Reduction of Intensive Care Unit Length of Stay: The Case of Early Mobilization.

Bed rest or immobilization is frequently part of treatment for patients in the intensive care unit (ICU) with critical illness. The average ICU length of stay (LOS) is 3.3 days, and for every day spent in an ICU bed, the average patient spends an additional 1.5 days in a non-ICU bed. The purpose of this research study was to analyze the effects of early mobilization for patients in the ICU to determine if it has an impact on the LOS, cost of care, and medical complications. The methodology for this study was a literature review. Five electronic databases were used, with a total of 26 articles referenced for this research. Early mobilization suggested a decrease in delirium by 2 days, reduced risk of readmission or death, and reduced ventilator-assisted pneumonia, central line, and catheter infections. Length of stay in the ICU was reduced with statistical significance in several studies examining early mobilization. Limited research on cost of ICU LOS indicated potential savings with early mobilization. When implementing early mobilization in the ICU, total costs were decreased and medical complications were reduced. Early mobilization should become a standard of care for critically ill but stable patients in the ICU.

Reduction of intensive care unit length of stay: the case of early mobilization.

Bed rest or immobilization is frequently part of treatment for patients in the intensive care unit (ICU) with critical illness. The average ICU length of stay (LOS) is 3.3 days, and for every day spent in an ICU bed, the average patient spends an additional 1.5 days in a non-ICU bed. The purpose of this research study was to analyze the effects of early mobilization for patients in the ICU to determine if it has an impact on the LOS, cost of care, and medical complications. The methodology for this study was a literature review. Five electronic databases were used, with a total of 26 articles referenced for this research. Early mobilization suggested a decrease in delirium by 2 days, reduced risk of readmission or death, and reduced ventilator-assisted pneumonia, central line, and catheter infections. Length of stay in the ICU was reduced with statistical significance in several studies examining early mobilization. Limited research on cost of ICU LOS indicated potential savings with early mobilization. When implementing early mobilization in the ICU, total costs were decreased and medical complications were reduced. Early mobilization should become a standard of care for critically ill but stable patients in the ICU.

Medicare fraud in the United States: can it ever be stopped?

The majority of the United States health care fraud has been focused on the major public program, Medicare. The yearly financial loss from Medicare fraud has been estimated at about $54 billion. The purpose of this research study was to explore the current state of Medicare fraud in the United States, identify current policies and laws that foster Medicare fraud, and determine the financial impact of Medicare fraud. The methodology for this study was a literature review. Research was conducted using a scholarly online database search and government Web sites. The number of individuals charged with criminal fraud increased from 797 cases in fiscal year 2008 to 1430 cases in fiscal year 2011-an increase of more than 75%. According to 2010 data, of the 7848 subjects investigated for criminal fraud, 25% were medical facilities, and 16% were medical equipment suppliers. In 2009 and 2010, the Health Care Fraud and Abuse Control Program recovered approximately $25.2 million of taxpayers' money. Educating providers about the policies and laws designed to prevent fraud would help them to become partners. Many new programs and partnerships with government agencies have also been developed to combat Medicare fraud. Medicare fraud has been a persistent crime, and laws and policies alone have not been enough to control the problem. With investments in governmental partnerships and new systems, the United States can reduce Medicare fraud but probably will not stop it altogether.

The renoprotective efficacy and safety of genetically-engineered human bone marrow-derived mesenchymal stromal cells expressing anti-fibrotic cargo.

BACKGROUND: Kidney fibrosis is a hallmark of chronic kidney disease (CKD) and compromises the viability of transplanted human bone marrow-derived mesenchymal stromal cells (BM-MSCs). Hence, BM-MSCs were genetically-engineered to express the anti-fibrotic and renoprotective hormone, human relaxin-2 (RLX) and green fluorescent protein (BM-MSCs-eRLX + GFP), which enabled BM-MSCs-eRLX + GFP delivery via a single intravenous injection. METHODS: BM-MSCs were lentiviral-transduced with human relaxin-2 cDNA and GFP, under a eukaryotic translation elongation factor-1α promoter (BM-MSCs-eRLX + GFP) or GFP alone (BM-MSCs-eGFP). The ability of BM-MSCs-eRLX + GFP to differentiate, proliferate, migrate, produce RLX and cytokines was evaluated in vitro, whilst BM-MSC-eRLX + GFP vs BM-MSCs-eGFP homing to the injured kidney and renoprotective effects were evaluated in preclinical models of ischemia reperfusion injury (IRI) and high salt (HS)-induced hypertensive CKD in vivo. The long-term safety of BM-MSCs-RLX + GFP was also determined 9-months after treatment cessation in vivo. RESULTS: When cultured for 3- or 7-days in vitro, 1 × 106 BM-MSCs-eRLX + GFP produced therapeutic RLX levels, and secreted an enhanced but finely-tuned cytokine profile without compromising their proliferation or differentiation capacity compared to naïve BM-MSCs. BM-MSCs-eRLX + GFP were identified in the kidney 2-weeks post-administration and retained the therapeutic effects of RLX in vivo. 1-2 × 106 BM-MSCs-eRLX + GFP attenuated the IRI- or therapeutically abrogated the HS-induced tubular epithelial damage and interstitial fibrosis, and significantly reduced the HS-induced hypertension, glomerulosclerosis and proteinuria. This was to an equivalent extent as RLX and BM-MSCs administered separately but to a broader extent than BM-MSCs-eGFP or the angiotensin-converting enzyme inhibitor, perindopril. Additionally, these renoprotective effects of BM-MSCs-eRLX + GFP were maintained in the presence of perindopril co-treatment, highlighting their suitability as adjunct therapies to ACE inhibition. Importantly, no major long-term adverse effects of BM-MSCs-eRLX + GFP were observed. CONCLUSIONS: BM-MSCs-eRLX + GFP produced greater renoprotective and therapeutic efficacy over that of BM-MSCs-eGFP or ACE inhibition, and may represent a novel and safe treatment option for acute kidney injury and hypertensive CKD.

Marathon running and cell-cycle arrest biomarkers of acute kidney injury.

OBJECTIVES: Endurance exercise is known to cause a rise in serum creatinine. It is not known to what extent this rise reflects renal stress and a potential acute kidney injury (AKI). Increases in Insulin Like Growth Factor Binding Protein 7 (IGFBP7) and Tissue Inhibitor of Metalloprotinases-2 (TIMP-2), urinary biomarkers of cell cycle arrest and renal stress, are associated with the development of AKI in clinical populations. DESIGN: Repeated measures study. METHODS: Runners were recruited at the 2019 Brighton Marathon (UK) and provided urine and blood samples at baseline, immediately post-race and 24 h post-race. Serum creatinine, urinary creatinine and urinary IGFBP7 and TIMP-2 were analysed from the samples. RESULTS: Seventy nine participants (23 females, 56 males), aged 43 ±â€¯10 yrs. (mean ±â€¯SD), finish time 243 ±â€¯40mins were included for analysis. Serum creatinine increased over the race by 40 ±â€¯26% (p < 0.001), TIMP-2 increased by 555 ±â€¯697% (p < 0.001) and IGFBP7 increased by 1094 ±â€¯1491% (p < 0.001) over the race. A subset of twenty-two participants supplied samples 24 h post-race, reporting values similar to baseline for all variables. CONCLUSIONS: This study is the first to report large rises in IGFBP7 and TIMP-2 following marathon running. This suggests that rises in creatinine are not fully explained by changes in production and clearance and marathon running induces a state of kidney stress and potential injury.

Agreement and validity of electronic patient self-triage (eTriage) with nurse triage in two UK emergency departments: a retrospective study.

BACKGROUND: Triage and redirection of patients to alternative care providers is one tool used to overcome the growing issue of crowding in emergency departments (EDs). Electronic patient self-triage (eTriage) may reduce waiting times and required face-to-face contact. There are limited studies into its efficacy, accuracy and validity in an ED setting. OBJECTIVES: The aim of this study was to assess the agreement and validity of eTriage with a reference standard of nurse face-to-face triage. A secondary aim was to assess the ability of both systems to predict high and low acuity outcomes. DESIGN: This was a retrospective study conducted over 8 months in two UK hospitals. Inclusion criteria were all ambulatory patients aged ≥18. All patients completed an eTriage and nurse-led triage using the Manchester Triage System (MTS). MAIN RESULTS: During the study period, 43 788 adult patients attended one of the two ED sites and 26 757 used eTriage. A total of 1424 patient episodes had no recorded MTS and were excluded from the study leaving 25 333 paired triages for the final cohort. Agreement between eTriage and nurse triage was low with a weighted Kappa coefficient of 0.14 (95% CI, 0.14-0.15) with an associated weak positive correlation (rs 0.321). Level of undertriage by eTriage compared with nurse triage was 10.1%, and overtriage was 59.2%. The sensitivity for prediction of high acuity outcomes was 88.5% (95% CI, 77.9-95.3%) for eTriage and 53.8% (95% CI 41.1-66.0%) for nurse MTS. The specificity for predicting low risk patients was 88.5% (95% CI, 87.4-89.5%) for eTriage and 80.6% (95% CI, 79.3-81.8%) for nurse MTS. CONCLUSION: Agreement and correlation of eTriage with the reference standard of nurse MTS was low; patients using eTriage tended to over triage when compared to the triage nurse. eTriage had a higher sensitivity for high acuity presentations and demonstrated similar specificity for low acuity presentations when compared to triage nurse MTS. Further work is necessary to validate eTriage as a potential tool for safe redirection of ED attenders to alternative care providers.

Using Smartwatches to Observe Changes in Activity During Recovery From Critical Illness Following COVID-19 Critical Care Admission: 1-Year, Multicenter Observational Study.

BACKGROUND: As a sequela of the COVID-19 pandemic, a large cohort of critical illness survivors have had to recover in the context of ongoing societal restrictions. OBJECTIVE: We aimed to use smartwatches (Fitbit Charge 3; Fitbit LLC) to assess changes in the step counts and heart rates of critical care survivors following hospital admission with COVID-19, use these devices within a remote multidisciplinary team (MDT) setting to support patient recovery, and report on our experiences with this. METHODS: We conducted a prospective, multicenter observational trial in 8 UK critical care units. A total of 50 participants with moderate or severe lung injury resulting from confirmed COVID-19 were recruited at discharge from critical care and given a smartwatch (Fitbit Charge 3) between April and June 2020. The data collected included step counts and daily resting heart rates. A subgroup of the overall cohort at one site-the MDT site (n=19)-had their smartwatch data used to inform a regular MDT meeting. A patient feedback questionnaire and direct feedback from the MDT were used to report our experience. Participants who did not upload smartwatch data were excluded from analysis. RESULTS: Of the 50 participants recruited, 35 (70%) used and uploaded data from their smartwatch during the 1-year period. At the MDT site, 74% (14/19) of smartwatch users uploaded smartwatch data, whereas 68% (21/31) of smartwatch users at the control sites uploaded smartwatch data. For the overall cohort, we recorded an increase in mean step count from 4359 (SD 3488) steps per day in the first month following discharge to 7914 (SD 4146) steps per day at 1 year (P=.003). The mean resting heart rate decreased from 79 (SD 7) beats per minute in the first month to 69 (SD 4) beats per minute at 1 year following discharge (P<.001). The MDT subgroup's mean step count increased more than that of the control group (176% increase vs 42% increase, respectively; +5474 steps vs +2181 steps, respectively; P=.04) over 1 year. Further, 71% (10/14) of smartwatch users at the MDT site and 48% (10/21) of those at the control sites strongly agreed that their Fitbit motivated them to recover, and 86% (12/14) and 48% (10/21), respectively, strongly agreed that they aimed to increase their activity levels over time. CONCLUSIONS: This is the first study to use smartwatch data to report on the 1-year recovery of patients who survived a COVID-19 critical illness. This is also the first study to report on smartwatch use within a post-critical care MDT. Future work could explore the role of smartwatches as part of a randomized controlled trial to assess clinical and economic effectiveness. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.12968/ijtr.2020.0102.

Association between collapse and serum creatinine and electrolyte concentrations in marathon runners: a 9-year retrospective study.

OBJECTIVE: Abnormal biochemical measurements have previously been described in runners following marathons. The incidence of plasma sodium levels outside the normal range has been reported as 31%, and the incidence of raised creatinine at 30%. This study describes the changes seen in electrolytes and creatinine in collapsed (2010-2019 events) and noncollapsed (during the 2019 event) runners during a UK marathon. METHODS: Point-of-care sodium, potassium, urea and creatinine estimates were obtained from any collapsed runner treated by the medical team during the Brighton Marathons, as part of their clinical care, and laboratory measurements from control subjects. RESULTS: Results from 224 collapsed runners were available. Serum creatinine was greater than the normal range in 68.9%. About 6% of sodium results were below, and 3% above the normal range, with the lowest 132 mmol/l. Seventeen percent of potassium readings were above the normal range; the maximum result was 8.4 mmol/l, but 97% were below 6.0 mmol/l. In the control group, mean creatinine was significantly raised in both the collapse and control groups, with 55.4% meeting the criteria for acute kidney injury, but had resolved to baseline after 24 h. Sodium concentration but not the potassium was significantly raised after the race compared with baseline, but only 15% were outside the normal range. CONCLUSION: In this study, incidence of a raised creatinine was higher than previously reported. However, the significance of such a rise remains unclear with a similar rise seen in collapsed and noncollapsed runners, and resolution noted within 24 h. Abnormal sodium concentrations were observed infrequently, and severely abnormal results were not seen, potentially reflecting current advice to drink enough fluid to quench thirst.

Factors affecting sedimentational separation of bacteria from blood.

Rapid diagnosis of blood infections requires fast and efficient separation of bacteria from blood. We have developed spinning hollow disks that separate bacteria from blood cells via the differences in sedimentation velocities of these particles. Factors affecting separation included the spinning speed and duration, and disk size. These factors were varied in dozens of experiments for which the volume of separated plasma, and the concentration of bacteria and red blood cells (RBCs) in separated plasma were measured. Data were correlated by a parameter of characteristic sedimentation length, which is the distance that an idealized RBC would travel during the entire spin. Results show that characteristic sedimentation length of 20 to 25 mm produces an optimal separation and collection of bacteria in plasma. This corresponds to spinning a 12-cm-diameter disk at 3,000 rpm for 13 s. Following the spin, a careful deceleration preserves the separation of cells from plasma and provides a bacterial recovery of about 61 ± 5%.

Rapid separation of bacteria from blood-review and outlook.

The high morbidity and mortality rate of bloodstream infections involving antibiotic-resistant bacteria necessitate a rapid identification of the infectious organism and its resistance profile. Traditional methods based on culturing the blood typically require at least 24 h, and genetic amplification by PCR in the presence of blood components has been problematic. The rapid separation of bacteria from blood would facilitate their genetic identification by PCR or other methods so that the proper antibiotic regimen can quickly be selected for the septic patient. Microfluidic systems that separate bacteria from whole blood have been developed, but these are designed to process only microliter quantities of whole blood or only highly diluted blood. However, symptoms of clinical blood infections can be manifest with bacterial burdens perhaps as low as 10 CFU/mL, and thus milliliter quantities of blood must be processed to collect enough bacteria for reliable genetic analysis. This review considers the advantages and shortcomings of various methods to separate bacteria from blood, with emphasis on techniques that can be done in less than 10 min on milliliter-quantities of whole blood. These techniques include filtration, screening, centrifugation, sedimentation, hydrodynamic focusing, chemical capture on surfaces or beads, field-flow fractionation, and dielectrophoresis. Techniques with the most promise include screening, sedimentation, and magnetic bead capture, as they allow large quantities of blood to be processed quickly. Some microfluidic techniques can be scaled up. © 2016 American Institute of Chemical Engineers Biotechnol. Prog., 32:823-839, 2016.