Using A3 thinking to improve the STAT medication process

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107994/1/jhm2222.pd

Hospital-level variation in the development of persistent critical illness

Purpose: Patients with persistent critical illness may account for up to half of all intensive care unit (ICU) bed-days. It is unknown if there is hospital variation in the development of persistent critical illness and if hospital performance affects the incidence of persistent critical illness. Methods: This is a retrospective analysis of Veterans admitted to the Veterans Administration (VA) ICUs from 2015 to 2017. Hospital performance was defined by the risk- and reliability-adjusted 30-day mortality. Persistent critical illness was defined as an ICU length of stay of at least 11 days. We used 2-level multilevel logistic regression models to assess variation in risk- and reliability-adjusted probabilities in the development of persistent critical illness. Results: In the analysis of 100 hospitals which encompassed 153,512 hospitalizations, 4.9% (N = 7640/153,512) developed persistent critical illness. There was variation in the development of persistent critical illness despite controlling for patient characteristics (intraclass correlation: 0.067, 95% CI 0.049–0.091). Hospitals with higher risk- and reliability-adjusted 30-day mortality had higher probabilities of developing persistent critical illness (predicted probability: 0.057, 95% CI 0.051–0.063, p < 0.01) compared to those with lower risk- and reliability-adjusted 30-day mortality (predicted probability: 0.046, 95% CI 0.041–0.051, p < 0.01). The median odds ratio was 1.4 (95% CI 1.33–1.49) implying that, for two patients with the same physiology on admission at two different VA hospitals, the patient admitted to the hospital with higher adjusted mortality would have 40% greater odds of developing persistent critical illness. Conclusion: Hospitals with higher risk- and reliability-adjusted 30-day mortality have a higher probability of developing persistent critical illness. Understanding the drivers of this variation may identify modifiable factors contributing to the development of persistent critical illness

Late vasopressor administration in ICU patients: a retrospective cohort study

Background: Little is known about the prevalence, predictors, and outcomes of late vasopressor administration which evolves after admission to the ICU. Study Design and Methods: We retrospectively studied a cohort of veterans admitted to the Veterans Administration ICUs for ≥ 4 days from 2014 to 2017. The timing of vasopressor administration was categorized as early (only within the initial 3 days), late (on day 4 or later and none on day 3), and continuous (within the initial 2 days through at least day 4). Regressions were performed to identify patient factors associated with late vasopressor administration and the timing of vasopressor administration with posthospitalization discharge mortality. Results: Among the 62,206 hospitalizations with at least 4 ICU days, late vasopressor administration occurred in 5.5% (3,429 of 62,206). Patients with more comorbidities (adjusted OR [aOR], 1.02 per van Walraven point; 95% CI, 1.02-1.03) and worse severity of illness on admission (aOR, 1.01 per percentage point risk of death; 95% CI, 1.01-1.02) were more likely to receive late vasopressor therapy. Nearly 50% of patients started a new antibiotic within 24 h of receiving late vasopressor therapy. One-year mortality after survival to discharge was higher for patients with continuous (adjusted hazard ratio [aHR], 1.48; 95% CI, 1.33-1.65) and late vasopressor administration (aHR, 1.26; 95% CI, 1.15-1.38) compared with only early vasopressor administration. Interpretation: Late vasopressor administration was modestly associated with comorbidities and admission illness severity. One-year mortality was higher among those who received late vasopressor administration compared with only early vasopressor administration. Research to understand optimization of late vasopressor therapy administration may improve long-term mortality

Acquisition of new medical devices among the persistently critically ill: a retrospective cohort study in the Veterans Affairs

Patients who develop persistent critical illness remain in the ICU predominately because they develop new late-onset organ failure(s), which may render them at risk of acquiring a new medical device. The epidemiology and short-term outcomes of patients with persistent critical illness who acquire a new medical device are unknown. We retrospectively studied a cohort admitted to the Veterans Affairs (VA) ICUs from 2014 to 2019. Persistent critical illness was defined as an ICU length of stay of at least 14 days. Receipt of new devices was defined as acquisition of a new tracheostomy, feeding tube (including gastrostomy and jejunostomy tubes), implantable cardiac device, or ostomy. Logistic regression models were fit to identify patient factors associated with the acquisition of each new medical device. Among hospitalized survivors, 90-day posthospitalization discharge location and mortality were identified. From 2014 to 2019, there were 13,184 ICU hospitalizations in the VA which developed persistent critical illness. In total, 30.4% of patients (N = 3998/13,184) acquired at least 1 medical device during their persistent critical illness period. Patients with an initial higher severity of illness and prolonged hospital stay preICU admission had higher odds of acquiring each medical device. Among patients who survived their hospitalization, discharge location and mortality did not significantly differ among those who acquired a new medical device as compared to those who did not. Less than one-third of patients with persistent critical illness acquire a new medical device and no significant difference in short-term outcomes was identified. Future work is needed to understand if the acquisition of new medical devices is contributing to the development of persistent critical illness

Serum Levels of Acylcarnitines and Amino Acids Are Associated with Liberation from Organ Support in Patients with Septic Shock

Sepsis-induced metabolic dysfunction is associated with mortality, but the signatures that differentiate variable clinical outcomes among survivors are unknown. Our aim was to determine the relationship between host metabolism and chronic critical illness (CCI) in patients with septic shock. We analyzed metabolomics data from mechanically ventilated patients with vasopressor-dependent septic shock from the placebo arm of a recently completed clinical trial. Baseline serum metabolites were measured by liquid chromatography-mass spectrometry and 1H-nuclear magnetic resonance. We conducted a time-to-event analysis censored at 28 days. Specifically, we determined the relationship between metabolites and time to extubation and freedom from vasopressors using a competing risk survival model, with death as a competing risk. We also compared metabolite concentrations between CCI patients, defined as intensive care unit level of care ≥ 14 days, and those with rapid recovery. Elevations in two acylcarnitines and four amino acids were related to the freedom from organ support (subdistributional hazard ratio < 1 and false discovery rate < 0.05). Proline, glycine, glutamine, and methionine were also elevated in patients who developed CCI. Our work highlights the need for further testing of metabolomics to identify patients at risk of CCI and to elucidate potential mechanisms that contribute to its etiology

Onset of Persistent Critical Illness in a Large US Integrated Healthcare System

No abstract available

Veterans Affairs patient database (VAPD 2014–2017): building nationwide granular data for clinical discovery

Abstract Background To study patient physiology throughout a period of acute hospitalization, we sought to create accessible, standardized nationwide data at the level of the individual patient-facility-day. This methodology paper summarizes the development, organization, and characteristics of the Veterans Affairs Patient Database 2014–2017 (VAPD 2014–2017). The VAPD 2014–2017 contains acute hospitalizations from all parts of the nationwide VA healthcare system with daily physiology including clinical data (labs, vitals, medications, risk scores, etc.), intensive care unit (ICU) indicators, facility, patient, and hospitalization characteristics. Methods The VA data structure and database organization represents a complex multi-hospital system. We define a single-site hospitalization as one or more consecutive stays with an acute treating specialty at a single facility. The VAPD 2014–2017 is structured at the patient-facility-day level, where every patient-day in a hospital is a row with separate identification variables for facility, patient, and hospitalization. The VAPD 2014–2017 includes daily laboratory, vital signs, and inpatient medication. Such data were validated and verified through lab value range and comparison with patient charts. Sepsis, risk scores, and organ dysfunction definitions were standardized and calculated. Results We identified 565,242 single-site hospitalizations (SSHs) in 2014; 558,060 SSHs in 2015; 553,961 SSHs in 2016; and 550,236 SSHs in 2017 at 141 VA hospitals. The average length of stay was four days for all study years. In-hospital mortality decreased from 2014 to 2017 (1.7 to 1.4%), 30-day readmission rates increased from 15.3% in 2014 to 15.6% in 2017; 30-day mortality also decreased from 4.4% in 2014 to 4.1% in 2017. From 2014 to 2017, there were 107,512 (4.8%) of SSHs that met the Center for Disease Control and Prevention’s Electronic Health Record-based retrospective definition of sepsis. Conclusion The VAPD 2014–2017 represents a large, standardized collection of granular data from a heterogeneous nationwide healthcare system. It is also a direct resource for studying the evolution of inpatient physiology during both acute and critical illness

The association of pregnancy with outcomes among critically ill reproductive-aged women: A propensity-score matched retrospective cohort analysis

The maternal mortality rate in the US is unacceptably high. However, the relative contribution of pregnancy to these outcomes is unknown. Studies comparing outcomes among pregnant versus non-pregnant critically ill patients show mixed results and are limited by small sample sizes. What is the association of pregnancy with critical illness outcomes? We performed a retrospective cohort study of 18-55-year-old women who received invasive mechanical ventilation (MV) on hospital day 0 or 1, or had sepsis present on admission (infection with organ failure) discharged from Premier Healthcare Database hospitals in 2008-2021. The exposure was pregnancy. The primary outcome was in-hospital mortality. We created propensity scores for pregnancy (using patient and hospital characteristics) and performed 1:1 propensity-score matching without replacement within age strata (to ensure exact age matching). We performed multilevel multivariable mixed-effects logistic regression for propensity-matched pairs with pair as a random effect. 3,093 pairs were included in the matched MV cohort, and 13,002 in the sepsis cohort. Cohort characteristics in both were well-balanced (all standard mean differences<0.1). Among matched pairs, unadjusted mortality was 8.0% versus 13.8% for MV and 1.4% versus 2.3% for sepsis, among pregnant and non-pregnant patients, respectively. In adjusted regression, pregnancy was associated with lower odds of in-hospital mortality (MV: odds ratio [OR] 0.50, 95% confidence interval [CI] 0.41-0.60, p<0.001; sepsis: OR 0.52, 95% CI 0.40-0.67, p<0.001). In our large US cohort, critically ill pregnant women receiving MV or with sepsis had better survival than propensity score-matched, non-pregnant women. These findings must be interpreted in the context of likely residual confounding