater improvements in the vitality and mental health domains of the Medical Outcomes Short Form Health Survey quality of life scores. CONCLUSIONS: Treatment of anemia in kidney transplant recipients to a hemoglobin level of 11.5 to 13.5 g/dL with erythropoietin improves some quality of life scores. The treatment was safe and not associated with adverse outcomes. There were no changes in rate of decline of graft function.

Managing Chloride and Bicarbonate in the Prevention and Treatment of Acute Kidney Injury.

Intravenous crystalloid therapy is one of the most ubiquitous aspects of hospital and critical care medicine. In recent years, there has been increasing focus on the electrolyte composition, and particularly chloride content, of crystalloid solutions. This has led to increasing clinical adoption of balanced solutions, containing substrates for bicarbonate generation and consequently a lower chloride content, in place of 0.9% saline. In this article we review the physiochemical rationale for avoidance of 0.9% saline and the effects of hyperchloremic acidosis on renal physiology. Finally, we review the current evidence and rationale for use of balanced solutions greater than 0.9% saline in acutely ill patients in a variety of clinical settings, as well as considering the role for sodium bicarbonate in preventing or correcting metabolic acidosis. In conclusion, there is a strong physiological rationale for avoidance of iatrogenic hyperchloremic acidosis from 0.9% saline administration in acutely unwell patients and an association with adverse renal outcomes in several studies. However, evidence from large definitive multicenter randomized trials is not yet available to establish the dose-relationship between 0.9% saline administration and potential harm and inform us if some 0.9% saline use is acceptable or if any exposure confers harm.

Challenges and opportunities caring for neurology outpatients across language differences.

BACKGROUND: With over 66 million Americans who speak over 350 languages other than English at home, we sought to examine attitudes and behaviors of neurology clinicians and staff when communicating across language differences. METHODS: We conducted an electronic-enabled cross-sectional survey of clinicians and patient services coordinators working at an academic neurology outpatient clinic. Questions focused on professional medical interpreter (PMI) services usage, satisfaction, and perceived barriers to utilization. RESULTS: A total of 82/235 (35%) neurology clinicians and 24/52 (46%) coordinators met the study eligibility criteria. Most clinicians (96%) reported seeing at least 1 non-English-speaking patient and using PMI services (85%) in the last month. Most commonly self-reported interpretation modalities were face-to-face PMI services (39%) and patients' family members or friends (28%). Perceived barriers to using PMI included time constraints (60%) and lack of available face-to-face PMI (51%). Among patient services coordinators, 33% reported consistently asking patients their preferred language and 50% if they needed a PMI for appointments. Most respondents (77% clinicians and 71% coordinators) were satisfied with PMI services. Recommendations included having more available face-to-face PMI, greater coordinated efforts to preschedule PMI, and more education on the effective use of PMI. CONCLUSIONS: More than 70% of outpatient neurology clinicians and patient services coordinators were satisfied with PMI. However, their perceived barriers and reported practices suggest a need for updated policies and education to improve the use of PMI services.

The incidence and associations of acute kidney injury in trauma patients admitted to critical care: A systematic review and meta-analysis.

BACKGROUND: As more patients are surviving the initial effects of traumatic injury clinicians are faced with managing the systemic complications of severe tissue injury. Of these, acute kidney injury (AKI) may be a sentinel complication contributing to adverse outcomes. OBJECTIVE: To establish the incidence of AKI in patients admitted to critical care after major trauma, to explore any risk factors and to evaluate the association of AKI with outcomes. DATA SOURCES: Systematic search of MEDLINE, Excerpta Medica database and Cochrane library from January 2004 to April 2018. STUDY SELECTION: Studies of adult major trauma patients admitted to critical care that applied consensus AKI criteria (risk injury failure loss end stage [RIFLE], AKI network, or kidney disease improving global outcomes) and reported clinical outcomes were assessed (PROSPERO Registration: CRD42017056781). Of the 35 full-text articles selected from the screening, 17 (48.6%) studies were included. DATA EXTRACTION AND SYNTHESIS: We followed the PRISMA guidelines and study quality was assessed using the Newcastle-Ottawa score. The pooled incidence of AKI and relative risk of death were estimated using random-effects models. MAIN OUTCOMES AND MEASURES: Incidence of AKI was the primary outcome. The secondary outcome was study-defined mortality. RESULTS: We included 17 articles describing AKI outcomes in 24,267 trauma patients. The pooled incidence of AKI was 20.4% (95% confidence interval [CI], 16.5-24.9). Twelve studies reported the breakdown of stages of AKI with 55.7% of patients classified as RIFLE-R or stage 1, 30.3% as RIFLE-I or stage 2, and 14.0% as RIFLE-F or stage 3. The pooled relative risk of death with AKI compared was 3.6 (95% CI, 2.4-5.3). In addition, there was a concordant increase in odds of death among six studies that adjusted for multiple variables (adjusted odds ratio, 2.7; 95% CI, 1.9-3.8; p = <0.01). CONCLUSION: Acute kidney injury is common after major trauma and associated with increased mortality. Future research is warranted to reduce the potential for harm associated with this subtype of AKI. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

Perioperative management of adult cadaveric and live donor renal transplantation in the UK: a survey of national practice.

BACKGROUND: There is a limited evidence base and no national consensus regarding the perioperative management of patients undergoing renal transplantation. We developed an electronic survey to capture an overview of renal transplant perioperative practice across UK renal transplant centres and determine the need for future guidelines on patient management. METHODS: A 29-question survey was developed to encompass the entire renal transplant perioperative pathway and input was sought from clinicians with expertise in renal transplant surgery, anaesthesia, nephrology and intensive care. The survey was sent to lead renal anaesthetists at each of the 23 transplant centres across the UK. RESULTS: A 96% response rate was achieved with 22 out of 23 centres returning complete responses. There was limited evidence of guideline-based approaches to preoperative workup. Questions regarding intraoperative fluid management, blood pressure targets, vasopressor administration and central venous pressure (CVP) monitoring identified a broad range of practice. Of note, the routine use of goal-directed fluid therapy based on cardiac output estimation was reported in six (27.3%) centres, while nine centres (40.9%) continue to target a specific CVP intraoperatively. In all, 12 (54.5%) centres perform transversus abdominis plane blocks with fentanyl-based patient-controlled analgesia as the most common mode of postoperative analgesia. A single centre reported a renal transplant-specific Enhanced Recovery after Surgery programme for cadaveric organ recipients. CONCLUSIONS: This questionnaire highlighted a high degree of heterogeneity in current UK practice as regards the perioperative management of renal transplant recipients. Development of evidence-based national consensus guidelines to standardize the perioperative care of these patients is recommended in order to improve patient outcomes and focus areas of future research.

The junior doctor contract 2 years on: one trust's experience of exception reporting.

The new junior doctor contract allows trainees to exception report when they breach safe working hours. After a full year of foundation year 1 rotations, analysis from a large NHS trust in London showed that exception reporting works to highlight rota and working issues. It is unsurprising that trainees are busy but simple things such as competent infrastructure and senior support could go a long way to improving working conditions. In addition, results from a local survey suggest that trainees think the new contract is less safe for both doctors and patients, with inflexibility of rota patterns having a significant impact on the ability to take annual and study leave. A drive to modernise the way health care is delivered in hospitals is needed as a shortage of doctors will only worsen the situation.