What Is the Place of Intermediate Care Unit in Patients with COVID-19? A Single Center Experience.

Introduction: COVID-19 pandemic has led to an increased rate of intensive care unit (ICU) stays. Intermediate care units (IMCUs) are a useful resource for the management of patients with severe COVID-19 that do not require ICU admission. In this research, we aimed to determine survival outcomes and parameters predicting mortality in patients who have been admitted to IMCU. Materials and Methods: Patients who were admitted to IMCU between April 2019 and January 2021 were analyzed retrospectively. Sociodemographics, clinical characteristics, and blood parameters on admission were compared between the patients who died in IMCU and the others. Blood parameters at discharge were compared between survived and deceased individuals. Survival analysis was performed via Kaplan-Meier analysis. Blood parameters predicting mortality were determined by univariate and multivariate Cox regression analysis. Results: A total of 140 patients were included within the scope of this study. The median age was 72.5 years, and 77 (55%) of them were male and 63 (45%) of them were female. A total of 37 (26.4%) patients deceased in IMCU, and 40 patients (28.5%) were transferred to ICU. Higher platelet count (HR 3.454; 95% CI 1.383-8.625; p=0.008), procalcitonin levels (HR 3.083; 95% CI 1.158-8.206; p=0.024), and lower oxygen saturation (HR 4.121; 95% CI 2.018-8.414; p < 0.001) were associated with an increased risk of mortality in IMCU. At discharge from IMCU, higher procalcitonin levels (HR 2.809; 95% CI 1.216-6.487; p=0.016), lower platelet count (HR 2.269; 95% CI 1.012-5.085; p=0.047), and noninvasive mechanic ventilation requirement (HR 2.363; 95% CI 1.201-4.651; p=0.013) were associated with an increased risk of mortality. Median OS was found as 41 days. The overall survival rate was found 40% while the IMCU survival rate was 73.6%. Conclusions: IMCU seems to have a positive effect on survival in patients with severe COVID-19 infection. Close monitoring of these parameters and early intervention may improve survival rates and outcomes.

Incidence and risk factors for norovirus-related diarrhea in Japanese geriatric intermediate care facilities: A prospective cohort study.

AIM: The risk of developing infectious diarrhea among elderly residents at Japanese geriatric intermediate care facilities is unclear. We investigated the incidence rate and risk factors of norovirus-related diarrhea at such facilities. METHODS: This prospective cohort study followed 1727 residents from November 2018 to April 2020 at 10 geriatric intermediate care facilities in Osaka, Japan regarding the occurrence of diarrhea. Resident data were collected from their medical records using structured forms at two to three of the following three time points: at recruitment, if they developed diarrhea, and when they left the facility. Residents who developed diarrhea were tested using rapid diagnostic tests for norovirus. Cox proportional hazard model was employed to hazard ratios (HRs) with 95% confidence intervals (CIs) to estimate the risk factors for norovirus-related diarrhea. RESULTS: During the study period, 74 residents developed diarrhea, 13 of whom were norovirus positive. The incidence rate of norovirus-related diarrhea was 10.11 per 1000 person-years (95% CI: 4.61-15.61). In terms of risk factors, people with care-needs level 3 were at a higher risk for developing norovirus-related diarrhea (adjusted HR [aHR] = 7.35, 95% CI: 1.45-37.30). Residents with hypertension (aHR = 3.41, 95% CI: 1.05-11.04) or stroke (aHR = 8.84, 95% CI: 2.46-31.83), and those who walked with canes (aHR = 16.68, 95% CI: 1.35-206.52) also had a significantly higher risk for norovirus-related diarrhea. CONCLUSIONS: Throughout the study period, the incidence of development of diarrhea was low. Care-needs level 3, stroke, hypertension and use of a cane were identified as risk factors for norovirus-related diarrhea in Japanese geriatric intermediate care facilities. Geriatr Gerontol Int 2023; 23: 179-187.

Intermediate Care Facilities for Individuals With Intellectual Disabilities: Does Ownership Type Affect Quality of Care?

Because many large, state-owned Intermediate Care Facilities for Individuals With Intellectual Disabilities (ICF/IIDs) have closed or downsized, their average size has fallen markedly, as has the number that are publicly owned. We probe the relationship between ownership type and four measures of care quality in ICF/IIDs. Data on deficiency citations suggest that for-profits underperform other ownership types, although data on complaints show no clear pattern. Meanwhile, data on staffing ratios and restrictive behavior management practices, based mostly on facility self-reports, generally tell the opposite story. Our results lend some credence to concerns regarding inadequate care in for-profit ICF/IIDs, while underscoring the importance of requiring ICF/IID operators to report more comprehensive, longitudinal data that are less prone to error and reporting bias.

Uso y seguridad de levosimendan en una unidad de cuidados intermedios: revisión de la experiencia de 3 años / Use and safety of Levosimendan in an Intermediate Care Unit: 3-year experience review

Introduction: Levosimendan is an inodilator with positive inotropiceffect whose demonstration of hemodynamic and clinical benefits hasnot always been consistent. The most recent meta-analyzes show stronger evidence of it, especially in some subgroups. The objective wasto evaluate the experience in the use of levosimendan, characterizingthe mode of prescription, the target population, clinical benefits andadverse effects.Materials and Methodologies: All patients who took Levosimendan in anIntermediate Care Unit during three full years were included. Generalclinical and analytical parameters, co-morbidities and characteristics ofhospitalization were obtained, as well as readmissions up to 6 months.Results: There were 39 events. Thirteen admissions were scheduled.Only 4 patients tolerated the maximum recommended levosimendanspeed. All completed 12.5 mg of levosimendan, 10 of which requiredaminergic support. In-hospital mortality was 15.4%. For all the patientswho died, admission was urgent.Conclusions: No patient with scheduled admission required aminergic support or died during hospitalization. It is not possible to inferwhether it would be possible to perform the same dose in a shorterperiod of time, even because of the small number that tolerated themaximum speed. Results of ongoing studies may help assess safetyand propose selection criteria for patients suitable for day hospitaladministration. Particularly in patients with advanced HF, intermittentand repeated administration, as occurred in this study, is a promising option. However, there are still important gaps, namely which isthe ideal cumulative dose and the frequency with which it shouldbe performed.

Introducción: El levosimendan es un sensibilizador de calcio con efectoinotrópico positivo cuya demostración de beneficios hemodinámicos yclínicos no siempre ha sido consistente. Los metanálisis más recientesmuestran pruebas más contundentes de ello, especialmente en algunossubgrupos. El objetivo fue evaluar la experiencia en el uso de levosimendan, caracterizando el modo de prescripción, la población, los beneficiosclínicos y los efectos adversos.Materiales y Metodologías: Se incluyeron todos los pacientes que tomaron Levosimendan en una Unidad de Cuidados Intermedios durante tresaños. Se obtuvieron parámetros clínicos y analíticos generales, comorbilidades y características de la hospitalización, así como reingresos hastalos 6 meses.Resultados: Hubo 39 eventos. Se programaron trece ingresos. Solo 4 pacientes toleraron la velocidad máxima recomendada de levosimendan.Todos completaron 12,5 mg de levosimendan, 10 de los cuales requirieron apoyo aminérgico. La mortalidad hospitalaria fue del 15,4%. Paratodos los pacientes que fallecieron, el ingreso fue urgente.Conclusiones: Ningún paciente con ingreso programado requirió apoyoaminérgico ni falleció durante la hospitalización. No es posible inferirsi sería posible realizar la misma dosis en un período de tiempo máscorto, incluso por el pequeño número que toleró la velocidad máxima.Los resultados de los estudios en curso pueden ayudar a evaluar la seguridad y proponer criterios de selección para pacientes adecuados para laadministración en un hospital de día. Particularmente en pacientes conIC avanzada, la administración intermitente y repetida, como ocurrió eneste estudio, es una opción prometedora. Sin embargo, existen lagunasimportantes, a saber, cuál es la dosis acumulativa ideal y la frecuenciacon la que debe realizarse.

Implementation of the nursing process in an intermediate care unit / Implementación del proceso de enfermería en una unidad de cuidados intermedios / Implantação do processo de enfermagem em unidade de cuidados intermediários

Objective: to describe the implementation of the Nursing Process in an intermediate care unit. Method: action research conducted in a public teaching hospital from December 2019 to March 2020 with four training on Nursing Process and Nursing Theories; presentation of nursing process instruments, implementation and follow-up. Changes suggested by the nurses occurred through participant observation and field diary in in loco visits. Results: difficulties in initial filling of instruments were reported, as well as practical inexperience and lack of time and work overload. The benefits mentioned were related to the clear and orderly formatting of the instruments; ease in the application of steps and safety in care practice. Final considerations: the implementation of the Nursing Process in the sector occurred after the identification of the previous knowledge of the nursing team, followed by the survey of the profile of patients, creation of instruments, execution of permanent education of professionals, application and monitoring in the use of the instruments.

Objetivo: describir la implementación del Proceso de Enfermería en una unidad de cuidados intermedios. Método: investigación-acción realizada en un hospital docente público de diciembre de 2019 a marzo de 2020 con cuatro capacitaciones sobre Procesos de Enfermería y Teorías de Enfermería; presentación de instrumentos del proceso de enfermería, implementación y seguimiento. Los cambios sugeridos por las enfermeras ocurrieron a través de la observación participante y el diario de campo en las visitas in loco. Resultados: se reportaron dificultades en el llenado inicial de los instrumentos; inexperiencia práctica; falta de tiempo y sobrecarga de trabajo. Los beneficios mencionados estaban relacionados con el formato claro y ordenado de los instrumentos; facilidad en la aplicación de pasos y seguridad en la práctica asistencial. Consideraciones finales: la implementación del Proceso de Enfermería en el sector ocurrió después de la identificación de los conocimientos previos del equipo de enfermería, seguido de la encuesta del perfil de los pacientes, creación de instrumentos, realización de educación permanente de los profesionales, aplicación y seguimiento en el uso de los instrumentos.

Objetivo: descrever a implantação do Processo de Enfermagem em uma unidade de cuidados intermediários. Método: pesquisa-ação realizada em hospital público de ensino de dezembro de 2019 a março de 2020 contando com quatro capacitações sobre Processo de Enfermagem e Teorias de Enfermagem; apresentação dos instrumentos do Processo de Enfermagem, implantação e acompanhamento. Alterações sugeridas pelos enfermeiros ocorreram mediante observação participante e diário de campo nas visitas in loco. Resultados: relatadas dificuldades no preenchimento inicial dos instrumentos; inexperiência prática; falta de tempo e sobrecarga de trabalho. Os benefícios mencionados foram relacionados à formatação clara e ordenada dos instrumentos; facilidade na aplicação das etapas e segurança na prática assistencial. Considerações finais: a implantação do Processo de Enfermagem no setor ocorreu após a identificação do conhecimento prévio da equipe de Enfermagem, seguida do levantamento do perfil de pacientes, criação dos instrumentos, realização de educação permanente dos profissionais, aplicação e acompanhamento no uso dos instrumentos.

Older assistant workers in intermediate care facilities, and their influence on the physical and mental burden of elderly care staff.

BACKGROUND: As there is a shortage of care staff in elderly care homes, seniors are expected to work as assistants to help the care staff. This study examined the influence of older assistant workers in intermediate elderly care facilities on care staff, specifically focusing on emotional exhaustion which is a sign of burnout. These facilities provide long-term nursing and supportive care to older residents. METHODS: Data from a mail survey of intermediate elderly care facilities with older assistant workers were analyzed. Care staff were asked about the advantages and disadvantages of introducing older assistant workers in elderly care work, and their degree of emotional exhaustion. We also assessed work self-evaluations of older assistant workers, including the benefits of the work, and physical and mental burdens. RESULTS: A significantly large number of care staff reported improvements in workload with the employment of older assistant workers. Intermediate elderly care facilities enrolling more older assistant workers showed lower mean emotional exhaustion among care staff, independent of possible covariates. While older assistant workers felt that their work contributed to helping both care users and staff, they also reported a mental burden. CONCLUSIONS: Our results suggest that older assistant workers can play a significant role in reducing the physical and mental burden of intermediate elderly care facility staff. Thus, employing older assistant workers can be an effective approach to addressing shortages of care staff in elderly care homes.

Use of psychotropic drugs and drugs with anticholinergic properties among residents with dementia in intermediate care facilities for older adults in Japan: a cohort study.

OBJECTIVES: To evaluate the prescription and discontinuation of psychotropic drugs (PD) and drugs with anticholinergic properties (DAP) in residents with dementia admitted to Roken, a major type of long-term care facility in Japan. DESIGN: Cohort study. SETTING: A nationwide questionnaire survey across 3598 Roken in Japan in 2015 (up to five randomly selected residents per facility). PARTICIPANTS: This study included 1201 residents from 343 Roken (response rate: 10%). We determined the presence and severity of dementia using a nationally standardised measure. PRIMARY AND SECONDARY OUTCOME MEASURES: Prescriptions of PD and DAP at admission and 2 months after admission were evaluated. Multivariable logistic regression was used to evaluate the associations of residents' baseline characteristics with prescriptions or discontinuation. RESULTS: Prescription rates decreased for antidementia drugs (19.4% to 13.0%), hypnotics (25.1% to 22.6%) and anxiolytics (12.3% to 10.7%), whereas those for other PD, such as antipsychotics (13.2% to 13.6%), antidepressants (7.4% to 6.7%), antiepileptic drugs (7.1% to 7.8%) and DAP (35.2% to 36.6%) did not statistically significantly decrease. Some factors were associated with the prescriptions, for example, for antipsychotics, older age (≥85 years) (adjusted OR (aOR), 0.60; 95% CI 0.43 to 0.85) and being bedridden (aOR 0.67; 95% CI 0.47 to 0.97) were associated with a lower use of antipsychotics, whereas severe dementia was associated with a higher use of antipsychotics (aOR 3.26; 95% CI 2.26 to 4.70). At an individual level, a quarter of residents prescribed PD or DAP at admission had discontinued at least one PD or DAP, respectively, 2 months after admission. Antidementia drug use in severe dementia (aOR 1.86; 95% CI 1.04 to 3.31) and PD use in older age (aOR 1.61; 95% CI 1.00 to 2.60; in residents with disabling dementia) were associated with discontinuation. CONCLUSIONS: There is possible scope for deprescribing PD and DAP in Roken residents with dementia to mitigate the risks of adverse events.

Characteristics associated with hospitalization within 30 days of geriatric intermediate care facility admission.

AIM: To identify facility-level characteristics associated with hospitalization within 30 days after admission to a geriatric intermediate care facility (GICF) (30-day hospitalization) in Japan. METHODS: This retrospective cohort study used nationwide long-term care insurance claims data and a national survey of long-term geriatric care facilities. The study population was residents admitted to GICFs between October 2016 and February 2018. The outcome variable was 30-day hospitalization. The independent variables were facility-level characteristics such as level of healthcare professionals. RESULTS: The final sample for analysis comprised 282 991 residents of mean age ± SD, 85.8 ± 7.2 years, of whom 12 814 (4.5%) experienced 30-day hospitalization. In a multivariable logistic generalized estimating equation model adjusted for facility- and resident-level characteristics, and clustering GICFs, the odds of 30-day hospitalization were 0.906 times lower (95% confidence interval [CI] 0.857-0.958) among residents in a GICF with dental hygienist than in those in a facility without. Furthermore, the risk of 30-day hospitalization was lower among residents who had been admitted to a GICF with higher staffing levels of pharmacists (adjusted odds ratio [aOR] 0.941, 95% CI 0.899-0.985), registered nurses (aOR 0.931, 95% CI 0.880-0.986), care workers (aOR 0.920, 95% CI 0.879-0.964) and speech-language pathologists (aOR 0.926, 95% CI 0.874-0.982) than in those who had been admitted to a GICF with fewer of these healthcare professionals. CONCLUSIONS: Transitional care including dental hygienist or higher staffing levels of pharmacists, registered nurses, care workers and speech-language pathologists may be a more effective way to prevent 30-day hospitalization. Geriatr Gerontol Int 2021; 21: 1010-1017.

Role of respiratory intermediate care units during the SARS-CoV-2 pandemic.

RATIONALE: The SARS-CoV2 pandemic increased exponentially the need for both Intensive (ICU) and Intermediate Care Units (RICU). The latter are of particular importance because they can play a dual role in critical and post-critical care of COVID-19 patients. Here, we describe the setup of 2 new RICUs in our institution to face the SARS-CoV-2 pandemic and discuss the clinical characteristics and outcomes of the patients attended. METHODS: Retrospective analysis of the characteristics and outcomes of COVID-19 patients admitted to 2 new RICUs built specifically in our institution to face the first wave of the SARS-CoV-2 pandemic, from April 1 until May 30, 2020. RESULTS: During this period, 106 COVID-19 patients were admitted to these 2 RICUs, 65 of them (61%) transferred from an ICU (step-down) and 41 (39%) from the ward or emergency room (step-up). Most of them (72%) were male and mean age was 66 ± 12 years. 31% of them required support with oxygen therapy via high-flow nasal cannula (HFNC) and 14% non-invasive ventilation (NIV). 42 of the 65 patients stepping down (65%) had a previous tracheostomy performed and most of them (74%) were successfully decannulated during their stay in the RICU. Length of stay was 7 [4-11] days. 90-day mortality was 19% being significantly higher in stepping up patients than in those transferred from the ICU (25 vs. 10% respectively; p < 0.001). CONCLUSIONS: RICUs are a valuable hospital resource to respond to the challenges of the SARS-CoV-2 pandemic both to treat deteriorating and recovering COVID-19 patients.

Adult Pulmonary Intensive and Intermediate Care Units: The Italian Thoracic Society (ITS-AIPO) Position Paper.

The imbalance between the prevalence of patients with acute respiratory failure (ARF) and acute-on-chronic respiratory failure and the number of intensive care unit (ICU) beds requires new solutions. The increasing use of non-invasive respiratory tools to support patients at earlier stages of ARF and the increased expertise of non-ICU clinicians in other types of supportive care have led to the development of adult pulmonary intensive care units (PICUs) and pulmonary intermediate care units (PIMCUs). As in other European countries, Italian PICUs and PIMCUs provide an intermediate level of care as the setting designed for managing ARF patients without severe non-pulmonary dysfunction. The PICUs and PIMCUs may also act as step-down units for weaning patients from prolonged mechanical ventilation and for discharging patients still requiring ventilatory support at home. These units may play an important role in the on-going coronavirus disease 2019 pandemic. This position paper promoted by the Italian Thoracic Society (ITS-AIPO) describes the models, facilities, staff, equipment, and operating methods of PICUs and PIMCUs.

Characteristics and mortality rates among patients requiring intermediate care: a national cohort study using linked databases.

BACKGROUND: Adults increasingly live and die with chronic progressive conditions into advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of marked decline, loss of function and increased risk of end of life. Intermediate care units support mainly older adults in transition between hospital and home to regain function and anticipate and plan for end of life. This study examined the patient characteristics and the factors associated with mortality over 1 year post-admission to an intermediate care unit to inform priorities for care. METHODS: A national cohort study of adults admitted to intermediate care units in England using linked individual-level Hospital Episode Statistics and death registration data. The main outcome was mortality within 1 year from admission. The cohort was examined as two groups with significant differences in mortality between main diagnosis of a non-cancer condition and cancer. Data analysis used Kaplan-Meier curves to explore mortality differences between the groups and a time-dependant Cox proportional hazards model to determine mortality risk factors. RESULTS: The cohort comprised 76,704 adults with median age 81 years (IQR 70-88) admitted to 220 intermediate care units over 1 year in 2016. Overall, 28.0% died within 1 year post-admission. Mortality varied by the main diagnosis of cancer (total n = 3680, 70.8% died) and non-cancer condition (total n = 73,024, 25.8% died). Illness-related factors had the highest adjusted hazard ratios [aHRs]. At 0-28 days post-admission, risks were highest for non-cancer respiratory conditions (pneumonia (aHR 6.17 [95%CI 4.90-7.76]), chronic obstructive pulmonary disease (aHR 5.01 [95% CI 3.78-6.62]), dementia (aHR 5.07 [95% CI 3.80-6.77]) and liver disease (aHR 9.75 [95% CI 6.50-14.6]) compared with musculoskeletal disorders. In cancer, lung cancer showed largest risk (aHR 1.20 [95%CI 1.04-1.39]) compared with cancer 'other'. Risks increased with high multimorbidity for non-cancer (aHR 2.57 [95% CI 2.36-2.79]) and cancer (aHR 2.59 [95% CI 2.13-3.15]) (reference: lowest). CONCLUSIONS: One in four patients died within 1 year. Indicators for palliative care assessment are respiratory conditions, dementia, liver disease, cancer and rising multimorbidity. The traditional emphasis on rehabilitation and recovery in intermediate care units has changed with an ageing population and the need for greater integration of palliative care.

Prevalence of opportunistic invasive aspergillosis in COVID-19 patients with severe pneumonia.

BACKGROUND: As the global coronavirus pandemic (COVID-19) spreads across the world, new clinical challenges emerge in the hospital landscape. Among these challenges, the increased risk of coinfections is a major threat to the patients. Although still in a low number, due to the short time of the pandemic, studies that identified a significant number of hospitalised patients with COVID-19 who developed secondary fungal infections that led to serious complications and even death have been published. OBJECTIVES: In this scenario, we aim to determine the prevalence of invasive fungal infections (IFIs) and describe possible associated risk factors in patients admitted due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. PATIENTS/METHODS: We designed an open prospective observational study at the Rey Juan Carlos University Hospital (Mostoles, Spain), during the period from February 1 to April 30, 2020. RESULTS: In this article, we reported seven patients with COVID-19-associated pulmonary aspergillosis (CAPA) who had a poor prognosis. Severely ill patients represent a high-risk group; therefore, we must actively investigate the possibility of aspergillosis in all of these patients. Larger cohort studies are needed to unravel the role of COVID-19 immunosuppressive therapy as a risk factor for aspergillosis. CONCLUSIONS: As the pandemic continues to spread across the world, further reports are needed to assess the frequency of emergent and highly resistant reemergent fungal infections during severe COVID-19. These coinfections are leading a significant number of patients with COVID-19 to death due to complications following the primary viral disease.

Evaluation of Risk-Adjusted Home Time After Hospitalization for Heart Failure as a Potential Hospital Performance Metric.

Importance: Thirty-day home time, defined as time spent alive and out of a hospital or facility, is a novel, patient-centered performance metric that incorporates readmission and mortality. Objectives: To characterize risk-adjusted 30-day home time in patients discharged with heart failure (HF) as a hospital-level quality metric and evaluate its association with the 30-day risk-standardized readmission rate (RSRR), 30-day risk-standardized mortality rate (RSMR), and 1-year RSMR. Design, Setting, and Participants: This hospital-level cohort study retrospectively analyzed 100% of Medicare claims data from 2 968 341 patients from 3134 facilities from January 1, 2012, to November 30, 2017. Exposures: Home time, defined as time spent alive and out of a short-term hospital, skilled nursing facility, or intermediate/long-term facility 30 days after discharge. Main Outcomes and Measures: For each hospital, a risk-adjusted 30-day home time for HF was calculated similar to the Centers for Medicare & Medicaid Services risk-adjustment models for 30-day RSRR and RSMR. Hospitals were categorized into quartiles (lowest to highest risk-adjusted home time). The correlations between hospital rates of risk-adjusted 30-day home time and 30-day RSRR, 30-day RSMR, and 1-year RSMR were estimated using the Pearson correlation coefficient. Distribution of days lost from a perfect 30-day home time were calculated. Reclassification of hospital performance using 30-day home time vs 30-day RSRR was also evaluated. Results: Overall, 2 968 341 patients (mean [SD] age, 81.0 [8.3] years; 53.6% female) from 3134 hospitals were included in this study. The median hospital risk-adjusted 30-day home time for patients with HF was 21.77 days (range, 8.22-28.41 days). Hospitals in the highest quartile of risk-adjusted 30-day home time (best-performing hospitals) were larger (mean [SD] number of beds, 285 [275]), with a higher volume of patients with HF (median, 797 patients; interquartile range, 395-1484) and were more likely academic hospitals (59.9%) with availability of cardiac surgery (51.1%) and cardiac rehabilitation (68.8%). A total of 72% of home time lost was attributable to stays in an intermediate- or long-term care facility (mean [SD], 2.65 [6.44] days) or skilled nursing facility (mean [SD], 3.96 [9.04] days), 13% was attributable to short-term readmissions (mean [SD], 1.25 [3.25] days), and 15% was attributable to death (mean [SD], 1.37 [6.04] days). Among 30-day outcomes, the 30-day RSRR and 30-day RSMR decreased in a graded fashion across increasing 30-day home time categories (correlation coefficients: 30-day RSRR and 30-day home time, -0.23, P < .001; 30-day RSMR and 30-day home time, -0.31, P < .001). Similar patterns of association were also noted for 1-year RSMR and 30-day home time (correlation coefficient, -0.35, P < .001). Thirty-day home time meaningfully reclassified hospital performance in 30% of the hospitals compared with 30-day RSRR and in 25% of hospitals compared with 30-day RSMR. Conclusions and Relevance: In this study, 30-day home time among patients discharged after a hospitalization for HF was objectively assessed as a hospital-level quality metric using Medicare claims data and was associated with readmission and mortality outcomes and with reclassification of hospital performance compared with 30-day RSRR and 30-day RSMR.

Inappropriate prescribing in intermediate care facilities.

Inappropriate prescribing for older people is a global healthcare problem. This study aimed to determine the prevalence of older patients receiving potentially inappropriate medications (PIMs) at admission and discharge at the intermediate care facility of ASP Pio Albergo Trivulzio. We consecutively enrolled 100 patients aged ≥ 65 from December 2017 to May 2018 and evaluated PIMs with the 2015 version of the Beers criteria. We found a significant reduction in the prescription of drugs to avoid and proton pump inhibitors (PPIs), while patients with at least one psychotropic drug to avoid or to use with caution significantly increased. The inappropriate prescription of PPIs was mainly associated with the use of heparin. Optimizing PPI and psychotropic drug prescriptions should be considered for deprescribing inappropriate polypharmacy in intermediate care facilities.

Short-Term Outcomes of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Kidney Transplant Recipients (from the US Nationwide Representative Study).

Kidney transplant recipients (KTRs) are considered high-risk patients for surgical interventions. Transcatheter aortic valve implantation (TAVI) has been introduced as an alternative to surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) at high operative risk. However, the outcomes of TAVI compared with SAVR KTRs have not been well-studied in nationally representative data. Patients with prior history of functioning kidney transplant who were hospitalized for TAVI and SAVR between January 2012 and December 2017 were identified retrospectively in the Nationwide Readmissions Database. Our study included 762 TAVI and 1,278 SAVR KTRs. Compared with SAVR, TAVI patients generally had higher rates of co-morbidities with lower risk of in-hospital mortality (3.1% vs 6.3, p = 0.002), blood transfusion (11.5% vs 38.6%, p <0.001), acute myocardial infarction (3.9% vs 6.5%, p = 0.16), acute kidney injury (24.5% vs 42.1%, p <0.001), sepsis (3.9% vs 9.5%, p <0.001) and discharge with disability (42.6% vs 68.4%, p <0.001). However, the rate of permanent pacemaker implantation was significantly higher in TAVI group (11.4% vs 3.9%, p <0.001). Of note, in-hospital stroke and 30-day readmission were comparable between both groups. These findings were confirmed after adjusting for other co-morbidities. TAVI is growing as a valid and safe alternative for KTRs with severe AS.

Lower limb deep vein thrombosis in COVID-19 patients admitted to intermediate care respiratory units.

COVID-19 has been associated with an increased risk of thrombotic events; however, the reported incidence of deep vein thrombosis varies depending, at least in part, on the severity of the disease. Aim of this prospective, multicenter, observational study was to investigate the incidence of lower limb deep vein thrombosis as assessed by compression ultrasound in consecutive patients admitted to three pulmonary medicine wards designated to care for patients with COVID-19 related pneumonia, with or without respiratory failure but not requiring admission to an intensive care unit. Consecutive patients admitted between March 27 and May 6, 2020 were enrolled. Patients were excluded if they were less than 18-year-old or if compression ultrasound could not be performed for any reason. Patients were assessed at admission (t0) and after 7 days (t1). Major and non-major clinically relevant bleedings were recorded. Sixty-eight patients were enrolled. Two were excluded due to anatomical abnormalities that prevented compression ultrasound; sixty patients were retested at (t1). All patients were started on antithrombotic prophylaxis, unless therapeutic anticoagulation was required. Deep vein thrombosis as assessed by compression ultrasound was observed in 2 patients (3%); one of them was later deemed to represent a previous episode. No new episodes were detected at t1. One major and 2 non-major clinically relevant bleedings were observed. In the setting of patients with COVID-related pneumonia not requiring admission to an intensive care unit, the incidence of deep vein thrombosis is low and our data support not screening asymptomatic patients.

From intensive care to step-down units: Managing patients throughput in response to COVID-19.

QUALITY PROBLEM OR ISSUE: The on-going COVID-19 pandemic may cause the collapse of healthcare systems because of unprecedented hospitalization rates. INITIAL ASSESSMENT: A total of 8.2 individuals per 1000 inhabitants have been diagnosed with COVID-19 in our province. The hospital predisposed 110 beds for COVID-19 patients: on the day of the local peak, 90% of them were occupied and intensive care unit (ICU) faced unprecedented admission rates, fearing system collapse. CHOICE OF SOLUTION: Instead of increasing the number of ICU beds, the creation of a step-down unit (SDU) close to the ICU was preferred: the aim was to safely improve the transfer of patients and to relieve ICU from the risk of overload. IMPLEMENTATION: A nine-bed SDU was created next to the ICU, led by intensivists and ICU nurses, with adequate personal protective equipment, monitoring systems and ventilators for respiratory support when needed. A second six-bed SDU was also created. EVALUATION: Patients were clinically comparable to those of most reports from Western Countries now available in the literature. ICU never needed supernumerary beds, no patient died in the SDU, and there was no waiting time for ICU admission of critical patients. SDU has been affordable from human resources, safety and economic points of view. LESSONS LEARNED: COVID-19 is like an enduring mass casualty incident. Solutions tailored on local epidemiology and available resources should be implemented to preserve the efficiency and adaptability of our institutions and provide the adequate sanitary response.

Evaluación del manejo del dolor post operatorio en pacientes adultos internados en cuidados intermedios del Hospital de Alta Complejidad en Red El Cruce Néstor Kirchner (Florencio Varela, Provincia de Buenos Aires) / Post-operative pain management note in adult patients hospitalized in intermediate care of the Hospital of High Complexity in Red El Cruce Néstor Kirchner (Florencio Varela, Province of Buenos Aires)

El dolor postoperatorio (DPO) es tratado insuficientemente. La incidencia del DPO es 40-53%. Objetivo general: Evaluar el DPO en pacientes internados en cuidados intermedios de adultos (CIADU) del Hospital El Cruce durante septiembre, octubre y noviembre de 2016. Objetivos específicos: Describir la intensidad y la prevalencia en pacientes ingresados a CIADU con DPO inmediato, a las 24 y 48 horas, las drogas utilizadas y los efectos adversos, estimar la efectividad del tratamiento y la satisfacción de los pacientes a las 24hs. Métodos: Estudio observacional, prospectivo. Se incluyeron 62 pacientes mayores de 18 años que ingresaron a CIADU cursando postoperatorio inmediato. Se analizaron las variables edad, sexo, comorbilidades, tratamientos previos del dolor, fecha de ingreso y egreso, tipo de cirugía, analgesia al ingreso, presencia e intensidad del dolor al ingreso, a las 24 y a las 48 horas, tratamiento instaurado en las primeras 24 horas, escala de Impresión Global Del Cambio a las 24 hs y registros en historia clínica del dolor. Resultados: La edad media fue de 43.5 años, 60% mujeres, las cirugías fueron programadas en el 97%, con técnica convencional el 68%. La mediana de días de internación fue de 3.1. El 51,6% tenía comorbilidades. Los tipos de cirugías fueron en el 29% traumatológicas, 18% generales, 15% neurológicas, 11% urológicas, 10% bariátricas. Al ingreso el 58% tenían dolor severo, 24 % moderado y 16% leve; 10% tenían tratamiento analgésico al ingreso; el 11% habían recibido tratamiento preventivo del dolor. A las 24hs el 11% tenía dolor severo y 36% moderado. A las 48 hs el 2% tenía dolor severo y 11% moderado. La adherencia a las guías de dolor fue 47%. Efectos adversos se dieron en el 11%. El registro en la historia clínica fue 6%.

Postoperative pain (DPO) is insufficiently treated. The incidence of DPO is 40-53%. General Objective: To evaluate the DPO in patients admitted in adult intermediate care (CIADU) of the El Cruce Hospital during September, October and November 2016. Specific objectives: To describe the intensity and prevalence in patients admitted to CIADU with immediate OPD, at 24 and 48 hours, the drugs used and the adverse effects, to estimate the effectiveness of the treatment and the satisfaction of the patients at 24 hours. Methods: Observational, prospective study. Sixty-two patients over 18 years of age who entered the CIADU undergoing immediate postoperative period were included. The variables age, sex, comorbidities, previous pain treatments, date of admission and discharge, type of surgery, analgesia at admission, presence and intensity of pain at admission, at 24 and 48 hours, treatment established in the first were analyzed. 24 hours, Global Impression of Change scale at 24 hours and records in the medical history of pain. Results: The average age was 43.5 years, 60% women, surgeries were scheduled in 97%, with conventional technique 68%. The median days of hospitalization was 3.1. 51.6% had comorbidities. The types of surgeries were 29% traumatic, 18% general, 15% neurological, 11% urological, 10% bariatric. On admission 58% had severe pain, 24% moderate and 16% mild; 10% had analgesic treatment on admission; 11% had received preventive pain treatment. At 24 hours, 11% had severe pain and 36% moderate. At 48 hours, 2% had severe pain and 11% moderate. Adherence to pain guidelines was 47%. Adverse effects occurred in 11%. The record in the medical record was 6%.

Aplicabilidad y limitaciones de las pruebas de ejecución funcional en el cribado de fragilidad al alta de un centro de atención intermedia / Applicability and limitations of physical performance tests for frailty screening on discharge from an intermediate care hospital

INTRODUCCIÓN: La fragilidad puede ser detectada con distintas herramientas y en múltiples entornos. Entre los diferentes sistemas de cribado, la velocidad de marcha (VM) y el Timed Up-and- Go (TUG) se postulan como sistemas sencillos y fácilmente aplicables. Existen pocos datos sobre su aplicabilidad en pacientes hospitalizados en centros de atención intermedia. MATERIAL Y MÉTODOS: Estudio descriptivo para determinar la aplicabilidad de la VM y el TUG como herramientas de cribado de fragilidad en un hospital de atención intermedia, así como una estimación de la prevalencia de fragilidad al alta mediante estas pruebas de ejecución funcional. Se consideraron frágiles los pacientes con una VM<1m/s y/o un TUG>12s. Se incluyeron todos pacientes atendidos por la unidad de rehabilitación del centro a lo largo del año 2015. RESULTADOS: Novecientos nueve fueron los pacientes incluidos (edad media de 80,12 años). De estos, solo 205 (22,6%) estaban en condiciones de realizar la VM y TUG en el momento del alta; de estas 205 personas, el 89,8% (VM) y el 92,2% (TUG) presentaban criterios de fragilidad, no habiendo diferencias estadísticamente significativas entre ambas herramientas (p = 0,25). CONCLUSIONES: La utilización de la VM y el TUG para el cribado de fragilidad tiene una aplicabilidad limitada en el entorno de atención intermedia. A pesar de ello, los resultados obtenidos indican una alta prevalencia de fragilidad en este entorno. Serán necesarios más estudios para corroborar estos datos

INTRODUCTION: Frailty screening can be performed with different tools and in multiple settings. Among the different evaluation systems, gait speed (GS) and Timed Up-and-Go (TUG) are postulated as simple and easy to apply systems. There are few data on the prevalence of frailty in intermediate care centre inpatients. MATERIAL AND METHODS: Descriptive study to determine the applicability of GS and TUG as frailty screening tools in an intermediate care hospital, as well as an estimate of frailty prevalence at discharge. Frailty was considered when GS<1m/s and / or TUG>12seconds. The study included all patients attending the rehabilitation unit of the centre throughout 2015. RESULTS: A total of 909 patients were included (mean age of 80.12 years). Only 205 (22.6%) were able to perform GS and TUG at discharge from the rehabilitation unit. Frailty prevalence for this group was between 89.8% (GS) and 92.2% (TUG), with no statistical differences between both tools (P=.25). CONCLUSIONS: The applicability of GS and TUG for frailty screening in intermediate care hospitals is limited. Despite this, the results obtained suggest a high prevalence of frailty. More studies will be necessary to corroborate this data