Predictive Ability of the Stability and Workload Index for Transfer Score to Predict Unplanned Readmissions After ICU Discharge

Objective: Unplanned readmission of hospitalized patients to an ICU is associated with an increased mortality and hospital length of stay. The ability to identify patients at risk, who would benefit from prolonged ICU treatment, is limited. The aim of this study is to validate a previously published numerical index named the Stability and Workload Index for Transfer in a heterogeneous group of ICU patients. Design: In this retrospective data analysis, the Stability and Workload Index for Transfer score was calculated for all patients, and the ability of the score to predict readmission was compared with the original publication. Setting: Four ICUs, one intermediate care unit, and one postanesthesia care unit of the department of anesthesia and intensive care of a university hospital. Patients: All consecutive patients treated in one of the units. Interventions: None. Measurements and Main Results: Unplanned ICU readmissions or unexpected death within 7 days of ICU discharge. The data of 7,175 patients were included in the analysis. Five hundred ninety-six patients were readmitted or died within 7 days of discharge. The patients who are readmitted to the ICU are significantly older and have significantly higher scores that define the severity of disease at the time of admission and discharge of their first ICU stay. The source of admission for the initial ICU stay did not differ (p = 0.055), and the last Glasgow Coma Scale and the last Pao(2)/Fio(2) ratio before discharge from the ICU were higher in patients who did not need a readmission to the ICU. The performance of the Stability and Workload Index for Transfer score is poor with an area under the receiver operator curve of 0.581 (95% CI, 0.556-0.605; p < 0.001). Conclusions: Based on the data from our patients, the proposed Stability and Workload Index for Transfer score by Gajic et al is not ideal in aiding the clinician in the decision, if a patient can be discharged safely from the ICU and further research is necessary to define the patients at risk for readmission

Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy

Objective: Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC. Methods: The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2-5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema. Results: A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient's symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9-23) days in the drainage group compared with 13 (IQR 11-23) days in the control group (p = 0.21). Conclusions: In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery

Cerebrovascular Events in Suspected Sepsis: Retrospective Prevalence Study in Critically Ill Patients Undergoing Full-Body Computed Tomography

Purpose: This study aimed at retrospectively evaluating full-body computed tomography (CT) examinations for the prevalence of cerebrovascular events in patients with suspected sepsis treated in the intensive care unit (ICU). Methods: All full-body CT examinations, i.e., both cranial CT (cCT) and body CT including chest, abdomen and pelvis, for focus search in septic patients over a 12-months period were identified from three ICUs, using full-text search. From this retrospective cohort, we fully analyzed 278 cCT examinations for the occurrence of acute cerebral findings. All acute cerebrovascular events were independently reviewed by two blinded readers. Clinical and laboratory findings were extracted. The data were statistically analyzed using contingency tests. Results: In our population of patients with suspected sepsis, 10.8% (n = 30/278) were identified to have major cerebral events, including 7.2% (n = 20/278) major cerebrovascular events and 4.3% (n = 12/278) generalized parenchymal damage. 13.4% (n = 22/163) of patients with a severe coma as compared with non-severe coma, 4.4% (n = 3/68), showed a major cerebral event (p = 0.04). Patients referred from the cardiology/nephrology ICU ward showed major cerebral events in 16.3% (n = 22/135), as compared with 4.9% (n = 3/61) in patients from pulmonary ICU and 6.1% (n = 5/82) major cerebral events with surgical referral (p = 0.02). Conclusion: Our study provides further evidence that septic patients may suffer from cerebral events with relevance to their prognosis. Severe coma and the referring ward were associated with acute cerebral conditions. Full-body CT has the advantage of both detecting of septic foci and possibly identifying ischemic or hemorrhagic stroke in this vulnerable patient population

Does adherence to a quality indicator regarding early weaning from invasive ventilation improve economic outcome? A single-centre retrospective study

ObjectivesTo measure and assess the economic impact of adherence to a single quality indicator (QI) regarding weaning from invasive ventilation.DesignRetrospective observational single-centre study, based on electronic medical and administrative records.SettingIntensive care unit (ICU) of a German university hospital, reference centre for acute respiratory distress syndrome.ParticipantsRecords of 3063 consecutive mechanically ventilated patients admitted to the ICU between 2012 and 2017 were extracted, of whom 583 were eligible adults for further analysis. Patients’ weaning protocols were evaluated for daily adherence to quality standards until ICU discharge. Patients with <65% compliance were assigned to the low adherence group (LAG), patients with ≥65% to the high adherence group (HAG).Primary and secondary outcome measuresEconomic healthcare costs, clinical outcomes and patients’ characteristics.ResultsThe LAG consisted of 378 patients with a median negative economic results of −€3969, HAG of 205 (−€1030), respectively (p<0.001). Median duration of ventilation was 476 (248; 769) hours in the LAG and 389 (247; 608) hours in the HAG (p<0.001). Length of stay (LOS) in the LAG on ICU was 21 (12; 35) days and 16 (11; 25) days in the HAG (p<0.001). LOS in the hospital was 36 (22; 61) days in the LAG, and within the HAG, respectively, 26 (18; 48) days (p=0.001).ConclusionsHigh adherence to this single QI is associated with better clinical outcome and improved economic returns. Therefore, the results support the adherence to QI. However, the examined QI does not influence economic outcome as the decisive factor

Dynamics of core–shell particle formation in drop-tube processed metastable monotectic alloys

We examine the apparent size of the core and shell as a function of cooling rate in core–shell particles of the metastable monotectic alloy Co-50 at% Cu, finding that the volume fraction of the core systematically increases with cooling rate and hence undercooling. A model for this variation is proposed. A Monte-Carlo simulation is used to correct for sectioning effects allowing the true core:shell volume ratio to be estimated. From this, and the observation of a second, spinodal, episode of liquid phase separation we are able to estimate the undercooling at solidification. This permits a calculation of the time available following liquid phase separation for the migration giving rise to the observed core–shell structure to occur and hence the required Marangoni velocity required to such migration

The evaluation of a feedback system for evidence-based process indicators of a patient data management system for intensive care units and their influence on treatment quality and financial outcome

Einführung: Ziel dieser kumulierten Arbeit war zu untersuchen, ob die Implementierungsrate von Standard Operating Procedures (SOP) für intensivmedizinische Behandlungsprozesse wie Sedierung, Beatmungsentwöhnung und Blutzuckermanagement durch Verwendung eines visuellen Feedback-Systems verbessert wird. Patienten Daten Management Systeme (PDMS) bieten sich als Plattform für solche Systeme an. Dabei soll eine zusätzliche Belastung der Mitarbeiter in der Intensivmedizin vermieden werden. Ebenso soll ein Einfluss auf ökonomische Effekte bei der Erhöhung der Compliance der protokollbasierten Intensivbehandlung untersucht werden. Methodik: In einer ersten Studie wurden 205 Patienten untersucht, die 3 Monate vor nach Einführung des Feedback-Systems auf einer Intensivstation behandelt wurden. Dabei wurden die Erfüllungsgrade der Qualitätsindikatoren für die Überwachung von Sedierung, Delir und Schmerz und die Adhärenz an ein Beatmungsentwöhnungsprotokoll verglichen. In der zweiten Studie wurde die Behandlungsqualität durch Einführung des pflegebasierten Blutzuckerprotokolls bei 175 Patienten im Vergleich zu 384 retrospektiven manuellen Kontrollen untersucht. Die dritte Studie untersuchte die Beziehung zwischen klinischem und ökonomischen Outcome von 583 Patienten aus den Aufnahmejahren 2012 – 2017 abhängig von der SOP-Einhaltung zum Beatmungsweaning. Dabei wurde eine Low Adherence Group (LAG; SOP-Adhärenz = 65%) verglichen. Ergebnisse: Die Einhaltung der SOPs für die Schmerz- und Delir Überwachung und des Entwöhnungsprotokolls war durch die Einführung eines visuellen Feedbacksystems erhöht. Die Implementierung eines BZ-Protokolls führte schon ohne zeitnahes Feedbacksystem zu einer deutlichen Abnahme der Hypoglykämie-Vorfälle (31% zu 12 %, P < 0,001) ohne eine Erhöhung der Arbeitslast der Pflege zu verzeichnen. Die Steigerung der Adhärenz zu dem Weaning-Protokoll führte zwar nicht direkt zu einer Verringerung der Behandlungskosten, allerdings war ein indirekter Einfluss durch eine kürzere Liegezeit feststellbar, da mehr Patienten im gleichen Zeitraum behandelt werden konnten. Schlussfolgerung: Die Einhaltung von protokollgestützten Verfahrensanweisungen kann durch die Verwendung eines täglichen visuellen Feedback-Systems verbessert werden. Es lassen sich Effekte im Bereich des Qualitätsmanagements ebenso feststellen, wie Auswirkungen auf Behandlungsergebnis und ökonomische Faktoren. Eine Weiterentwicklung elektronischer Feedbacksysteme scheint in der Zukunft sinnvoll.Introduction: The aim of this cumulative work was to investigate whether the implementation rate of Standard Operating Procedures (SOP) for intensive care treatment processes such as sedation, weaning from mechanical ventilation and blood glucose management is improved by using a visual feedback system. Patient Data Management Systems (PDMS) offer a platform for such systems. The aim is to avoid additional work load for intensive care staff. Likewise the influence on economic effects of improved compliance to protocol-based intensive treatment was investigated. Methods: A first study examined 205 patients who had been treated in an intensive care unit 3 months before and after the introduction of the feedback system. The degree of compliance with the quality indicators for the monitoring of sedation, delirium and pain and the adherence to a ventilation weaning protocol was compared. The second study looked at the quality of treatment by introducing automated blood glucose protocol in 175 patients compared with 384 retrospective controls. The third study examined the relationship between clinical and economic outcomes of 583 patients admitted to the ICU between 2012 and 2017, with regard to SOP adherence for a protocol for weaning from mechanical ventilation. A low adherence group (LAG; SOP adherence = 65%) were compared. Results: Adherence to SOPs for pain and delirium monitoring and the weaning protocol was improved with the introduction of a visual feedback system. Even without a timely feedback system, implementation of a BG protocol resulted in a significant decrease in hypoglycemic events (31% to 12%, P < 0. 001) without an increase in nursing workload. While increasing adherence to the weaning protocol did not directly reduce treatment costs, there was an indirect influence due to a shorter length of stay, as more patients could be treated in the same period of time. Conclusion: Compliance with protocol-based procedural instructions can be improved by using a daily visual feedback system. Effects in the field of quality management can be identified as well as effects on treatment outcome and economic factors. Further development of electronic feedback systems seems to be reasonable in the future

Development and application of three-dimensional optical bridge-evaluation system

There has been a growing interest in developing remote sensing technologies to quickly assess the condition of bridges while minimizing traffic disruptions and limiting inspection crews\u27 exposure to traffic. Currently, the calculation of the National Bridge Inspection (NBI) Rating for a bridge deck is done by inspectors visually inspecting the bridge deck. 3D optics is an innovative technology that can help assess bridge deck condition while at the same time enhance the ability to preserve the data for future reference and decision making. 3DOBS (the 3D Optical Bridge-evaluation System) was developed to address these issues while at the same time providing data that can be used to understand changes in condition in the future. The system is comprised of standard Digital Single Lens Reflex camera (DSLR) that is mounted to a vehicle, close-range photogrammetry software, and an automated spall detection algorithm. The camera is driven over each lane of the bridge collecting photos with a 60% overlap and then processed in the photogrammetric software. The resulting output is a Digital Elevation Model (DEM) of the bridge deck. This is then processed through the spall detection algorithm to identify spalls, calculate area and volume of individual spalls, and percent of the total bridge deck that is spalled. This information can be integrated into bridge management systems and decision making processes on bridge preservation

Outcome and management of decompressive hemicraniectomy in malignant hemispheric stroke following cardiothoracic surgery

Abstract Management of malignant hemispheric stroke (MHS) after cardiothoracic surgery (CTS) remains difficult as decision-making needs to consider severe cardiovascular comorbidities and complex coagulation management. The results of previous randomized controlled trials on decompressive surgery for MHS cannot be generally translated to this patient population and the expected outcome might be substantially worse. Here, we analyzed mortality and functional outcome in patients undergoing decompressive hemicraniectomy (DC) for MHS following CTS and assessed the impact of perioperative coagulation management on postoperative hemorrhagic and cardiovascular complications. All patients that underwent DC for MHS resulting as a complication of CTS between June 2012 and November 2021 were included in this observational cohort study. Outcome was determined according to the modified Rankin Scale (mRS) score at 1 and 3–6 months. Clinical and demographic data, anticoagulation management and postoperative hemorrhagic and thromboembolic complications were assessed. In order to evaluate a predictive association between clinical and radiological parameters and the outcome, we used a multivariate logistic regression analysis. Twenty-nine patients undergoing DC for MHS after CTS with a female-to-male ratio of 1:1.9 and a median age of 60 (IQR 49–64) years were identified out of 123 patients undergoing DC for MHS. Twenty-four patients (83%) received pre- or intraoperative substitution. At 30 days, the in-hospital mortality rate and neurological outcome corresponded to 31% and a median mRS of 5 (5–6), which remained stable at 3–6 months [Mortality: 42%, median mRS: 5 (4–6)]. Postoperatively, 15/29 patients (52%) experienced new hemorrhagic lesions and Bayesian logistic regression predicting mortality (mRS = 6) after imputing missing data demonstrated a significantly increased risk for mortality with longer aPPT (OR = 13.94, p = .038) and new or progressive hemorrhagic lesions after DC (OR = 3.03, p = .19). Notably, all but one hemorrhagic lesion occurred before discontinued anticoagulation and/or platelet inhibition was re-initiated. Despite perioperative discontinuation of anticoagulation and/or platelet inhibition, no coagulation-associated cardiovascular complications were noted. In conclusion, Cardiothoracic surgery patients suffering MHS will likely experience severe neurological disability after DC, which should remain a central aspect during counselling and decision-making. The complex coagulation situation after CTS, however, should not per se rule out the option of performing life-saving surgical decompression

Evaluation of commercially available remote sensors for highway bridge condition assessment

Improving transportation infrastructure inspection methods and the ability to assess conditions of bridges has become a priority in recent years as the transportation infrastructure continues to age. Current bridge inspection techniques consist largely of labor-intensive subjective measures for quantifying deterioration of various bridge elements. Some advanced nondestructive testing techniques, such as ground- penetrating radar, are being implemented; however, little attention has been given to remote sensing technologies. Remote sensing technologies can be used to assess and monitor the condition of bridge infrastructure and improve the efficiency of inspection, repair, and rehabilitation efforts. Most important, monitoring the condition of a bridge using remote sensors can eliminate the need for traffic disruption or total lane closure because remote sensors do not come in direct contact with the structure. The purpose of this paper is to evaluate 12 potential remote sensing technologies for assessing the bridge deck and superstructure condition. Each technology was rated for accuracy, commercial availability, cost of measurement, precollection preparation, complexity of analysis and interpretation, ease of data collection, stand-off distance, and traffic disruption. Results from this study demonstrate the capabilities of each technology and their ability to address bridge challenges