Association Between COVID-19 Diagnosis and In-Hospital Mortality in Patients Hospitalized With ST-Segment Elevation Myocardial Infarction.

IMPORTANCE: There has been limited research on patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19. OBJECTIVE: To compare characteristics, treatment, and outcomes of patients with STEMI with vs without COVID-19 infection. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up in January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient Clinical Database (N = 80 449). EXPOSURES: Active COVID-19 infection present during the same encounter. MAIN OUTCOMES AND MEASURES: The primary outcome was in-hospital mortality. Patients were propensity matched on the likelihood of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared with those without COVID-19 during the previous calendar year. RESULTS: The out-of-hospital STEMI group included 76 434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51-74 years; 70.3% men). The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs 756 without COVID-19 after matching) from 353 centers (58.3% aged 51-74 years; 60.7% men). In patients with out-of-hospital STEMI, there was no significant difference in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19. Among patients with out-of-hospital STEMI and COVID-19 vs out-of-hospital STEMI without COVID-19, the rates of in-hospital mortality were 15.2% vs 11.2% (absolute difference, 4.1% [95% CI, 1.1%-7.0%]; P = .007). Among patients with in-hospital STEMI and COVID-19 vs in-hospital STEMI without COVID-19, the rates of in-hospital mortality were 78.5% vs 46.1% (absolute difference, 32.4% [95% CI, 29.0%-35.9%]; P < .001). CONCLUSIONS AND RELEVANCE: Among patients with out-of-hospital or in-hospital STEMI, a concomitant diagnosis of COVID-19 was significantly associated with higher rates of in-hospital mortality compared with patients without a diagnosis of COVID-19 from the past year. Further research is required to understand the potential mechanisms underlying this association.

Medication Safety in Two Intensive Care Units of a Community Teaching Hospital After Electronic Health Record Implementation: Sociotechnical and Human Factors Engineering Considerations.

OBJECTIVE: The aim of the study was to assess the impact of Electronic Health Record (EHR) implementation on medication safety in two intensive care units (ICUs). METHODS: Using a prospective pre-post design, we assessed 1254 consecutive admissions to two ICUs before and after an EHR implementation. Each medication event was evaluated with regard to medication error (error type, medication-management stage) and impact on patient (severity of potential or actual harm). RESULTS: We identified 4063 medication-related events either pre-implementation (2074 events) or post-implementation (1989 events). Although the overall potential for harm due to medication errors decreased post-implementation only 2 of the 3 error rates were significantly lower post-implementation. After EHR implementation, we observed reductions in rates of medication errors per admission at the stages of transcription (0.13-0, P < 0.001), dispensing (0.49-0.16, P < 0.001), and administration (0.83-0.56, P = 0.011). Within the ordering stage, 4 error types decreased post-implementation (orders with omitted information, error-prone abbreviations, illegible orders, failure to renew orders) and 4 error types increased post-implementation (orders of wrong drug, orders containing a wrong start or stop time, duplicate orders, orders with inappropriate or wrong information). Within the administration stage, we observed a reduction of late administrations and increases in omitted administrations and incorrect documentation. CONCLUSIONS: Electronic Health Record implementation in two ICUs was associated with both improvement and worsening in rates of specific error types. Further safety improvements require a nuanced understanding of how various error types are influenced by the technology and the sociotechnical work system of the technology implementation. Recommendations based on human factors engineering principles are provided for reducing medication errors.

Integrating a safety smart list into the electronic health record decreases intensive care unit length of stay and cost.

PURPOSE: To measure how an integrated smartlist developed for critically ill patients would change intensive care units (ICUs) length of stay (LOS), mortality, and charges. MATERIALS AND METHODS: Propensity-score analysis of adult patients admitted to one of 14 surgical and medical ICUs between June 2017 and May 2018. The smart list aimed to certain preventative measures for all critical patients (e.g., removing unneeded catheters, starting thromboembolic prophylaxis, etc.) and was integrated into the electronic health record workflows at the hospitals under study. RESULTS: During the study period, 11,979 patients were treated in the 14 participating ICUs by 518 unique providers. Patients who had the smart list used during ≥60% of their ICU stay (N = 432 patients, 3.6%) were significantly more likely to have a shorter ICU LOS (HR = 1.20, 95% CI:1.0 to 1.4, p = 0.015) with an average decrease of -$1218 (95% CI: -$1830 to -$607, P < 0.001) in the amount charged per day. The intervention cohort had fewer average ventilator days (3.05 vent days, SD = 2.55) compared to propensity score matched controls (3.99, SD = 4.68, p = 0.015), but no changes in mortality (16.7% vs 16.0%, p = 0.78). CONCLUSIONS: An integrated smart list shortened LOS and lowered charges in a diverse cohort of critically ill patients.

Incident chronic kidney disease: trends in management and outcomes.

BACKGROUND: Management trends in early chronic kidney disease (CKD) and their associations with clinical outcomes have not previously been reported. METHODS: We evaluated incident (Stage G3A) CKD patients from an integrated health care system in 2004-06, 2007-09 and 2010-12 to determine adjusted trends in screening (urinary protein quantification), treatment [prescription for angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), and statin] and nephrology referral. For the same time periods, adjusted rates for mortality, progression to Stage G4 CKD and hospitalization for myocardial infarction or heart failure were calculated and compared across time periods. RESULTS: There were 728, 788 and 956 patients with incident CKD in 2004-06, 2007-09 and 2010-12, respectively. Adjusted rates of proteinuria quantification (31, 39 and 51 screens/100 person-years), statin prescription (53, 63 and 64 prescriptions/100 person-years) and nephrology referral (2, 3 and 5 referrals/100 person-years) all increased over time (P for trend <0.001 in all cases). ACEI/ARB prescription rates did not change (88, 83 and 80 prescriptions/100 person-years, P = 0.68). Adjusted death rates (7, 5 and 6 deaths/100 person-years), CKD progression (9, 10 and 7 progressors/100 person-years) and cardiovascular hospitalization (10, 8 and 9 hospitalizations per 100/person-years) did not change (P for trend >0.4 in all cases). CONCLUSION: In this integrated health care system, management of incident CKD over the past decade has intensified.

Medical Malpractice: Reform for Today's Patients and Clinicians.

The current system of medical malpractice does a poor job of serving the best interests of physicians or patients. Economic and societal forces are shifting the nature of health care from the individual physician to a system of health care professionals, characterized by accountable care organizations. In particular, more physicians are employed, quality and outcomes are routinely measured, and reimbursement is moving to value-based purchasing. Medical malpractice likewise needs to transition to a new model that is consistent with the modern era of patient-centered care. Collective accountability, the concept that patient care is the responsibility of all the members of the health care organization, requires malpractice reform that reflects a systems-based practice of medicine. Enterprise liability, coupled with medical error communication and resolution programs, provides the legal framework necessary for the patient-centered practice of medicine in today's environment.

Biomarkers in Hepatic Disease: A Review Focused on Critically Ill Patients.

The ability to make a diagnosis early and appropriately is paramount for the survival of the critically ill ICU patient. Along with the myriad physical examination and imaging modalities available, biomarkers provide a window on the disease process. Herein we review hepatic biomarkers in the context of the critical care patient.

StratBAM: A Discrete-Event Simulation Model to Support Strategic Hospital Bed Capacity Decisions.

The ability to accurately measure and assess current and potential health care system capacities is an issue of local and national significance. Recent joint statements by the Institute of Medicine and the Agency for Healthcare Research and Quality have emphasized the need to apply industrial and systems engineering principles to improving health care quality and patient safety outcomes. To address this need, a decision support tool was developed for planning and budgeting of current and future bed capacity, and evaluating potential process improvement efforts. The Strategic Bed Analysis Model (StratBAM) is a discrete-event simulation model created after a thorough analysis of patient flow and data from Geisinger Health System's (GHS) electronic health records. Key inputs include: timing, quantity and category of patient arrivals and discharges; unit-level length of care; patient paths; and projected patient volume and length of stay. Key outputs include: admission wait time by arrival source and receiving unit, and occupancy rates. Electronic health records were used to estimate parameters for probability distributions and to build empirical distributions for unit-level length of care and for patient paths. Validation of the simulation model against GHS operational data confirmed its ability to model real-world data consistently and accurately. StratBAM was successfully used to evaluate the system impact of forecasted patient volumes and length of stay in terms of patient wait times, occupancy rates, and cost. The model is generalizable and can be appropriately scaled for larger and smaller health care settings.

How Do Residents Spend Their Time in the Intensive Care Unit?

PURPOSE: To describe the work of residents and the distribution of their time in 6 intensive care units (ICUs) of 2 medical centers (MCs). METHODS: A total of 242 hours of observation to capture data on tasks performed by residents in 6 ICUs, including adult, pediatric, medical and surgical units, were conducted. For each observation period, the percentages of total time spent on each task and on the aggregated task categories were calculated. RESULTS: Overall, while in the ICUs, residents spent almost half of their time in clinical review and documentation (19%), conversation with team physicians (16%), conversation attendance (6%) and order management (6%). The 2 MCs differed in the time that residents spent on administrative review and documentation (4% in one MC and 15% in the other). The pediatric ICUs were similar in the 2 MCs, whereas the adult ICUs exhibited differences in the time spent on order management and administrative review and documentation. CONCLUSIONS: While in the ICUs, residents spent most time performing direct patient care and care coordination activities. The distribution of activities varied across 2 MCs and across ICUs, which highlights the need to consider the local context on residents' work in ICUs.

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit.

OBJECTIVE: To assess the impact of EHR technology on the work and workflow of ICU physicians and compare time spent by ICU resident and attending physicians on various tasks before and after EHR implementation. DESIGN: EHR technology with electronic order management (CPOE, medication administration and pharmacy system) and physician documentation was implemented in October 2007. MEASUREMENT: We collected a total of 289 h of observation pre- and post-EHR implementation. We directly observed the work of residents in three ICUs (adult medical/surgical ICU, pediatric ICU and neonatal ICU) and attending physicians in one ICU (adult medical/surgical ICU). RESULTS: EHR implementation had an impact on the time distribution of tasks as well as the temporal patterns of tasks. After EHR implementation, both residents and attending physicians spent more of their time on clinical review and documentation (40% and 55% increases, respectively). EHR implementation also affected the frequency of switching between tasks, which increased for residents (from 117 to 154 tasks per hour) but decreased for attendings (from 138 to 106 tasks per hour), and the temporal flow of tasks, in particular around what tasks occurred before and after clinical review and documentation. No changes in the time spent in conversational tasks or the physical care of the patient were observed. CONCLUSIONS: The use of EHR technology has a major impact on ICU physician work (e.g., increased time spent on clinical review and documentation) and workflow (e.g., clinical review and documentation becoming the focal point of many other tasks). Further studies should evaluate the impact of changes in physician work on the quality of care provided.

Risk stratification in acute pulmonary embolism: frequency and impact on treatment decisions and outcomes.

OBJECTIVES: Guidelines have recommended that risk stratification be performed in patients diagnosed with an acute pulmonary embolism (PE). No study has described the use of risk stratification in routine clinical practice. The purpose of this study was to measure the frequency and impact of risk stratification on treatment decisions and outcomes in patients admitted with acute PE. METHODS: A retrospective cohort study was conducted of all of the patients admitted with acute PE at two Geisinger community-based teaching hospitals between 2006 and 2011. Baseline demographics, vital signs, and relevant clinical variables were recorded. The Pulmonary Embolism Severity Index was calculated for each patient. Risk stratification was defined as the measurement of either a biomarker or an echocardiogram within 24 hours of admission. The outcomes measured were short-term adverse events (in-hospital mortality or need for intensive care) and 30-day mortality. RESULTS: The mean age for the study cohort (n = 889) was 61 ± 17 years and 52% were men. Overall, 59% of study subjects were risk stratified. The frequency of risk stratification did not change over time. Risk stratification was associated with assignment to a higher acuity of care and increased use of thrombolysis and inferior vena cava filter placement. When controlling for severity of illness, risk stratification was a significant predictor of worsened short-term adverse outcome (odds ratio 3.43, 95% confidence interval 1.75-6.74, P < 0.001) but was not associated with improved 30-day mortality (odds ratio 1.14, 95% confidence interval 0.66-1.95, P = 0.64). CONCLUSIONS: Risk stratification is frequently performed in patients admitted with acute PE and has had a stable prevalence during a 5-year period. The use of risk stratification in acute PE is associated with assignment to higher levels of care and with more advanced treatments. Despite more intense treatment, risk stratification does not improve either short-term outcomes or 30-day mortality.

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units.

OBJECTIVE: To examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the medication-management process. METHODS: Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (eg, medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process. RESULTS: An average of 2.9 preventable or potential ADEs occurred in each admission, that is, 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1000 patient-days was 276, whereas the rate of preventable ADEs per 1000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16-24% of potential and preventable ADEs, clusters of errors occurred either as a sequence of errors (eg, delay in medication dispensing leading to delay in medication administration) or grouped errors (eg, route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process. CONCLUSIONS: Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerised physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.

Clinical characteristics, sepsis interventions and outcomes in the obese patients with septic shock: an international multicenter cohort study.

INTRODUCTION: Data are sparse as to whether obesity influences the risk of death in critically ill patients with septic shock. We sought to examine the possible impact of obesity, as assessed by body mass index (BMI), on hospital mortality in septic shock patients. METHODS: We performed a nested cohort study within a retrospective database of patients with septic shock conducted in 28 medical centers in Canada, United States and Saudi Arabia between 1996 and 2008. Patients were classified according to the World Health Organization criteria for BMI. Multivariate logistic regression analysis was performed to evaluate the association between obesity and hospital mortality. RESULTS: Of the 8,670 patients with septic shock, 2,882 (33.2%) had height and weight data recorded at ICU admission and constituted the study group. Obese patients were more likely to have skin and soft tissue infections and less likely to have pneumonia with predominantly Gram-positive microorganisms. Crystalloid and colloid resuscitation fluids in the first six hours were given at significantly lower volumes per kg in the obese and very obese patients compared to underweight and normal weight patients (for crystalloids: 55.0 ± 40.1 ml/kg for underweight, 43.2 ± 33.4 for normal BMI, 37.1 ± 30.8 for obese and 27.7 ± 22.0 for very obese). Antimicrobial doses per kg were also different among BMI groups. Crude analysis showed that obese and very obese patients had lower hospital mortality compared to normal weight patients (odds ratio (OR) 0.80, 95% confidence interval (CI) 0.66 to 0.97 for obese and OR 0.61, 95% CI 0.44 to 0.85 for very obese patients). After adjusting for baseline characteristics and sepsis interventions, the association became non-significant (OR 0.80, 95% CI 0.62 to 1.02 for obese and OR 0.69, 95% CI 0.45 to 1.04 for very obese). CONCLUSIONS: The obesity paradox (lower mortality in the obese) documented in other populations is also observed in septic shock. This may be related in part to differences in patient characteristics. However, the true paradox may lie in the variations in the sepsis interventions, such as the administration of resuscitation fluids and antimicrobial therapy. Considering the obesity epidemic and its impact on critical care, further studies are warranted to examine whether a weight-based approach to common therapeutic interventions in septic shock influences outcome.

Motivation and job satisfaction of Tele-ICU nurses.

INTRODUCTION: Although the first tele-ICU has been in existence for more than 12 years, little is known about the work of tele-ICU nurses. This study examines sources of motivation and satisfaction of tele-ICU nurses. METHODS: A total of 50 nurses in 5 tele-ICUs were interviewed about reasons for working as a tele-ICU nurse and sources of satisfaction and dissatisfaction in their job. RESULTS: Nurses have different motivations to work in the tele-ICU, including the challenges and opportunities for new learning that occur while interacting with clinicians in the tele-ICU and the various ICUs being monitored. Tele-ICU nurses also appreciate the opportunities for teamwork with tele-ICU physicians and nurses. The relationship and interactions with the ICUs is sometimes mentioned as a dissatisfier. Some nurses miss being physically at the bedside, as well as interacting with patients and families. CONCLUSION: Most tele-ICU nurses are satisfied with their job. They like the challenge in their work and the opportunity to learn. For some nurses, the transition from a bedside caregiver to an information manager can be difficult. Other nurses have found a balance by working part-time in the tele-ICU and part-time in the ICU.

Impact of electronic order management on the timeliness of antibiotic administration in critical care patients.

OBJECTIVE: To examine the effect of implementing electronic order management on the timely administration of antibiotics to critical-care patients. METHODS: We used a prospective pre-post design, collecting data on first-dose IV antibiotic orders before and after the implementation of an integrated electronic medication-management system, which included computerized provider order entry (CPOE), pharmacy order processing and an electronic medication administration record (eMAR). The research was performed in a 24-bed adult medical/surgical ICU in a large, rural, tertiary medical center. Data on the time of ordering, pharmacy processing and administration were prospectively collected and time intervals for each stage and the overall process were calculated. RESULTS: The overall turnaround time from ordering to administration significantly decreased from a median of 100 min before order management implementation to a median of 64 min after implementation. The first part of the medication use process, i.e., from order entry to pharmacy processing, improved significantly whereas no change was observed in the phase from pharmacy processing to medication administration. DISCUSSION: The implementation of an electronic order-management system improved the timeliness of antibiotic administration to critical-care patients. Additional system changes are required to further decrease the turnaround time.

Major pulmonary embolism.

The scope and spectrum of pulmonary embolism (PE) that are likely to challenge the intensivist are dominantly confined to 2 scenarios; first, a patient presenting with undifferentiated shock or respiratory failure and, second, an established intensive care unit (ICU) or hospital patient who develops hemodynamically unstable PE after admission. In either scenario, the diagnostic approach and therapeutic options are challenging. Differentiating PE from other life-threatening cardiopulmonary disorders can be exceedingly difficult. This article will review a structured pathophysiologic approach to the diagnostic, resuscitative and management strategies related to PE in the ICU.