RATIONALE: Communities of color are bearing a disproportionate burden of coronavirus disease 2019 (COVID-19) morbidity and mortality. Social determinants of health have resulted in higher prevalence and severity of COVID-19 among minority groups. Published work on COVID-19 disparities has focused on higher transmission, hospitalization, and mortality risk among people of color, but studies on disparities in the post-acute care setting are scarce. Our aim was to identify socioeconomic disparities in health resource utilization after hospital discharge. METHODS: This was a retrospective study. We identified adult patients who were hospitalized at CUIMC or the Allen Hospital from March 1st through April 30th 2020, had a positive RT-PCR for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), developed severe hypoxemic respiratory failure requiring invasive mechanical ventilation, and were successfully discharged from the hospital without need for ventilator support. Patients who received a tracheostomy and were weaned off the ventilator prior to discharge were included. Exclusion criteria included transfer from or to another institution, prior tracheostomy, in-hospital death, and discharge with a ventilator. RESULTS: We identified 195 patients meeting inclusion criteria. The median age was 59 (IQR 47-67), and 135 (66.5%) were men. There were 25 (12.8%) patients who were uninsured and 116 (59.5%) patients who had public insurance. There were 121 (62%) Hispanic, 34 (17%) Black, and 18 (9%) White patients. Uninsured patients within our cohort were more likely to be Hispanic and Spanish-speaking (p=0.027;p<0.001, respectively). Uninsured patients were also more likely to be discharged to home (p<0.001) than to a rehabilitation facility. 8.8% of patients were readmitted to CUIMC within 30 days and 41.5% saw a medical provider at CUIMC within 30 days of discharge. Insurance status did not predict 30-day re-hospitalization or completion of outpatient follow-up, although our study was underpowered to answer these questions. CONCLUSION: Our study demonstrated that race/ethnicity and primary language are associated with insurance status with Hispanic and Spanish-speaking patients being more likely to be uninsured. Uninsured patients were more likely to be discharged home after hospitalization, rather than to facility for further care and rehabilitation. We did not demonstrate any short-term differences in 30-day re-hospitalization rates or follow-up visits but we suspect socioeconomic disparities represent a significant barrier to adequate follow-up care in the long term. We plan to investigate this further with longitudinal follow-up and survey data.
{"title":"Disparities in Access to Medical Care After Hospitalization for Severe COVID-19 Pneumonia","authors":"A. Cañas, L. Gómez, A. Wolf, D. Furfaro, J. Zelnick, Aby Watson, C. Rodriguez, J. Iyasere, R. Fullilove, K. M. Burkart, M. O’Donnell","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2543","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2543","url":null,"abstract":"RATIONALE: Communities of color are bearing a disproportionate burden of coronavirus disease 2019 (COVID-19) morbidity and mortality. Social determinants of health have resulted in higher prevalence and severity of COVID-19 among minority groups. Published work on COVID-19 disparities has focused on higher transmission, hospitalization, and mortality risk among people of color, but studies on disparities in the post-acute care setting are scarce. Our aim was to identify socioeconomic disparities in health resource utilization after hospital discharge. METHODS: This was a retrospective study. We identified adult patients who were hospitalized at CUIMC or the Allen Hospital from March 1st through April 30th 2020, had a positive RT-PCR for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), developed severe hypoxemic respiratory failure requiring invasive mechanical ventilation, and were successfully discharged from the hospital without need for ventilator support. Patients who received a tracheostomy and were weaned off the ventilator prior to discharge were included. Exclusion criteria included transfer from or to another institution, prior tracheostomy, in-hospital death, and discharge with a ventilator. RESULTS: We identified 195 patients meeting inclusion criteria. The median age was 59 (IQR 47-67), and 135 (66.5%) were men. There were 25 (12.8%) patients who were uninsured and 116 (59.5%) patients who had public insurance. There were 121 (62%) Hispanic, 34 (17%) Black, and 18 (9%) White patients. Uninsured patients within our cohort were more likely to be Hispanic and Spanish-speaking (p=0.027;p<0.001, respectively). Uninsured patients were also more likely to be discharged to home (p<0.001) than to a rehabilitation facility. 8.8% of patients were readmitted to CUIMC within 30 days and 41.5% saw a medical provider at CUIMC within 30 days of discharge. Insurance status did not predict 30-day re-hospitalization or completion of outpatient follow-up, although our study was underpowered to answer these questions. CONCLUSION: Our study demonstrated that race/ethnicity and primary language are associated with insurance status with Hispanic and Spanish-speaking patients being more likely to be uninsured. Uninsured patients were more likely to be discharged home after hospitalization, rather than to facility for further care and rehabilitation. We did not demonstrate any short-term differences in 30-day re-hospitalization rates or follow-up visits but we suspect socioeconomic disparities represent a significant barrier to adequate follow-up care in the long term. We plan to investigate this further with longitudinal follow-up and survey data.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"51 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122199745","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Rationale: Corona virus disease 2019 (COVID-19) related pneumonia carries high morbidity and mortality, especially in patients with acute respiratory distress syndrome (ARDS). The goal of this study was to evaluate the outcomes of patients admitted with COVID-19 pneumonia who required additional oxygen supplementation for hypoxia. We compared patients with and without ARDS based in their initial D-Dimer levels. Methods: Retrospective study conducted at BronxCare Hospital. Included all adult patients admitted with COVID-19 pneumonia requiring supplemental oxygen for hypoxia during the period of March to May 2020. Patients were classified in two groups based in the presence or absence of ARDS;then they were sub-classified based in their initial D-dimer levels, D-dimer levels ≥ 4 times upper limit of normal (ULN) compared with patients with D-dimer levels ≤ 4 times ULN. Primary outcome was mortality and secondary outcomes were length of stay (LOS), mechanical ventilation, shock, acute renal failure and thrombotic complications. Results: We identified 1242 patients. There were no differences for age, gender, race or comorbidities among the groups except for BMI. Mean age was 62.8 with 61% been males. There were 254(20.4%) patients in the ARDS and 988(79.5%) in the non-ARDS group. Hospital and ICU LOS was higher in patients with ARDS with D-dimer levels ≤ 4 times ULN. 33% of patients received mechanical ventilation, mainly in the ARDS group. Overall mortality was 36.6%. Mortality rate was higher in ARDS with D-dimer levels ≥ 4 ULN (81.4%) followed by patients with ARDS with D-dimer levels ≤ 4 times ULN (70.1%), non ARDS with D-dimer levels ≥ 4 ULN (35.7%) and non ARDS with D-dimer levels ≤ 4 times ULN (21.1%) (p< 0.0001). On logistic regression analysis, higher mortality was seen in patients with ARDS irrespective of D-dimer levels, older age, history of asthma and presence of acute renal failure. Female sex and use of ascorbic acid showed decrease in mortality. Conclusions: Our study confirms prior findings in COVID-19 pneumonia. Patient with non-ARDS requiring supplemental oxygen despite lower levels of D-dimer have a significant mortality. Use of readily available data on admission can assist the clinicians for admission triage decisions and have implications on discharge planning and follow up. Closely monitor patients with Covid-19 associated acute respiratory failure for the need for mechanical ventilation, shock, acute renal failure and thrombotic complications. (Table Presented).
{"title":"Outcomes of Hospitalized Patients with Coronavirus 19 Pneumonia and Respiratory Failure Based in D- Dimer Levels","authors":"A. Alapati, S. Venkatram, A. Reyes, R. Singhal, A. Dileep, L. Yapor, D. Ronderos, A. Jog, G. Díaz-Fuentes","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2540","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2540","url":null,"abstract":"Rationale: Corona virus disease 2019 (COVID-19) related pneumonia carries high morbidity and mortality, especially in patients with acute respiratory distress syndrome (ARDS). The goal of this study was to evaluate the outcomes of patients admitted with COVID-19 pneumonia who required additional oxygen supplementation for hypoxia. We compared patients with and without ARDS based in their initial D-Dimer levels. Methods: Retrospective study conducted at BronxCare Hospital. Included all adult patients admitted with COVID-19 pneumonia requiring supplemental oxygen for hypoxia during the period of March to May 2020. Patients were classified in two groups based in the presence or absence of ARDS;then they were sub-classified based in their initial D-dimer levels, D-dimer levels ≥ 4 times upper limit of normal (ULN) compared with patients with D-dimer levels ≤ 4 times ULN. Primary outcome was mortality and secondary outcomes were length of stay (LOS), mechanical ventilation, shock, acute renal failure and thrombotic complications. Results: We identified 1242 patients. There were no differences for age, gender, race or comorbidities among the groups except for BMI. Mean age was 62.8 with 61% been males. There were 254(20.4%) patients in the ARDS and 988(79.5%) in the non-ARDS group. Hospital and ICU LOS was higher in patients with ARDS with D-dimer levels ≤ 4 times ULN. 33% of patients received mechanical ventilation, mainly in the ARDS group. Overall mortality was 36.6%. Mortality rate was higher in ARDS with D-dimer levels ≥ 4 ULN (81.4%) followed by patients with ARDS with D-dimer levels ≤ 4 times ULN (70.1%), non ARDS with D-dimer levels ≥ 4 ULN (35.7%) and non ARDS with D-dimer levels ≤ 4 times ULN (21.1%) (p< 0.0001). On logistic regression analysis, higher mortality was seen in patients with ARDS irrespective of D-dimer levels, older age, history of asthma and presence of acute renal failure. Female sex and use of ascorbic acid showed decrease in mortality. Conclusions: Our study confirms prior findings in COVID-19 pneumonia. Patient with non-ARDS requiring supplemental oxygen despite lower levels of D-dimer have a significant mortality. Use of readily available data on admission can assist the clinicians for admission triage decisions and have implications on discharge planning and follow up. Closely monitor patients with Covid-19 associated acute respiratory failure for the need for mechanical ventilation, shock, acute renal failure and thrombotic complications. (Table Presented).","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"120 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127154580","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Rationale: Prone positioning in acute respiratory distress syndrome (ARDS) improves patient outcomes but has been underutilized. In this study, we hypothesize that prone positioning use has increased during the COVID-19 pandemic. Methods: We conducted a retrospective study of patients treated in the medical ICU of a large academic tertiary care hospital in Baltimore, Maryland. Use of prone positioning among patients with COVID-19 ARDS treated from March 20th, 2020 to June 16th, 2020 were compared to patients with ARDS in 2019. Potential participants were identified from a registry of patients admitted with acute hypoxemic respiratory failure. Inclusion criteria required use of mechanical ventilation, the presence of ARDS, and a PaO2/FiO2 of < 150 during the first 72 hours following intubation. The primary outcome was use of prone positioning within 48 hours of the first qualifying PaO2/FiO2. Secondary outcomes were time to prone positioning and in-hospital mortality. The proportions of patients placed in the prone position in 2019 versus 2020 was compared using Fisher's exact test. Logistic regression was used to examine the association of early prone position (within 6 hours) with inhospital mortality in univariate models and models adjusted for age, sex and sequential organ failure assessment (SOFA) score. Results: Of 43 patients with COVID-19 that met inclusion criteria, 35 (81%) were proned within 48 hours of meeting oxygen criteria compared to 5 (25%) of 20 qualifying ARDS cases in 2019 (p<0.001) (Figure 1). Among those patients in whom it was used, prone positioning was used within 6 hours of meeting in oxygen criteria in 37% vs. 10% of patients in the COVID-19 vs. pre-COVID-19 ARDS patients (p=0.04). Overall, 37% of COVID-19 participants and 50% of non-COVID-19 ARDS patients died. Those proned within 6 hours of meeting oxygen criteria had numerically lower mortality compared to those not proned or proned later (33 vs. 44%), but this was not statistically significantly associated with in-hospital mortality in univariate or adjusted logistic regression models (adjusted odds ratio=0.43, 95% CI 0.12-1.57). Conclusions: Use of prone positioning for patients with moderate to severe ARDS markedly increased during the COVID-19 pandemic. Larger studies are needed to define the changes in prone positioning frequency in different settings and to understand why and how this rapid change in practice occurred. This understanding may inform interventions to more broadly implement evidence based ARDS care in a sustained fashion.
理由:俯卧位可改善急性呼吸窘迫综合征(ARDS)患者的预后，但尚未得到充分利用。在本研究中，我们假设在COVID-19大流行期间，俯卧位的使用有所增加。方法:我们对在马里兰州巴尔的摩市一家大型三级专科医院重症监护室治疗的患者进行了回顾性研究。将2020年3月20日至2020年6月16日治疗的COVID-19 ARDS患者的俯卧位使用情况与2019年ARDS患者进行比较。潜在的参与者是从急性低氧性呼吸衰竭患者登记中确定的。纳入标准为使用机械通气，存在ARDS, PaO2/FiO2为<插管后72小时内死亡150人。主要结局是在第一次合格PaO2/FiO2后48小时内使用俯卧位。次要结局为俯卧位时间和住院死亡率。使用Fisher的精确测试比较了2019年和2020年俯卧位患者的比例。在单变量模型和调整了年龄、性别和顺序器官衰竭评估(SOFA)评分的模型中，采用Logistic回归来检验早期俯卧位(6小时内)与住院死亡率的关系。结果:在符合纳入标准的43例COVID-19患者中，35例(81%)在达到氧气标准后48小时内进行了俯卧，而2019年20例符合条件的ARDS患者中有5例(25%)(p<0.001)(图1)。在使用俯卧位的患者中，37%的患者在达到氧气标准后6小时内进行了俯卧位，而在COVID-19与COVID-19前ARDS患者中，这一比例为10% (p=0.04)。总体而言，37%的COVID-19参与者和50%的非COVID-19 ARDS患者死亡。在满足供氧标准的6小时内发作的患者与未发作或较晚发作的患者相比，死亡率较低(33比44%)，但在单变量或调整后的logistic回归模型中，这与住院死亡率没有统计学上的显著相关性(调整优势比=0.43,95% CI 0.12-1.57)。结论:在COVID-19大流行期间，中重度ARDS患者采用俯卧位的人数明显增加。需要更大规模的研究来定义不同环境下俯卧定位频率的变化，并了解这种快速变化在实践中发生的原因和方式。这一认识可能为干预措施提供信息，以便更广泛地以持续的方式实施基于证据的ARDS护理。
{"title":"Use of Prone Positioning for the Acute Respiratory Distress Syndrome Increased During the Coronavirus Disease 19 Pandemic","authors":"C. Hochberg, M. Eakin, D. Hager","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2541","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2541","url":null,"abstract":"Rationale: Prone positioning in acute respiratory distress syndrome (ARDS) improves patient outcomes but has been underutilized. In this study, we hypothesize that prone positioning use has increased during the COVID-19 pandemic. Methods: We conducted a retrospective study of patients treated in the medical ICU of a large academic tertiary care hospital in Baltimore, Maryland. Use of prone positioning among patients with COVID-19 ARDS treated from March 20th, 2020 to June 16th, 2020 were compared to patients with ARDS in 2019. Potential participants were identified from a registry of patients admitted with acute hypoxemic respiratory failure. Inclusion criteria required use of mechanical ventilation, the presence of ARDS, and a PaO2/FiO2 of < 150 during the first 72 hours following intubation. The primary outcome was use of prone positioning within 48 hours of the first qualifying PaO2/FiO2. Secondary outcomes were time to prone positioning and in-hospital mortality. The proportions of patients placed in the prone position in 2019 versus 2020 was compared using Fisher's exact test. Logistic regression was used to examine the association of early prone position (within 6 hours) with inhospital mortality in univariate models and models adjusted for age, sex and sequential organ failure assessment (SOFA) score. Results: Of 43 patients with COVID-19 that met inclusion criteria, 35 (81%) were proned within 48 hours of meeting oxygen criteria compared to 5 (25%) of 20 qualifying ARDS cases in 2019 (p<0.001) (Figure 1). Among those patients in whom it was used, prone positioning was used within 6 hours of meeting in oxygen criteria in 37% vs. 10% of patients in the COVID-19 vs. pre-COVID-19 ARDS patients (p=0.04). Overall, 37% of COVID-19 participants and 50% of non-COVID-19 ARDS patients died. Those proned within 6 hours of meeting oxygen criteria had numerically lower mortality compared to those not proned or proned later (33 vs. 44%), but this was not statistically significantly associated with in-hospital mortality in univariate or adjusted logistic regression models (adjusted odds ratio=0.43, 95% CI 0.12-1.57). Conclusions: Use of prone positioning for patients with moderate to severe ARDS markedly increased during the COVID-19 pandemic. Larger studies are needed to define the changes in prone positioning frequency in different settings and to understand why and how this rapid change in practice occurred. This understanding may inform interventions to more broadly implement evidence based ARDS care in a sustained fashion.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"256 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122818656","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
RATIONALE The first confirmed case of COVID-19 in New York was on March 1, 2020.(1) A nationwide emergency declared on March 13 made New York immediately eligible for FEMA public assistance.(2) At the peak of this pandemic, over 50,094 FEMA employees, Public Health Service Commissioned Corps officers from HHS and the National Guard were deployed across the US(2) to care for suspected or confirmed COVID-19 cases, including 10,437 NYC H+H cases, many of which required ICU level care. Elmhurst Hospital Center (EHC) experienced an unprecedented surge, resulting in resource strain. At EHC 2,409 patients (1501, COVID-19 positive) were newly admitted between March 1st to May 29, 2020, drastically surpassing hospital capacity. Herein, we compare patient outcomes before and after assistance. METHODS A retrospective review of cardiopulmonary resuscitation code team data was carried out for admitted adults requiring code response team between March 11 to May 25. A total of 145 cases were analyzed with respect to different grades of FEMA assistance to determine impacts of ancillary staff to patient ratios on survival. RESULTS Prior to FEMA support (3/11-3/25), code survival was 47% (8/17) and survival to discharge was 0% (0/17). The first wave of FEMA support (3/26-4/8) brought 221 Critical Care providers. Code survival was 39% (24/62) and survival to discharge was 5% (3/62). The second wave (4/9-4/23) included both 86 providers and volunteers, after which code survival was 56% (28/50) and survival to discharge was 2% (1/50). A third wave of 79 additional providers (4/24-5/10) resulted in decreased number of codes, code survival to 38% (3/8) and improved survival to discharge 38% (3/8). During the subsequent weeks while FEMA support staff remained at EHC (5/11-5/25), code survival was 50% (4/8), and the improved survival to discharge of 38% (3/8) was maintained. Overall, while the probability of code survival remained relatively constant (38-56%), survival to discharge showed significant and sustained improvement with additional provider support. CONCLUSION Given the exponential rise in COVID-19 admissions, hospitals are likely to become overwhelmed and medical practice is forced to adapt.(3) Swift action from FEMA and optimal ancillary staff deployment was critical to improving survival to discharge in critically ill patients requiring cardiopulmonary resuscitation.(4) Flexibility in step-up planning with timely high acuity capacity and appropriately trained provider staffing is vital to ensuring proper care during a pandemic surge.
{"title":"Impact of FEMA on Rapid Response System During the COVID-19 Surge","authors":"K. Johnson, R. Durrance, U. Dhamrah, N. Sheth, R. Payal, D. Papademetriou, A. Astua","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2570","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2570","url":null,"abstract":"RATIONALE The first confirmed case of COVID-19 in New York was on March 1, 2020.(1) A nationwide emergency declared on March 13 made New York immediately eligible for FEMA public assistance.(2) At the peak of this pandemic, over 50,094 FEMA employees, Public Health Service Commissioned Corps officers from HHS and the National Guard were deployed across the US(2) to care for suspected or confirmed COVID-19 cases, including 10,437 NYC H+H cases, many of which required ICU level care. Elmhurst Hospital Center (EHC) experienced an unprecedented surge, resulting in resource strain. At EHC 2,409 patients (1501, COVID-19 positive) were newly admitted between March 1st to May 29, 2020, drastically surpassing hospital capacity. Herein, we compare patient outcomes before and after assistance. METHODS A retrospective review of cardiopulmonary resuscitation code team data was carried out for admitted adults requiring code response team between March 11 to May 25. A total of 145 cases were analyzed with respect to different grades of FEMA assistance to determine impacts of ancillary staff to patient ratios on survival. RESULTS Prior to FEMA support (3/11-3/25), code survival was 47% (8/17) and survival to discharge was 0% (0/17). The first wave of FEMA support (3/26-4/8) brought 221 Critical Care providers. Code survival was 39% (24/62) and survival to discharge was 5% (3/62). The second wave (4/9-4/23) included both 86 providers and volunteers, after which code survival was 56% (28/50) and survival to discharge was 2% (1/50). A third wave of 79 additional providers (4/24-5/10) resulted in decreased number of codes, code survival to 38% (3/8) and improved survival to discharge 38% (3/8). During the subsequent weeks while FEMA support staff remained at EHC (5/11-5/25), code survival was 50% (4/8), and the improved survival to discharge of 38% (3/8) was maintained. Overall, while the probability of code survival remained relatively constant (38-56%), survival to discharge showed significant and sustained improvement with additional provider support. CONCLUSION Given the exponential rise in COVID-19 admissions, hospitals are likely to become overwhelmed and medical practice is forced to adapt.(3) Swift action from FEMA and optimal ancillary staff deployment was critical to improving survival to discharge in critically ill patients requiring cardiopulmonary resuscitation.(4) Flexibility in step-up planning with timely high acuity capacity and appropriately trained provider staffing is vital to ensuring proper care during a pandemic surge.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"13 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131954620","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Rationale: Though the United States has the highest number of ICU beds per capita in the world, the regional distribution of these beds is variable. Rural areas have 1% of American ICU beds despite having 16% of the country's population. Telehealth is frequently promoted as a tool that can augment care for the critically ill in rural communities. Yet, ICU telehealth still requires clinicians at the bedside who are able to provide critical care. We sought to examine telemedicine within rural ICUs in the context of potential workforce shortages related to the COVID-19 pandemic. Methods: We identified all hospitals with ICUs in Michigan using the 2018 American Hospital Association annual survey database and internet searches. Within each hospital, an ICU physician or nurse leader was surveyed between April 6, 2020 and May 8, 2020. At that time, the state of Michigan had the fifth highest total of COVID-19 hospitalizations within the country. Participants were asked about current telehealth utilization in the ICU. Participants were also asked to rate their concern on a 4-point Likert scale regarding exceeding existing ICU capacity and ICU staffing capabilities due to the pandemic. Results: Of the 28 rural hospitals in Michigan, 14 were surveyed (response rate 50%). Among responding hospitals, 12 (86%) had fewer than 11 ICU beds and an average pre-COVID-19 census of fewer than 4 patients. At the time of the survey, ten hospitals (71%) reported using ICU telehealth support, of which two used telehealth providers exclusively overnight. Of the four hospitals without telehealth, two planned to add telehealth in response to the pandemic. In the context of the COVID-19 pandemic, 11 hospitals (79%) reported concern about exceeding their ICU capacity, and 12 hospitals (86%) planned to create more ICU beds. The majority of rural hospitals worried about impending ICU workforce shortages, with 78% of hospitals concerned about having enough nurses, 64% about having enough respiratory therapists, and 50% about having enough physicians as a result of the pandemic. Conclusions: At the onset of the COVID-19 pandemic, most rural hospitals in Michigan utilized ICU telehealth support in some capacity. Despite broad use of telemedicine, rural hospitals remained concerned about exceeding ICU capacity and a lack of ICU nurses, respiratory therapists, and physicians. Expansion of existing telehealth infrastructures within rural hospitals may improve access to critical care clinicians virtually but would not ease concerns related to capacity and workforce shortages, particularly among ICU-trained nurses.
{"title":"ICU Telehealth Use and Concern for Workforce Shortages Among Rural Hospitals in Michigan at the Onset of the COVID-19 Pandemic","authors":"K. Epler, A. Schutz, T. Valley","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2568","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2568","url":null,"abstract":"Rationale: Though the United States has the highest number of ICU beds per capita in the world, the regional distribution of these beds is variable. Rural areas have 1% of American ICU beds despite having 16% of the country's population. Telehealth is frequently promoted as a tool that can augment care for the critically ill in rural communities. Yet, ICU telehealth still requires clinicians at the bedside who are able to provide critical care. We sought to examine telemedicine within rural ICUs in the context of potential workforce shortages related to the COVID-19 pandemic. Methods: We identified all hospitals with ICUs in Michigan using the 2018 American Hospital Association annual survey database and internet searches. Within each hospital, an ICU physician or nurse leader was surveyed between April 6, 2020 and May 8, 2020. At that time, the state of Michigan had the fifth highest total of COVID-19 hospitalizations within the country. Participants were asked about current telehealth utilization in the ICU. Participants were also asked to rate their concern on a 4-point Likert scale regarding exceeding existing ICU capacity and ICU staffing capabilities due to the pandemic. Results: Of the 28 rural hospitals in Michigan, 14 were surveyed (response rate 50%). Among responding hospitals, 12 (86%) had fewer than 11 ICU beds and an average pre-COVID-19 census of fewer than 4 patients. At the time of the survey, ten hospitals (71%) reported using ICU telehealth support, of which two used telehealth providers exclusively overnight. Of the four hospitals without telehealth, two planned to add telehealth in response to the pandemic. In the context of the COVID-19 pandemic, 11 hospitals (79%) reported concern about exceeding their ICU capacity, and 12 hospitals (86%) planned to create more ICU beds. The majority of rural hospitals worried about impending ICU workforce shortages, with 78% of hospitals concerned about having enough nurses, 64% about having enough respiratory therapists, and 50% about having enough physicians as a result of the pandemic. Conclusions: At the onset of the COVID-19 pandemic, most rural hospitals in Michigan utilized ICU telehealth support in some capacity. Despite broad use of telemedicine, rural hospitals remained concerned about exceeding ICU capacity and a lack of ICU nurses, respiratory therapists, and physicians. Expansion of existing telehealth infrastructures within rural hospitals may improve access to critical care clinicians virtually but would not ease concerns related to capacity and workforce shortages, particularly among ICU-trained nurses.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"106 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128117937","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Racial and ethnic minorities have accounted for the majority of intensive care unit (ICU) hospitalizations for COVID-19. At the same time, ICUs were forced to deviate from long-established care processes in response to a steep increase in admissions and to prevent healthcare worker infections. These shifts may have resulted in changes to sedation practices, such as level of sedation or sedation holidays, that differed by patient race or ethnicity. We aimed to examine associations among patient race and ethnicity, sedation practices, and mortality in a large, national sample of patients receiving mechanical ventilation for COVID-19. Methods: We analyzed granular daily data from the Viral Infection and Respiratory Illness Universal Study (VIRUS) Registry for COVID-19 patients admitted to ICUs between February and November 2020. We included patients over 18 years of age, who were mechanically ventilated following clinical or PCR-confirmed COVID-19 diagnosis. We will calculate descriptive statistics for mortality at discharge and 28 days by patient race/ethnicity, sex, and two care processes associated with mechanical ventilation: sedation level and sedation holidays. We will estimate risk-adjusted, hospital-level mortality differentials by race. We will use mixed effects logistic regression and causal mediation analysis to test associations among patient race/ethnicity, sedation practices for mechanical ventilation, and mortality at 28 days, controlling for comorbidities, markers of severity, and time to admission, and adjusting for clustering by ICU. Results: Among 19,626 patients hospitalized for COVID-19, 8,668 (14.6%) received mechanical ventilation at 238 hospitals. The median age was 62 (IQR 40-72) and 45.1% were female. Among hospitalized patients, 23.3% self-identified as Hispanic, 26.6% as non-Hispanic Black, 35.6% as non-Hispanic White, and 14.5% as non-Hispanic and another racial group. Approximately 1% (n=236) of patients were missing race/ethnicity. At 28 days, 20.7% (n=4,076) of hospitalized patients were deceased. Use of benzodiazepines was highly clustered by hospital (intraclass correlation coefficient of 0.63). In cluster-adjusted analyses, Hispanic patients were more likely to receive benzodiazepines at least once during hospitalization than either non-Hispanic White (Odds Ratio (OR) 0.76, p=0.013) or non-Hispanic Black (OR 0.70, p=0.003) patients. Multivariable mixed effects and causal mediation analyses are ongoing. Conclusions: Sedation practices, such as level of sedation and sedation holidays, are associated with mortality;yet these practices may differ based on a patient's race or ethnicity. We will leverage a unique, multi-center database with granular clinical information to understand how these differences may influence racial and ethnic disparities in respiratory failure.
{"title":"Associations Among Patient Race, Sedation Practices, and Mortality in a Large Multi-Center Registry of COVID-19 Patients","authors":"T. Valley, T. Iwashyna, S. Cook, C. Hough, M. Armstrong-Hough","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2567","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2567","url":null,"abstract":"Introduction: Racial and ethnic minorities have accounted for the majority of intensive care unit (ICU) hospitalizations for COVID-19. At the same time, ICUs were forced to deviate from long-established care processes in response to a steep increase in admissions and to prevent healthcare worker infections. These shifts may have resulted in changes to sedation practices, such as level of sedation or sedation holidays, that differed by patient race or ethnicity. We aimed to examine associations among patient race and ethnicity, sedation practices, and mortality in a large, national sample of patients receiving mechanical ventilation for COVID-19. Methods: We analyzed granular daily data from the Viral Infection and Respiratory Illness Universal Study (VIRUS) Registry for COVID-19 patients admitted to ICUs between February and November 2020. We included patients over 18 years of age, who were mechanically ventilated following clinical or PCR-confirmed COVID-19 diagnosis. We will calculate descriptive statistics for mortality at discharge and 28 days by patient race/ethnicity, sex, and two care processes associated with mechanical ventilation: sedation level and sedation holidays. We will estimate risk-adjusted, hospital-level mortality differentials by race. We will use mixed effects logistic regression and causal mediation analysis to test associations among patient race/ethnicity, sedation practices for mechanical ventilation, and mortality at 28 days, controlling for comorbidities, markers of severity, and time to admission, and adjusting for clustering by ICU. Results: Among 19,626 patients hospitalized for COVID-19, 8,668 (14.6%) received mechanical ventilation at 238 hospitals. The median age was 62 (IQR 40-72) and 45.1% were female. Among hospitalized patients, 23.3% self-identified as Hispanic, 26.6% as non-Hispanic Black, 35.6% as non-Hispanic White, and 14.5% as non-Hispanic and another racial group. Approximately 1% (n=236) of patients were missing race/ethnicity. At 28 days, 20.7% (n=4,076) of hospitalized patients were deceased. Use of benzodiazepines was highly clustered by hospital (intraclass correlation coefficient of 0.63). In cluster-adjusted analyses, Hispanic patients were more likely to receive benzodiazepines at least once during hospitalization than either non-Hispanic White (Odds Ratio (OR) 0.76, p=0.013) or non-Hispanic Black (OR 0.70, p=0.003) patients. Multivariable mixed effects and causal mediation analyses are ongoing. Conclusions: Sedation practices, such as level of sedation and sedation holidays, are associated with mortality;yet these practices may differ based on a patient's race or ethnicity. We will leverage a unique, multi-center database with granular clinical information to understand how these differences may influence racial and ethnic disparities in respiratory failure.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132105550","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Coronavirus Disease 2019 (COVID-19) is caused by novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). It was initially identified as the cause of pneumonia cases in Wuhan, China and has now rapidly spread throughout the world causing a pandemic. Although, 81% of patients have mild disease (pneumonia), 14% could have severe disease leading to hospitalization and 5% end up in intensive care unit. The mortality of patients in ICU is variable and has been reported to be as high as 80%, particularly the patient who require intubation. Not much is known about the factors leading to progression of hospitalized patient needing ICU care and the predictors of mortality among ICU patients. We did the univariate followed by multivariate logistic regression analysis to determine the predictors of mortality in ICU. Method: Retrospective data were collected from consecutive 101 patients admitted from March, 2020 to June, 2020. Data were collected from 5 different community hospitals in Eastern Virginia with varied demographics. Univariate and multivariate logistic regression was done to determine the factors associated with progression of hospitalized patient to ICU and the predictors of mortality in ICU. Result: Total 101 consecutive hospitalized patients in 5 community hospitals in Eastern Virginia were enrolled in the study. Total 52/101 patients were admitted into the ICU for respiratory failure. Of these, 40 patients required intubation and mechanical ventilation. Altogether, 32/52 patients died. Of these 32 patients, 25 had required intubation. Total 22/25 (88%) intubated patients passed away while 3 were successfully extubated. Of these 32 patients, one had mild ARDS, 6 had moderate ARDS and 18 had severe ARDS. Patients aged 60 years and above accounted for >2/3rd of the cases in ICU;mortality rate was higher in this age group as well. The inflammatory markers (CRP, D-dimer, Ferritin) peaked on day 8. The medications like Hydroxychloroquine, Azithromycin, Tocilizumab and Remdesivir did not alter the outcomes. Logistic regression analysis (univariate and multivariate) were done in the patients to determine the predictors of ICU admission from floor or ED. Logistic regression analysis was also done in the patients admitted to the ICU to look for the predictors of mortality. Conclusion: Based on logistic regression, none of the demographics (age, sex, race), symptoms, laboratory findings, chest imaging, ventilator settings or treatment identified the predictors of mortality in ICU in patients with COVID 19.
简介:冠状病毒病2019 (COVID-19)是由新型冠状病毒引起的严重急性呼吸综合征冠状病毒2 (SARS-CoV-2)。它最初被确定为导致中国武汉肺炎病例的原因，现在已迅速蔓延到世界各地，造成大流行。尽管81%的患者患有轻度疾病(肺炎)，但14%的患者可能患有导致住院的严重疾病，5%的患者最终进入重症监护病房。ICU患者的死亡率各不相同，据报道高达80%，特别是需要插管的患者。导致住院患者需要ICU护理进展的因素和ICU患者死亡率的预测因素尚不清楚。我们进行了单因素分析，然后进行了多因素logistic回归分析，以确定ICU死亡率的预测因素。方法:收集我院2020年3月至2020年6月收治的101例患者的回顾性资料。数据是从弗吉尼亚州东部5家不同的社区医院收集的，这些医院的人口统计数据各不相同。采用单因素和多因素logistic回归确定与住院患者转入ICU相关的因素和ICU死亡率的预测因素。结果:东维吉尼亚州5家社区医院共101例连续住院患者纳入研究。101例患者中52例因呼吸衰竭入住ICU。其中，40例患者需要插管和机械通气。总共32/52例患者死亡。在这32例患者中，有25例需要插管。死亡22/25例(88%)，成功拔管3例。32例患者中，1例为轻度ARDS, 6例为中度ARDS, 18例为重度ARDS。60岁及以上患者占ICU病例的2/3，该年龄组死亡率也较高。炎症标志物(CRP, d -二聚体，铁蛋白)在第8天达到峰值。羟氯喹、阿奇霉素、托珠单抗和雷姆德西韦等药物并没有改变结果。对患者进行Logistic回归分析(单因素和多因素)，以确定从楼层或急诊科进入ICU的预测因素。对入住ICU的患者进行Logistic回归分析，以寻找死亡率的预测因素。结论:基于logistic回归，人口统计学(年龄、性别、种族)、症状、实验室检查、胸部影像学、呼吸机设置或治疗均不能确定COVID - 19患者在ICU中的死亡率预测因素。
{"title":"Predictors of ICU Admission and Mortality in Patients with Coronavirus Disease - 2019 (COVID 19) in Community Hospitals","authors":"V. Pathak, C. Conklin","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2551","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2551","url":null,"abstract":"Introduction: Coronavirus Disease 2019 (COVID-19) is caused by novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). It was initially identified as the cause of pneumonia cases in Wuhan, China and has now rapidly spread throughout the world causing a pandemic. Although, 81% of patients have mild disease (pneumonia), 14% could have severe disease leading to hospitalization and 5% end up in intensive care unit. The mortality of patients in ICU is variable and has been reported to be as high as 80%, particularly the patient who require intubation. Not much is known about the factors leading to progression of hospitalized patient needing ICU care and the predictors of mortality among ICU patients. We did the univariate followed by multivariate logistic regression analysis to determine the predictors of mortality in ICU. Method: Retrospective data were collected from consecutive 101 patients admitted from March, 2020 to June, 2020. Data were collected from 5 different community hospitals in Eastern Virginia with varied demographics. Univariate and multivariate logistic regression was done to determine the factors associated with progression of hospitalized patient to ICU and the predictors of mortality in ICU. Result: Total 101 consecutive hospitalized patients in 5 community hospitals in Eastern Virginia were enrolled in the study. Total 52/101 patients were admitted into the ICU for respiratory failure. Of these, 40 patients required intubation and mechanical ventilation. Altogether, 32/52 patients died. Of these 32 patients, 25 had required intubation. Total 22/25 (88%) intubated patients passed away while 3 were successfully extubated. Of these 32 patients, one had mild ARDS, 6 had moderate ARDS and 18 had severe ARDS. Patients aged 60 years and above accounted for >2/3rd of the cases in ICU;mortality rate was higher in this age group as well. The inflammatory markers (CRP, D-dimer, Ferritin) peaked on day 8. The medications like Hydroxychloroquine, Azithromycin, Tocilizumab and Remdesivir did not alter the outcomes. Logistic regression analysis (univariate and multivariate) were done in the patients to determine the predictors of ICU admission from floor or ED. Logistic regression analysis was also done in the patients admitted to the ICU to look for the predictors of mortality. Conclusion: Based on logistic regression, none of the demographics (age, sex, race), symptoms, laboratory findings, chest imaging, ventilator settings or treatment identified the predictors of mortality in ICU in patients with COVID 19.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"59 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116563965","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction and rationale: Many patients with COVID-19 admitted to the intensive care units require prolonged mechanical ventilation. Tracheostomy has been avoided due to increased risk of aerosolization especially during tracheal dilation resulting in increased risk for personnel infection. We describe our novel protocol to prevent exposure during percutaneous tracheostomy.Methods: Patients with COVID-19, on mechanical ventilation requiring prolonged mechanical ventilation were evaluated for bed-side percutaneous tracheostomy. The procedure was performed under bronchoscopic guidance and using a disposable bronchoscope. The scope was secured in position 1 cm from the end of the endotracheal tube with tape at the insertion site to allow the bronchoscopist to withdraw the ETT/bronchoscope en-bloc to the appropriate location in the trachea for adequate visualization during the procedure. Once the puncture point was identified, an expiratory pause was performed during which the trachea was punctured, a guide wire was placed, the anterior wall was dilated, and a tracheostomy was advanced and placed in the trachea. The time of the expiratory pause, any desaturation, complication and personnel conversion were measured.Results: A total of 18 percutaneous tracheostomies were performed. The total time of the expiratory pause, tracheal puncture to tracheostomy placement was thirty seconds to sixty seconds. There was no evidence of desaturation during the procedure, and there were no cases of staff conversion to positive COVID-19 status up to 14 days post procedure.Conclusions: we conclude that expiratory pause during percutaneous tracheostomy is safe, and importantly, may play significant role in decreasing aerosolization and staff exposure in patients with COVID-19 respiratory failure.
{"title":"Safety and Efficacy of a Novel Percutaneous Tracheostomy Protocol Adapted to Patients with COVID-19","authors":"R. Bechara, S. Islam, E. Fountain, S. Allen","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2563","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2563","url":null,"abstract":"Introduction and rationale: Many patients with COVID-19 admitted to the intensive care units require prolonged mechanical ventilation. Tracheostomy has been avoided due to increased risk of aerosolization especially during tracheal dilation resulting in increased risk for personnel infection. We describe our novel protocol to prevent exposure during percutaneous tracheostomy.Methods: Patients with COVID-19, on mechanical ventilation requiring prolonged mechanical ventilation were evaluated for bed-side percutaneous tracheostomy. The procedure was performed under bronchoscopic guidance and using a disposable bronchoscope. The scope was secured in position 1 cm from the end of the endotracheal tube with tape at the insertion site to allow the bronchoscopist to withdraw the ETT/bronchoscope en-bloc to the appropriate location in the trachea for adequate visualization during the procedure. Once the puncture point was identified, an expiratory pause was performed during which the trachea was punctured, a guide wire was placed, the anterior wall was dilated, and a tracheostomy was advanced and placed in the trachea. The time of the expiratory pause, any desaturation, complication and personnel conversion were measured.Results: A total of 18 percutaneous tracheostomies were performed. The total time of the expiratory pause, tracheal puncture to tracheostomy placement was thirty seconds to sixty seconds. There was no evidence of desaturation during the procedure, and there were no cases of staff conversion to positive COVID-19 status up to 14 days post procedure.Conclusions: we conclude that expiratory pause during percutaneous tracheostomy is safe, and importantly, may play significant role in decreasing aerosolization and staff exposure in patients with COVID-19 respiratory failure.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"36 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116566344","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Purpose: Extracorporeal membrane oxygenation (ECMO) is a refractorytreatment for acute respiratory distress syndrome (ARDS) due toinfluenza and severe acute respiratory syndrome coronavirus 2(SARS-CoV-2, also referred to as COVID-19). We conducted this study tocompare the outcomes of influenza patients treated with veno-venous-ECMO(VV-ECMO) to COVID-19 patients treated with VV-ECMO, during the firstwave of COVID-19. Materials and Methods: Patients in our institutionwith ARDS due to COVID-19 or influenza who were placed on ECMO betweenAugust 1, 2010 and September 15, 2020 were included in this comparative,retrospective study. To improve homogeneity, only VV -ECMO patients wereanalyzed. The clinical characteristics and outcomes were extracted andanalyzed. Results: 28 COVID-19 patients and 17 influenza patients wereidentified and included. ECMO survival rates were 68% (19/28) inCOVID-19 patients and 94% (16/17) in influenza patients (p=0.04).30-day survival rates after ECMO decannulation were 54% (15/28) inCOVID-19 patients and 76% (13/17) in influenza patients (p=0.13).COVID-19 patients spent a longer time on ECMO compared to flu patients(21 days vs. 12 days, p=0.025), and more COVID-19 patients (26/28 vs.2/17) were on immunomodulatory therapy prior to ECMO initiation(p<0.001). COVID-19 patients had higher rates of newinfections during ECMO (50% vs. 18%, p=0.03) and bacterial pneumonia(36% vs 6%, p=0.024). Conclusions: COVID-19 patients who were treatedin our institution with VV-ECMO had statistically lower ECMO survivalrates than influenza patients. It is possible that COVID-19immunomodulation therapies may increase the risk of other superimposedinfections.
{"title":"Outcomes of Extracorporeal Membrane Oxygenation in Influenza vs. COVID-19 During the First Wave of COVID-19","authors":"C. Blazoski, M. Baram, H. Hirose","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2542","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2542","url":null,"abstract":"Purpose: Extracorporeal membrane oxygenation (ECMO) is a refractory\u0000treatment for acute respiratory distress syndrome (ARDS) due to\u0000influenza and severe acute respiratory syndrome coronavirus 2\u0000(SARS-CoV-2, also referred to as COVID-19). We conducted this study to\u0000compare the outcomes of influenza patients treated with veno-venous-ECMO\u0000(VV-ECMO) to COVID-19 patients treated with VV-ECMO, during the first\u0000wave of COVID-19. Materials and Methods: Patients in our institution\u0000with ARDS due to COVID-19 or influenza who were placed on ECMO between\u0000August 1, 2010 and September 15, 2020 were included in this comparative,\u0000retrospective study. To improve homogeneity, only VV -ECMO patients were\u0000analyzed. The clinical characteristics and outcomes were extracted and\u0000analyzed. Results: 28 COVID-19 patients and 17 influenza patients were\u0000identified and included. ECMO survival rates were 68% (19/28) in\u0000COVID-19 patients and 94% (16/17) in influenza patients (p=0.04).\u000030-day survival rates after ECMO decannulation were 54% (15/28) in\u0000COVID-19 patients and 76% (13/17) in influenza patients (p=0.13).\u0000COVID-19 patients spent a longer time on ECMO compared to flu patients\u0000(21 days vs. 12 days, p=0.025), and more COVID-19 patients (26/28 vs.\u00002/17) were on immunomodulatory therapy prior to ECMO initiation\u0000(p<0.001). COVID-19 patients had higher rates of new\u0000infections during ECMO (50% vs. 18%, p=0.03) and bacterial pneumonia\u0000(36% vs 6%, p=0.024). Conclusions: COVID-19 patients who were treated\u0000in our institution with VV-ECMO had statistically lower ECMO survival\u0000rates than influenza patients. It is possible that COVID-19\u0000immunomodulation therapies may increase the risk of other superimposed\u0000infections.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"11 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128662992","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Rationale: Deficiencies exist in the communication of prognosis for patients requiring prolonged mechanical ventilation (PMV) from COVID-19 pneumonia, in part because of clinician uncertainty about the natural history of disease and observational cohort studies with variable outcomes. In order to address this gap for PMV patients, we developed a modified clinical prediction model based on the ProVent-14 model to predict in-hospital mortality for patients receiving at least 14 days of mechanical ventilation for acute respiratory distress syndrome (ARDS) from COVID-19. Methods: We evaluated 107 patients with COVID-19 requiring PMV (at least 14 days of mechanical ventilation (MV)) at 2 tertiary care medical centers in the US in a retrospective observational cohort study. On day 14 of MV, we collected data for the original ProVent-14 variables (age, platelet count, requirement for vasopressors, non-trauma admission, and dialysis requirement). We also collected data for 2 other potential predictor variables (extra-corporeal membrane oxygenation (ECMO) on day 14 and neutrophil to lymphocyte ratio). Model Development: Logistic regression models were used to evaluate the performance of the ProVent-14 variables with the outcome inhospital mortality. We then assessed successive models adding variable combinations including requirement of ECMO and neutrophil to lymphocyte ratio on day 14 to predict inhospital mortality. We assessed discrimination of the models by measuring the area under the receiver operating characteristic curve (AUC). We assessed calibration by the Hosmer-Lemeshow goodness of fit statistic. Results: The AUC for the model using original Provent-14 variables was 0.78 (trauma omitted for N=1). The most parsimonious model using the additional variables includes risk factors age 50-64 and ≥65;platelet count <100, and requirement for vasopressors, renal replacement or ECMO on day 14 of MV. The area under the curve for this model is 0.83. Calibration for the modified parsimonious model is provided in the table below (Goodness-of-fit statistic p=0.80). Dichotomized neutrophil to lymphocyte ratio on day 14 (N:L>15) improves the model slightly AUC=0.83, Goodness-of-fit p=0.61, though this variable was available for only 60% of the cohort. Conclusion: A modified clinical prediction model based on the previously validated ProVent-14 model is a simple method to accurately identify patients with ARDS from COVID-19 requiring PMV who are at high risk of in-hospital mortality. Further validation of model performance in a larger population and including long-term survival is warranted.
{"title":"Modification and Application of the ProVent-14 Model to a Covid-19 Cohort to Predict Risk for In-Hospital Mortality","authors":"B. Sines, L. Chang, T. Reid, S. Carson, I. Douglas","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2536","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2536","url":null,"abstract":"Rationale: Deficiencies exist in the communication of prognosis for patients requiring prolonged mechanical ventilation (PMV) from COVID-19 pneumonia, in part because of clinician uncertainty about the natural history of disease and observational cohort studies with variable outcomes. In order to address this gap for PMV patients, we developed a modified clinical prediction model based on the ProVent-14 model to predict in-hospital mortality for patients receiving at least 14 days of mechanical ventilation for acute respiratory distress syndrome (ARDS) from COVID-19. Methods: We evaluated 107 patients with COVID-19 requiring PMV (at least 14 days of mechanical ventilation (MV)) at 2 tertiary care medical centers in the US in a retrospective observational cohort study. On day 14 of MV, we collected data for the original ProVent-14 variables (age, platelet count, requirement for vasopressors, non-trauma admission, and dialysis requirement). We also collected data for 2 other potential predictor variables (extra-corporeal membrane oxygenation (ECMO) on day 14 and neutrophil to lymphocyte ratio). Model Development: Logistic regression models were used to evaluate the performance of the ProVent-14 variables with the outcome inhospital mortality. We then assessed successive models adding variable combinations including requirement of ECMO and neutrophil to lymphocyte ratio on day 14 to predict inhospital mortality. We assessed discrimination of the models by measuring the area under the receiver operating characteristic curve (AUC). We assessed calibration by the Hosmer-Lemeshow goodness of fit statistic. Results: The AUC for the model using original Provent-14 variables was 0.78 (trauma omitted for N=1). The most parsimonious model using the additional variables includes risk factors age 50-64 and ≥65;platelet count <100, and requirement for vasopressors, renal replacement or ECMO on day 14 of MV. The area under the curve for this model is 0.83. Calibration for the modified parsimonious model is provided in the table below (Goodness-of-fit statistic p=0.80). Dichotomized neutrophil to lymphocyte ratio on day 14 (N:L>15) improves the model slightly AUC=0.83, Goodness-of-fit p=0.61, though this variable was available for only 60% of the cohort. Conclusion: A modified clinical prediction model based on the previously validated ProVent-14 model is a simple method to accurately identify patients with ARDS from COVID-19 requiring PMV who are at high risk of in-hospital mortality. Further validation of model performance in a larger population and including long-term survival is warranted.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"11 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115476456","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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