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BACKGROUND: Acute respiratory failure occurs frequently in hospitalized patients and often begins outside the ICU, associated with increased length of stay, cost, and mortality. Delays in decompensation recognition are associated with worse outcomes. OBJECTIVES: The objective of this study is to predict acute respiratory failure requiring any advanced respiratory support (including noninvasive ventilation). With the advent of the coronavirus disease pandemic, concern regarding acute respiratory failure has increased. DERIVATION COHORT: All admission encounters from January 2014 to June 2017 from three hospitals in the Emory Healthcare network (82,699). VALIDATION COHORT: External validation cohort: all admission encounters from January 2014 to June 2017 from a fourth hospital in the Emory Healthcare network (40,143). Temporal validation cohort: all admission encounters from February to April 2020 from four hospitals in the Emory Healthcare network coronavirus disease tested (2,564) and coronavirus disease positive (389). PREDICTION MODEL: All admission encounters had vital signs, laboratory, and demographic data extracted. Exclusion criteria included invasive mechanical ventilation started within the operating room or advanced respiratory support within the first 8 hours of admission. Encounters were discretized into hour intervals from 8 hours after admission to discharge or advanced respiratory support initiation and binary labeled for advanced respiratory support. Prediction of Acute Respiratory Failure requiring advanced respiratory support in Advance of Interventions and Treatment, our eXtreme Gradient Boosting-based algorithm, was compared against Modified Early Warning Score. RESULTS: Prediction of Acute Respiratory Failure requiring advanced respiratory support in Advance of Interventions and Treatment had significantly better discrimination than Modified Early Warning Score (area under the receiver operating characteristic curve 0.85 vs 0.57 [test], 0.84 vs 0.61 [external validation]). Prediction of Acute Respiratory Failure requiring advanced respiratory support in Advance of Interventions and Treatment maintained a positive predictive value (0.31-0.21) similar to that of Modified Early Warning Score greater than 4 (0.29-0.25) while identifying 6.62 (validation) to 9.58 (test) times more true positives. Furthermore, Prediction of Acute Respiratory Failure requiring advanced respiratory support in Advance of Interventions and Treatment performed more effectively in temporal validation (area under the receiver operating characteristic curve 0.86 [coronavirus disease tested], 0.93 [coronavirus disease positive]), while achieving identifying 4.25-4.51× more true positives. CONCLUSIONS: Prediction of Acute Respiratory Failure requiring advanced respiratory support in Advance of Interventions and Treatment is more effective than Modified Early Warning Score in predicting respiratory failure requiring advanced respiratory support at external validation and in coronavirus disease 2019 patients. Silent prospective validation necessary before local deployment.
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INTRODUCTION: As many as 50% of all nursing home (NH) residents meet the World Health Organization criteria for anemia. The objectives of this study were to determine the prevalence and appropriateness of prescribing and monitoring of erythropoiesis-stimulating agents (ESAs) used to treat anemia in the NH setting. METHODS: Cross-sectional, 1-month study of all NH residents in 4 community-based, university-affiliated NHs between January and February 2008. Residents were included in the analysis if they received at least 1 dose of an ESA during the study duration. Data collected through chart review included basic demographic information, ESA indication, ESA dosage, concurrent administration of iron supplements, hemoglobin (Hgb) monitoring, and blood pressure measurements. RESULTS: A total of 4.5% (22/485) of NH residents received at least 1 dose of an ESA. Residents who received ESAs had a mean age of 80.4 (+/- 14.5) years. Most residents who received ESAs were female (64% [14/22]), white (68% [15/22]), and had a mean weight of 72.0 (+/- 20.84) kg. Only 27% (6/22) of residents were prescribed an ESA for an FDA-approved indication. Darbepoetin alfa was the most commonly prescribed ESA (64% [14/22]) with a mean weekly dose of 70.8 (+/- 68.1) mug, followed by epoetin alfa (37% [8/22]) with a mean weekly dose of 22,625 (+/- 21,232) units. More than one quarter (27% [6/22]) of those who received an ESA had an Hgb value of 12g/dL or more, the maximum recommended threshold for use of these medications. Of the 18 residents who had blood pressure measurements, 11% (2/18) were hypertensive. CONCLUSION: Suboptimal prescribing and monitoring of ESAs were common in the NHs we studied. Future studies are needed to determine if the development and use of computerized decision support systems can improve prescribing and monitoring of ESAs in the NH setting.
