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1.
AORN J ; 113(2): 165-178, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33534154

RESUMO

Early in 2020, government leaders declared a public health emergency because of the coronavirus disease 2019 (COVID-19) outbreak. After World Health Organization leaders declared that the spread of COVID-19 was a pandemic, it became evident that patients suspected or confirmed to have COVID-19 would present for surgery at our community hospital, the only facility in the county. The Maryland governor charged hospital administrators with expanding bed capacity in anticipation of a surge of critically ill patients. Concurrently, the Maryland secretary of health prohibited all elective procedures. During the early phase of preparation and response, processes, information, and hospital capabilities and capacity changed frequently and rapidly. Effective communication, teamwork, and interprofessional and interdepartmental collaboration helped us prepare to deliver safe surgical care to patients during the pandemic and maintain safety for all involved. This article describes our health care facility's response to the pandemic and lessons learned during the process.


Assuntos
Hospitais Comunitários/organização & administração , Enfermagem Perioperatória , Humanos , Maryland
2.
J Nurs Adm ; 51(3): 117-119, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33570365

RESUMO

Dynamic nursing leadership and engagement of nursing at all levels are critical to effective care delivery. During the COVID-19 crisis, many organizations suspended non-COVID-related meetings, including professional governance councils where practice decisions are made. This article highlights how shared or professional governance was leveraged during this global pandemic at a large academic medical center and community hospital effectively sustaining autonomous nursing practice while responding to a rapidly changing environment and impacting quality patient care.


Assuntos
/enfermagem , Conselho Diretor/organização & administração , Hospitais Comunitários/organização & administração , Liderança , Enfermeiras Administradoras/organização & administração , Cuidados de Enfermagem/organização & administração , Recursos Humanos de Enfermagem no Hospital/organização & administração , Adulto , Chicago , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Organizacionais , Pandemias
3.
Ann Glob Health ; 87(1): 1, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33505860

RESUMO

Background: UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the US-Mexico border area of California contiguous to the Mexican Northern Baja region. The COVID-19 pandemic deeply influenced UCSDHS activities as new public health challenges increasingly related to high population density, cross-border traffic, economic disparities, and interconnectedness between cross-border communities, which accelerated development of clinical collaborations between UCSDHS and several border community hospitals - one in the US, two in Mexico - as high volumes of severely ill patients overwhelmed hospitals. Objective: We describe the development, implementation, feasibility, and acceptance of a novel critical care support program in three community hospitals along the US-Mexico border. Methods: We created and instituted a hybrid critical care program involving: 1) in-person activities to perform needs assessments of equipment and supplies and hands-on training and education, and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or consultative, education-based experiences. We collected performance metrics surrounding adherence to evidence-based practices and staff perceptions of critical care delivery. Findings: In-person intervention phase identified and filled gaps in equipment and supplies, and Tele-ICU program promoted adherence to evidence-based practices and improved staff confidence in caring for critically ill COVID-19 patients at each hospital. Conclusion: A collaborative, hybrid critical care program across academic and community centers is feasible and effective to address cross-cultural public health emergencies.


Assuntos
Centros Médicos Acadêmicos , Cuidados Críticos/métodos , Hospitais Comunitários , Comunicação Interdisciplinar , Telemedicina , Algoritmos , California , Cuidados Críticos/organização & administração , Equipamentos e Provisões Hospitalares , Medicina Baseada em Evidências , Pessoal de Saúde/educação , Humanos , Controle de Infecções/métodos , Unidades de Terapia Intensiva , Cooperação Internacional , México , Enfermagem/métodos , Autoeficácia
4.
Arch Osteoporos ; 16(1): 8, 2021 01 06.
Artigo em Inglês | MEDLINE | ID: mdl-33409668

RESUMO

Treatment rates for osteoporosis after a major osteoporotic fracture are unacceptably low. We evaluate the effectiveness of an ortho-geriatric team (OGT) in initiating pharmacologic therapy for osteoporosis post-hip fracture. The OGT was able to achieve a higher treatment rate for patients post-hip fracture in comparison to usual care provided by the primary care hospitalist. Potential reasons for delaying or not proceeding with drug therapy include patient concern regarding potential rare side effects of antiresorptive therapy including osteonecrosis of the jaw and atypical femoral fracture. These events however are rare, and in this study, only 3% of hip fractures were atypical femoral fractures. INTRODUCTION: Currently, a significant care gap for osteoporosis therapy exists post-hip fracture despite advances in pharmacologic therapy. We evaluate the effectiveness of the OGT at the Oakville Trafalgar Memorial Hospital (OTMH), Ontario, Canada, in reducing the care gap and initiating pharmacologic therapy in hip fracture patients prior to hospital discharge. We also evaluated the incidence of atypical femoral fracture (AFF) separately. METHODS: A retrospective chart review of patients 59 years and older with a hip fracture admitted to OTMH from January 1, 2016, to February 1, 2017, was conducted. The primary outcome was the proportion of hip fracture patients discharged from the hospital with appropriate treatment for their underlying osteoporosis. A sub-analysis was completed reporting the incidence of AFF among older adults. RESULTS: A total of 197 patients with a hip fracture were identified, 134/197 (68%) patients were seen by the OGT, 98/134 (73%) of these patients were started on pharmacologic therapy prior to discharge, and 120/134 (89%) of patients seen by the OGT were on treatment within 3 months of discharge following assessment in the complex osteoporosis clinic. Sixty-three patients of the 197 (63/197) (32%) of the hip fracture patients were seen by a hospitalist, and treatment rates prior to discharge were 5%. Only 6/197 patients had experienced an AFF during the study period, and all patients with an atypical femoral fracture had been on long-term bisphosphonate therapy. All of the patients with an AFF had thigh or groin pain for several weeks to months prior to the development of the atypical femoral fracture, providing an opportunity to stop therapy and possibly prevent the development of a complete AFF. CONCLUSION: The OGT was able to initiate anti-osteoporosis therapy in significantly more patients in comparison to usual care, and higher treatment rates are possible with an OGT.


Assuntos
Conservadores da Densidade Óssea , Fraturas do Fêmur , Fraturas do Quadril , Osteoporose , Fraturas por Osteoporose , Idoso , Conservadores da Densidade Óssea/efeitos adversos , Difosfonatos , Fraturas do Quadril/epidemiologia , Hospitais Comunitários , Humanos , Ontário , Osteoporose/tratamento farmacológico , Osteoporose/epidemiologia , Fraturas por Osteoporose/epidemiologia , Estudos Retrospectivos
5.
Public Health ; 190: 93-98, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33385640

RESUMO

OBJECTIVES: The objective of the study is the identification of racial differences in characteristics and comorbidities in patients hospitalized for COVID-19 and the impact on outcomes. STUDY DESIGN: The study design is a retrospective observational study. METHODS: Data for all patients admitted to seven community hospitals in Michigan, United States, with polymerase chain reaction confirmed diagnosis of COVID-19 from March 10 to April 15, 2020 were analyzed. The primary outcomes of racial disparity in inpatient mortality and intubation were analyzed using descriptive statistics and multivariate regression models. RESULTS: The study included 336 Black and 408 White patients. Black patients were younger (62.9 ± 15.0 years vs 71.8 ± 16.4, P < .001), had a higher mean body mass index (32.4 ± 8.6 kg/m2 vs 28.8 ± 7.5, P < .001), had higher prevalence of diabetes (136/336 vs 130/408, P = .02), and presented later (6.6 ± 5.3 days after symptom onset vs. 5.4 ± 5.4, P = .006) compared with White patients. Younger Black patients had a higher prevalence of obesity (age <65 years, 69.9%) than older Black patients (age >65 years, 39.2%) and younger White patients (age < 65, 55.1%). Intubation did not reach statistical significance for racial difference (Black patients 61/335 vs. 54/406, P = .08). Mortality was not higher in Black patients (65/335 vs. 142/406 in White patients, odds ratio 0.61, 95% confidence interval: 0.37 to 0.99, 2-sided P = .05) in multivariate analysis, accounting for other risk factors associated with mortality. CONCLUSIONS: Higher prevalence of obesity and diabetes in young Black populations may be the critical factor driving disproportionate COVID-19 hospitalizations in Black populations. Hospitalized Black patients do not have worse outcomes compared with White patients.


Assuntos
/etnologia , Grupos de Populações Continentais/estatística & dados numéricos , Diabetes Mellitus/epidemiologia , Hospitalização/estatística & dados numéricos , Obesidade/epidemiologia , Afro-Americanos/estatística & dados numéricos , Idoso , Índice de Massa Corporal , /virologia , Comorbidade , Grupos de Populações Continentais/etnologia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hospitais Comunitários , Humanos , Unidades de Terapia Intensiva , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Pandemias , Prevalência , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Estudos Retrospectivos , Fatores de Risco
7.
Am J Emerg Med ; 40: 1-5, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33326910

RESUMO

OBJECTIVE: To describe emergency department (ED) antibiotic prescribing for urinary tract infections (UTIs) and asymptomatic bacteriuria (ASB) and to identify improvement opportunities. METHODS: Patients treated for UTI in 16 community hospital EDs were reviewed to identify prescribing that was unnecessary (any treatment for ASB, duration >7 days for cystitis or >14 days for pyelonephritis) or suboptimal [ineffective antibiotics (nitrofurantoin/fosfomycin) or duration <7 days for pyelonephritis]. Duration criteria were based on recommendations for complicated UTI since criteria for uncomplicated UTI were not reviewed. 14-day repeat ED visits were evaluated. RESULTS: Of 250,788 ED visits, UTI was diagnosed in 13,466 patients (5%), and 1427 of these (11%) were manually reviewed. 286/1427 [20%, 95% CI: 18-22%] met criteria for ASB and received 2068 unnecessary antibiotic days [mean (±SD) 7 (2) days]. Mean treatment duration was 7 (2) days for cystitis and 9 (2) days for pyelonephritis. Of 446 patients with cystitis, 128 (29%) were prescribed >7 days (total 396 unnecessary). Of 422 pyelonephritis patients, 0 (0%) were prescribed >14 days, 20 (5%) were prescribed <7 days, and 9 (2%) were given ineffective antibiotics. Overall, prescribing was unnecessary or suboptimal in 443/1427 [31%, 95% CI: 29-33%] resulting in 2464/11,192 (22%) unnecessary antibiotic days and 8 (0.5%) preventable ED visits. CONCLUSIONS: Among reviewed patients, poor UTI prescribing in 16 EDs resulted in unnecessary antibiotic days and preventable readmissions. Key areas for improvement include non-treatment of ASB and shorter durations for cystitis.


Assuntos
Antibacterianos/uso terapêutico , Bacteriúria/tratamento farmacológico , Serviço Hospitalar de Emergência , Padrões de Prática Médica/estatística & dados numéricos , Piúria/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Hospitais Comunitários , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
8.
Can J Surg ; 63(5): E460-E467, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33107814

RESUMO

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization. METHODS: A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization. RESULTS: Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively). CONCLUSION: Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.


Assuntos
Colo/cirurgia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Recuperação Pós-Cirúrgica Melhorada/normas , Complicações Pós-Operatórias/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Reto/cirurgia , Centros Médicos Acadêmicos/normas , Centros Médicos Acadêmicos/estatística & dados numéricos , Adulto , Protocolos Clínicos/normas , Feminino , Fidelidade a Diretrizes/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Hospitais Comunitários/normas , Hospitais Comunitários/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Ontário , Satisfação do Paciente , Complicações Pós-Operatórias/etiologia , Padrões de Prática Médica/normas , Padrão de Cuidado , Cirurgiões/normas , Inquéritos e Questionários/estatística & dados numéricos
9.
BMC Emerg Med ; 20(1): 82, 2020 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-33059583

RESUMO

BACKGROUND: Emergency department personnel routinely bear witness to traumatic experiences and critical incidents that can affect their own well-being. Peer support through debriefing has demonstrated positive impacts on clinicians' well-being following critical incidents. This study explored community hospital emergency department staff's perceptions of critical incidents, assessed openness to debriefing and measured baseline well-being. Our analysis provides a baseline of provider well-being immediately prior to the local onset of COVID-19. The potential need for additional resources to support frontline providers during the pandemic can be evaluated. METHOD: We conducted a cross-sectional study for 4-weeks prior to the first COVID-19 case in Connecticut using a survey offered to an interprofessional group of emergency department clinical staff. The main outcome measures were the Hospital Anxiety and Depression Scale (HADS) and the Professional Quality of Life (ProQOL) scale. Pearson's chi-square test was used to identify significant differences in perceptions of critical incidents and debriefings between professional categories. One-way ANOVA and Tukey's test were used to analyze significant differences in well-being between professional categories. RESULTS: Thirty-nine clinical personnel from St. Vincent's Emergency Department responded to the survey. Events frequently selected as critical incidents were caring for critically ill children (89.7%), mass casualty events (84.6%), and death of a patient (69.2%). Critical incidents were commonly reported (81.6%) as occurring once per week. Additionally, 76.2% of participants reported wanting to discuss a critical incident with their team. Across all respondents, 45.7% scored borderline or abnormal for anxiety, 55.9% scored moderate for burnout, and 55.8% scored moderate to high for secondary traumatic stress. CONCLUSIONS: At baseline, providers reported caring for critically ill children, mass casualty events, and death of a patient as critical incidents, which typically occurred once per week. Death of a patient occurs at increased frequency during the protracted mass casualty experience of COVID-19 and threatens provider well-being. Receptiveness to post-event debriefing is high but the method is still underutilized. With nearly half of staff scoring borderline or abnormal for anxiety, burnout, and secondary traumatic stress at baseline, peer support measures should be implemented to protect frontline providers' well-being during and after the pandemic.


Assuntos
Infecções por Coronavirus/epidemiologia , Serviço Hospitalar de Emergência/organização & administração , Retroalimentação , Promoção da Saúde/organização & administração , Recursos Humanos em Hospital/psicologia , Pneumonia Viral/epidemiologia , Local de Trabalho/psicologia , Adulto , Betacoronavirus , Esgotamento Profissional/epidemiologia , Esgotamento Profissional/prevenção & controle , Estudos Transversais , Feminino , Hospitais Comunitários/organização & administração , Humanos , Masculino , Incidentes com Feridos em Massa/psicologia , Pessoa de Meia-Idade , Pandemias , Percepção , Qualidade de Vida , Apoio Social , Fatores Socioeconômicos , Estresse Psicológico/epidemiologia , Estresse Psicológico/prevenção & controle
11.
J Opioid Manag ; 16(4): 253-266, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32885833

RESUMO

OBJECTIVE: This study aimed to compare provider gestalt to assigned Narx score, a common prescription drug monitor-ing program (PDMP) component that gauges the patient's risk of misuse or abuse. DESIGN: This is a prospective, anonymous survey from advanced practice providers (APPs), emergency medicine resi-dents, and emergency medicine attendings. SETTING: Data from two emergency departments (EDs) within the OhioHealth network were included. One hospital is a 213-bed academic, community hospital. The other hospital is a 434-bed academic level I trauma center. PATIENTS, PARTICIPANTS: The survey was open to all providers. Exclusion criteria for patients included prior knowledge of the patient and/or their Narx score, or cancer-related pain. INTERVENTIONS: Surveys were collected over a 3-month period. Variables included provider type and level of experience, participant demographics, provider gestalt, and the patient's actual Narx score. MAIN OUTCOME MEASURE(S): Primary outcome was the ability of providers to accurately estimate a patient's Narx score. Groups were defined as Match = No (gestalt and actual score did not match) and Match = Yes (gestalt and actual score matched). Various characteristics were compared between these two groups. RESULTS: Providers were able to accurately estimate actual Narx score (72.7 percent). The Match = Yes group was younger (p = 0.01). Dental pain was more common in the Match = No group, 11.5 percent versus 0 percent (p = 0.02). Match = No group also had a higher incidence of triggers. Specifically, any trigger (p = 0.006), explicitly asking for pain medication (p = 0.03), and asking for opioids by name (p = 0.03). Every 10-year decrease in age showed a 1.5 times increased likelihood of accurately estimating Narx score (p = 0.02). Having no triggers showed a three times increased likelihood of accurately estimating Narx score (p = 0.02). Prescribing was largely unchanged after viewing the actual Narx score. CONCLUSIONS: Providers are able to accurately estimate Narx score, though there are limiting factors. Older patients, those with dental pain, and those who give specific triggers are more difficult to estimate. Providers did not change their prescribing patterns after viewing the actual Narx score. Overestimation versus underestimation of Narx score was not directly studied.


Assuntos
Analgésicos Opioides , Hospitais Comunitários , Manejo da Dor , Padrões de Prática Médica , Software , Analgésicos Opioides/uso terapêutico , Serviço Hospitalar de Emergência , Humanos , Dor , Estudos Prospectivos
13.
PLoS One ; 15(8): e0237558, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32785285

RESUMO

BACKGROUND: The Covid-19 pandemic threatens to overwhelm scarce clinical resources. Risk factors for severe illness must be identified to make efficient resource allocations. OBJECTIVE: To evaluate risk factors for severe illness. DESIGN: Retrospective, observational case series. SETTING: Single-institution. PARTICIPANTS: First 117 consecutive patients hospitalized for Covid-19 from March 1 to April 12, 2020. EXPOSURE: None. MAIN OUTCOMES AND MEASURES: Intensive care unit admission or death. RESULTS: In-hospital mortality was 24.8% and average total length of stay was 11.82 days (95% CI: 10.01 to 13.63 days). 30.8% of patients required intensive care unit admission and 29.1% required mechanical ventilation. Multivariate regression identified the amount of supplemental oxygen required at admission (OR: 1.208, 95% CI: 1.011-1.443, p = .037), sputum production (OR: 6.734, 95% CI: 1.630-27.812, p = .008), insulin dependent diabetes mellitus (OR: 11.873, 95% CI: 2.218-63.555, p = .004) and chronic kidney disease (OR: 4.793, 95% CI: 1.528-15.037, p = .007) as significant risk factors for intensive care unit admission or death. Of the 48 patients who were admitted to the intensive care unit or died, this occurred within 3 days of arrival in 42%, within 6 days in 71%, and within 9 days in 88% of patients. CONCLUSIONS: At our regional medical center, patients with Covid-19 had an average length of stay just under 12 days, required ICU care in 31% of cases, and had a 25% mortality rate. Patients with increased sputum production and higher supplemental oxygen requirements at admission, and insulin dependent diabetes or chronic kidney disease may be at increased risk for severe illness. A model for predicting intensive care unit admission or death with excellent discrimination was created that may aid in treatment decisions and resource allocation. Early identification of patients at increased risk for severe illness may lead to improved outcomes in patients hospitalized with Covid-19.


Assuntos
Betacoronavirus/genética , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/patologia , Hospitalização , Pneumonia Viral/epidemiologia , Pneumonia Viral/patologia , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Estado Terminal , Feminino , Alocação de Recursos para a Atenção à Saúde , Mortalidade Hospitalar , Hospitais Comunitários , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Maryland/epidemiologia , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Respiração Artificial , Estudos Retrospectivos , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Fatores de Risco
14.
Ann Hematol ; 99(10): 2323-2328, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32808105

RESUMO

Infection with SARS-CoV-2 (COVID-19) can cause prothrombotic complications. We aim to study the frequency of thrombotic complications and impact of anticoagulation on outcomes in hospitalized patients. We conducted a retrospective chart review of 921 consecutive patients admitted to our hospital with COVID-19. Patients were divided into four groups depending on whether they were on anticoagulation prior to admission, started anticoagulation during the admission, received prophylactic anticoagulation, or did not receive any anticoagulation. At the time of analysis, 325 patients (35.3%) had died, while 544 patients (59%) had been discharged resulting in inpatient mortality of 37.3%. Male sex, age > 65 years, and high D-dimer at admission were associated with higher mortality. Sixteen patients (1.7%) had venous thromboembolism confirmed with imaging, 11 patients had a stroke, and 2 patients developed limb ischemia. Treatment with therapeutic anticoagulation was associated with improved inpatient mortality compared with prophylactic anticoagulation alone (63% vs 86.2%, p < 0.0001) in patients requiring mechanical ventilation. Other outcomes such as rates of liberation from mechanical ventilation and duration of mechanical ventilation were not significantly impacted by the type of anticoagulation.


Assuntos
Anticoagulantes/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Trombose/prevenção & controle , Trombose/virologia , Grupo com Ancestrais do Continente Africano , Idoso , Anticoagulantes/administração & dosagem , Infecções por Coronavirus/terapia , Feminino , Hemorragia/epidemiologia , Hispano-Americanos , Hospitais Comunitários , Hospitais Urbanos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Pneumonia Viral/terapia , Respiração Artificial , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Trombose/epidemiologia , Resultado do Tratamento , Tromboembolia Venosa/epidemiologia
15.
Stroke ; 51(10): 2918-2924, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32762619

RESUMO

BACKGROUND AND PURPOSE: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. METHODS: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. RESULTS: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92-104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130-136]; P<0.001). Stroke discharges also dropped, in concordance with acute stroke alerts decrease. In total, 9120 patients were included: 8337 in pre- and 783 in post-SIP cohorts. There were no differences in patient demographics. Compared with pre-SIP, post-SIP patients had higher National Institutes of Health Stroke Scale scores (P=0.003), lower comorbidity score (P<0.001), and arrived more often by ambulance (P<0.001). Post-SIP, more patients had large vessel occlusions (P=0.03), and there were fewer stroke mimics (P=0.001). Discharge outcomes were similar for post-SIP and pre-SIP cohorts. CONCLUSIONS: In this cohort study, regional stroke alert and ischemic stroke discharge volumes decreased significantly in the early COVID-19 pandemic. Compared with pre-SIP, the post-SIP population showed no significant demographic differences but had lower comorbidity scores, more severe strokes, and more large vessel occlusions. The inpatient mortality was similar in both cohorts. Further studies are needed to understand the causes and implications of care avoidance to patients and healthcare systems.


Assuntos
Infecções por Coronavirus , Mortalidade Hospitalar , Hospitais Comunitários , Pandemias , Pneumonia Viral , Acidente Vascular Cerebral/epidemiologia , Telemedicina , Adulto , Idoso , Idoso de 80 Anos ou mais , Ambulâncias , Fibrilação Atrial/epidemiologia , Betacoronavirus , California/epidemiologia , Estudos de Coortes , Comorbidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Aceitação pelo Paciente de Cuidados de Saúde , Alta do Paciente , Índice de Gravidade de Doença , Acidente Vascular Cerebral/terapia , Resultado do Tratamento
17.
Aust Health Rev ; 44(5): 728-732, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32854819

RESUMO

This case study describes the process of selecting the most appropriate state-wide hospital system to manage COVID-19 cases in a setting of low community transmission of COVID-19 infection. A rapid review of the literature was conducted of the advantages and disadvantages of having designated COVID hospitals. This led to three different options being presented for discussion. Following consultation, the option chosen was for all hospital facilities to remain prepared to care for COVID-19 patients where they present rather than having specified designated hospitals because this was considered the most practical option currently.


Assuntos
Infecções por Coronavirus/terapia , Transmissão de Doença Infecciosa/estatística & dados numéricos , Hospitais Comunitários/organização & administração , Pandemias/prevenção & controle , Pneumonia Viral/terapia , Austrália , Betacoronavirus/patogenicidade , Humanos , Austrália Ocidental
19.
Ann Intern Med ; 173(10): 782-790, 2020 11 17.
Artigo em Inglês | MEDLINE | ID: mdl-32726151

RESUMO

BACKGROUND: Obesity is a risk factor for pneumonia and acute respiratory distress syndrome. OBJECTIVE: To determine whether obesity is associated with intubation or death, inflammation, cardiac injury, or fibrinolysis in coronavirus disease 2019 (COVID-19). DESIGN: Retrospective cohort study. SETTING: A quaternary academic medical center and community hospital in New York City. PARTICIPANTS: 2466 adults hospitalized with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection over a 45-day period with at least 47 days of in-hospital observation. MEASUREMENTS: Body mass index (BMI), admission biomarkers of inflammation (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), cardiac injury (troponin level), and fibrinolysis (D-dimer level). The primary end point was a composite of intubation or death in time-to-event analysis. RESULTS: Over a median hospital length of stay of 7 days (interquartile range, 3 to 14 days), 533 patients (22%) were intubated, 627 (25%) died, and 59 (2%) remained hospitalized. Compared with overweight patients, patients with obesity had higher risk for intubation or death, with the highest risk among those with class 3 obesity (hazard ratio, 1.6 [95% CI, 1.1 to 2.1]). This association was primarily observed among patients younger than 65 years and not in older patients (P for interaction by age = 0.042). Body mass index was not associated with admission levels of biomarkers of inflammation, cardiac injury, or fibrinolysis. LIMITATIONS: Body mass index was missing for 28% of patients. The primary analyses were conducted with multiple imputation for missing BMI. Upper bounding factor analysis suggested that the results are robust to possible selection bias. CONCLUSION: Obesity is associated with increased risk for intubation or death from COVID-19 in adults younger than 65 years, but not in adults aged 65 years or older. PRIMARY FUNDING SOURCE: National Institutes of Health.


Assuntos
Betacoronavirus , Índice de Massa Corporal , Infecções por Coronavirus/epidemiologia , Intubação Intratraqueal/estatística & dados numéricos , Obesidade/epidemiologia , Pneumonia Viral/epidemiologia , Centros Médicos Acadêmicos , Fatores Etários , Idoso , Biomarcadores/sangue , Sedimentação Sanguínea , Proteína C-Reativa/análise , Estudos de Coortes , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Hospitalização , Hospitais Comunitários , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Troponina/sangue
20.
West J Emerg Med ; 21(4): 779-784, 2020 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-32726241

RESUMO

INTRODUCTION: Rapid spread of coronavirus disease 2019 (COVID-19) in the United States, especially in New York City (NYC), led to a tremendous increase in hospitalizations and mortality. There is very limited data available that associates outcomes during hospitalization in patients with COVID-19. METHODS: In this retrospective cohort study, we reviewed the health records of patients with COVID-19 who were admitted from March 9-April 9, 2020, to a community hospital in NYC. Subjects with confirmed reverse transcriptase-polymerase chain reaction (RT-PCR) of the nasopharyngeal swab for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were included. We collected data related to demographics, laboratory results, and outcome of hospitalization. Outcome was measured based on whether the patient was discharged home or died during hospitalization. RESULTS: There were 888 consecutive admissions with COVID-19 during the study period, of which 513 were excluded with pending outcome or incomplete information. We included a total of 375 patients in the study, of whom 215 (57%) survived and 160 (43%) died during hospitalization. The majority of patients were male (63%) and of Hispanic origin (66%) followed by Blacks (25%), and others (9%). Hypertension (60%) stands out to be the most common comorbidity followed by diabetes mellitus (47%), cardiovascular disease (17%), chronic kidney disease (17%), and human immunodeficiency virus/acquired immunodeficiency syndrome (9%). On multiple regression analysis, increasing odds of mortality during hospitalization was associated with older age (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.01-1.06 per year increase; p < 0.0001), admission D-dimer more than 1000 nanograms per milliliter (ng/mL) (OR 3.16; 95% CI, 1.75-5.73; p<0.0001), admission C-reactive protein (CRP) levels of more than 200 milligrams per liter (mg/L) (OR 2.43; 95% CI, 1.36-4.34; p = 0.0028), and admission lymphopenia (OR 2.63; CI, 1.47-4.69; p 0.0010). CONCLUSION: In this retrospective cohort study originating in NYC, older age, admission levels of D-dimer of more than 1000 ng/mL, CRP of more than 200 mg/L and lymphopenia were associated with mortality in individuals hospitalized for COVID-19. We recommend using these risk factors on admission to triage patients to critical care units or surge units to maximize the use of surge capacity beds.


Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Hospitalização , Pneumonia Viral/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Proteína C-Reativa/análise , Doenças Cardiovasculares/epidemiologia , Estudos de Coortes , Comorbidade , Grupos de Populações Continentais/estatística & dados numéricos , Diabetes Mellitus/epidemiologia , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Infecções por HIV/epidemiologia , Hospitais Comunitários , Humanos , Hipertensão/epidemiologia , Linfopenia/epidemiologia , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Insuficiência Renal Crônica/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
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