Variation in risk-adjusted cardiac intensive care unit (CICU) length of stay and the association with in-hospital mortality: An analysis from the Critical Care Cardiology Trials Network (CCCTN) registry.

BACKGROUND: Previous studies have suggested that there is wide variability in cardiac intensive care unit (CICU) length of stay (LOS); however, these studies are limited by the absence of detailed risk assessment at the time of admission. Thus, we evaluated inter-hospital differences in CICU LOS, and the association between LOS and in-hospital mortality. METHODS: Using data from the Critical Care Cardiology Trials Network (CCCTN) registry, we included 22,862 admissions between 2017 and 2022 from 35 primarily tertiary and quaternary CICUs that captured consecutive admissions in annual 2-month snapshots. The primary analysis compared inter-hospital differences in CICU LOS, as well as the association between CICU LOS and all-cause in-hospital mortality using a Fine and Gray competing risk model. RESULTS: The overall median CICU LOS was 2.2 (1.1-4.8) days, and the median hospital LOS was 5.9 (2.8-12.3) days. Admissions in the longest tertile of LOS tended to be younger with higher rates of pre-existing comorbidities, and had higher Sequential Organ Failure Assessment (SOFA) scores, as well as higher rates of mechanical ventilation, intravenous vasopressor use, mechanical circulatory support, and renal replacement therapy. Unadjusted all-cause in-hospital mortality was 9.3%, 6.7%, and 13.4% in the lowest, intermediate, and highest CICU LOS tertiles. In a competing risk analysis, individual patient CICU LOS was correlated (r2 = 0.31) with a higher risk of 30-day in-hospital mortality. The relationship remained significant in admissions with heart failure, ST-elevation myocardial infarction and non-ST segment elevation myocardial infarction. CONCLUSIONS: In a large registry of academic CICUs, we observed significant variation in CICU LOS and report that LOS is independently associated with all-cause in-hospital mortality. These findings could potentially be used to improve CICU resource utilization planning and refine risk prognostication in critically ill cardiovascular patients.

Serum 8-Hydroxydeoxyguanosine Is a Potential Indicator for the Severity and Prognosis in Patients with Community-Acquired Pneumonia: A Prospective Cohort Study.

Previous studies have demonstrated that 8-hydroxydeoxyguanosine (8-OHdG) exerted key roles in various pulmonary diseases, but the evidence for its role in community-acquired pneumonia (CAP) was lacking. The goal of this research was to evaluate the correlations of serum 8-OHdG with the severity and prognosis among patients with CAP through a prospective cohort study. A total of 239 patients with CAP and 239 healthy participants were enrolled. Fasting blood samples were collected. 8-OHdG and inflammatory cytokines were measured by ELISA. On admission, serum 8-OHdG was significantly increased in patients with CAP compared with control subjects. Besides, serum 8-OHdG was incrementally increased in line with CAP severity scores. Pearson correlative analysis found that serum 8-OHdG was correlated with clinical characteristics and inflammatory cytokines in patients with CAP. Linear and logistic regression analysis showed that serum 8-OHdG was positively associated with CAP severity scores. Furthermore, the prognostic outcomes were tracked. Higher serum 8-OHdG on admission increased the risks for intensive care unit admission, mechanical ventilation, vasoactive agent usage, death, and longer hospital stay among patients with CAP. Serum 8-OHdG combination with confusion, respiratory rate, blood pressure, and age ≥65 y or pneumonia severity index had stronger predictive powers for death than single 8-OHdG, CAP severity scores, or several inflammatory cytokines in patients with CAP. These results indicated that serum 8-OHdG is positively associated with the severity and poor prognosis in patients with CAP, demonstrating that 8-OHdG may be involved in the pathophysiology process of CAP.

Composite outcome measures in high-impact critical care randomised controlled trials: a systematic review.

BACKGROUND: The use of composite outcome measures (COM) in clinical trials is increasing. Whilst their use is associated with benefits, several limitations have been highlighted and there is limited literature exploring their use within critical care. The primary aim of this study was to evaluate the use of COM in high-impact critical care trials, and compare study parameters (including sample size, statistical significance, and consistency of effect estimates) in trials using composite versus non-composite outcomes. METHODS: A systematic review of 16 high-impact journals was conducted. Randomised controlled trials published between 2012 and 2022 reporting a patient important outcome and involving critical care patients, were included. RESULTS: 8271 trials were screened, and 194 included. 39.1% of all trials used a COM and this increased over time. Of those using a COM, only 52.6% explicitly described the outcome as composite. The median number of components was 2 (IQR 2-3). Trials using a COM recruited fewer participants (409 (198.8-851.5) vs 584 (300-1566, p = 0.004), and their use was not associated with increased rates of statistical significance (19.7% vs 17.8%, p = 0.380). Predicted effect sizes were overestimated in all but 6 trials. For studies using a COM the effect estimates were consistent across all components in 43.4% of trials. 93% of COM included components that were not patient important. CONCLUSIONS: COM are increasingly used in critical care trials; however effect estimates are frequently inconsistent across COM components confounding outcome interpretations. The use of COM was associated with smaller sample sizes, and no increased likelihood of statistically significant results. Many of the limitations inherent to the use of COM are relevant to critical care research.

Clinical Full-Time Equivalent in PICUs: Survey of the U.S. Pediatric Critical Care Chiefs Network, 2020-2022.

OBJECTIVES: To inform workforce planning for pediatric critical care (PCC) physicians, it is important to understand current staffing models and the spectrum of clinical responsibilities of physicians. Our objective was to describe the expected workload associated with a clinical full-time equivalent (cFTE) in PICUs across the U.S. Pediatric Critical Care Chiefs Network (PC3N). DESIGN: Cross-sectional survey. SETTING: PICUs participating in the PC3N. SUBJECTS: PICU division chiefs or designees participating in the PC3N from 2020 to 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A series of three surveys were used to capture unit characteristics and clinical responsibilities for an estimated 1.0 cFTE intensivist. Out of a total of 156 PICUs in the PC3N, the response rate was 46 (30%) to all three distributed surveys. Respondents used one of four models to describe the construction of a cFTE-total clinical hours, total clinical shifts, total weeks of service, or % full-time equivalent. Results were stratified by unit size. The model used for construction of a cFTE did not vary significantly by the total number of faculty nor the total number of beds. The median (interquartile range) of clinical responsibilities annually for a 1.0 cFTE were: total clinical hours 1750 (1483-1858), total clinical shifts 142 (129-177); total weeks of service 13.0 (11.3-16.0); and total night shifts 52 (36-60). When stratified by unit size, larger units had fewer nights or overnight hours, but covered more beds per shift. CONCLUSIONS: This survey of the PC3N (2020-2022) provides the most contemporary description of clinical responsibilities associated with a cFTE physician in PCC. A 1.0 cFTE varies depending on unit size. There is no correlation between the model used to construct a cFTE and the associated clinical responsibilities.

Fluid administration and fluid accumulation in intensive care units-Protocol for an international inception cohort study (FLUID-ICU).

INTRODUCTION: Fluid accumulation is associated with adverse outcomes in critically ill patients admitted to the intensive care unit (ICU). Fluid administration in the ICU may be a clinically relevant source of fluid accumulation in ICU patients. However, the extent is unknown, and no standard definition exists. We aim to provide epidemiological data on fluid accumulation, risk factors, use of fluid removal strategies, patient outcomes and describe current fluid administration practices in the ICU. METHODS: We will conduct an international 14-day inception cohort study including a minimum of 1000 acutely admitted adult ICU patients. Data will be collected from medical records and laboratory reports at baseline and daily from ICU admission to discharge with a maximum of 28 days. Follow-up will be performed on day 90 after inclusion. The primary outcome is the number of patients with fluid accumulation. Secondary outcomes include the number of days with fluid accumulation, use of active fluid removal, days alive without life support at day 28, days alive and out of hospital day 90, and all-cause mortality at day 90. Furthermore, we will assess risk factors for fluid accumulation and its association with 90-day mortality and report on the types of fluid administration. CONCLUSION: This international inception cohort study will provide contemporary epidemiological data on fluid administration and fluid accumulation in adult ICU patients.

Patients with aneurysmal subarachnoid haemorrhage treated in Swedish intensive care: A registry study.

BACKGROUND: Aneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening disease with high mortality and morbidity. Patients with aSAH in Sweden are cared for at one of six neuro intensive care units (NICU) or at a general intensive care unit (ICU).This study aimed to describe the incidence, length of stay, time in ventilator and mortality for these patients. METHODS: This is a retrospective, descriptive study of patients with aSAH, registered in the Swedish Intensive care Registry between 2017 and 2019. The cohort was divided in sub-cohorts (NICU and general ICU) and regions. Mortality was analysed with logistic regression. RESULTS: A total of 1520 patients with aSAH from five regions were included in the study. Mean age of the patients were 60.6 years and 58% were female. Mortality within 180 days of admission was 30% (n = 456) of which 17% (n = 258) died during intensive care. A majority of the patients were treated at one hospital and in one ICU (70%, n = 1062). More than half of the patients (59%, n = 897) had their first intensive care admission at a hospital with a NICU. Patients in the North region had the lowest median GCS (10) and the highest SAPS3 score (60) when admitted to NICU. Treatment with invasive mechanical ventilation differed significantly between regions; 91% (n = 80) in the region with highest proportion versus 56% (n = 94) in the region with the lowest proportion, as did mortality; 16% (n = 44) versus 8% (n = 23). No differences between regions were found regarding age, sex and length of stay. CONCLUSIONS: Patients with aSAH treated in a NICU or in an ICU in Sweden differs in characteristics. The study further showed some differences between regions which might be reduced if there were national consensus and treatment guidelines implemented.

Sex differences in the use of mechanical ventilation in a neurointensive care population: a retrospective study.

BACKGROUND: In the general intensive care unit (ICU) women receive invasive mechanical ventilation (IMV) less frequently than men. We investigated whether sex differences in the use of IMV also exist in the neurocritical care unit (NCCU), where patients are intubated not only due to respiratory failure but also due to neurological impairment. METHODS: This retrospective single-centre study included adults admitted to the NCCU of the University Hospital Zurich between January 2018 and August 2021 with neurological or neurosurgical main diagnosis. We collected data on demographics, intubation, re-intubation, tracheotomy, and duration of IMV or other forms of respiratory support from the Swiss ICU registry or the medical records. A descriptive statistics was performed. Baseline and outcome characteristics were compared by sex in the whole population and in subgroup analysis. RESULTS: Overall, 963 patients were included. No differences between sexes in the use and duration of IMV, frequency of emergency or planned intubations, tracheostomy were found. The duration of oxygen support was longer in women (men 2 [2, 4] vs. women 3 [1, 6] days, p = 0.018), who were more often admitted due to subarachnoid hemorrhage (SAH). No difference could be found after correction for age, diagnosis of admission and severity of disease. CONCLUSION: In this NCCU population and differently from the general ICU population, we found no difference by sex in the frequency and duration of IMV, intubation, reintubation, tracheotomy and non-invasive ventilation support. These results suggest that the differences in provision of care by sex reported in the general ICU population may be diagnosis-dependent. The difference in duration of oxygen supplementation observed in our population can be explained by the higher prevalence of SAH in women, where we aim for higher oxygenation targets due to the specific risk of vasospasm.

A Canadian survey of perceptions and practices related to ordering of blood tests in the intensive care unit.

PURPOSE: The ordering of routine blood test panels in advance is common in intensive care units (ICUs), with limited consideration of the pretest probability of finding abnormalities. This practice contributes to anemia, false positive results, and health care costs. We sought to understand practices and attitudes of Canadian adult intensivists regarding ordering of blood tests in critically ill patients. METHODS: We conducted a nationwide Canadian cross-sectional survey consisting of 15 questions assessing three domains (global perceptions, test ordering, daily practice), plus 11 demographic questions. The target sample was one intensivist per adult ICU in Canada. We summarized responses using descriptive statistics and present data as mean with standard deviation (SD) or count with percentage as appropriate. RESULTS: Over seven months, 80/131 (61%) physicians responded from 77 ICUs, 50% of which were from Ontario. Respondents had a mean (SD) clinical experience of 12 (9) years, and 61% worked in academic centres. When asked about their perceptions of how frequently unnecessary blood tests are ordered, 61% responded "sometimes" and 23% responded "almost always." Fifty-seven percent favoured ordering complete blood counts one day in advance. Only 24% of respondents believed that advanced blood test ordering frequently led to changes in management. The most common factors perceived to influence blood test ordering in the ICU were physician preferences, institutional patterns, and order sets. CONCLUSION: Most respondents to this survey perceived that unnecessary blood testing occurs in the ICU. The survey identified possible strategies to decrease the number of blood tests.

RéSUMé: OBJECTIF: La prescription à l'avance de tests sanguins de routine est courante dans les unités de soins intensifs (USI), avec une prise en compte limitée de la probabilité de découverte d'anomalies avant le test. Cette pratique contribue à l'anémie, aux résultats faussement positifs et aux coûts des soins de santé. Nous avons cherché à comprendre les pratiques et les attitudes des intensivistes pour adultes au Canada en ce qui concerne la prescription d'analyses sanguines chez la patientèle gravement malade. MéTHODE: Nous avons mené un sondage transversal à l'échelle nationale au Canada en posant 15 questions évaluant trois domaines (perceptions globales, commande de tests, pratique quotidienne), ainsi que 11 questions démographiques. L'échantillon cible était composé d'un·e intensiviste par unité de soins intensifs pour adultes au Canada. Nous avons résumé les réponses à l'aide de statistiques descriptives et présenté les données sous forme de moyennes avec écarts type (ET) ou de dénombrements avec pourcentages, selon le cas. RéSULTATS: Sur une période de sept mois, 80 médecins sur 131 (61%) ont répondu dans 77 unités de soins intensifs, dont 50% en Ontario. Les répondant·es avaient une expérience clinique moyenne (ET) de 12 (9) ans, et 61% travaillaient dans des centres universitaires. Lorsqu'on leur a demandé ce qu'ils ou elles pensaient de la fréquence à laquelle des tests sanguins inutiles étaient prescrits, 61% ont répondu « parfois ¼ et 23% ont répondu « presque toujours ¼. Cinquante-sept pour cent étaient en faveur de la réalisation d'une formule sanguine complète un jour à l'avance. Seulement 24% des personnes interrogées estimaient que la prescription de tests sanguins à l'avance entraînait fréquemment des changements dans la prise en charge. Les facteurs les plus souvent perçus comme influençant la prescription d'analyses sanguines à l'unité de soins intensifs étaient les préférences des médecins, les habitudes institutionnelles et les ensembles d'ordonnances. CONCLUSION: La plupart des répondant·es à ce sondage ont l'impression que des tests sanguins inutiles sont prescrits aux soins intensifs. L'enquête a permis d'identifier des stratégies possibles pour réduire le nombre de tests sanguins.

A lay of the land: a description of academic acute care surgery models in Canada.

BACKGROUND: Patients who require emergency general surgery (EGS) are at a substantially higher risk for perioperative morbidity and mortality than patients undergoing elective general surgery. The acute care surgery (ACS) model has been shown to improve EGS patient outcomes and cost-effectiveness. A recent systematic review has shown extensive heterogeneity in the structure of ACS models worldwide. The objective of this study was to describe the current landscape of ACS models in academic centres across Canada. METHODS: We sent an online questionnaire to the 18 academic centres in Canada. The lead ACS physicians from each institution completed the questionnaire, describing the structure of their ACS models. RESULTS: In total, 16 institutions responded, all of which reported having ACS models, with a total of 29 ACS services described. All services had resident coverage. Of the 29, 18 (62%) had dedicated allied health care staff. The staff surgeon was free from elective duties while covering ACS in 17/29 (59%) services. More than half (15/29; 52%) of the services described protected ACS operating room time, but only 7/15 (47%) had a dedicated ACS room all 5 weekdays. Four of 29 services (14%) had no protected ACS operating room time. Only 1/16 (6%) institutions reported a mandate to conduct ACS research, while 12/16 (75%) found ACS research difficult, owing to lack of resources. CONCLUSION: We saw large variations in the structure of ACS models in academic centres in Canada. The components of ACS models that are most important to patient outcomes remain poorly defined. Future research will focus on defining the necessary cornerstones of ACS models.

Medical device-related pressure injuries in intensive care patients: A prospective and descriptive study.

BACKGROUND: Treatment and care of patients in intensive care units require the use of many medical and technological instruments. Pressure injuries occur when medical devices, which are used more in intensive care patients and are in direct or indirect contact with the skin, cause focal and localized forces on the superficial or deep tissues. OBJECTIVE: In this study, it was aimed to examine the risk factors, incidence and characteristics of medical device-related pressure injuries in intensive care patients. METHODS: This study has a prospective and descriptive design. The study was carried out in the adult intensive care unit of a healthcare institution located in the western Turkey. 138 intensive care patients treated in the level 3 adult intensive care unit were enrolled in the study. The first observations and evaluations of intensive care patients in terms of pressure injuries were made within the first 24 h after admission to the clinic. Observations continued daily during the hospitalization period of the patient. Data were collected with the Intensive Care Patient Information Form, Glasgow Coma Scale, Braden Pressure Ulcer Risk Assessment Scale and Identification Form for Medical device-related Pressure Ulcers. Analysis of data was performed with descriptive statistical methods, Shapiro-Wilk Test, Mann-Whitney U Test and Chi-Square analysis. RESULTS: Medical device-related pressure injury developed in 11.6% (n = 16) of intensive care patients. Anatomically, pressure injury occurred most frequently on the lip (37.5%) and most frequently due to the intubation tube (37.5%). Most of the developed wounds (75.0%) were found to be stage 2. Multinominal logistic regression analysis, which was performed to determine the effect of independent variables on medical device-related pressure injuries in intensive care patients, was found to be statistically significant (X2 = 37.098, p < 0.001). When the regression coefficients were examined, it was found that total hospitalization time in the intensive care unit (ß = 0.948, p < 0.01) and PaCO2 level (ß = 0.923, p < 0.01) had a positive, and duration of aerobic respiration with nasal cannula or mask (ß = -0.920, p < 0.01) and Braden score (ß = -0.948, p < 0.01) had a negative and significant effect on medical device-related pressure injuries. CONCLUSIONS: In this study found that the MDRPIs development rate was lower than other studies. It was observed that pressure injuries due to medical devices developed more frequently in patients with longer hospitalization days, higher PaCO2 levels, shorter duration of oxygenated breathing with nasal cannula or mask, and lower Braden scores.

Publications in paediatric critical care medicine: Trends from Pakistan.

Objective: To analyse the characteristics of research published from Pakistan on paediatric critical care medicine. METHODS: The exploratory study was conducted at the Aga Khan University, Karachi from July 2021 to March 2022, and comprised a comprehensive search on MedLine, Google Scholar and PakMediNet databases for literature from Pakistan pertaining to paediatric critical care medicine published between January 2010 and December 2021. The search was done using appropriate key words. Conference abstracts and papers authored by paediatric intensivists with unrelated topics were excluded. Data was extracted on a structured spreadsheet, and was subjected to bibliometric analysis. Data was analysed using SPSS 20. RESULTS: Of the 7,514 studies identified, 146(1.94%) were analysed. These were published in 51 journals with a frequency of 13.3 per year. There were 107(73.3%) original articles, 96(65.8%) were published in PubMed-indexed journals, and 35(24%) were published in locally indexed journals. Further, 100(69.4%) papers were published from 5 paediatric intensive care units in Karachi, and 81(56%) were contributed by a single private-sector hospital. The total citation count was 1072, with 2(1.4%) papers receiving >50 citations. There was a linear trend with some skewing and an annual growth rate of >15%. Conclusion: Publications from Pakistan related to paediatric critical care medicine showed positive linear growth. There was a paucity of multicentre studies, randomised controlled trials, and high-impact publications.

Pediatric Critical Care Referrals for Tertiary Inpatient and Transport Services in Canada's Maritime Provinces: A Retrospective Cohort Study.

OBJECTIVE: Accurate triage of children referred for tertiary pediatric critical care services is crucial to ensure optimal disposition and resource conservation. We aimed to explore the characteristics and level of care needs of children referred to tertiary pediatric critical care inpatient and transport services and the characteristics of referring physicians and hospitals to which these children present. METHODS: We conducted a 1-year retrospective cohort study of children (< 16 years) with documented referral to pediatric critical care and specialized transport services at a tertiary pediatric hospital from regional (24/7 pediatrician on-call coverage) and community (no pediatric specialty services) hospitals in Canada's Maritime provinces. RESULTS: We identified 205 documented referrals resulting in 183 (89%) transfers; 97 (53%) were admitted to the pediatric intensive care unit (PICU). Of 150 children transferred from centers with 24/7 pediatric specialist coverage, 45 (30%) were admitted to the tertiary hospital pediatric medical unit with no subsequent admission to the PICU. Of 20 children transferred from community hospitals and admitted to the tertiary hospital general pediatric medical unit, 9 (45%) bypassed proximate regional hospitals with specialist pediatric care capacity. The specialized pediatric critical care transport team performed 151 (83%) of 183 interfacility transfers; 83 (55%) were admitted to the PICU. CONCLUSION: One third of the children accepted for interfacility transfer after pediatric critical care referral were triaged to a similar level of care as could be provided at the sending or nearest regional hospital. Improved utilization of pediatric expertise in regional hospitals may reduce unnecessary pediatric transports and conserve valuable health care resources.

Anterior internal versus external fixation of unstable pelvis fractures was not associated with discharge destination, critical care, length of stay, or hospital charges.

PURPOSE: Determine if anterior internal versus supra-acetabular external fixation of unstable pelvic fractures is associated with care needs or discharge. METHODS: A retrospective cohort study was performed at two tertiary trauma referral centers. Adults with unstable pelvis fractures (AO/OTA 61B/61C) who received operative fixation of the anterior and posterior pelvic ring by two orthopedic trauma surgeons from October 2020 to November 2022 were included. The primary outcome was discharge destination. Secondary outcomes included intensive care unit (ICU) or ventilator days, length of stay, and hospital charges. RESULTS: Eighty-three eligible patients were 38.6% female, with a mean age of 47.2 ± 20.3 years and BMI 28.1 ± 6.4 kg/m2. Fifty-nine patients (71.1%) received anterior pelvis internal fixation and 24 (28.9%) received external fixation. External fixation was associated with weight-bearing restrictions (91.7% versus 49.2%, p = 0.01). No differences in demographic, functional status, insurance type, fracture classification, or injury severity measures were observed by treatment. Internal versus external anterior pelvic fixation was not associated with discharge to home (49.2% versus 29.2%, p = 0.10), median ICU days (3.0 [interquartile range (IQR) 7.8 versus 5.5 [IQR 4.3], p = 0.14, ventilator days (0 [IQR 6.0] versus 0 [IQR 2.8], p = 0.51), length of stay (13.0 [IQR 13.0] versus 17.5 (IQR 20.5), p = 0.38), or total hospital charges (US dollars 180,311 [IQR 219,061.75] versus 243,622 [IQR 187,111], p = 0.14). CONCLUSIONS: Anterior internal versus supra-acetabular external fixation of unstable pelvis fractures was not significantly associated with discharge destination, critical care, hospital length of stay, or hospital charges. This sample may be underpowered to detect differences between groups. LEVEL OF EVIDENCE: Therapeutic Level IV.

The intensive care population profile in Denmark before and during the first wave of the SARS-CoV-2 pandemic; a national register-based study.

OBJECTIVE: To describe the change in admission rate and demographic profile of patients admitted to ICUs throughout Denmark before and during first wave of the SARS-CoV-2 pandemic. METHODS: A register-based national observational study of all patients admitted to ICU from December 2019 until April 2020, comparing ICU admission before and after lockdown. RESULTS: The number of admissions declined, especially in the age groups below 18 and above 70. The sex distribution and the comorbidity-level remained unchanged. The length of hospital stay prior to ICU admission increased. Overall fewer patients were admitted electively. CONCLUSION: Fewer patients were admitted to ICU and waited longer for admission during the first wave of the COVID-19 pandemic.

COVID-19 mortality and use of intensive care among ethnic minorities - a national register-based Danish population study.

Migrants and ethnic minorities are disproportionately affected by the Coronavirus Disease 2019 (COVID-19) pandemic compared to the majority population. Therefore, we studied mortality and use of mechanical ventilation (MV) by country of birth and migrant status in a nationwide cohort in Denmark. Nationwide register data on all cases hospitalized for > 24-hours with COVID-19 between February 2020 and March 2021. Main outcome measures were mortality and MV within 30 days of hospitalization for COVID-19. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated by region of origin and migrant status using logistic regression analyses, adjusting for age, sex, comorbidity and sociodemographic factors. Of 6,406 patients, 977 (15%) died and 342 (5%) were treated with mechanical ventilation. Immigrants (OR:0.55;95%CI: 0.44-0.70) and individuals of non-Western origin had a lower odds (OR: 0.49; 95% CI: 0.37-0.65) of death upon admission with COVID-19 compared to Danish born individuals. Immigrants and descendants (OR: 1.62; 95% CI: 1.22-2.15) as well as individuals of non-Western origin (OR: 1.83; 95% CI: 1.35-2.47) had a significantly higher odds of MV compared to Danish born individuals. Outcomes of individuals with Western origin did not differ. Immigrants and individuals of non-Western origin had a significantly lower COVID-19 associated mortality compared to individuals of Danish origin after adjustment for sociodemographic factors and comorbidity. In contrast, the odds of MV was higher for immigrants and individuals of non-Western origin compared to individuals of Danish origin.

Asthma Phenotypes and COVID-19 Risk: A Population-based Observational Study.

Rationale: Studies have suggested some patients with asthma are at risk of severe coronavirus disease (COVID-19), but they have had limited data on asthma phenotype and have not considered if risks are specific to COVID-19. Objectives: To determine the effect of asthma phenotype on three levels of COVID-19 outcomes. Compare hospitalization rates with influenza and pneumonia. Methods: Electronic medical records were used to identify patients with asthma and match them to the general population. Patient-level data were linked to Public Health England severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test data, hospital, and mortality data. Asthma was phenotyped by medication, exacerbation history, and type 2 inflammation. The risk of each outcome, adjusted for major risk factors, was measured using Cox regression. Measurements and Main Results: A total of 434,348 patients with asthma and 748,327 matched patients were included. All patients with asthma had a significantly increased risk of a General Practice diagnosis of COVID-19. Asthma with regular inhaled corticosteroid (ICS) use (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.01-1.61), intermittent ICS plus add-on asthma medication use (HR, 2.00; 95% CI, 1.43-2.79), regular ICS plus add-on use (HR, 1.63; 95% CI, 1.37-1.94), or with frequent exacerbations (HR, 1.82; 95% CI, 1.34-2.47) was significantly associated with hospitalization. These phenotypes were significantly associated with influenza and pneumonia hospitalizations. Only patients with regular ICS plus add-on asthma therapy (HR, 1.70; 95% CI, 1.27-2.26) or frequent exacerbations (HR, 1.66; 95% CI, 1.03-2.68) had a significantly higher risk of ICU admission or death. Atopy and blood eosinophil count were not associated with severe COVID-19 outcomes. Conclusions: More severe asthma was associated with more severe COVID-19 outcomes, but type 2 inflammation was not. The risk of COVID-19 hospitalization appeared to be similar to the risk with influenza or pneumonia.

The Detrimental Impact of the COVID-19 Pandemic on Major Trauma Outcomes in the Netherlands: A Comprehensive Nationwide Study.

OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on the outcome of major trauma patients in the Netherlands. SUMMARY BACKGROUND DATA: Major trauma patients highly rely on immediate access to specialized services, including ICUs, shortages caused by the impact of the COVID-19 pandemic may influence their outcome. METHODS: A multi-center observational cohort study, based on the Dutch National Trauma Registry was performed. Characteristics, resource usage, and outcome of major trauma patients (injury severity score ≥16) treated at all trauma-receiving hospitals during the first COVID-19 peak (March 23 through May 10) were compared with those treated from the same period in 2018 and 2019 (reference period). RESULTS: During the peak period, 520 major trauma patients were admitted, versus 570 on average in the pre-COVID-19 years. Significantly fewer patients were admitted to ICU facilities during the peak than during the reference period (49.6% vs 55.8%; P=0.016). Patients with less severe traumatic brain injuries in particular were less often admitted to the ICU during the peak (40.5% vs 52.5%; P=0.005). Moreover, this subgroup showed an increased mortality compared to the reference period (13.5% vs 7.7%; P=0.044). These results were confirmed using multivariable logistic regression analyses. In addition, a significant increase in observed versus predicted mortality was recorded for patients who had a priori predicted mortality of 50% to 75% (P=0.012). CONCLUSIONS: The COVID-19 peak had an adverse effect on trauma care as major trauma patients were less often admitted to ICU and specifically those with minor through moderate brain injury had higher mortality rates.

Pathophysiologic Signature of Impending ICU Hypoglycemia in Bedside Monitoring and Electronic Health Record Data: Model Development and External Validation.

OBJECTIVES: We tested the hypothesis that routine monitoring data could describe a detailed and distinct pathophysiologic phenotype of impending hypoglycemia in adult ICU patients. DESIGN: Retrospective analysis leading to model development and validation. SETTING: All ICU admissions wherein patients received insulin therapy during a 4-year period at the University of Virginia Medical Center. Each ICU was equipped with continuous physiologic monitoring systems whose signals were archived in an electronic data warehouse along with the entire medical record. PATIENTS: Eleven thousand eight hundred forty-seven ICU patient admissions. INTERVENTIONS: The primary outcome was hypoglycemia, defined as any episode of blood glucose less than 70 mg/dL where 50% dextrose injection was administered within 1 hour. We used 61 physiologic markers (including vital signs, laboratory values, demographics, and continuous cardiorespiratory monitoring variables) to inform the model. MEASUREMENTS AND MAIN RESULTS: Our dataset consisted of 11,847 ICU patient admissions, 721 (6.1%) of which had one or more hypoglycemic episodes. Multivariable logistic regression analysis revealed a pathophysiologic signature of 41 independent variables that best characterized ICU hypoglycemia. The final model had a cross-validated area under the receiver operating characteristic curve of 0.83 (95% CI, 0.78-0.87) for prediction of impending ICU hypoglycemia. We externally validated the model in the Medical Information Mart for Intensive Care III critical care dataset, where it also demonstrated good performance with an area under the receiver operating characteristic curve of 0.79 (95% CI, 0.77-0.81). CONCLUSIONS: We used data from a large number of critically ill inpatients to develop and externally validate a predictive model of impending ICU hypoglycemia. Future steps include incorporating this model into a clinical decision support system and testing its effects in a multicenter randomized controlled clinical trial.

The Coronavirus Disease 2019 Pandemic Impacts Burnout Syndrome Differently Among Multiprofessional Critical Care Clinicians-A Longitudinal Survey Study.

OBJECTIVES: To determine the impact of coronavirus disease 2019 on burnout syndrome in the multiprofessional ICU team and to identify factors associated with burnout syndrome. DESIGN: Longitudinal, cross-sectional survey. SETTING: All adult ICUs within an academic health system. SUBJECTS: Critical care nurses, advanced practice providers, physicians, respiratory therapists, pharmacists, social workers, and spiritual health workers were surveyed on burnout in 2017 and during the coronavirus disease 2019 pandemic in 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Burnout syndrome and contributing factors were measured using the Maslach Burnout Inventory of Health and Human Service and Areas of Worklife Survey. Response rates were 46.5% (572 respondents) in 2017 and 49.9% (710 respondents) in 2020. The prevalence of burnout increased from 59% to 69% (p < 0.001). Nurses were disproportionately impacted, with the highest increase during the pandemic (58-72%; p < 0.0001) with increases in emotional exhaustion and depersonalization, and personal achievement decreases. In contrast, although burnout was high before and during coronavirus disease 2019 in all specialties, most professions had similar or lower burnout in 2020 as they had in 2017. Physicians had the lowest rates of burnout, measured at 51% and 58%, respectively. There was no difference in burnout between clinicians working in ICUs who treated coronavirus disease 2019 than those who did not (71% vs 67%; p = 0.26). Burnout significantly increased in females (71% vs 60%; p = 0.001) and was higher than in males during the pandemic (71% vs 60%; p = 0.01). CONCLUSIONS: Burnout syndrome was common in all multiprofessional ICU team members prior to and increased substantially during the pandemic, independent of whether one treated coronavirus disease 2019 patients. Nurses had the highest prevalence of burnout during coronavirus disease 2019 and had the highest increase in burnout from the prepandemic baseline. Female clinicians were significantly more impacted by burnout than males. Different susceptibility to burnout syndrome may require profession-specific interventions as well as work system improvements.

Comparison of demographic and clinical characteristics of hospitalized COVID-19 patients with severe/critical illness in the first wave versus the second wave.

Due to current advances and growing experience in the management of coronavirus Disease 2019 (COVID-19), the outcome of COVID-19 patients with severe/critical illness would be expected to be better in the second wave compared with the first wave. As our hospitalization criteria changed in the second wave, we aimed to investigate whether a favorable outcome occurred in hospitalized COVID-19 patients with only severe/critical illness. Among 642 laboratory-confirmed hospitalized COVID-19 patients in the first wave and 1121 in the second wave, those who met World Health Organization (WHO) definitions for severe or critical illness on admission or during follow-up were surveyed. Data on demographics, comorbidities, C-reactive protein (CRP) levels on admission, and outcomes were obtained from an electronic hospital database. Univariate analysis was performed to compare the characteristics of patients in the first and second waves. There were 228 (35.5%) patients with severe/critical illness in the first wave and 681 (60.7%) in the second wave. Both groups were similar in terms of age, gender, and comorbidities, other than chronic kidney disease. Median serum CRP levels were significantly higher in patients in the second wave compared with those in the first wave [109 mg/L (interquartile range [IQR]: 65-157) vs. 87 mg/L (IQR: 39-140); p < 0.001]. However, intensive care unit admission and mortality rates were similar among the waves. Even though a lower mortality rate in the second wave has been reported in previous studies, including all hospitalized COVID-19 patients, we found similar demographics and outcomes among hospitalized COVID-19 patients with severe/critical illness in the first and second wave.