A Description of Mechanically Ventilated Patients Admitted From the Emergency Department With a Short Critical Care Stay.

BACKGROUND: Patients admitted to an intensive care unit (ICU) requiring invasive mechanical ventilation who are discharged alive from the ICU within 24 h are poorly characterized in the literature. OBJECTIVE: Our aim was to characterize a cohort of intubated emergency department (ED) patients who are extubated and discharged from the ICU within 24 h. METHODS: We conducted a retrospective, observational cohort study at a single level I trauma center from January 2017 to December 2019. We included adults who were admitted to an ICU from the ED requiring invasive mechanical ventilation. Our primary outcome was the proportion of patients who were discharged from the ICU alive within 24 h. RESULTS: Of 13,374 ED patients admitted to an ICU during the study period, 2871 patients were intubated and ventilated in the prehospital or ED settings. Of these, 14% were discharged alive from the ICU within 24 h of admission. Only 21% of these patients were intubated in the ED. We identified the following two distinct subpopulations comprising 62% of this short-stay group: patients with a primary discharge diagnosis of intoxication (47%) and minimally injured trauma patients (53%), with 4% of patients in both subgroups. CONCLUSIONS: A total of 14% of patients receiving intubation with mechanical ventilation in the prehospital environment or in the ED were discharged alive from the ICU within 24 h. We identified two distinct subgroups of patients with a short stay in intensive care who may be candidates for ED extubation, including patients with intoxication and minimally injured trauma patients.

Association of Psychosocial Factors and Hospital Complications with Risk for Readmission After Trauma.

BACKGROUND: Unplanned hospital readmissions are associated with morbidity and high cost. Existing literature on readmission after trauma has focused on how injury characteristics are associated with readmission. We aimed to evaluate how psychosocial determinants of health and complications of hospitalization combined with injury characteristics affect risk of readmission after trauma. MATERIALS AND METHODS: We conducted a retrospective cohort study of adult trauma admissions from July 2015 to September 2017 to Harborview Medical Center in Seattle, Washington. We assessed patient, injury, and hospitalization characteristics and estimated associations between risk factors and unplanned 30-d readmission using multivariable generalized linear Poisson regression models. RESULTS: Of 8916 discharged trauma patients, 330 (3.7%) had an unplanned 30-d readmission. Patients were most commonly readmitted with infection (41.5%). Independent risk factors for readmission among postoperative patients included public insurance (adjusted Relative Risk (aRR) 1.34, 95% CI 1.02-1.76), mental illness (aRR 1.39, 1.04-1.85), and chronic renal failure (aRR 2.17, 1.39-3.39); undergoing abdominal, thoracic, or neurosurgical procedures; experiencing an index hospitalization surgical site infection (aRR 4.74, 3.00-7.50), pulmonary embolism (aRR 3.38, 2.04-5.60), or unplanned ICU readmission (aRR 1.74, 1.16-2.62); shorter hospital stay (aRR 0.98/d, 0.97-0.99), and discharge to jail (aRR 4.68, 2.63-8.35) or a shelter (aRR 4.32, 2.58-7.21). Risk factors varied by reason for readmission. Injury severity, trauma mechanism, and body region were not independently associated with readmission risk. CONCLUSIONS: Psychosocial factors and hospital complications were more strongly associated with readmission after trauma than injury characteristics. Improved social support and follow-up after discharge for high-risk patients may facilitate earlier identification of postdischarge complications.

Clinical Experience With a Dedicated Neurocritical Care Quality Improvement Program in an Academic Medical Center.

Background Managing neurocritical care patients encompasses many complex challenges, necessitating specialized care and continuous quality improvement efforts. In recent years, the focus on enhancing patient outcomes in neurocritical care may have led to the development of dedicated quality improvement programs. These programs are designed to systematically evaluate and refine care practices, aligning them with the latest clinical guidelines and research findings. Objective To describe the structure, processes, and outcomes of a dedicated Neurocritical Care Quality Improvement Program (NCC-QIP) at Harborview Medical Center, United States; a quaternary academic medical center, level I trauma, and a comprehensive stroke center. Materials and methods We describe the development of the NCC-QIP, its structure, function, challenges, and evolution. We examine our performance with several NCC-QI quality measures as proposed by the Joint Commission, the American Association of Neurology, and the Neurocritical Care Society, self-reported quality improvement (QI) concerns and QI initiatives undertaken because of the information obtained during our event/measure reporting process for patients admitted between 1/1/2014 and 06/30/2023. Results The NCC-QI reviewed data from 20,218 patients; mean age 57.9 (standard deviation 18.1) years, 56% (n=11,326) males, with acute ischemic stroke (AIS; 22.3%, n=4506), spontaneous intracerebral hemorrhage (ICH; 14.8%, n=2,996), spontaneous subarachnoid hemorrhage (SAH; 8.9%, n=1804), and traumatic brain injury (TBI; 16.6%, n=3352) among other admissions, 37.4% (n=7,559) were mechanically ventilated, and 13.6% (n=2,753) received an intracranial pressure monitor. The median intensive care unit length of stay was two days (Quartile 1-Quartile 3: 2-5 days), and the median hospital length of stay was seven days (Quartile 1-Quartile 3: 3-14 days); 53.9% (n=10,907) were discharged home while 11.4% (2,309) died. The three most commonly reported QI concerns were related to care coordination/communication/handoff (40.4%, n=283), medication-related concerns (14.9%, n=104), and equipment/devices-related concerns (11.7%, n=82). Hospital-acquired infections were in the form of ventilator-associated pneumonia (16.3%, n=419/2562), ventriculostomy catheter-associated infections (4%, n=102/2246), and deep venous thrombosis/pulmonary embolism (3.2%, n=647). The quality metrics documentation was as follows: nimodipine after SAH (99.8%, 1802/1810), Hunt and Hess score (36%, n=650/1804), and ICH score (58.4% n=1752/2996). In comparison, 72% (n=3244/4506) of patients with AIS had a documented National Institute of Health Stroke Scale. Admission Glasgow Coma Score was recorded in 99% of patients with SAH, ICH, and TBI. Educational modules were implemented in response to event reporting. Conclusion A dedicated NCC-QIP can be successfully implemented at a quaternary medical medical center. It is possible to monitor and review a large volume of neurocritical care patients, The three most reported NCC-QI concerns may be related to care coordination-communication/handoff, medication-related concerns, and equipment/devices-related complications. The documentation of illness severity scores and stroke measures depends upon the type of measure and ability to reliably and accurately abstract and can be challenging. The quality improvement process can be enhanced by educational modules that reinforce quality and safety.

Incidence and Risk Model of Venous Thromboembolism in Patients with Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Venous thromboembolism (VTE) is a significant source of morbidity and mortality in hospitalized patients. We describe our experience with VTE prophylaxis and treatment in patients with aneurysmal subarachnoid hemorrhage (aSAH), risk factors for VTE, and a hazard model describing the daily risk of VTE. METHODS: A retrospective cohort study was performed on patients with aSAH admitted from 2014 to 2018. Patients were screened for VTE based on clinical suspicion. Demographics, perioperative data, and in-hospital data were assessed as risk factors for VTE using survival analysis with death as a competing risk. RESULTS: Among 485 patients, the overall incidence of VTE, deep vein thrombosis, and pulmonary embolism were 5.6%, 4.3%, and 2.3%, respectively. Increasing length of stay in the intensive care unit (hazard ratio [HR], 1.79; P < 0.0001; 95% confidence interval [CI], 1.49-2.16) and ventilation immediately after aneurysm treatment was associated with VTE (HR, 8.87; P < 0.01; 95% CI, 1.86-42.38). Hunt and Hess grade was negatively associated with VTE (HR, 0.61; P = 0.045; 95% CI, 0.37-1.00) due to its increased association with the competing risk of death (HR, 2.57; P < 0.0001; 95% CI, 1.89-3.49). The adjusted 4-year cumulative incidence for VTE is 11.1% and at mean day of hospital discharge is 5.4%. Treatment of VTEs with anticoagulation and/or inferior vena cava filter placement was not associated with immediate complications. CONCLUSIONS: We describe the largest single-institution cohort of VTEs in aSAH patients. Our hazard model quantifies the cumulative incidence of VTEs during the course of hospitalization. We suggest a standardized protocol for screening, prophylaxis, and treatment of VTEs in this patient population.

The Association Between Illness Severity Scores and In-hospital Mortality After Aneurysmal Subarachnoid Hemorrhage.

INTRODUCTION: The purpose of this study was to examine the association with in-hospital mortality of 8 illness severity scores in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: In a retrospective cohort study, we investigated the association with in-hospital mortality of admission Hunt and Hess (HH) score, Fisher grade, severity of illness and risk of mortality scores, and serial Glasgow coma scale (GCS) score in patients with aSAH. We also explored the changes in GCS between admission and discharge using a multivariate model adjusting for age, clinical vasospasm, and external ventricular drain status. RESULTS: Data from 480 patients with aSAH, of which 383 (79.8%) aneurysms were in the anterior circulation, were included in analysis. Patients were female (n=340, 70.8%) with a median age of 56 (interquartile range: 48 to 66) years. The majority (n=332, 69.2%) had admission HH score 3 to 5, Fisher grade 3 to 4 (n=437, 91%), median severity of illness 3 (range: 1 to 4), median risk of mortality 3 (range: 1 to 4), and median admission GCS of 13 (interquartile range: 7 to 15). Overall, 406 (84.6%) patients received an external ventricular drain, 469 (97.7%) underwent aneurysm repair, and 60 died (12.5%). Compared with admission HH score, GCS 24 hours after admission (area under the curve: 0.84, 95% confidence interval [CI]: 0.79-0.88) and 24 hours after aneurysm repair (area under the curve: 0.87, 95% CI: 0.82-0.90) were more likely to be associated with in-hospital mortality. Among those who died, the greatest decline in GCS was noted between 24 hours after aneurysm repair and discharge (-3.38 points, 95% CI: -4.17, -2.58). CONCLUSIONS: Compared with admission HH score, GCS 24 hours after admission (or 24 h after aneurysm repair) is more likely to be associated with in-hospital mortality after aSAH.

Using an electronic medical record tool to improve pneumococcal screening and vaccination rates for older patients admitted with community-acquired pneumonia.

An electronic medical record tool was developed that determines if a patient meets criteria for screening for the vaccine; it then poses a series of screening questions. Use of the tool has improved performance on pneumococcal vaccination from 44% to more than 90%, with an increase in vaccine units of 305%.

Analysis of Risk Factors for Patient Readmission 30 Days Following Discharge From General Surgery.

IMPORTANCE: Previous studies investigating patients at risk for hospital readmissions focus on medical services and have found chronic conditions as contributors. Little is known, however, of the characteristics of patients readmitted from surgical services. OBJECTIVE: Surgical patients readmitted within 30 days following discharge were analyzed to identify opportunities for intervention in a cohort that may differ from the medical population. DESIGN, SETTING, AND PARTICIPANTS: Medical record review of patients readmitted to any service within 30 days of discharge from the general surgery service to characterize index and readmission data between July 1, 2014, and June 30, 2015, at a Level I trauma center and safety-net hospital. MAIN OUTCOMES AND MEASURES: Reasons for readmission identified by manual medical record review and risk factors identified via statistical analysis of all discharges during this period. RESULTS: One hundred seventy-three patients were identified as being unplanned readmissions within 30 days among 2100 discharges (8.2%). Of these 173 patients, 91 were men. Common reasons for readmission included 29 patients with injection drug use who were readmitted with soft tissue infections at new sites (16.8% of readmissions), 25 with disposition support issues (14.5%), 23 with infections not detectable during index admission (13.3%), and 16 with sequelae of their injury or condition (9.2%). Sixteen patients were identified as having a likely preventable complication of care (9.2%), and 2 were readmitted owing to deterioration of medical conditions (1.2%). On univariate and multivariate analyses, female sex (men to women risk of readmission odds ratio [OR], 0.5; 95% CI, 0.37-0.71; P < .001), presence of diabetes (OR, 1.7; 95% CI, 1.1-2.6; P = .009), sepsis on admission (OR, 1.7; 95% CI, 1.05-2.6; P = .03), or intensive care unit stay during index admission (OR, 1.7; 95% CI, 1.2-2.4; P = .002), as well as discharge to respite care (OR, 2.3; 95% CI, 1.2-4.5; P = .01) and payer status (Medicaid/Medicare compared with commercial OR, 2.0; 95% CI, 1.3-3.0; P = .002) , were identified as risk factors for readmission. CONCLUSIONS AND RELEVANCE: Many readmissions may be unavoidable in our current paradigms of care. While medical comorbidities are contributory, a large number of readmissions were not caused by suboptimal medical care or deterioration of medical conditions but by confounding issues of substance abuse or homelessness. Identification of the highest risk cohort for readmission can allow more targeted intervention for similar populations with socially challenged patients.

Patient safety measures in burn care: do National reporting systems accurately reflect quality of burn care?

Recently, much attention has been placed on quality of care metrics and patient safety. Groups such as the University Health-System Consortium (UHC) collect and review patient safety data, monitor healthcare facilities, and often report data using mortality and complication rates as outcomes. The purpose of this study was to analyze the UHC database to determine if it differentiates quality of care across burn centers. We reviewed UHC clinical database (CDB) fields and available data from 2006 to 2008 for the burn product line. Based on the September 2008 American Burn Association (ABA) list of verified burn centers, we categorized centers as American Burn Association-verified burn centers, self-identified burn centers, and other centers that are not burn units but admit some burn patients. We compared total burn admissions, risk pool, complication rates, and mortality rates. Overall mortality was compared between the UHC and National Burn Repository. The UHC CDB provides fields for number of admissions, % intensive care unit admission, risk pool, length of stay, complication profiles, and mortality index. The overall numbers of burn patients in the database for the study period included 17,740 patients admitted to verified burn centers (mean 631 admissions/burn center/yr or per 2 years), 10,834 for self-identified burn centers (mean 437 admissions/burn center/yr or per 2 years), and 1,487 for other centers (mean 11.5 admissions/burn center/yr or per 2 years). Reported complication rates for verified burn centers (21.6%), self-identified burn centers (21.3%), and others (20%) were similar. Mortality rates were highest for self-identified burn centers (3.06%), less for verified centers (2.88%), and lowest for other centers (0.74%). However, these outcomes data may be misleading, because the risk pool criteria do not include burn-specific risk factors, and the inability to adjust for injury severity prevents rigorous comparison across centers. Databases such as the UHC CDB provide a potential to benchmark quality of care. However, reporting quality data for trauma and burns requires stringent understanding of injury data collection. Although quality measures are important for improving patient safety and establishing benchmarks for complication and mortality rates, caution must be taken when applying them to specific product lines.