Asociación entre Glucemia inestable, tiempo de estancia y mortalidad de pacientes en estado críticos: Estudio de cohorte / Associação Entre Glicemia Instável, Tempo de Permanência e Mortalidade de Pacientes Críticos: Estudo de Coorte / Relationships between unstable Glycemia, Hospital Length Of Stay, and mortality In Critically Ill patients: A cohort study

Resumen Introducción: El control y la evaluación de los niveles glucémicos de pacientes en estado críticos es un desafío y una competencia del equipo de enfermería. Por lo que, determinar las consecuencias de esta durante la hospitalización es clave para evidenciar la importancia del oportuno manejo. Objetivo: Determinar la asociación entre la glucemia inestable (hiperglucemia e hipoglucemia), el resultado de la hospitalización y la duración de la estancia de los pacientes en una unidad de cuidados intensivos. Metodología: Estudio de cohorte prospectivo realizado con 62 pacientes a conveniencia en estado crítico entre marzo y julio de 2017. Se recogieron muestras diarias de sangre para medir la glucemia. Se evaluó la asociación de la glucemia inestable con la duración de la estancia y el resultado de la hospitalización mediante ji al cuadrado de Pearson. El valor de p<0.05 fue considerado significativo. Resultados: De las 62 personas participantes, 50 % eran hombres y 50 % mujeres. La edad media fue de 63.3 años (±21.4 años). La incidencia de glucemia inestable fue del 45.2 % y se asoció con una mayor duración de la estancia en la UCI (p<0.001) y una progresión a la muerte como resultado de la hospitalización (p=0.03). Conclusión: Entre quienes participaron, la glucemia inestable se asoció con una mayor duración de la estancia más prolongada y con progresión hacia la muerte, lo que refuerza la importancia de la actuación de enfermería para prevenir su aparición.

Resumo Introdução: O controle e avaliação dos níveis glicêmicos em pacientes críticos é um desafio e uma competência da equipe de enfermagem. Portanto, determinar as consequências da glicemia instável durante a hospitalização é chave para evidenciar a importância da gestão oportuna. Objetivo: Determinar a associação entre glicemia instável (hiperglicemia e hipoglicemia), os desfechos hospitalares e o tempo de permanência dos pacientes em uma unidade de terapia intensiva. Métodos: Um estudo de coorte prospectivo realizado com 62 pacientes a conveniência em estado crítico entre março e julho de 2017. Foram coletadas amostras diariamente de sangue para medir a glicemia. A associação entre a glicemia instável com o tempo de permanência e o desfecho da hospitalização foi avaliada pelo teste qui-quadrado de Pearson. O valor de p <0,05 foi considerado significativo. Resultados: Das 62 pessoas participantes, 50% eram homens e 50% mulheres. A idade média foi de 63,3 anos (±21,4 anos). A incidência de glicemia instável foi de 45,2% e se associou a um tempo de permanência mais prolongado na UTI (p <0,001) e uma progressão para óbito como desfecho da hospitalização (p = 0,03). Conclusão: Entre os participantes, a glicemia instável se associou a um tempo mais longo de permanência e com progressão para óbito, enfatizando a importância da actuação da equipe de enfermagem para prevenir sua ocorrência.

Abstract Introduction: The control and evaluation of glycemic levels in critically ill patients is a challenge and a responsibility of the nursing team; therefore, determining the consequences of this during hospitalization is key to demonstrate the importance of timely management. Objective: To determine the relationship between unstable glycemia (hyperglycemia and hypoglycemia), hospital length of stay, and the hospitalization outcome of patients in an Intensive Care Unit (ICU). Methods: A prospective cohort study conducted with 62 critically ill patients by convenience sampling between March and July 2017. Daily blood samples were collected to measure glycemia. The correlation of unstable glycemia with the hospital length of stay and the hospitalization outcome was assessed using Pearson's chi-square. A p-value <0.05 was considered significant. Results: Among the 62 patients, 50% were male and 50% were female. The mean age was 63.3 years (±21.4 years). The incidence of unstable glycemia was 45.2% and was associated with a longer ICU stay (p<0.001) and a progression to death as a hospitalization outcome (p=0.03). Conclusion: Among critically ill patients, unstable glycemia was associated with an extended hospital length of stay and a progression to death, emphasizing the importance of nursing intervention to prevent its occurrence.

Exploring intensivist involvement: Patient characteristics, interventions and outcomes.

Introduction: Intensivists play a critical role in the management of intensive care units (ICUs) and in providing high quality care. While international guidelines recommend intensivist staffing for improved patient outcomes, there is a shortage of qualified intensivists in many regions, including Türkiye. This study aimed to assess the impact of introducing a full-time intensivist to a medical ICU on patient characteristics, outcomes, and ICU interventions. Materials and Methods: This retrospective study analyzed data from the Internal Medicine ICU at Van Yüzüncü Yil University Dursun Odabas Medical Center over two periods: Pre- and post-intensivist recruitment. The study included adult patients admitted to the ICU from February 2018 to January 2020. Patient demographics, reasons for ICU admission, APACHE-II and SOFA scores, ICU interventions, and outcomes were recorded and compared between the two periods. Result: Of the 868 patients admitted during the study period, 820 were included in the analysis. There were no significant differences in demographic characteristics between the pre- and post-intensivist periods. However, patients in the post-intensivist period had higher APACHE-II and SOFA scores. Intensive care units mortality rates were comparable between the two periods. The post-intensivist period saw increased use of invasive mechanical ventilation and non-invasive ventilation compared to the pre-intensivist period. Renal replacement therapy usage and enteral nutrition provision also increased in the post-intensivist period. ICU and hospital lengths of stay remained similar between the two periods. Conclusions: The introduction of a full-time intensivist to the medical ICU led to changes in ICU interventions, including increased use of mechanical ventilation and renal replacement therapy. Despite these changes, ICU mortality rates remained unchanged. Further research is needed to explore the longterm impact of intensivist staffing on patient outcomes in Türkiye.

Measuring the impact of maternal critical care admission on short- and longer-term maternal and birth outcomes.

PURPOSE: Factors increasing the risk of maternal critical illness are rising in prevalence in maternity populations. Studies of general critical care populations highlight that severe illness is associated with longer-term physical and psychological morbidity. We aimed to compare short- and longer-term outcomes between women who required critical care admission during pregnancy/puerperium and those who did not. METHODS: This is a cohort study including all women delivering in Scottish hospitals between 01/01/2005 and 31/12/2018, using national healthcare databases. The primary exposure was intensive care unit (ICU) admission, while secondary exposures included high dependency unit admission. Outcomes included hospital readmission (1-year post-hospital discharge, 1-year mortality, psychiatric hospital admission, stillbirth, and neonatal critical care admission). Multivariable Cox and logistic regression were used to report hazard ratios (HR) and odds ratios (OR) of association between ICU admission and outcomes. RESULTS: Of 762,918 deliveries, 1449 (0.18%) women were admitted to ICU, most commonly due to post-partum hemorrhage (225, 15.5%) followed by eclampsia/pre-eclampsia (133, 9.2%). Over-half (53.8%) required mechanical ventilation. One-year hospital readmission was more frequent in women admitted to ICU compared with non-ICU populations [24.5% (n = 299) vs 8.9% (n = 68,029)]. This association persisted after confounder adjustment (HR 1.93, 95% confidence interval [CI] 1.33, 2.81, p < 0.001). Furthermore, maternal ICU admission was associated with increased 1-year mortality (HR 40.06, 95% CI 24.04, 66.76, p < 0.001), stillbirth (OR 12.31, 95% CI 7.95,19.08, p < 0.001) and neonatal critical care admission (OR 6.99, 95% CI 5.64,8.67, p < 0.001) after confounder adjustment. CONCLUSION: Critical care admission increases the risk of adverse short-term and long-term maternal, pregnancy and neonatal outcomes. Optimizing long-term post-partum care may benefit maternal critical illness survivors.

Application of the Sepsis-3 criteria to describe sepsis epidemiology in the Amsterdam UMCdb intensive care dataset.

INTRODUCTION: Sepsis is a major cause of morbidity and mortality worldwide. In the updated, 2016 Sepsis-3 criteria, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, where organ dysfunction can be represented by an increase in the Sequential Organ Failure Assessment (SOFA) score of 2 points or more. We sought to apply the Sepsis-3 criteria to characterise the septic cohort in the Amsterdam University Medical Centres database (Amsterdam UMCdb). METHODS: We examined adult intensive care unit (ICU) admissions in the Amsterdam UMCdb, which contains de-identified data for patients admitted to a mixed surgical-medical ICU at a tertiary academic medical centre in the Netherlands. We operationalised the Sepsis-3 criteria, defining organ dysfunction as an increase in the SOFA score of 2 points or more, while infection was defined as a new course of antibiotics or an escalation in antibiotic therapy, with at least one antibiotic given intravenously. Patients with sepsis were determined to be in septic shock if they additionally required the use of vasopressors and had a lactate level >2 mmol/L. RESULTS: We identified 18,221 ICU admissions from 16,408 patients in our cohort. There were 6,312 unique sepsis episodes, of which 30.2% met the criteria for septic shock. A total of 4,911/6,312 sepsis (77.8%) episodes occurred on ICU admission. Forty-seven percent of emergency medical admissions and 36.7% of emergency surgical admissions were for sepsis. Overall, there was a 12.5% ICU mortality rate; patients with septic shock had a higher ICU mortality rate (38.4%) than those without shock (11.4%). CONCLUSIONS: We successfully operationalised the Sepsis-3 criteria to the Amsterdam UMCdb, allowing the characterization and comparison of sepsis epidemiology across different centres.

Critical care ultrasound among Tunisian intensive care residents: A Cross-sectional Survey.

INTRODUCTION: Critical Care ultrasound (CCUS) is more and more used in Tunisian critical care units. An objective assessment of this training has not yet been performed. AIM: To assess the theoretical and practical knowledge about CCUS among Intensive Care Unit (ICU) residents. METHODS: This is a cross-sectional study conducted during the period from January to June 2021. Data were collected using a French language questionnaire distributed on the day of the selection of the residents' posts for the next training period (at the end of June 2021). RESULTS: Out of 75 residents, 37 accepted to answer to the survey (Participation rate =49 %). The majority were female (66.4%). The mean age was 29±12.36 years. Only 5.4% of participants (n=2) had previously received training concerning echocardiography and only 8.1% of the participants have received dedicated training for lung ultrasound (LU). Among the participants, 80.1% of residents (n=30) had never performed a transthoracic echocardiography (TTE). Competence in performing echocardiography was self-assessed quite good and bad by 5.4% and 43.2% of responders respectively. Most of the residents (86%) did not insert before ultrasound-guided central venous catheters. Views known by the participants using TTE were mainly parasternal long axis section (56.8%) and apical 4/5 chambers section (52.8%). All participants (100%) thought that teaching CCU is a necessary part of the training of intensivists. CONCLUSION: Our study highlighted the lack of training of Tunisian ICU residents regarding CCUS learning. Therefore, it is crucial to integrate such learning and training into their training programs.

COVID-19 Pandemic and Impact on Research Publications in Critical Care.

OBJECTIVES: The COVID-19 pandemic precipitated a significant transformation of scientific journals. Our aim was to determine how critical care (CC) journals and their impact may have evolved during the COVID-19 pandemic. We hypothesized that the impact, as measured by citations and publications, from the field of CC would increase. DESIGN: Observational study of journal publications, citations, and retractions status. SETTING: All work was done electronically and retrospectively. SUBJECTS: The top 18 CC journals broadly concerning CC, and the top 5 most productive CC journals on the SCImago list. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For the top 18 CC journals and specifically Critical Care Medicine (CCM), time series analysis was used to estimate the trends of total citations, citations per publication, and publications per year by using the best-fit curve. We used PubMed and Retraction Watch to determine the number of COVID-19 publications and retractions. The average total citations and citations per publication for all journals was an upward quadratic trend with inflection points in 2020, whereas publications per year spiked in 2020 before returning to prepandemic values in 2021. For CCM total publications trend downward while total citations and citations per publication generally trend up from 2017 onward. CCM had the lowest percentage of COVID-related publications (15.7%) during the pandemic and no reported retractions. Two COVID-19 retractions were noted in our top five journals. CONCLUSIONS: Citation activity across top CC journals underwent a dramatic increase during the COVID-19 pandemic without significant retraction data. These trends suggest that the impact of CC has grown significantly since the onset of COVID-19 while maintaining adherence to a high-quality peer-review process.

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.

Sex and gender-based analysis and diversity metric reporting in acute care trials published in high-impact journals: a systematic review.

OBJECTIVE: To characterise sex and gender-based analysis (SGBA) and diversity metric reporting, representation of female/women participants in acute care trials and temporal changes in reporting before and after publication of the 2016 Sex and Gender Equity in Research guideline. DESIGN: Systematic review. DATA SOURCES: We searched MEDLINE for trials published in five leading medical journals in 2014, 2018 and 2020. STUDY SELECTION: Trials that enrolled acutely ill adults, compared two or more interventions and reported at least one clinical outcome. DATA ABSTRACTION AND SYNTHESIS: 4 reviewers screened citations and 22 reviewers abstracted data, in duplicate. We compared reporting differences between intensive care unit (ICU) and cardiology trials. RESULTS: We included 88 trials (75 (85.2%) ICU and 13 (14.8%) cardiology) (n=111 428; 38 140 (34.2%) females/women). Of 23 (26.1%) trials that reported an SGBA, most used a forest plot (22 (95.7%)), were prespecified (21 (91.3%)) and reported a sex-by-intervention interaction with a significance test (19 (82.6%)). Discordant sex and gender terminology were found between headings and subheadings within baseline characteristics tables (17/32 (53.1%)) and between baseline characteristics tables and SGBA (4/23 (17.4%)). Only 25 acute care trials (28.4%) reported race or ethnicity. Participants were predominantly white (78.8%) and male/men (65.8%). No trial reported gendered-social factors. SGBA reporting and female/women representation did not improve temporally. Compared with ICU trials, cardiology trials reported significantly more SGBA (15/75 (20%) vs 8/13 (61.5%) p=0.005). CONCLUSIONS: Acute care trials in leading medical journals infrequently included SGBA, female/women and non-white trial participants, reported race or ethnicity and never reported gender-related factors. Substantial opportunity exists to improve SGBA and diversity metric reporting and recruitment of female/women participants in acute care trials. PROSPERO REGISTRATION NUMBER: CRD42022282565.

Comparative performance of intensive care mortality prediction models based on manually curated versus automatically extracted electronic health record data.

INTRODUCTION: Benchmarking intensive care units for audit and feedback is frequently based on comparing actual mortality versus predicted mortality. Traditionally, mortality prediction models rely on a limited number of input variables and significant manual data entry and curation. Using automatically extracted electronic health record data may be a promising alternative. However, adequate data on comparative performance between these approaches is currently lacking. METHODS: The AmsterdamUMCdb intensive care database was used to construct a baseline APACHE IV in-hospital mortality model based on data typically available through manual data curation. Subsequently, new in-hospital mortality models were systematically developed and evaluated. New models differed with respect to the extent of automatic variable extraction, classification method, recalibration usage and the size of collection window. RESULTS: A total of 13 models were developed based on data from 5,077 admissions divided into a train (80%) and test (20%) cohort. Adding variables or extending collection windows only marginally improved discrimination and calibration. An XGBoost model using only automatically extracted variables, and therefore no acute or chronic diagnoses, was the best performing automated model with an AUC of 0.89 and a Brier score of 0.10. DISCUSSION: Performance of intensive care mortality prediction models based on manually curated versus automatically extracted electronic health record data is similar. Importantly, our results suggest that variables typically requiring manual curation, such as diagnosis at admission and comorbidities, may not be necessary for accurate mortality prediction. These proof-of-concept results require replication using multi-centre data.

Postoperative intensive care allocation and mortality in high-risk surgical patients: evidence from a low- and middle-income country cohort.

BACKGROUND: The escalation of surgeries for high-risk patients in Low- and Middle-Income Countries (LMICs) lacks evidence on the positive impact of Intensive Care Unit (ICU) admission and lacks universal criteria for allocation. This study explores the link between postoperative ICU allocation and mortality in high-risk patients within a LMIC. Additionally, it assesses the Ex-Care risk model's utility in guiding postoperative allocation decisions. METHODS: A secondary analysis was conducted in a cohort of high-risk surgical patients from a 800-bed university-affiliated teaching hospital in Southern Brazil (July 2017 to January 2020). Inclusion criteria encompassed 1431 inpatients with Ex-Care Model-assessed all-cause postoperative 30-day mortality risk exceeding 5%. The study compared 30-day mortality outcomes between those allocated to the ICU and the Postanesthetic Care Unit (PACU). Outcomes were also assessed based on Ex-Care risk model classes. RESULTS: Among 1431 high-risk patients, 250 (17.47%) were directed to the ICU, resulting in 28% in-hospital 30-day mortality, compared to 8.9% in the PACU. However, ICU allocation showed no independent effect on mortality (RR = 0.91; 95% CI 0.68‒1.20). Patients in the highest Ex-Care risk class (Class IV) exhibited a substantial association with mortality (RR = 2.11; 95% CI 1.54-2.90) and were more frequently admitted to the ICU (23.3% vs. 13.1%). CONCLUSION: Patients in the highest Ex-Care risk class and those with complications faced elevated mortality risk, irrespective of allocation. Addressing the unmet need for adaptable postoperative care for high-risk patients outside the ICU is crucial in LMICs. Further research is essential to refine criteria and elucidate the utility of risk assessment tools like the Ex-Care model in assisting allocation decisions.

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.

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.

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.

Table 0; documenting the steps to go from clinical database to research dataset.

OBJECTIVES: Data-driven decision support tools have been increasingly recognized to transform health care. However, such tools are often developed on predefined research datasets without adequate knowledge of the origin of this data and how it was selected. How a dataset is extracted from a clinical database can profoundly impact the validity, interpretability and interoperability of the dataset, and downstream analyses, yet is rarely reported. Therefore, we present a case study illustrating how a definitive patient list was extracted from a clinical source database and how this can be reported. STUDY DESIGN AND SETTING: A single-center observational study was performed at an academic hospital in the Netherlands to illustrate the impact of selecting a definitive patient list for research from a clinical source database, and the importance of documenting this process. All admissions from the critical care database admitted between January 1, 2013, and January 1, 2023, were used. RESULTS: An interdisciplinary team collaborated to identify and address potential sources of data insufficiency and uncertainty. We demonstrate a stepwise data preparation process, reducing the clinical source database of 54,218 admissions to a definitive patient list of 21,553 admissions. Transparent documentation of the data preparation process improves the quality of the definitive patient list before analysis of the corresponding patient data. This study generated seven important recommendations for preparing observational health-care data for research purposes. CONCLUSION: Documenting data preparation is essential for understanding a research dataset originating from a clinical source database before analyzing health-care data. The findings contribute to establishing data standards and offer insights into the complexities of preparing health-care data for scientific investigation. Meticulous data preparation and documentation thereof will improve research validity and advance critical care.

Encuesta nacional sobre cambios en las políticas de comunicación, visitas y cuidados al final de la vida en las unidades de cuidados intensivos durante las diferentes olas de la pandemia de COVID-19 (estudio COVIFAUCI) / National survey on changes in visitation, communication and end-of-life care policies in intensive care units through the different COVID-19 pandemic's waves (COVIFAUCI study)

Introducción La pandemia derivada de la infección por SARS-CoV-2 propició cambios en los cuidados tanto a familiares como a pacientes de cuidados intensivos durante las diferentes olas de incidencia del virus. La línea de humanización seguida por la mayoría de los hospitales se vio gravemente afectada por las restricciones aplicadas. Como objetivo, planteamos conocer las modificaciones experimentadas durante las diferentes olas de la pandemia por SARS-CoV-2 en España respecto a la política de visitas a los pacientes en UCI, el acompañamiento al final de la vida, y el uso de las nuevas tecnologías de la comunicación entre familiares, pacientes y profesionales. Métodos Estudio descriptivo transversal multicéntrico mediante encuesta a las UCI españolas desde febrero a abril de 2022. Se realizaron métodos de análisis estadísticos a los resultados según lo apropiado. El estudio fue avalado por la Sociedad Española de Enfermería Intensiva y Unidades Coronarias. Resultados Respondieron un 29% de las unidades contactadas. Los minutos de visita diarios de los familiares se redujeron drásticamente de 135 (87,5-255) a 45 (25-60) en el 21,2% de las unidades que permitían su acceso, mejorando levemente con el paso de las olas. En el caso de duelo, la permisividad fue mayor, aumentando el uso de las nuevas tecnologías para la comunicación paciente-familia en el caso del 96,5% de las unidades. Conclusiones Las familias de los pacientes ingresados en UCI durante las diferentes olas de la pandemia por COVID-19 han experimentado restricciones en las visitas y cambio de la presencialidad por técnicas virtuales de comunicación. Los tiempos de acceso se redujeron a niveles mínimos durante la primera ola, recuperándose con el avance de la pandemia pero sin llegar nunca a los niveles iniciales... (AU)

Introduction The pandemic derived from the SARS-CoV-2 infection led to changes in care for both relatives and intensive care patients during the different waves of incidence of the virus. The line of humanization followed by the majority of the hospitals was seriously affected by the restrictions applied. As an objective, we propose to know the modifications suffered during the different waves of the SARS-CoV-2 pandemic in Spain regarding the policy of visits to patients in the ICU, monitoring at the end of life, and the use of new technologies of communication between family members, patients and professionals. Methods Multicenter cross-sectional descriptive study through a survey of Spanish ICUs from February to April 2022. Statistical analysis methods were performed on the results as appropriate. The study was endorsed by the Spanish Society of Intensive Nursing and Coronary Units. Results Twenty-nine percent of the units contacted responded. The daily visiting minutes of relatives dropped drastically from 135 (87.5-255) to 45 (25-60) in the 21.2% of units that allowed their access, improving slightly with the passing of the waves. In the case of bereavement, the permissiveness was greater, increasing the use of new technologies for patient-family communication in the case of 96.5% of the units. Conclusions The family of patients admitted to the ICU during the different waves of the COVID-19 pandemic have suffered restrictions on visits and a change from face-to-face to virtual communication techniques. Access times were reduced to minimum levels during the first wave, recovering with the advance of the pandemic but never reaching initial levels. Despite the implemented solutions and virtual communication, efforts should be directed towards improving the protocols for the humanization of healthcare that allow caring for families and patients whatever the healthcare context. (AU)

Encuesta nacional sobre cambios en las políticas de comunicación, visitas y cuidados al final de la vida en las unidades de cuidados intensivos durante las diferentes olas de la pandemia de COVID-19 (estudio COVIFAUCI) / National survey on changes in visitation, communication and end-of-life care policies in intensive care units through the different COVID-19 pandemic's waves (COVIFAUCI study)

Introducción La pandemia derivada de la infección por SARS-CoV-2 propició cambios en los cuidados tanto a familiares como a pacientes de cuidados intensivos durante las diferentes olas de incidencia del virus. La línea de humanización seguida por la mayoría de los hospitales se vio gravemente afectada por las restricciones aplicadas. Como objetivo, planteamos conocer las modificaciones experimentadas durante las diferentes olas de la pandemia por SARS-CoV-2 en España respecto a la política de visitas a los pacientes en UCI, el acompañamiento al final de la vida, y el uso de las nuevas tecnologías de la comunicación entre familiares, pacientes y profesionales. Métodos Estudio descriptivo transversal multicéntrico mediante encuesta a las UCI españolas desde febrero a abril de 2022. Se realizaron métodos de análisis estadísticos a los resultados según lo apropiado. El estudio fue avalado por la Sociedad Española de Enfermería Intensiva y Unidades Coronarias. Resultados Respondieron un 29% de las unidades contactadas. Los minutos de visita diarios de los familiares se redujeron drásticamente de 135 (87,5-255) a 45 (25-60) en el 21,2% de las unidades que permitían su acceso, mejorando levemente con el paso de las olas. En el caso de duelo, la permisividad fue mayor, aumentando el uso de las nuevas tecnologías para la comunicación paciente-familia en el caso del 96,5% de las unidades. Conclusiones Las familias de los pacientes ingresados en UCI durante las diferentes olas de la pandemia por COVID-19 han experimentado restricciones en las visitas y cambio de la presencialidad por técnicas virtuales de comunicación. Los tiempos de acceso se redujeron a niveles mínimos durante la primera ola, recuperándose con el avance de la pandemia pero sin llegar nunca a los niveles iniciales... (AU)

Introduction The pandemic derived from the SARS-CoV-2 infection led to changes in care for both relatives and intensive care patients during the different waves of incidence of the virus. The line of humanization followed by the majority of the hospitals was seriously affected by the restrictions applied. As an objective, we propose to know the modifications suffered during the different waves of the SARS-CoV-2 pandemic in Spain regarding the policy of visits to patients in the ICU, monitoring at the end of life, and the use of new technologies of communication between family members, patients and professionals. Methods Multicenter cross-sectional descriptive study through a survey of Spanish ICUs from February to April 2022. Statistical analysis methods were performed on the results as appropriate. The study was endorsed by the Spanish Society of Intensive Nursing and Coronary Units. Results Twenty-nine percent of the units contacted responded. The daily visiting minutes of relatives dropped drastically from 135 (87.5-255) to 45 (25-60) in the 21.2% of units that allowed their access, improving slightly with the passing of the waves. In the case of bereavement, the permissiveness was greater, increasing the use of new technologies for patient-family communication in the case of 96.5% of the units. Conclusions The family of patients admitted to the ICU during the different waves of the COVID-19 pandemic have suffered restrictions on visits and a change from face-to-face to virtual communication techniques. Access times were reduced to minimum levels during the first wave, recovering with the advance of the pandemic but never reaching initial levels. Despite the implemented solutions and virtual communication, efforts should be directed towards improving the protocols for the humanization of healthcare that allow caring for families and patients whatever the healthcare context. (AU)

Telemedicine critical care availability and outcomes among mechanically ventilated patients.

PURPOSE: Telemedicine Critical Care (TCC) improves adherence to evidence based protocols associated with improved mortality among patients receiving invasive mechanical ventilation (IMV). We sought to evaluate the relationship between hospital availability of TCC and outcomes among patients receiving IMV. MATERIALS AND METHODS: We performed a cross-sectional study of 66,522 adults who received IMV for non-postoperative acute respiratory failure at 318 non-federal hospitals in New York, Massachusetts, Maryland, and Florida in 2018. Hospital-level TCC availability was ascertained from the 2018 American Hospital Association Annual Survey. The primary outcome was in-hospital mortality. Secondary outcomes included the composite of tracheostomy or reintubation and duration of IMV. We used two-level hierarchical multivariable regression models to investigate the association between TCC availability and outcomes. RESULTS: 20,270 (30.5%) patients were admitted into 89 TCC-available hospitals. There was no difference between TCC and non-TCC-available hospitals in mortality (odds ratio [OR] 0.94, 99% confidence interval [CI] 0.84-1.05), composite of tracheostomy or reintubation (OR 0.95 [0.82-1.11], or duration of IMV (OR 0.95 [0.83-1.09]). There was no difference in outcomes among the subgroup of patients with acute respiratory distress syndrome. CONCLUSIONS: Hospital TCC availability was not associated with improved outcomes among patients receiving IMV.

Association of medical care capacity and the patient mortality of septic shock: a cross-sectional study.

BACKGROUND: Hospitals with higher septic shock case volume demonstrated lower hospital mortality. We conducted this study to investigate whether this phenomenon was only caused by the increase in the number of admissions or the need to improve the medical care capacity in septic shock at the same time. METHODS: Seven-hundred and eighty-seven hospitals from China collected in a survey from January 1, 2021 to December 31, 2021. Medical care capacity for septic shock was explored by patients with septic shock in intensive care units (ICU) divided into beds, intensivists, and nurses respectively. MAIN RESULTS: The proportion of ICU patients with septic shock was negatively associated with the patient mortality of septic shock (Estimate [95%CI], -0.2532 [-0.5038, -0.0026]) (p-value 0.048). The ratios of patients with septic shock to beds, intensivists, and nurses were negatively associated with mortality of septic shock (Estimate [95%CI], -0.370 [-0.591, -0.150], -0.136 [-0.241, -0.031], and -0.774 [-1.158, -0.389]) (p-value 0.001, 0.011 and < 0.001). Severe pneumonia, the most common infection that caused a septic shock, correlated positively with its mortality (Estimate [95%CI], 0.1002 [0.0617, 0.1387]) (p-value < 0.001). CONCLUSIONS: Hospitals with higher medical care capacity for septic shock were associated with lower hospital mortality.

Associations between burn care services and impairment at discharge after burn injury: Analysis of the Global Burn Registry.

BACKGROUND: Throughout the world, burn injury is a major cause of death and disability. In resource-limited countries, burn injury is one of the leading causes of permanent disability among children who survive traumatic injuries, and burn injury is the fourth leading cause of disability worldwide. This study applied Andersen's model of health care access to evaluate if patient characteristics (predisposing factors), burn care service availability (enabling factors) and injury characteristics (need) are associated with physical impairment at hospital discharge for patients surviving burn injuries globally. Specifically, access to rehabilitation, nutrition, operating theatre, specialized burn unit services, and critical care were investigated as enabling factors. The secondary aim was to determine whether associations between burn care service availability and impairment differed by country income level. METHODS: This is a cross-sectional secondary analysis of prospectively collected data from the World Health Organization, Global Burn Registry. The outcome of interest was physical impairment at discharge. Simple and multivariable logistic regressions were used to test the unadjusted and adjusted associations between the availability of burn care services and impairment at hospital discharge, controlling for patient and injury characteristics. Effect modification was analyzed with service by country income level interaction terms added to the models and, if significant, the models were stratified by income. RESULTS: The sample included 6622 patients from 20 countries, with 11.2% classified with physical impairment at discharge. In the fully adjusted model, patients had 89% lower odds impairment at discharge if the treatment facility provided reliable rehabilitation services compared to providing limited or no rehabilitation services (OR.11, 95%CI.08,.16, p < .01). However, this effect was modified by county income with the strong and significant association only present in high/upper middle-income countries. Sophisticated nutritional services were also significantly associated with less impairment in high/upper middle-income countries (OR=.04, 95% CI 0.203, 0.05, p < .01), but significantly more impairment in lower middle/low-income countries (OR=2.01, 95% CI 1.50, 2.69, p < .01). Patients had 444% greater odds of impairment if treated at a center with specialty burn unit services (OR 5.44, 95%CI 3.71, 7.99, p < .01), possibly due to a selection effect. DISCUSSION: Access to reliable rehabilitation services and sophisticated nutritional services were strongly associated with less physical impairment at discharge, but only in resource-rich countries. Although these findings support the importance of rehabilitation and nutrition after burn injury, they also highlight potential disparities in the quantity or quality of services available to burn survivors in poorer countries.