Publications by authors named "Brian H Nathanson"

124 Publications

Descriptive Epidemiology and Outcomes of Hospitalizations With Complicated Urinary Tract Infections in the United States, 2018.

Open Forum Infect Dis 2022 Jan 10;9(1):ofab591. Epub 2022 Jan 10.

Washington Hospital Center, Washington, DC, USA.

Background: Hospitalizations with complicated urinary tract infection (cUTI) in the United States have increased. Though most often studied as a subset of cUTI, catheter-associated UTI (CAUTI) afflicts a different population of patients and carries outcomes distinct from non-CA cUTI (nCAcUTI). We examined the epidemiology and outcomes of hospitalizations in these groups.

Methods: We conducted a cross-sectional multicenter study within the 2018 National Inpatient Sample (NIS) database, a 20% stratified sample of discharges from US community hospitals, to explore characteristics and outcomes of patients discharged with a UTI diagnosis. We divided cUTI into mutually exclusive categories of nCAcUTI and CAUTI. We applied survey methods to develop national estimates.

Results: Among 2837385 discharges with a UTI code, 500400 (17.6%, 19.8% principal diagnosis [PD]) were nCAcUTI and 126120 (4.4%, 63.8% PD) were CAUTI. Though similar in age (CAUTI, 70.1 years; and nCAcUTI, 69.7 years), patients with nCAcUTI had lower comorbidity (mean Charlson, 4.3) than those with CAUTI (mean Charlson, 4.6). Median (interquartile range [IQR]) length of stay (LOS) was 5 (3-8) days in nCAcUTI and 5 (3-9) days in CAUTI. Overall median (IQR) hospital costs were similar in nCAcUTI ($9713 [$5923-$17423]) and CAUTI ($9711 [$5969-$17420]). Though low in both groups, hospital mortality was lower in nCAcUTI (2.8%) than in CAUTI (3.4%). Routine discharges home were higher in nCAcUTI (41.5%) than CAUTI (22.1%).

Conclusions: There are >626000 hospital admissions with a cUTI, comprising ~1.8% of all annual admissions in the United States; 4/5 are nCAcUTI. Because CAUTI is frequently the reason for admission, preventive efforts are needed beyond the acute care setting.
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http://dx.doi.org/10.1093/ofid/ofab591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8754377PMC
January 2022

Descriptive Epidemiology and Outcomes of Nonventilated Hospital-Acquired, Ventilated Hospital-Acquired, and Ventilator-Associated Bacterial Pneumonia in the United States, 2012-2019.

Crit Care Med 2021 Sep 16. Epub 2021 Sep 16.

Division of Health Services Research, EviMed Research Group, LLC, Goshen, MA. OptiStatim, LLC, Longmeadow, MA. Merck, Kenilworth, NJ. Department of Pulmonary and Critical Care Medicine, Washington Hospital Center, Washington, DC.

Objectives: Multiple randomized controlled trials exploring the outcomes of patients with ventilator-associated bacterial pneumonia and hospital-acquired bacterial pneumonia have noted that hospital-acquired bacterial pneumonia patients who require subsequent ventilated hospital-acquired bacterial pneumonia suffered higher mortality than either those who did not (nonventilated hospital-acquired bacterial pneumonia) or had ventilator-associated bacterial pneumonia. We examined the epidemiology and outcomes of all three conditions in a large U.S. database.

Design: Retrospective cohort.

Setting: Two hundred fifty-three acute-care hospitals, United States, contributing data (including microbiology) to Premier database, 2012-2019.

Patients: Patients with hospital-acquired bacterial pneumonia or ventilator-associated bacterial pneumonia identified based on a slightly modified previously published International Classification of Diseases, 9th Edition/International Classification of Diseases, 10th Edition-Clinical Modification algorithm.

Interventions: None.

Measurements And Main Results: Among 17,819 patients who met enrollment criteria, 26.5% had nonventilated hospital-acquired bacterial pneumonia, 25.6% vHAPB, and 47.9% ventilator-associated bacterial pneumonia. Ventilator-associated bacterial pneumonia predominated in the Northeastern United States and in large urban teaching hospitals. Patients with nonventilated hospital-acquired bacterial pneumonia were oldest (mean 66.7 ± 15.1 yr) and most likely White (76.9%), whereas those with ventilator-associated bacterial pneumonia were youngest (59.7 ± 16.6 yr) and least likely White (70.3%). Ventilated hospital-acquired bacterial pneumonia was associated with the highest comorbidity burden (mean Charlson score 4.1 ± 2.8) and ventilator-associated bacterial pneumonia with the lowest (3.2 ± 2.5). Similarly, hospital mortality was highest among patients with ventilated hospital-acquired bacterial pneumonia (29.2%) and lowest in nonventilated hospital-acquired bacterial pneumonia (11.7%), with ventilator-associated bacterial pneumonia in-between (21.3%). Among survivors, 24.5% of nonventilated hospital-acquired bacterial pneumonia required a rehospitalization within 30 days of discharge, compared with 22.5% among ventilated hospital-acquired bacterial pneumonia and 18.8% ventilator-associated bacterial pneumonia. Unadjusted hospital length of stay after infection onset was longest among ventilator-associated bacterial pneumonia and shortest among nonventilated hospital-acquired bacterial pneumonia patients. Median total hospital costs mirrored length of stay: ventilator-associated bacterial pneumonia $77,657, ventilated hospital-acquired bacterial pneumonia $62,464, and nonventilated hospital-acquired bacterial pneumonia $39,911.

Conclusions: Both hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia remain associated with significant mortality and cost in the United States. Our analyses confirm that of all three conditions, ventilated hospital-acquired bacterial pneumonia carries the highest risk of death. In contrast, ventilator-associated bacterial pneumonia remains most costly. Nonventilated hospital-acquired bacterial pneumonia survivors were most likely to require a readmission within 30 days of discharge.
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http://dx.doi.org/10.1097/CCM.0000000000005298DOI Listing
September 2021

Monochromic light reduces emergence delirium in children undergoing adenotonsillectomy; a double-blind randomized observational study.

BMC Anesthesiol 2021 09 8;21(1):217. Epub 2021 Sep 8.

Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX, USA.

Background: Emergence delirium (ED) is common in pediatric anesthesia. This dissociative state in which the patient is confused from their surroundings and flailing can be self-injurious and traumatic for parents. Treatment is by administration of sedatives which can prolong recovery. The aim of this study was to determine if exposure to monochromatic blue light (MBL) in the immediate phase of recovery could reduce the overall incidence of emergence delirium in children following general inhalational anesthesia.

Methods: This double blinded randomized controlled study included patients ages 2-6 undergoing adenotonsillectomy. Postoperatively, 104 patients were randomization (52 in each group) for exposure to sham blue or MBL during the first phase (initial 30 min) of recovery. The primary outcome was the incidence of emergence delirium during the first phase. We also examined Pediatric Anesthesia Emergence Delirium (PAED) scores throughout the first phase.

Results: Emergence Delirium was reported in 5.9% of MBL patients versus 33.3% in the sham group, p = 0.001. Using logistic regression adjusting for age, weight, gender, ASA classification and PAED scores provided an adjusted relative risk ratio of 0.18; 95% CI (0.06, 0.54); p = 0.001 for patients in the MBL group. 23.5% of MBL patients versus 52.9% of sham patients had either ED or PAED scores of 12 or more throughout the first phase of recovery, p = 0.002. This produced an adjusted relative risk of 0.46, 95% CI (0.29, 0.75), p = 0.001.

Conclusions: Monochromatic blue light represents a non-pharmacologic method to reduce the incidence of emergence delirium and PAED scores in children.

Trial Registration: #NCT03285243 registered on 15/09/2017.
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http://dx.doi.org/10.1186/s12871-021-01435-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424999PMC
September 2021

Annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest in the United States: A study for the CARES Surveillance Group.

Resuscitation 2021 10 10;167:111-117. Epub 2021 Aug 10.

Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, United States.

Objective: To estimate the annual and lifetime economic productivity loss due to adult out-of-hospital cardiac arrest (OHCA) in the United States (U.S.).

Methods: All adult (age ≥ 18 years) non-traumatic EMS-treated OHCA with complete data for age, sex, race, and survival outcomes from the CARES database for 2013-2018 were included. Annual and lifetime labor productivity values, based on age and gender, were obtained from previously published national economic data. Productivity losses for OHCA events were calculated by year in U.S. dollars. Productivity losses for survivors were assigned by cerebral performance category score (CPC): CPC 1 and 2 = 0% productivity loss; CPC 3-5 = 100% productivity loss. Sensitivity analyses were performed assigning CPC 2 varying productivity losses (0-100%) based on CPC score and discharge location. Lifetime productivity values assumed 1% annual growth and 3% discount rate and were adjusted for inflation based on 2016 values. Results were extrapolated to annual U.S. population estimates for the study period.

Results: A total of 338,492 (96.5%) cases met inclusion criteria. The mean annual and lifetime productivity losses per OHCA in 2018 were $48,224 and $638,947 respectively. The total annual economic productivity loss due to OHCA in the U.S. increased from $7.4B in 2013 to $11.3B in 2018. Lifetime economic productivity loss increased from $95.2B in 2013 to $150.2B in 2018. Sensitivity analyses yielded similar findings. Per annual death, OHCA ranked third ($10.2B) in annual economic productivity loss in the U.S. behind cancer ($22.9B) and heart disease ($20.3B) in 2018.

Conclusion: Adult non-traumatic OHCA events are associated with significant annual and lifetime economic productivity losses and should be the focus of public health resources to improve preventative measures and survival outcomes.
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http://dx.doi.org/10.1016/j.resuscitation.2021.07.034DOI Listing
October 2021

Hospital admission patterns of adult patients with complicated urinary tract infections who present to the hospital by disease acuity and comorbid conditions: How many admissions are potentially avoidable?

Am J Infect Control 2021 12 30;49(12):1528-1534. Epub 2021 May 30.

Spero Therapeutics, Cambridge, MA.

Background: Hospital admissions for complicated urinary tract infections (cUTI) in the United States are increasing but there are limited information on the acuity of patients who are admitted.

Objective: Describe hospitalization patterns among adult cUTI patients who present to the hospital with cUTI and to determine the proportion of admissions that were of low acuity.

Methods: A retrospective multi-center analysis using data from the Premier Healthcare Database (2013-2018) was performed.

Inclusion Criteria: age ≥ 18 years, cUTI diagnosis, positive blood or urine culture. Hospital admissions were stratified by presence of sepsis, systemic symptoms but no sepsis, and Charlson Comorbidity Index (CCI).

Results: 187,789 patients met the inclusion criteria. The mean (SD) age was 59.7 (21.9), 40.4% were male, 29.4% had sepsis, 16.7% had at least 1 systemic symptom (but no sepsis), and 53.9% had no sepsis or systemic symptoms. The median [inter-quartile range] CCI was 1 [0, 3]. Sixty-four percent of patients were admitted to hospital, and 18.9% of admissions occurred in patients with low acuity (no sepsis or systemic symptoms and a CCI ≤ 2). The median [IQR] LOS and costs for low acuity inpatients who were admitted were 3 [2, 5] days and $5,575 [$3,607, $9,133], respectively.

Conclusion: Nearly 1 in 5 cUTI hospital admissions occurred in patients with low acuity, and therefore may be avoidable.
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http://dx.doi.org/10.1016/j.ajic.2021.05.013DOI Listing
December 2021

An assessment of opioids on respiratory depression in children with and without obstructive sleep apnea.

Paediatr Anaesth 2021 Sep 16;31(9):977-984. Epub 2021 Jun 16.

Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.

Background: Obstructive sleep apnea is a risk factor for respiratory depression following opioid administration as well as opioid-induced hyperalgesia. Little is known on how obstructive sleep apnea status is associated with central ventilatory depression in pediatric surgical patients given a single dose of fentanyl.

Methods: This was a single-center, prospective trial in children undergoing surgery requiring intubation and opioid administration. Sixty patients between the ages of 2-8 years presenting for surgery at Texas Children's Hospital were recruited. Twenty non-obstructive sleep apnea controls and 30 patients with moderate to severe obstructive sleep apnea met inclusion criteria. Following induction of general anesthesia and establishment of steady-state ventilation, participants received 1 mcg/kg intravenous fentanyl. Ventilatory variables (tidal volume, respiratory rate, end-tidal CO , and minute ventilation) were assessed each minute for 10 min. The primary outcome was the extent of opioid-induced central ventilatory depression over time by obstructive sleep apnea status when compared with baseline values. Secondary aims assessed the impact of demographics and SpO nadir on ventilatory depression.

Results: We found no significant difference in percent decrease in respiratory rate (38.1% and 37.1%; p = .950), tidal volume (6.4% and 5.4%; p = .992), and minute ventilation (35.0 L/min and 35.0 L/min; p = .890) in control and obstructive sleep apnea patients, respectively. Both groups experienced similar percent increases in end-tidal CO (4.0% vs. 2.2%; p = .512) in control and obstructive sleep apnea patients, respectively.

Conclusions: In pediatric surgical patients, obstructive sleep apnea status was not associated with significant differences in central respiratory depression following a single dose of fentanyl (1 mcg/kg). These findings can help determine safe opioid doses in future pediatric obstructive sleep apneapatients.
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http://dx.doi.org/10.1111/pan.14228DOI Listing
September 2021

Assessing accuracy of estimated dry weight in dialysis patients post transplantation: the kidney knows best.

J Nephrol 2021 Dec 24;34(6):2093-2097. Epub 2021 May 24.

University of Massachusetts, Amherst, MA, 01106, USA.

Introduction: Estimated dry weight is used to guide fluid removal during outpatient hemodialysis sessions. Errors in estimated dry weight can result in intradialytic hypotension and interdialytic fluid overload. The goal of this study was to assess the accuracy of estimated dry weight by comparing it to the 2-week post-transplant weight in two cohorts of hemodialysis patients.

Methods: This observational, multi-center, retrospective cohort study included maintenance hemodialysis patients who underwent kidney transplantation at two medical centers in Massachusetts. The relationship between estimated dry weight pre-transplant and weight at week 2 post-transplant in patients with good allograft function (serum creatinine ≤ 1.5 mg/dL) was analyzed. Estimated dry weight was considered accurate if it was within ± 2% of the week 2 post-transplant weight.

Results: Fifty seven patients with good allograft function were identified: mean age 54 ± 14 years, 32 (58%) from deceased donors, 22 (38.6%) females. 38 were Caucasian (66.7%), 11 Hispanic (19.3%), 3 black (5.3%), and 5 others (8.8%). 2-week mean post transplantation serum creatinine was 1.2 ± 0.2 mg/dL. Mean (SD) estimated dry weight was 71.4 ± 15.9. Before transplantation, only 14 (24.6%) patients were within ± 2% of the 2-week post-transplant weight; 23 (40.3%) were above and 20 (35.1%) were below.

Conclusions: Our point of view, based on the assumption that the weight of patients with good allograft function at 2 weeks post-transplant approaches their accurate dry weight, is that a majority of maintenance hemodialysis patients (75.4%) are hypervolemic or hypovolemic prior to renal transplantation. This highlights the importance of finding novel tools to achieve euvolemia in patients undertaking dialysis. Timely feedback regarding achieved weight 2 weeks post-transplant to treating nephrologists and dialysis centers may be a starting point for assessing accuracy of dry weight.
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http://dx.doi.org/10.1007/s40620-021-01029-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8611116PMC
December 2021

The Association of Dexmedetomidine on Perioperative Opioid Consumption in Children Undergoing Adenotonsillectomy With and Without Obstructive Sleep Apnea.

Anesth Analg 2021 11;133(5):1260-1268

From the Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.

Background: Dexmedetomidine is used to reduce opioid consumption in pediatric anesthesia. However, there is conflicting evidence in pediatric adenotonsillectomy literature regarding the total perioperative opioid-sparing effects of dexmedetomidine. The aim of this study was to examine the association between dexmedetomidine and total perioperative opioid consumption in children undergoing adenotonsillectomy.

Methods: This was a retrospective cohort study of the children undergoing adenotonsillectomy surgery at Texas Children's Hospital between November 2017 and October 2018. Intraoperative dexmedetomidine was the exposure of interest. The primary outcome was total perioperative opioid consumption calculated as oral morphine equivalents (OME). Secondary outcomes of interest included opioid consumption and pain scores based on presence and absence of obstructive sleep apnea (OSA) and postanesthesia care unit (PACU) duration. We used multivariable linear regression to estimate the association of dexmedetomidine on the outcomes.

Results: A total of 941 patients met inclusion criteria, 697 (74.1%) received intraoperative dexmedetomidine. For every 0.1 µg/kg increase in intraoperative dexmedetomidine, the total perioperative OME (mg/kg) decreases by 0.021 mg/kg (95% CI, -0.027 to -0.015; P < .001). Pain scores did not significantly vary by OSA status. PACU duration increased by 1.14 minutes (95% CI, 0.30-1.99; P = .008) for each 0.1 µg/kg of intraoperative dexmedetomidine.

Conclusions: Dexmedetomidine is associated with an overall perioperative opioid-sparing effect in children undergoing adenotonsillectomy and a small but statistically significant increase in PACU duration. Additionally, children with OSA did not have reduced perioperative opioid consumption.
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http://dx.doi.org/10.1213/ANE.0000000000005410DOI Listing
November 2021

Multiple antimicrobial resistance and outcomes among hospitalized patients with complicated urinary tract infections in the US, 2013-2018: a retrospective cohort study.

BMC Infect Dis 2021 Feb 8;21(1):159. Epub 2021 Feb 8.

Washington Hospital Center, 110 Irving Street NW, Washington, DC, 20010, USA.

Background: Complicated urinary tract infection (cUTI) is common among hospitalized patients. Though carbapenems are an effective treatment in the face of rising resistance, overuse drives carbapenem resistance (CR). We hypothesized that resistance to routinely used antimicrobials is common, and, despite frequent use of carbapenems, associated with an increased risk of inappropriate empiric treatment (IET), which in turn worsens clinical outcomes.

Methods: We conducted a retrospective cohort study of patients hospitalized with a culture-positive non-CR cUTI. Triple resistance (TR) was defined as resistance to > 3 of the following: 3rd generation cephalosporins, fluoroquinolones, trimethoprim-sulfamethoxazole, fosfomycin, and nitrofurantoin. Multivariable models quantified the impact of TR and inappropriate empiric therapy (IET) on mortality, hospital LOS, and costs.

Results: Among 23,331 patients with cUTI, 3040 (13.0%) had a TR pathogen. Compared to patients with non-TR, those with TR were more likely male (57.6% vs. 47.7%, p < 0.001), black (17.9% vs. 13.6%, p < 0.001), and in the South (46.3% vs. 41.5%, p < 0.001). Patients with TR had higher chronic (median [IQR] Charlson score 3 [2, 4] vs. 2 [1, 4], p < 0.001) and acute (mechanical ventilation 7.0% vs. 5.0%, p < 0.001; ICU admission 22.3% vs. 18.6%, p < 0.001) disease burden. Despite greater prevalence of empiric carbapenem exposure (43.3% vs. 16.2%, p < 0.001), patient with TR were also more likely to receive IET (19.6% vs. 5.4%, p < 0.001) than those with non-TR. Although mortality was similar between groups, TR added 0.38 (95% CI 0.18, 0.49) days to LOS, and $754 (95% CI $406, $1103) to hospital costs. Both TR and IET impacted the outcomes among cUTI patients whose UTI was not catheter-associated (CAUTI), but had no effect on outcomes in CAUTI.

Conclusions: TR occurs in 1 in 8 patients hospitalized with cUTI. It is associated with an increase in the risk of IET exposure, as well as a modest attributable prolongation of LOS and increase in total costs, particularly in the setting of non-CAUTI.
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http://dx.doi.org/10.1186/s12879-021-05842-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869420PMC
February 2021

A clinical investigation into the benefits of using charge codes in perioperative and critical care epidemiology: A retrospective cohort database study.

Int J Crit Illn Inj Sci 2020 Sep 16;10(Suppl 1):39-42. Epub 2020 Sep 16.

Department of Anesthesiology, Duke University Medical Center, Durham, USA.

Context: Epidemiologic studies in critical care routinely rely on the codes listed in International Classification of Diseases (ICD) manuals which are primarily intended for reimbursement of claims to payers. Standardized billing codes may minimize the measurement error when used in conjunction with ICD codes.

Aims: The aim was to examine the impact of using charge codes in addition to ICD codes for ascertaining two common procedures in surgical intensive care unit (ICU) settings: hemodialysis (HD) and red blood cell (RBC) transfusions.

Settings And Design: This was a retrospective cohort study of Premier Inc. Database.

Subjects And Methods: Elective surgical patients aged >18 years treated in the ICU postoperatively were included in this study. This includes the ascertainment of HD and RBC transfusions in the population using a standard "ICD code" versus an "either ICD code or charge code" approach.

Statistical Analysis Used: Descriptive analysis using -tests, Chi-square tests as appropriate was used.

Results: A total of 40,357 patients were identified as having undergone elective surgery, followed by admission to an ICU across 520 US hospitals. The use of "ICD codes only" uniformly underestimated rates of HD or RBC transfusions when compared to "Charge Codes only" and "ICD Codes or Charge Codes" (% increase of 15.4%-45.6% and 50.8%-93.1%, respectively). Differences varied with specific surgical populations studied. Patients identified using the "ICD code" approach had more comorbidities, were more likely to be female, and more likely to be Medicare beneficiaries.

Conclusions: Epidemiologic studies in critical care should consider using multiple independent data sources to improve ascertainment of common critical care interventions.
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http://dx.doi.org/10.4103/IJCIIS.IJCIIS_47_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759074PMC
September 2020

Trend analysis of disability-adjusted life years following adult out-of-hospital cardiac arrest in the United States: A study from the CARES Surveillance Group.

Resuscitation 2021 06 29;163:124-129. Epub 2020 Dec 29.

Department of Emergency Medicine, University of Alabama School of Medicine, OHB 251, 619 19th Street, Birmingham, AL, United States; Department of Surgery, Division of Acute Care Surgery, University of Alabama School of Medicine, Birmingham, AL, United States; Center for Injury Science, University of Alabama School of Medicine, Birmingham, AL, United States.

Aim: To estimate and trend disability-adjusted life years (DALY) following adult out-of-hospital cardiac arrest (OHCA) over time, and to compare OHCA DALY to other leading causes of death and disability in the U.S.

Methods: DALY were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). Adult non-traumatic emergency medical services-treated OHCA from the Cardiac Arrest Registry to Enhance Survival (CARES) database for 2013-2018 were used to estimate YLL. Cerebral performance category score disability weights were used to estimate YLD. The calculated DALY for the study population was extrapolated to a national level to estimate total U.S. DALY. Data were reported as DALY total and rate. Data were compared to the top 10 causes of DALY in the U.S.

Results: 337,991 OHCA met study inclusion criteria. Total U.S. OHCA DALY increased from 3,005,308 in 2013 to 4,326,745 in 2018. The DALY rate increased from 950.9 per 100,000 individuals to 1322.4 per 100,000 individuals. OHCA DALY ranked fifth in the U.S. behind ischemic heart disease (2470), drug use disorders (1703), chronic obstructive pulmonary disease (1449), and back pain (1336). OHCA represented the largest percent increase in DALY rate (40.3%) over the study period.

Conclusion: Adult non-traumatic OHCA is a leading cause of DALY in the U.S. and the burden of disease due to OHCA has increased rapidly over time. These findings are likely due to more precise national OHCA surveillance, and suggest that the public health impact of OHCA is larger than previously described.
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http://dx.doi.org/10.1016/j.resuscitation.2020.10.048DOI Listing
June 2021

The association between scene time interval and neurologic outcome following adult bystander witnessed out-of-hospital cardiac arrest.

Am J Emerg Med 2021 08 2;46:628-633. Epub 2020 Dec 2.

Cardiac Arrest Registry to Enhance Survival (CARES) Surveillance Group, Atlanta, GA, United States of America.

Objective: To analyze the association between Emergency Medical Services (EMS) scene time interval (STI) and survival with functional neurologic recovery following adult out-of-hospital cardiac arrest (OHCA).

Methods: A retrospective analysis of prospectively collected data from the national Cardiac Arrest Registry to Enhance Survival from January 2013 to December 2018. All adult non-traumatic, EMS-treated, bystander-witnessed OHCA with complete data were included. Patients with STI times >60 min, defined as the time from EMS arrival at the patient's side to the time the transport vehicle left the scene, unwitnessed OHCA, nursing home events, EMS-witnessed OHCA, or patients with termination of resuscitation in the field were excluded. The primary outcome was survival with functional recovery (Cerebral Performance Category [CPC] = 1 or 2). Multivariable logistic regression was used to quantify the association of STI with the primary.

Outcome:

Results: 67,237 patients met inclusion criteria with 12,098 (18.0%) surviving with functional recovery. Mean STI (SD) for survivors with CPC 1 or 2 was 19 (8.4) and 22.8 (10.5) for those with poor outcomes (death or CPC 3-4; p < 0.001). For every 1-min increase in STI, the adjusted odds of a poor outcome increased by 3.5%; odds ratio = 1.035; 95% CI (1.027, 1.044); p < 0.001. Restricted cubic spline analysis showed increased risk of poor outcome after approximately 20 min.

Conclusion: Longer STI times are strongly associated with poor neurologic outcome in bystander-witnessed OHCA patients. After a STI duration of approximately 20 min, the associated risk of a poor neurologic outcome increased more rapidly.
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http://dx.doi.org/10.1016/j.ajem.2020.11.059DOI Listing
August 2021

A Minority of Patients on Mechanical Ventilation Consume Disproportionate Resources: A Retrospective Cohort Study.

Chest 2021 05 28;159(5):1854-1866. Epub 2020 Nov 28.

Washington Hospital Center, Washington, DC.

Background: The Pareto principle states that the majority of any effect comes from a minority of the causes. This property is widely used in quality improvement science.

Research Question: Among patients requiring mechanical ventilation (MV), are there subgroups according to MV duration that may serve as potential nodes for high-value interventions aimed at reducing costs without compromising quality?

Study Design And Methods: This multicenter retrospective cohort study included approximately 780 hospitals in the Premier Research Database (2014-2018). Patients receiving MV were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, codes. They were then divided into quintiles according to MV duration; their hospital costs, post-MV onset length of stay (LOS), ICU LOS, and cumulative post-MV onset hospital days per quintile were compared.

Results: A total of 691,961 patients were included in the analysis. Median [interquartile range] duration of MV in days by quintile was as follows: quintile 1 (Q1), 1 [1, 1]; Q2, 2 [2, 2]; Q3, 3 [3, 3]; Q4, 6 [6, 7]; and Q5, 13 [10, 19]. Median [interquartile range] post-MV onset LOS (Q1, 2 [0, 5]; Q5, 17 [12, 26]) and hospital costs (Q1, $15,671 [$9,180, $27,901]; Q5, $70,133 [$47,136, $108,032]) rose from Q1 through Q5. Patients in Q5 consumed 47.7% of all post-MV initiation hospital days among all patients requiring MV, and the mean per-patient hospital costs in Q5 exceeded the sum of costs incurred by Q1 to Q3. Adjusted marginal mean (95% CI) hospital costs rose exponentially from Q1 through Q5: Q2 vs Q1, $3,976 ($3,354, $4,598); Q3 vs Q2, $5,532 ($5,103, $5,961); Q4 vs Q3, $11,705 ($11,071, $12,339); and Q5 vs Q4, $26,416 ($25,215, $27,616).

Interpretation: Patients undergoing MV in the highest quintiles according to duration of MV consume a disproportionate amount of resources, as evidenced by MV duration, hospital LOS, and costs, making them a potential target for streamlining MV care.
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http://dx.doi.org/10.1016/j.chest.2020.11.022DOI Listing
May 2021

Symptomatology and racial disparities among children undergoing universal preoperative COVID-19 screening at three US children's hospitals: Early pandemic through resurgence.

Paediatr Anaesth 2021 03 2;31(3):368-371. Epub 2020 Dec 2.

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.

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http://dx.doi.org/10.1111/pan.14074DOI Listing
March 2021

Stress Biomarkers Do Not Correlate With Risk Factors for Kidney Injury After Cardiac Surgery.

Ann Thorac Surg 2021 08 1;112(2):532-538. Epub 2020 Nov 1.

Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.

Background: The urinary cell cycle arrest biomarkers (UBs) insulin-like growth factor-binding protein-7 and tissue inhibitor of metalloproteinases-2 provide early detection of kidney stress, and elevations may predict cardiac surgery-associated acute kidney injury (CS-AKI). We sought to determine whether known clinical risk factors for CS-AKI correlated with increased UB values.

Methods: UBs were measured over a 12-month period the morning after on-pump cardiac surgery. Patients with a preoperative serum creatinine level greater than 2.0 mg/dL or patients undergoing dialysis were excluded. Known clinical AKI risk factors in patients with elevated UB (>0.3 (ng/mL)/1000), that is known to correlate with kidney stress, were compared with patients with low scores (≤0.3 (ng/mL)/1000) by using logistic regression; the analysis was repeated with UB as a continuous variable.

Results: A total of 412 patients met inclusion criteria. Unadjusted results demonstrated a clinically similar CS-AKI risk profile in patients with either elevated or low UB values. The Pearson correlation between preoperative estimated glomerular filtration rate and UB was low (r = 0.16). Clinical risk factors for CS-AKI were not associated with elevated UB values in the logistic regression model, thus producing an area under the receiver operating characteristic curve of 0.63. Linear regression analysis also found few associations between CS-AKI clinical risk factors and UB when measured as a continuous variable, (R) = 0.15.

Conclusions: Traditional CS-AKI clinical risk factors do not differ between patients with normal or elevated UB values. This UB test may identify patients at increased risk for AKI who otherwise would appear to be at low risk by traditional metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.025DOI Listing
August 2021

Characteristics, Hospital Course, and Outcomes of Patients Requiring Prolonged Acute Versus Short-Term Mechanical Ventilation in the United States, 2014-2018.

Crit Care Med 2020 11;48(11):1587-1594

Division of Pulmonary and Critical Care, Department of Medicine, Washington Hospital Center, Washington, DC.

Objectives: Most patients requiring mechanical ventilation only require it for a short term (< 4 d of mechanical ventilation). Those undergoing prolonged acute mechanical ventilation (≥ 4 d mechanical ventilation) represent a select cohort who face significant morbidity, mortality, and resource utilization. Using administrative codes, we identified prolonged acute mechanical ventilation and short-term mechanical ventilation patients and compared their baseline characteristics, hospital events, and hospital outcomes.

Design: Retrospective cohort.

Setting: Seven-hundred eighty-seven acute care hospitals, United States, contributing data to Premier database, 2014-2018.

Patients: Patients on mechanical ventilation.

Interventions: None.

Measurements And Main Results: Among 691,961 patients meeting the enrollment criteria, 266,374 (38.5%) received prolonged acute mechanical ventilation. At baseline, patients on prolonged acute mechanical ventilation were similar to short-term mechanical ventilation in age (years: 62.0 ± 15.8 prolonged acute mechanical ventilation vs 61.7 ± 17.2 short-term mechanical ventilation), gender (males: 55.6% prolonged acute mechanical ventilation vs 53.9% short-term mechanical ventilation), and race (white: 69.1% prolonged acute mechanical ventilation vs 72.4% short-term mechanical ventilation). The prolonged acute mechanical ventilation group had a higher comorbidity burden than short-term mechanical ventilation (mean Charlson Score 3.5 ± 2.7 vs 3.1 ± 2.7). The prevalence of vasopressors (50.3% vs 36.9%), dialysis (19.4% vs 10.3%), severe sepsis (20.3% vs 10.3%), and septic shock (33.5% vs 15.9%) was higher in prolonged acute mechanical ventilation than short-term mechanical ventilation. Hospital mortality (29.75% vs 21.1%), combined mortality, or discharge to hospice (37.2% vs 25.3%), extubation failure (12.3% vs 6.1%), tracheostomy (21.6% vs 4.5%), development of Clostridium difficile (4.5% vs 1.7%), and incidence density of ventilator-associated pneumonia (2.4/1,000 patient-days vs 0.6/1,000 patient-days) were all higher in the setting of prolonged acute mechanical ventilation than short-term mechanical ventilation. Median (interquartile range) post mechanical ventilation onset length of stay (13 [8-20] vs 4 d [1-8 d]) and hospital costs ($55,014 [$35,051-$88,007] vs $20,120 [$12,071-$34,915] were higher in prolonged acute mechanical ventilation than short-term mechanical ventilation.

Conclusions: Over one-third of all hospitalized patients on mechanical ventilation require it for greater than or equal to 4 days. Prolonged acute mechanical ventilation patients exhibit a higher burden of both chronic and acute illness and experience higher rates than those on short-term mechanical ventilation of hospital-acquired complications and worse clinical and economic outcomes.
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http://dx.doi.org/10.1097/CCM.0000000000004525DOI Listing
November 2020

Bleeding After Musculoskeletal Surgery in Hospitals That Switched From Hydroxyethyl Starch to Albumin Following a Food and Drug Administration Warning.

Anesth Analg 2020 10;131(4):1193-1200

From the Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Background: While US Food and Drug Administration (FDA) black box warnings are common, their impact on perioperative outcomes is unclear. Hydroxyethyl starch (HES) is associated with increased bleeding and kidney injury in patients with sepsis, leading to an FDA black box warning in 2013. Among patients undergoing musculoskeletal surgery in a subset of hospitals where colloid use changed from HES to albumin following the FDA warning, we examined the rate of major perioperative bleeding post- versus pre-FDA warning.

Methods: The authors of this article used a retrospective, quasi-experimental, repeated cross-sectional, interrupted time series study of patients undergoing musculoskeletal surgery in hospitals within the Premier Healthcare Database, in the year before and year after the 2013 FDA black box warning. We examined patients in 23 "switcher" hospitals (where the percentage of colloid recipients receiving HES exceeded 50% before the FDA warning and decreased by at least 25% in absolute terms after the FDA warning) and patients in 279 "nonswitcher" hospitals. Among patients having surgery in "switcher" and "nonswitcher" hospitals, we determined monthly rates of major perioperative bleeding during the 12 months after the FDA warning, compared to 12 months before the FDA warning. Among patients who received surgery in "switcher" hospitals, we conducted a propensity-weighted segmented regression analysis assessing differences-in-differences (DID), using patients in "nonswitcher" hospitals as a control group.

Results: Among 3078 patients treated at "switcher" hospitals (1892 patients treated pre-FDA warning versus 1186 patients treated post-FDA warning), demographic and clinical characteristics were well-balanced. Two hundred fifty-one (13.3%) received albumin pre-FDA warning, and 900 (75.9%) received albumin post-FDA warning. Among patients undergoing surgery in "switcher" hospitals during the pre-FDA warning period, 282 of 1892 (14.9%) experienced major bleeding during the hospitalization, compared to 149 of 1186 (12.6%) following the warning. In segmented regression, the adjusted ratio of slopes for major perioperative bleeding post- versus pre-FDA warning was 0.98 (95% confidence interval [CI], 0.93-1.04). In the DID estimate using "nonswitcher" hospitals as a control group, the ratio of ratios was 0.93 (95% CI, 0.46-1.86), indicating no significant difference.

Conclusions: We identified a subset of hospitals where colloid use for musculoskeletal surgery changed following a 2013 FDA black box warning regarding HES use in sepsis. Among patients undergoing musculoskeletal surgery at these "switcher" hospitals, there was no significant decrease in the rate of major perioperative bleeding following the warning, possibly due to incomplete practice change. Evaluation of the impact of systemic changes in health care may contribute to the understanding of patient outcomes in perioperative medicine.
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http://dx.doi.org/10.1213/ANE.0000000000004942DOI Listing
October 2020

Antimicrobial Susceptibility and Cross-Resistance Patterns among Common Complicated Urinary Tract Infections in U.S. Hospitals, 2013 to 2018.

Antimicrob Agents Chemother 2020 07 22;64(8). Epub 2020 Jul 22.

Washington Hospital Center, Washington, DC, USA.

In the face of increasing rates of antimicrobial resistance in complicated urinary tract infections (cUTIs), clinicians need to understand cross-resistance patterns among commonly encountered pathogens. We performed a multicenter, retrospective cohort study in the Premier database of approximately 180 hospitals, from 2013 to 2018. Using an ICD-9/10-based algorithm, we identified all adult patients hospitalized with cUTIs and included those with a positive blood or urine culture. We examined the microbiology and susceptibilities to common cUTI antimicrobials (3rd-generation cephalosporin [C3], fluoroquinolones [FQ], trimethoprim-sulfamethoxazole [TMP/SMZ], fosfomycin [FFM], and nitrofurantoin [NFT]) singly and in groups of two. Among 28,057 organisms from 23,331 patients, the 3 most common pathogens were (41.0%; C3, 15.1%), (12.1%; C3, 13.2%), and (11.0%; C3, 12.0%). was most frequently resistant to FQ (43.5%) and least to NFT (6.7%). was most frequently resistant to NFT (60.8%) and least to FFM (0.1%). was most frequently resistant to FQ (34.4%) and least to TMP/SMZ (4.2%). Of the C3 isolates, 87.1% were also FQ, 63.7% were TMP/SMZ, and 13.3% were NFT C3 isolates had a 76.5% chance of being FQ, 78.1% were TMP/SMZ, and 77.6% were NFT C3 coexisted with FQ in 47.3%, TMP/SMZ in 18.9%, and NFT in 28.7%. Among the most common pathogens isolated from hospitalized patients with cUTIs, the rates of single resistance to common treatments and of cross-resistance to these regimens are substantial. Knowing the patterns of cross-resistance may help clinicians tailor empirical therapy more precisely.
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http://dx.doi.org/10.1128/AAC.00346-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7526848PMC
July 2020

Abnormal shock index exposure and clinical outcomes among critically ill patients: A retrospective cohort analysis.

J Crit Care 2020 06 21;57:5-12. Epub 2020 Jan 21.

Department of Critical Care Medicine, Orlando Regional Medical Center, 86 W Underwood Suite 101, Orlando, FL 32806, USA.

Purpose: To assess the predictive value of a single abnormal shock index reading (SI ≥0.9; heart rate/systolic blood pressure [SBP]) for mortality, and association between cumulative abnormal SI exposure and mortality/morbidity.

Materials And Methods: Cohort comprised of adult patients with an intensive care unit (ICU) stay ≥24-h (years 2010-2018). SI ≥0.9 exposure was evaluated via cumulative minutes or time-weighted average; SBP ≤100-mmHg was analyzed. Outcomes were in-hospital mortality, acute kidney injury (AKI), and myocardial injury.

Results: 18,197 patients from 82 hospitals were analyzed. Any single SI ≥0.9 within the ICU predicted mortality with 90.8% sensitivity and 36.8% specificity. Every 0.1-unit increase in maximum-SI during the first 24-h increased the odds of mortality by 4.8% [95%CI; 2.6-7.0%; p < .001]. Every 4-h exposure to SI ≥0.9 increased the odds of death by 5.8% [95%CI; 4.6-7.0%; p < .001], AKI by 4.3% [95%CI; 3.7-4.9%; p < .001] and myocardial injury by 2.1% [95%CI; 1.2-3.1%; p < .001]. ≥2-h exposure to SBP ≤100-mmHg was significantly associated with mortality.

Conclusions: A single SI reading ≥0.9 is a poor predictor of mortality; cumulative SI exposure is associated with greater risk of mortality/morbidity. The associations with in-hospital mortality were comparable for SI ≥0.9 or SBP ≤100-mmHg exposure. Dynamic interactions between hemodynamic variables need further evaluation among critically ill patients.
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http://dx.doi.org/10.1016/j.jcrc.2020.01.024DOI Listing
June 2020

Carbapenem Treatment and Outcomes Among Patients With Culture-Positive Complicated Intra-abdominal Infections in US Hospitals: A Retrospective Cohort Study.

Open Forum Infect Dis 2019 Dec 25;6(12):ofz504. Epub 2019 Nov 25.

Washington Hospital Center, Washington, DC, USA.

Background: Carbapenems are a frequent firstline therapy in complicated intra-abdominal infections (cIAIs). We examined the microbiology, epidemiology, and outcomes among patients hospitalized in the United States with culture-positive cIAIs in the context of their exposure to empiric carbapenem treatment (ECT).

Methods: We performed a multicenter retrospective cohort study of Premier database of ~180 hospitals, 2013-2017. Using an International Classification of Diseases (ICD)-9/10-based algorithm, we identified all culture-positive adult patients hospitalized with cIAI and examined their microbiology, epidemiology, and outcomes.

Results: Among 4453 patients with cIAIs, 3771 (84.7%) had a gram-negative (GN) and 1782 (40.0%) a gram-positive organism; 1185 (26.6%) received ECT. Compared with those on non-ECT, patients on ECT were less frequently admitted from home (82.5% vs 86.0%) or emergently (76.0% vs 81.4%; < .05 for each); were less frequent, whereas and spp. were more prevalent and resistance to third-generation cephalosporins (C3R; 10.1% vs 5.1%; < .001) and carbapenems (CR; 3.6% vs 1.2%; < .001) was more common. In adjusted analyses, ECT was associated with no rise in mortality, shorter postinfection length of stay (-0.59 days; 95% confidence interval [CI], -1.15 to -0.03), but higher postinfection costs ($3844; 95% CI, $1921 to $5767) and risk of (odds ratio, 2.15; 95% CI, 1.02 to 4.50).

Conclusions: Among patients hospitalized with cIAI, the majority were gram-negative. Despite a 10% prevalence of C3R, fully one-quarter of all empiric regimens contained a carbapenem. ECT was a marker for slightly lower postinfection length of stay, but higher costs and risk of hospital complications.
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http://dx.doi.org/10.1093/ofid/ofz504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911695PMC
December 2019

Use of a Transfusion Checklist by Student Nurses to Improve Patient Safety.

J Nurses Prof Dev 2020 Jan/Feb;36(1):33-38

Sue S. Scott, PhD, RN, is Assistant Professor in Nursing, Westfield State University, Massachusetts. Elizabeth A. Henneman, PhD, RN, is Professor, College or Nursing, University of Massachusetts, Amherst. Brian H. Nathanson, PhD, is Chief Executive Officer, OptiStaTim, LLC, Longmeadow, Massachusetts. Chester Andrzejewski Jr., MD, PhD, is Medical Director Baystate Health, Transfusion Medicine Services, Springfield, Massachusetts. Megan Gonzalez, MSN, RN, is Simulation Lab Coordinator, Westfield State University, Massachusetts. Rachel Walker, PhD, RN, is Assistant Professor in Nursing, University of Massachusetts, Amherst. Vanessa I. Martinez, MS, is with the Department of Mechanical and Industrial Engineering, University of Massachusetts, Amherst.

Better education around the recognition of transfusion-associated adverse events is warranted. It is unknown if checklist use improves recognition by student nurses. This study examined whether using a checklist could improve transfusion-associated adverse event recognition behaviors. There was an increased frequency of transfusion-associated adverse event management behaviors in the checklist group, but overall recognition was no greater than other groups. A transfusion-associated adverse event checklist may increase patient safety by promoting identification behaviors.
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http://dx.doi.org/10.1097/NND.0000000000000600DOI Listing
September 2020

Using urinary biomarkers to reduce acute kidney injury following cardiac surgery.

J Thorac Cardiovasc Surg 2020 11 17;160(5):1235-1246.e2. Epub 2019 Oct 17.

Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Mass.

Background: Prediction of acute kidney injury (AKI) following cardiac surgery is unreliable through the use of serum creatinine or urinary output alone. Cell cycle arrest urinary biomarkers insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP2) provide early detection of kidney stress and possibly AKI. We sought to determine whether therapeutic interventions driven by elevated urinary biomarkers (UB) reduces post-cardiac surgery stage 2/3 AKI.

Methods: A quality improvement initiative based on UB was undertaken in all adult on-pump cardiac surgical patients with a preoperative serum creatinine level ≤2.0 mg/dL. A UB score the morning after cardiac surgery that was considered positive for kidney stress (≥0.3 [ng/mL]/1000) triggered activation of a multidisciplinary acute kidney response team (AKRT) with implementation of a predefined staged protocol, including targeted goal-directed fluid management, liberalized transfusion thresholds, continued invasive hemodynamic monitoring and its optimization in the intensive care unit, and avoidance of nephrotoxins. We compared the incidence of stage 2/3 AKI before (pre-UB) versus after (post-UB) implementation of the Kidney Disease: Improving Global Outcomes quality improvement initiative. Standardized, protocolized, evidence-based care pathways were used pre-UB.

Results: The incidence of stage 2/3 AKI was compared in 435 pre-UB patients and 412 post-UB patients. Fifty-five percent of the post-UB patients had a moderate or high UB score (≥0.3 [ng/mL]/1000). Ten patients (2.30%) had stage 2/3 AKI pre-UB, compared with 1 patient (0.24%) post-UB, a relative reduction of 89% (P = .01). The total and postoperative lengths of stay, cost, mortality, and readmissions were similar in the 2 groups. The negative predictive value for AKI of UB <0.3 [ng/mL]/1000 was 100%.

Conclusions: The routine measurement of UB and subsequent activation of an AKRT are useful post-cardiac surgery therapeutic adjuncts. They are associated with early detection of kidney stress, allowing for targeted proactive intervention, and a significant decrease in postoperative stage 2/3 AKI without increases in cost or length of stay.
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http://dx.doi.org/10.1016/j.jtcvs.2019.10.034DOI Listing
November 2020

Pressure Injuries at Intensive Care Unit Admission as a Prognostic Indicator of Patient Outcomes.

Crit Care Nurse 2019 Jun;39(3):44-50

William T. McGee is an intensivist in the Division of Critical Care, Department of Medicine, Baystate Medical Center, Springfield, Massachusetts; Brian H. Nathanson is Chief Executive Officer of OptiStatim, LLC, Longmeadow, Massachusetts; Elizabeth Lederman is APACHE data coordinator, Baystate Medical Center, Springfield, Massachusetts; Thomas L. Higgins is Chief Medical Officer at The Center for Case Management, Natick, Massachusetts, and Professor of Medicine at the University of Massachusetts School of Medicine-Baystate, Springfield, Massachusetts.

Background: Pressure injuries, also known as pressure ulcers, are a serious complication of immobility. Patients should be thoroughly examined for pressure injuries when admitted to the intensive care unit to optimize treatment. Whether community-acquired pressure injuries correlate with poor hospital outcomes among critically ill patients is understudied.

Objectives: To determine whether pressure injuries present upon admission to the intensive care unit can serve as a predictive marker for longer hospitalization and increased mortality.

Methods: This study retrospectively analyzed admissions of adult patients to a 24-bed medical-surgical intensive care unit in a large level I trauma center in the northeast United States from 2010 to 2012. The association of pressure injuries with mortality and length of stay was assessed, using multivariable logistic regression and generalized linear models, adjusted for age, comorbidities, Acute Physiology and Chronic Health Evaluation III score, and other patient characteristics.

Results: Among 2723 patients, 180 (6.6%) had a pressure injury at admission. Patients with a pressure injury had longer mean unadjusted stay (15.6 vs 10.5 days; < .001) and higher in-hospital mortality rate (32.2% vs 18.3%; < .001) than did patients without a pressure injury at admission. After multivariable adjustment, pressure injuries were associated with a mean increase in length of stay of 3.1 days (95% CI 1.5-4.7; < .001). Pressure injuries were not associated with mortality after adjusting for the Acute Physiology and Chronic Health Evaluation III score, but they may serve as a marker for increased risk of mortality if an Acute Physiology and Chronic Health Evaluation III score is unavailable.

Conclusion: Pressure injuries present at admission to the intensive care unit are an objective, easy-to-identify finding associated with longer stays. Pressure injuries might have a modest association with higher risk of mortality.
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http://dx.doi.org/10.4037/ccn2019530DOI Listing
June 2019

Disability-Adjusted Life Years Following Adult Out-of-Hospital Cardiac Arrest in the United States.

Circ Cardiovasc Qual Outcomes 2019 03;12(3):e004677

Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield (T.J.M.).

Background Disability-adjusted life years (DALY) are a common public health metric used to consistently estimate and compare health loss because of both fatal and nonfatal disease burden. The annual number of DALY because of adult out-of-hospital cardiac arrest (OHCA) in the United States is unknown. Our objective was to estimate the DALY after adult nontraumatic, emergency medical services-treated OHCA, and to compare OHCA DALY to other leading causes of death and disability in the US. Methods and Results The DALY were calculated as the sum of years of life lost and years lived with disability. The years of life lost were calculated using all adult nontraumatic emergency medical services-treated OHCA with complete data from the national Cardiac Arrest Registry to Enhance Survival database for 2016, and actuarial data for remaining life expectancy at the age of death. Cerebral performance category scores from the Cardiac Arrest Registry to Enhance Survival database and previously established disability weights were used to estimate years lived with disability. The cohort's calculated DALY were extrapolated to a national level to estimate total US DALY. Data were reported as total, mean, and DALY per 100 000 individuals. A total of 59 752 OHCA met study inclusion criteria. The DALY for the study population were 1 194 993 (years of life lost, 1 194 069; years lived with disability, 924) in 2016. The estimated total DALY following adult nontraumatic emergency medical services-treated OHCA in the US were 4 354  192 (years of life lost, 4 350  825; years lived with disability, 3365) for the index year 2016. The rate of OHCA DALY were 1347 per 100 000 population, which ranked third in the US behind ischemic heart disease (2447) and low back and neck pain (1565). Sensitivity analyses yielded similar findings. Conclusions Adult nontraumatic OHCA is a leading cause of annual DALY in the US and should be a focus of public health policy and resources.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.118.004677DOI Listing
March 2019

A Novel Algorithm to Analyze Epidemiology and Outcomes of Carbapenem Resistance Among Patients With Hospital-Acquired and Ventilator-Associated Pneumonia: A Retrospective Cohort Study.

Chest 2019 06 24;155(6):1119-1130. Epub 2019 Jan 24.

Washington Hospital Center, Washington, DC.

Background: Carbapenem resistance is a growing concern. Applying a novel algorithm, we examined epidemiology and outcomes of carbapenem resistance among gram-negative pathogens in hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP).

Methods: In a retrospective cohort design within the Premier Research database (2009-2016), all hospitalized adult patients with a gram-negative organism in a respiratory or blood culture specimen who fit criteria for HAP/VAP based on International Classification of Diseases, Ninth Revision, Clinical Modification, codes were included in the study.

Results: Among 8,969 patients with HAP/VAP, 1,059 isolates (11.8%) were carbapenem-resistant (CR) organisms. Patients with CR organisms were more likely female (41.4% vs 33.2%; P < .001) and medical admissions (33.8% vs 27.4%, P < .001) than those with carbapenem-susceptible (CS) organisms. Patients with carbapenem resistance had higher comorbidity burden than those with carbapenem susceptibility (median [interquartile range] Charlson Comorbidity Index score, 3 [1-4] vs 2 [1-4]; P < .001). Pseudomonas aeruginosa was the most common gram-negative pathogen overall (24.9%) and among CS organisms (23.5%), and was second to Stenotrophomonas maltophilia (44.0%) among CR organisms (35.3%). Acinetobacter baumannii accounted for 11.8% of CR organisms and 2.5% of CS organisms (P < .001). Patients with carbapenem resistance were more likely than those with carbapenem susceptibility to receive inappropriate empiric therapy (25.8% vs 10.0%; P < .001). Carbapenem resistance did not affect adjusted mortality (22.9% CR vs 21.6% CS) or postinfection length of stay (except among survivors of VAP), but it was associated with excess costs ($8,921; 95% CI, 3,864-13,977).

Conclusions: Using administrative data, our novel algorithm identified patients with pneumonia at high risk for death, consistent with HAP/VAP. Among them, carbapenem resistance occurred in 12% of all cases and was associated with substantial excess in hospital costs.
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http://dx.doi.org/10.1016/j.chest.2018.12.024DOI Listing
June 2019

An analysis of homeless patients in the United States requiring ICU admission.

J Crit Care 2019 02 30;49:118-123. Epub 2018 Oct 30.

Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA, United States; Division of Critical Care Medicine, Baystate Medical Center, Springfield, MA, United States.

Purpose: To assess how homelessness impacts mortality and length of stay (LOS) among select the intensive care unit (ICU) patients.

Methods: We used ICD-9 code V60.0 to identify homeless patients using the Premier Perspective Database from January 2010 to June 2011. We identified three subpopulations who received critical care services using ICD-9 and Medicare Severity Diagnosis Related Groups (MS-DRG) codes: patients with a diagnosis of sepsis who were treated with antibiotics by Day 2, patients with an alcohol or drug related MS-DRG, and patients with a diabetes related MS-DRG. We used multivariable logistic regression to predict mortality and multivariable generalized estimating equations to predict hospital and ICU LOS.

Results: 781,540 hospitalizations met inclusion criteria; 2278 (0.3%) were homeless. We found homelessness had no significant adjusted association with mortality among sepsis patients, but was associated with substantially longer hospital LOS: (3.7 days longer; 95% CI (1.7, 5.7, p < .001). LOS did not differ in the Diabetes or Alcohol and Drug related DRG groups.

Conclusions: Critically ill homeless patients with sepsis had longer hospital LOS but similar ICU LOS and mortality risk compared to non-homeless patients. Homelessness was not associated with increased LOS in the diabetes or alcohol and drug related groups.
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http://dx.doi.org/10.1016/j.jcrc.2018.10.026DOI Listing
February 2019

Derivation and validation of a prognostic model to predict mortality in patients with advanced chronic kidney disease.

Nephrol Dial Transplant 2019 09;34(9):1517-1525

Division of Nephrology, Baystate Medical Center, University of Massachusetts Medical School-Baystate, Springfield, MA, USA.

Background: Guiding patients with advanced chronic kidney disease (CKD) through advance care planning about future treatment obliges an assessment of prognosis. A patient-specific integrated model to predict mortality could inform shared decision-making for patients with CKD.

Methods: Patients with Stages 4 and 5 CKD from Massachusetts (749) and West Virginia (437) were prospectively evaluated for clinical parameters, functional status [Karnofsky Performance Score (KPS)] and their provider's response to the Surprise Question (SQ). A predictive model for 12-month mortality was derived with the Massachusetts cohort and then validated externally on the West Virginia cohort. Logistic regression was used to create the model, and the c-statistic and Hosmer-Lemeshow statistic were used to assess model discrimination and calibration, respectively.

Results: In the derivation cohort, the SQ, KPS and age were most predictive of 12-month mortality with odds ratios (ORs) [95% confidence interval (CI)] of 3.29 (1.87-5.78) for a 'No' response to the SQ, 2.09 (95% CI 1.19-3.66) for fair KPS and 1.41 (95% CI 1.15-1.74) per 10-year increase in age. The c-statistic for the 12-month mortality model for the derivation cohort was 0.80 (95% CI 0.75-0.84) and for the validation cohort was 0.74 (95% CI 0.66-0.83).

Conclusions: Our integrated prognostic model for 12-month mortality in patients with advanced CKD had good discrimination and calibration. This model provides prognostic information to aid nephrologists in identifying and counseling advanced CKD patients with poor prognosis who are facing the decision to initiate dialysis or pursue medical management without dialysis.
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http://dx.doi.org/10.1093/ndt/gfy305DOI Listing
September 2019
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