Rachel Kohn

Perceptions of organ donation after circulatory determination of death among critical care physicians and nurses: a national survey.

Objective:We sought to identify factors related to critical care physicians’ and nurses’ willingness to help manage potential donors after circulatory determination of death, and to elicit opinions on the presence of role conflict in donors after circulatory determination of death and its impact on end-of-life care. Design and SettingRandomized trial administered by Web or post of four donors after circulatory determination of death vignettes. Response rates were 31.0% and 44.3%, respectively. Subjects:Two thousand two hundred and six academic intensive care unit physicians and 988 intensive care unit nurses in the United States. Measurements and Main Results:Majorities of intensive care unit physicians (72.5%; 95% confidence interval 69.2–75.9) and nurses (74.3%; 95% confidence interval 70.2–78.5) believed they should help manage potential donors after circulatory determination of death. 14.7% (95% confidence interval 12.0–17.4) of physicians and 14.3% (95% confidence interval 11.0–17.6) of nurses believed that management of donors after circulatory determination of death would create professional role conflicts. 33.8% (95% confidence interval 30.0–37.4) of physicians and 55.1% (95% confidence interval 50.3–59.7) of nurses believed that preserving opportunities for donors after circulatory determination of death could improve end-of-life care. More favorable views of donors after circulatory determination of death were provided by clinicians randomly assigned to vignettes depicting donors with previously denoted preferences for organ donation; similar effects were not introduced by vignettes in which surrogates actively initiated donation discussions. Conclusions:These findings suggest that critical care physicians and nurses are generally supportive of managing donors after circulatory determination of death, particularly when patients were registered organ donors. However, minorities of clinicians harbor concerns regarding conflicts of interest, and many are uncertain of the practice’s impact on end-of-life care.

Do Windows or Natural Views Affect Outcomes or Costs Among Patients in Icus

Objective:To determine whether potential exposure to natural light via windows or to more pleasing views through windows affects outcomes or costs among critically ill patients. Design:Retrospective cohort study. Setting:An academic hospital in Philadelphia, PA. Patients:Six thousand one hundred thirty-eight patients admitted to a 24-bed medical ICU and 6,631 patients admitted to a 24-bed surgical ICU from July 1, 2006, to June 30, 2010. Interventions:Assignment to medical ICU rooms with vs. without windows and to surgical ICU rooms with natural vs. industrial views based on bed availability. Measurements and Main Results:In primary analyses adjusting for patient characteristics, medical ICU patients admitted to rooms with (n = 4,093) versus without (n = 2,243) windows did not differ in rates of ICU (p = 0.25) or in-hospital (p = 0.94) mortality, ICU readmissions (p = 0.37), or delirium (p = 0.56). Surgical ICU patients admitted to rooms with natural (n = 3,072) versus industrial (n = 3,588) views experienced slightly shorter ICU lengths of stay and slightly lower variable costs. Instrumental variable analyses based on initial bed assignment and exposure time did not show any differences in any outcomes in either the medical ICU or surgical ICU cohorts, and none of the differences noted in primary analyses remained statistically significant when adjusting for multiple comparisons. In a prespecified subgroup analysis among patients with ICU length of stay greater than 72 hours, MICU windows were associated with reduced ICU (p = 0.02) and hospital mortality (p = 0.04); these results did not meet criteria for significance after adjustment for multiple comparisons. Conclusions:ICU rooms with windows or natural views do not improve outcomes or reduce costs of in-hospital care for general populations of medical and surgical ICU patients. Future work is needed to determine whether targeting light from windows directly toward patients influences outcomes and to explore these effects in patients at high risk for adverse outcomes.

Ward Capacity Strain: A Novel Predictor of 30-Day Hospital Readmissions

Department ofMedicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, Perelman School ofMedicine at the University of Pennsylvania, Philadelphia, PA, USA; Palliative andAdvanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, PA, USA; Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Department of Public Health Sciences and Division of Biostatistics at the University of Virginia, Charlottesville, VA, USA.

Early oseltamivir after hospital admission is associated with shortened hospitalization: A five-year analysis of oseltamivir timing and clinical outcomes

BACKGROUND Neuraminidase inhibitors (NAIs) are the only effective therapy for influenza, but few studies have assessed the impact of early NAI therapy on clinical outcomes or the patient-level factors that determine early NAI delivery in hospitalized patients. METHODS We conducted a retrospective cohort study of all adults hospitalized in a metropolitan tertiary care hospital with confirmed influenza from April 2009 to March 2014. We performed logistic regression to determine patient-level factors that were associated with early NAI therapy. We analyzed the association of early NAI therapy with hospital lengths of stay (LOS) and in-hospital mortality rates using linear and logistic regression, respectively. RESULTS In total, 699 patients were admitted with influenza during the 5 influenza seasons. Of those, 582 (83.4%) received NAI therapy; however, only 26.0% received the first dose within 6 hours of hospitalization (early NAI). Patients with diabetes mellitus or pregnancy were more likely to receive early NAI (P = .01, vs. P < .001 in those without these conditions), as were those reporting fever or myalgias at presentation (P = .002, vs. P = .005 without). Immunosuppressed patients were less likely to receive early NAI (P = .04). Early NAI was associated with shorter hospital LOS (P < .001). No patients died in the early NAI group, compared to 18 deaths in the 399 patients receiving NAI after 6 hours (4.5%) and 4 deaths in the 116 patients not receiving NAI (3.4%). CONCLUSIONS Over multiple influenza seasons, early NAI therapy was associated with shorter LOS in patients admitted with influenza. This suggests that efforts should focus on facilitating earlier therapy in patients with suspected influenza.

Associations of ICU Capacity Strain with Disposition and Outcomes of Patients with Sepsis Presenting to the Emergency Department

Rationale: Intensive care unit (ICU) capacity strain refers to the potential limits placed on an ICUs ability to provide high‐quality care for all patients who may need it at a given time. Few studies have investigated how fluctuations in ICU capacity strain might influence care outside the ICU. Objectives: To determine whether ICU capacity strain is associated with initial level of inpatient care and outcomes for emergency department (ED) patients hospitalized for sepsis. Methods: We performed a retrospective cohort study of patients with sepsis admitted from the ED to a medical ward or ICU at three hospitals within the University of Pennsylvania Health System between 2012 and 2015. Patients were excluded if they required life support therapies, defined as invasive or noninvasive ventilatory support or vasopressors, at the time of admission. The exposures were four measures of ICU capacity strain at the time of the ED disposition decision: ICU occupancy, ICU turnover, ICU census acuity, and ward occupancy. The primary outcome was the decision to admit to a ward or to an ICU. Secondary analyses assessed the association of ICU capacity strain with in‐hospital outcomes, including mortality. Results: Among 77,142 hospital admissions from the ED, 3,067 patients met the studys eligibility criteria. The ICU capacity strain metrics varied between and within study hospitals over time. In unadjusted analyses, ICU occupancy, ICU turnover, ICU census acuity, and ward occupancy were all negatively associated with ICU admission. In the fully adjusted model including patient‐level covariates, only ICU occupancy remained associated with ICU admission (odds ratio, 0.87; 95% confidence interval, 0.79‐0.96; P = 0.005), such that a 10% increase in ICU occupancy (e.g., one additional patient in a 10‐bed ICU) was associated with a 13% decrease in the odds of ICU admission. Among the subset of patients admitted initially from the ED to a medical ward, ICU occupancy at the time of admission was associated with increased odds of hospital mortality (odds ratio, 1.61; 95% confidence interval, 1.21‐2.14; P = 0.001). Conclusions: The odds that patients in the ED with sepsis who do not require life support therapies will be admitted to the ICU are reduced when those ICUs experience high occupancy but not high levels of other previously explored measures of capacity strain. Patients with sepsis admitted to the wards during times of high ICU occupancy had increased odds of hospital mortality.