Search Results (26)

Background/Objectives: Due to challenges in securing hospital beds, elderly patients may face prolonged emergency department (ED) stays. Recent studies have highlighted an association between ED overnight stays (EDOSs) before admission and increased mortality. This study aimed to evaluate the potential impact of EDOSs on mortality among elderly patients awaiting a regular bed in a standard hospital ward. Methods: This monocentric, retrospective study included subjects ≥ 75 years who required urgent hospitalization between 2017 and 2022. Two groups were compared: patients hospitalized between 00:00 and 08:00 following an ED overnight stay (EDOS group), and those admitted directly to conventional medical units between 08:00 and 00:00 (Ward group). The primary outcome was in-hospital mortality 30 days after ED visit. Results: Among the 20,009 patients included (median age: 85 years [IQR: 80–89]), 3064 (15.3%) belonged to the EDOS group, while 16,945 (84.7%) were in the Ward group. In-hospital mortality occurred in 3020 cases (15.1%), with no significant differences observed between the groups. The variables identified by the logistic model as predictors of mortality included age > 85 years, Charlson Comorbidity Index (CCI) ≥ 5, National Early Warning Score (NEWS) > 6 at arrival, infectious diseases, respiratory diseases, and circulatory system diseases, yielding an accuracy of 0.700 ± 0.007. EDOS while awaiting inpatient beds was not a predictor of mortality. Conclusions: The results of our study did not show an association between mortality and EDOS, even when considering the large sample size collected over 6 years and the varying percentages of patients awaiting hospital beds. Full article

Chronic obstructive pulmonary disease (COPD) represents one of the most frequent causes of hospital readmissions and in-hospital mortality. One in five patients requires readmission within 30 days of discharge following an admission for exacerbation. These ‘early readmissions’ increase morbidity and mortality, as patients often do not recover their baseline lung function. The identification of factors associated with increased risk has been a major focus of research in recent years. Studies describe patient-related predictors, although some studies also suggest that better-resourced centres provide superior care. Objective: To describe resources, performance, and care provided in pneumology units in Spain, assessing their association with 30-day readmission for COPD and in-hospital mortality. Methods: This survey was conducted in 116 hospitals responsible for the COPD pathway in pneumology units/departments from November 2022 to March 2023. Results: Of the 116 participating hospitals, 56% had a pneumology department while 25.9% had a pneumology section. The vast majority were public and university hospitals. The number of beds allocated to pneumology/100,000 inhabitants was 6.6 (3.1–9.2) and pulmonologist staffing was 3.3 (2.6–4.1) per 100,000 inhabitants. There was an intermediate respiratory care unit (IMCU) dependent on the pneumology department in 31.9% of units and a respiratory team for 24 h emergency care in 30% of units, while only 9.5% had interventional pneumology units for bronchoscopic procedures. COPD rehabilitation programmes were offered in 58.6% of pneumology units. The average rate of patients on ventilatory support in acute failure was 13.8 (9.2–25) per 100 discharges, with a 30-day COPD readmission rate of 14.9%, with significant differences according to the level of complexity (p = 0.041), with a mean length of stay of 8.72 (1.26) days. The overall in-hospital mortality in pneumology units was 4.10 (1.18) per 100 admissions. In the adjusted model, having a discharge support programme and interventions performed during admission (number of patients with ventilatory support) were predictors of a favourable outcome. Hospital stay was also maintained as a predictor of an unfavourable outcome. Conclusions: There is significant variability in resources and the organisation of care in pneumology units in Spain. The availability of a discharge support programme and greater use of ventilatory support at discharge are factors associated with a lower 30-day COPD readmission rate in the pneumology unit. This information is relevant to improve the care of patients with COPD and as a future line of research. Full article

Objectives: This real-life study aimed to evaluate the safety of acetazolamide (ACZ), a carbonic anhydrase inhibitor with diuretic effects. ACZ has recently been proven to improve decongestion in the context of patients hospitalized for acute heart failure (HF). However, data in terms of safety are lacking. Methods: We conducted a monocentric observational prospective study from November 2023 to February 2024 in a 12-bed cardiology department, recording adverse events (hypotension, severe metabolic acidosis, severe hypokalemia and renal events) during in-hospital HF treatment. All patients hospitalized for acute HF during the study period treated with ACZ (500 mg IV daily for 3 days) on top of IV furosemide (n = 28, 48.3%) were compared with patients who have been treated with IV furosemide alone (n = 30, 51.7%). Results: The patients treated with ACZ were younger than those without (median age 78 (range 67–86) vs. 85 (79–90) years, respectively, p = 0.01) and had less frequent chronic kidney disease (median estimated glomerular fraction rate (60 (35–65) vs. 38 (26–63) mL/min, p = 0.02). As concerned adverse events during HF treatment, there were no differences in the occurrences of hypotension (three patients [10.7%] in the ACZ group vs. four [13.3%], p = 0.8), renal events (four patients [14.3%] in the ACZ group vs. five [16.7%], p = 1) and severe hypokalemia (two [7.1%] in the ACZ group vs. three [10%], p = 1). No severe metabolic acidosis occurred in either group. Conclusions: Although the clinical characteristics differed at baseline, with younger age and better renal function in patients receiving ACZ, the tolerance profile did not significantly differ from patients receiving furosemide alone. Additional observational data are needed to further assess the safety of ACZ–furosemide combination in the in-hospital management of HF, especially in older, frail populations. Full article

We aimed to evaluate the effectiveness of an intensive care unit (ICU) round checklist, FAST HUGS BID (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel regimen, Indwelling catheter removal, and De-escalation of antibiotics—abbreviated as FD hereafter), in improving clinical outcomes in patients with severe trauma. We included patients admitted to our trauma ICU from 2016 to 2020 and divided them into two groups: before (before-FD, 2016–2017) and after (after-FD, 2019–2020) implementation of the checklist. We compared patient characteristics and clinical outcomes, including ICU and hospital length of stay (LOS) and in-hospital mortality. Survival analysis was performed using Kaplan–Meier curves and multivariable logistic regression models; furthermore, multiple linear regression analysis was used to identify independent factors associated with ICU and hospital LOS. Compared with the before-FD group, the after-FD group had significantly lower in-hospital mortality and complication rates, shorter ICU and hospital LOS, and reduced duration of mechanical ventilation. Moreover, implementation of the checklist was a significant independent factor in reducing ICU and hospital LOS and in-hospital mortality. Implementation of the FD checklist is associated with decreased ICU and hospital LOS and in-hospital mortality. Full article

We investigated independent factors predicting neurological outcome and death, comparing in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) patients. The study was conducted in the mixed 34-bed Intensive Care Department at the Hôpital Universitaire de Bruxelles (HUB), Belgium. All adult consecutive cardiac arrest (CA) survivors were included between 2004 and 2022. For all patients, demographic data, medical comorbidities, CA baseline characteristics, treatments received during Intensive Care Unit stay, in-hospital major complications, and neurological outcome at three months after CA, using the Cerebral Performance Category (CPC) scale, were collected. In the multivariable analysis, in the IHCA group (n = 540), time to return of spontaneous circulation (ROSC), older age, unwitnessed CA, higher lactate on admission, asystole as initial rhythm, a non-cardiac cause of CA, the occurrence of shock, the occurrence of acute kidney injury (AKI), and the presence of previous neurological disease and of liver cirrhosis were independent predictors of an unfavorable neurological outcome. Among patients with OHCA (n = 567), time to ROSC, older age, higher lactate level on admission, unwitnessed CA, asystole or pulseless electrical activity (PEA) as initial rhythm, the occurrence of shock, a non-cardiac cause of CA, and a previous neurological disease were independent predictors of an unfavorable neurological outcome. To conclude, in our large cohort of mixed IHCA and OHCA patients, we observed numerous factors independently associated with a poor neurological outcome, with minimal differences between the two groups, reflecting the greater vulnerability of hospitalized patients. Full article

Background: Among the clinical predictors of a heart failure (HF) prognosis, different personal factors have been established in previous research, mainly age, gender, anemia, renal insufficiency and diabetes, as well as mediators (pulmonary embolism, hypertension, chronic obstructive pulmonary disease (COPD), arrhythmias and dyslipidemia). We do not know the role played by contextual and individual factors in the prediction of in-hospital mortality. Methods: The present study has added hospital and management factors (year, type of hospital, length of stay, number of diagnoses and procedures, and readmissions) in predicting exitus to establish a structural predictive model. The project was approved by the Ethics Committee of the province of Almeria. Results: A total of 529,606 subjects participated, through databases of the Spanish National Health System. A predictive model was constructed using correlation analysis (SPSS 24.0) and structural equation models (SEM) analysis (AMOS 20.0) that met the appropriate statistical values (chi-square, usually fit indices and the root-mean-square error approximation) which met the criteria of statistical significance. Individual factors, such as age, gender and chronic obstructive pulmonary disease, were found to positively predict mortality risk. Isolated contextual factors (hospitals with a greater number of beds, especially, and also the number of procedures performed, which negatively predicted the risk of death. Conclusions: It was, therefore, possible to introduce contextual variables to explain the behavior of mortality in patients with HF. The size or level of large hospital complexes, as well as procedural effort, are key contextual variables in estimating the risk of mortality in HF. Full article

Patients on extracorporeal membrane oxygenation (ECMO) often require prolonged periods of bed rest owing to the severity of their illness. Care is also required to maintain the position and integrity of the ECMO cannula. However, they experience a range of effects due to prolonged bed rest. This systematic review examined the possible effects of the early mobilization in patients on ECMO. The database PUBMED was searched by using appropriate keywords: “rehabilitation”, “mobilization”, “ECMO” and “extracorporeal membrane oxygenation”. The selection criteria for the article search were the following: (a) studies published in the last five years, (b) descriptive studies, (c) randomized studies, (d) published in the English language and (e) studies in adults. A total of 259 studies were found, 8 of which were finally selected. Most of the studies showed that early intensive physical rehabilitation related to a decrease in in-hospital stay and a reduction in the duration of mechanical ventilation and doses of vasopressors. In addition, improvements in the functional status and rate of mortality were observed along with a reduction in health care costs. Exercise training should be a fundamental part of the management of patients on ECMO. Full article

Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated and compared with in-hospital mortality. Results: A total of 336 patients were recruited, of whom 40 died. There is a significant difference between the patients in the mortality group and survival group in terms of the six scoring systems. MEWS had the highest area under the curve (AUC) value (0.82). A subgroup analysis was performed for a total of 180 very elderly patients (i.e., older than 75 years), of whom 27 died. MEWS also had the best predictive performance in this subgroup (AUC, 0.82). Conclusions: This simple, rapid, and obtainable-by-the-bed parameter could assist emergency physicians in risk stratification and decision making for this vulnerable group. Full article

Heart failure exacerbations impart significant morbidity and mortality, however, large- scale studies assessing outcomes in the setting of concurrent coronavirus disease-19 (COVID-19) are limited. We utilized National Inpatient Sample (NIS) database to compare clinical outcomes in patients admitted with acute congestive heart failure exacerbation (CHF) with and without COVID-19 infection. A total of 2,101,980 patients (Acute CHF without COVID-19 (n = 2,026,765 (96.4%) and acute CHF with COVID-19 (n = 75,215, 3.6%)) were identified. Multivariate logistic regression analysis was utilized to compared outcomes and were adjusted for age, sex, race, income level, insurance status, discharge quarter, Elixhauser co-morbidities, hospital location, teaching status and bed size. Patients with acute CHF and COVID-19 had higher in-hospital mortality compared to patients with acute CHF alone (25.78% vs. 5.47%, adjust OR (aOR) 6.3 (95% CI 6.05–6.62, p < 0.001)) and higher rates of vasopressor use (4.87% vs. 2.54%, aOR 2.06 (95% CI 1.86–2.27, p < 0.001), mechanical ventilation (31.26% vs. 17.14%, aOR 2.3 (95% CI 2.25–2.44, p < 0.001)), sudden cardiac arrest (5.73% vs. 2.88%, aOR 1.95 (95% CI 1.79–2.12, p < 0.001)), and acute kidney injury requiring hemodialysis (5.56% vs. 2.94%, aOR 1.92 (95% CI 1.77–2.09, p < 0.001)). Moreover, patients with heart failure with reduced ejection fraction had higher rates of in-hospital mortality (26.87% vs. 24.5%, adjusted OR 1.26 (95% CI 1.16–1.36, p < 0.001)) with increased incidence of vasopressor use, sudden cardiac arrest, and cardiogenic shock as compared to patients with heart failure with preserved ejection fraction. Furthermore, elderly patients and patients with African-American and Hispanic descents had higher in-hospital mortality. Acute CHF with COVID-19 is associated with higher in-hospital mortality, vasopressor use, mechanical ventilation, and end organ dysfunction such as kidney failure and cardiac arrest. Full article

The relative contributions of occupational and community sources of COVID-19 among health-care workers (HCWs) are still subject to debate. In a cohort study at a 2814-bed tertiary medical center (five hospitals) in the Paris area of France, we assessed the proportion of hospital-acquired cases among staff and identified risk factors. Between May 2020 and June 2021, HCWs were invited to complete a questionnaire on their COVID-19 risk factors. RT-PCR and serology test results were retrieved from the virology department. Mixed-effects logistic regression was used to account for clustering by hospital. The prevalence of COVID-19 was 15.6% (n = 213/1369 respondents) overall, 29.7% in the geriatric hospitals, and 56.8% of the infections were hospital-acquired. On multivariable analyses adjusted for COVID-19 incidence and contact in the community, a significantly higher risk was identified for staff providing patient care (especially nursing assistants), staff from radiology/functional assessment units and stretcher services, and staff working on wards with COVID-19 clusters among patients or HCWs. The likelihood of infection was greater in geriatric wards than in intensive care units. The presence of significant occupational risk factors after adjustment for community exposure is suggestive of a high in-hospital risk and emphasizes the need for stronger preventive measures—especially in geriatric settings. Clinicaltrials.gov NCT04386759. Full article

The study aims to characterize community-acquired sepsis patients admitted to our 1300-bedded tertiary care hospital in South India from the Surviving Sepsis Campaign (SSC) guideline-compliant e-sepsis registry stratified by focus of infection. The prospective observational study recruited 1009 adult sepsis patients presenting to the emergency department at the center based on Sepsis-2 criteria for a period of three years. Of the patients, 41% were between 61 and 80 years with a mean age of 57.37 ± 13.5%. A total of 13.5% (136) was under septic shock and in-hospital mortality for the study cohort was 25%. The 3 h and 6 h bundle compliance rates observed were 37% and 49%, respectively, without significant survival benefits. Predictors of mortality among patients with bloodstream infections were septic shock (p = 0.01, OR 2.4, 95% CI 1.23–4.79) and neutrophil-to-lymphocyte ratio (p = 0.008, OR 1.01, 95% CI 1.009–1.066). The presence of Acinetobacter (p = 0.005, OR 4.07, 95% CI 1.37–12.09), Candida non-albicans (p = 0.001, OR16.02, 95% CI 3.0–84.2) and septic shock (p = 0.071, OR 2.5, 95% CI 0.97–6.6) were significant predictors of mortality in patients with community-acquired pneumonia. The registry has proven to be a key data source detailing regional microbial etiology and clinical outcomes of adult sepsis patients, enabling comprehensive evaluation of regional community-acquired sepsis to tailor institutional sepsis treatment protocols. Full article

Background: Bed rest with limited physical activity is common during admission. The aim was to determine the association between daily step count and physical activity levels during and after admission with community-acquired pneumonia (CAP) and the risk of readmission and mortality. Methods: A prospective cohort study of 166 patients admitted with CAP. Step count and physical activity were assessed with accelerometers during and after admission and were categorised as sedentary, light, or moderate-vigorous physical activity. Linear regression was used to assess the association between step count and length of stay. Logistic regression was used to assess the association between step count, physical activity level, and risk of readmission and mortality. Results: Patients admitted with CAP were sedentary, light physically active, and moderate-to-vigorous physically active 96.4%, 2.6%, and 0.9% of their time, respectively, with 1356 steps/d. For every 500-step increase in daily step count on day 1, the length of stay was reduced by 6.6%. For every 500-step increase in daily step count during admission, in-hospital and 30-day mortality was reduced. Increased light and moderate-to-vigorous physical activity during admission were associated with reduced risk of in-hospital and 30-day mortality. After discharge, patients increased their daily step count to 2654 steps/d and spent more time performing light and moderate-to-vigorous physical activity. For every 500-step increase in daily step count after discharge, the risk of readmission was reduced. Higher moderate-to-vigorous physical activity after discharge was associated with a reduced risk of readmission. Conclusions: Increased physical activity during admission was associated with a reduced length of stay and risk of mortality, whereas increased physical activity after discharge was associated with a reduced risk of readmission in patients with CAP. Interventions focusing on increasing physical activity levels should be prioritised to improve the prognosis of patients admitted with CAP. Full article

We aimed to summarize the evidence of an association between nurse staffing and nursing sensitivity outcomes in Japanese hospitals. A scoping review was conducted and reported following the PRISMA-SR 2020 statement. The ICHUSHI and CiNii databases were searched for published articles written in Japanese and PubMed and CINAHL for those written in English. Out of the 15 included studies, all observational studies, 3 were written in Japanese and the others in English. The nurse staffing level measures were grouped into three categories: patient-to-nurse ratio, nursing hours per patient day, and nurse-to-bed ratio. The outcome measures were grouped into three categories: patient outcome, nursing care quality reported by nurses, and nurse outcome/nursing care quality. Some studies reported that the nursing staff increasingly favored positive patient outcome. Conversely, the findings regarding failure to rescue, in-hospital fracture, and post-operative complications were inconsistent. Although some studies indicated that more nurse staffing was favored toward better patient and nurse outcomes, due to the sparse accumulation of studies and heterogeneity among the findings, it is difficult to draw robust conclusions between nurse staffing level and outcomes in Japanese acute care hospitals. Full article

The unexpected advent of the COVID-19 pandemic led to a sudden disruption of routine medical care, with a subsequent reorganization of hospital structures and of care. Case studies are becoming available in the literature referring to the logistical difficulties involved in a hospital resuming normal activity following the first COVID-19 lockdown period. This paper details the experience of a study site, a private hospital in Dublin, Ireland, in the redesign of service delivery in compliance with new COVID-19 prevention regulations to facilitate the resumption of routine hospital activity following the first wave of COVID-19. The aim was to resume routine activity and optimize patient activity, whilst remaining compliant with COVID-19 guidelines. We employed a pre-/post-intervention design using Lean methodology and utilised a rapid improvement event (RIE) approach underpinned by person-centred principles. This was a system-wide improvement including all hospital staff, facilitated by a specific project team including the chief operation officer, allied therapy manager (encompassing health and social care professionals), infection prevention and control team, head of surgical services, clinical nurse managers, patient services manager and the head of procurement. Following our intervention, hospital services resumed successfully, with the initial service resumption meeting the organizational target of a 75% bed occupancy rate, while the number of resumed surgeries exceeded the target by 13%. Our outpatient visits recovered to exceed the attendance numbers pre-COVID-19 in 2019 by 10%. In addition, patient satisfaction improved from 93% to 95%, and importantly, we had no in-hospital patient COVID-19 transmission in the study period of July to December 2020. Full article

Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract can be fatal. However, very few studies have provided comprehensive analyses and specified the differences in symptoms observed in different parts of the GI tract. This study aimed to comprehensively analyze clinical manifestations and management of GI CMV disease. This retrospective cohort study enrolled the patients who had CMV diseases of the GI tract proved by CMV immunohistochemistry stain from the pathology database in a 4000-bed tertiary medical center between January 2000 and May 2021. The patient characteristics, clinical manifestations, endoscopic features, treatments, outcomes, and prognostic factors were analyzed. A total of 356 patients were enrolled, including 46 infected in the esophagus, 76 in the stomach, 30 in the small intestine, and 204 in the colon. In total, 49.4% patients were immunocompromised. The overall in-hospital mortality rate was 20.8%: CMV enteritis had the highest rate (23.3%). Sixty percent of patients received antiviral treatment and 16% were administered both intravenous and oral anti-viral drugs (Combo therapy, minimal and mean treatment duration were 14 and 39.9 ± 25 days). Prognostic factors of in-hospital mortality included age, immune status, albumin level, platelet count, GI bleeding, time-to-diagnosis, and Combo therapy. In the survival analysis, immunocompetent patients receiving Combo therapy had the best survival curve, and immunocompromised patients receiving non-Combo therapy had the worst survival curve. Combo therapy ≥14 days resulted in a better outcome for both immunocompromised and immunocompetent patients. In conclusion, CMV GI diseases affect both immunocompromised and immunocompetent hosts, and a complete treatment course should be considered for patients with poor prognostic factors. Full article