Critical care staffing ratio and outcome of COVID-19 patients requiring intensive care unit admission during the first pandemic wave: a retrospective analysis across Switzerland from the RISC-19-ICU observational cohort.

STUDY AIM: The surge of admissions due to severe COVID-19 increased the patients-to-critical care staffing ratio within the ICUs. We investigated whether the daily level of staffing was associated with an increased risk of ICU mortality (primary endpoint), length of stay (LOS), mechanical ventilation and the evolution of disease (secondary endpoints). METHODS: We employed a retrospective multicentre analysis of the international Risk Stratification in COVID-19 patients in the ICU (RISC-19-ICU) registry, limited to the period between March 1 and May 31, 2020, and to Switzerland. Hierarchical regression models were used to investigate crude and adjusted effects of the critical care staffing ratio on study endpoints. We adjusted for disease severity and weekly caseload. RESULTS: Among the 38 participating Swiss ICUs, 17 recorded staffing information. The study population included 437 patients and 2,342 daily assessments of patient-to-critical care staffing ratio. Median of daily patient-to-nurse ratio started at 1.0 [IQR 0.5-1.5; calendar week 9] and peaked at 2.4 (IQR 0.4-2.0; calendar week 16), while the median of daily patient-to-physician ratio started at 4.0 (IQR 2.1-5.0; calendar week 9) and peaked at 6.8 (IQR 6.3-7.3; calendar week 19). Neither the patient-to-nurse (adjusted OR 1.28, 95% CI 0.85-1.93; doubling of ratio) nor the patient-to-physician ratio (adjusted OR 1.07, 95% CI 0.87-1.32; doubling of ratio) were associated with ICU mortality. We found no association of daily critical care staffing on the secondary endpoints in adjusted models. CONCLUSION: We found no association of reduced availability of critical care staffing resources in Swiss ICUs with overall ICU length of stay nor mortality. Whether long-term outcome of critically ill patients with COVID-19 have been affected remains to be studied.

Early mobilisation and rehabilitation in Swiss intensive care units: a cross-sectional survey.

BACKGROUND: Patients in intensive care units (ICUs) are at high risk of developing physical, functional, cognitive, and mental impairments. Early mobilisation aims to improve patient outcomes and is increasingly considered the standard of care. This survey aimed to investigate the characteristics, current use and variations of early mobilisation and rehabilitation in Swiss ICUs. METHODS: We conducted a cross-sectional survey among all ICU lead physicians, who provided data on their institutional characteristics, early mobilisation and rehabilitation practices, and their perceptions of the use and variation of early rehabilitation practices in Switzerland. RESULTS: The survey response rate was 44% (37/84). Among ICUs caring for adults (34/37), 26 were in the German-speaking region, five in the French-speaking region, and three in the Italian-speaking region. All ICUs regularly involved physiotherapy in the rehabilitation process and 50% reported having a specialised physiotherapy team. All ICUs reported performing early mobilisation, starting within the first 7 days after ICU admission. About half reported the use of a rehabilitation (45%) or early mobilisation protocol (50%). Regular, structured, interdisciplinary rounds or meetings of the ICU care team to discuss rehabilitation measures and goals for patients were stated to be held by 53%. The respondents stated that 82% of their patients received early mobilisation measures during their ICU stay. Most frequently provided mobilisation measures included passive range of motion (97%), passive chair position in bed (97%), active range of motion muscle activation and training (88%), active side to side turning (91%), sitting on the edge of the bed (94%), transfer from bed to a chair (97%), and ambulation (94%). The proportion of ICUs providing a specific early mobilisation measure, the proportion of patients receiving it, and the time dedicated to it varied across language regions, hospital types, ICU types, and ICU sizes. Almost one third of the ICU lead physicians considered early rehabilitation to be underused in their own ICU and about half considered it to be underused in Switzerland more generally. ICU lead physicians stressed lack of personnel, financial resources, and time as key causes for underuse. Moreover, they highlighted the importance of early and systematic or protocol-based rehabilitation and interprofessional approaches that are adaptive to the patients' rehabilitation needs and potential. CONCLUSION: This survey suggests that almost all ICUs in Switzerland practice some form of early mobilisation with the aim of early rehabilitation. However, the described approaches, as well as the reported use of early mobilisation measures were heterogenous across Swiss ICUs.

[Smarter Intensive Care Medicine: Choosing Wisely®, less is more, appropriate is better and so what? The current situation in the Swiss intensive care medicine!] / Smarter Intensive Care Medicine: Choosing Wisely®, less is more, appropriate is better and so what?

Smarter Intensive Care Medicine: Choosing Wisely®, less is more, appropriate is better … and so what? The current situation in the Swiss intensive care medicine! Abstract. The top 9 list of the Swiss Society for Intensive Care Medicine (SSICM) was published in 2017. What is the status of this initiative in terms of its implementation in Swiss intensive care units, its impact on patient care and on the costs of intensive care medicine? What developments in the published evidence justify updating the list and what measures are needed to continue this initiative in the coming years? This article provides an up-to-date overview of the SSICM's Choosing Wisely® initiative.

Use of B-type natriuretic peptide in the management of hypoxaemic respiratory failure.

AIMS: Evaluation and management of patients with hypoxaemic respiratory failure in the intensive care unit (ICU) are difficult. The use of B-type natriuretic peptide (BNP), a quantitative marker of cardiac stress and heart failure (HF), may be helpful. The purpose of this study is to describe the prevalence of causative disorders of hypoxaemic respiratory failure in the ICU and to determine the impact of a BNP-guided diagnostic strategy. METHODS AND RESULTS: This prospective, multi-centre, randomized, single-blind, controlled trial included 314 ICU patients with hypoxaemic respiratory failure: 159 patients were randomly assigned to a diagnostic strategy involving the measurement of BNP and 155 were assessed in a standard manner. The time to discharge and the total cost of treatment were the primary endpoints. Hypoxaemic respiratory failure was multi-causal in 27% of the patients. Heart failure was the most common diagnosis in both groups. The use of BNP levels, in conjunction with other clinical information, significantly increased the detection of HF in combination with an additional diagnosis (32 vs. 16%, P = 0.001) and also increased the application of HF-specific medical therapy (nitrates: 32 vs. 23%, P < 0.05 and diuretics: 65 vs. 50%, P < 0.01). Time to discharge (median, 13 vs.14 days, P = 0.50) and total cost of treatment (median, US-$6190 vs. 7155, P = 0.24) were comparable in both groups. CONCLUSION: Hypoxaemic respiratory failure in the ICU is often a multi-causal disorder. The use of BNP increased the detection of HF, but did not significantly improve patient management as quantified by time to discharge or treatment cost. ClinicalTrials.gov Identifier: NCT00130559.

Effect of oral ß-blocker on short and long-term mortality in patients with acute respiratory failure: results from the BASEL-II-ICU study.

INTRODUCTION: Acute respiratory failure (ARF) is responsible for about one-third of intensive care unit (ICU) admissions and is associated with adverse outcomes. Predictors of short- and long-term outcomes in unselected ICU-patients with ARF are ill-defined. The purpose of this analysis was to determine predictors of in-hospital and one-year mortality and assess the effects of oral beta-blockers in unselected ICU patients with ARF included in the BASEL-II-ICU study. METHODS: The BASEL II-ICU study was a prospective, multicenter, randomized, single-blinded, controlled trial of 314 (mean age 70 (62 to 79) years) ICU patients with ARF evaluating impact of a B-type natriuretic peptide- (BNP) guided management strategy on short-term outcomes. RESULTS: In-hospital mortality was 16% (51 patients) and one-year mortality 41% (128 patients). Multivariate analysis assessed that oral beta-blockers at admission were associated with a lower risk of both in-hospital (HR 0.33 (0.14 to 0.74) P = 0.007) and one-year mortality (HR 0.29 (0.16 to 0.51) P = 0.0003). Kaplan-Meier analysis confirmed the lower mortality in ARF patients when admitted with oral beta-blocker and further shows that the beneficial effect of oral beta-blockers at admission holds true in the two subgroups of patients with ARF related to cardiac or non-cardiac causes. Kaplan-Meier analysis also shows that administration of oral beta-blockers before hospital discharge gives striking additional beneficial effects on one-year mortality. CONCLUSIONS: Established beta-blocker therapy appears to be associated with a reduced mortality in ICU patients with acute respiratory failure. Cessation of established therapy appears to be hazardous. Initiation of therapy prior to discharge appears to confer benefit. This finding was seen regardless of the cardiac or non-cardiac etiology of respiratory failure. TRIAL REGISTRATION: clinicalTrials.gov Identifier: NCT00130559.

Endotoxin concentration in modern animal houses in southern Bavaria.

Agricultural work, particularly livestock farming, is considered to be a notable risk factor for occupational diseases. Endotoxin as a major component of organic dust causes adverse health effects of the airways among farmers. Endotoxin concentrations in airborne and settled dust were measured in modern, naturally ventilated animal houses for different species. Median values of airborne inhalable endotoxin ranged from 16.9 EU/m3 for dairy cattle, 557.9 EU/m3 for beef cattle, 668.7 EU/m3 for pigs, 463.2 EU/m3 for laying hens, to 1,902 EU/m3 for turkeys. The endotoxin levels in settled dust followed the same pattern as the airborne samples. The concentrations were lower than in previous studies, but the proposed Dutch endotoxin threshold (50 EU/m3) was exceeded in most cases. Thus, endotoxin levels in modern animal houses still give concern for health and further reduction of endotoxin exposure in animal houses is desirable.