Moreno Franco, Pablo

BACKGROUND: Publicly reported 30-day acute myocardial infarction (AMI) mortality rates are widely used to benchmark hospital performance. However, these measures may lack validity when they include deaths among patients with do-not-resuscitate (DNR) orders or those receiving palliative care—groups for whom mortality may be expected and goal-concordant. METHODS: We analyzed the national 100% Medicare Inpatient Standard Analytic File and Medicare Beneficiary Summary file to assess 30-day AMI mortality rates stratified by DNR status (absent, present-on-admission, and postadmission) and palliative care involvement. We then conducted a retrospective chart review of all 30-day AMI mortalities at a single academic medical center (2019–2025), applying Global Registry of Acute Coronary Events and a Palliative Performance Scale scores to identify unpreventable deaths, which we defined as a Global Registry of Acute Coronary Events >190.5 or Palliative Performance Scale ≤40%. Global Registry of Acute Coronary Events is a risk-stratification tool using clinical and laboratory variables whereas the Palliative Performance Scale is a bedside functional status and palliative care assessment quantifying patient’s self-care ability. RESULTS: Across n=467 259 total AMI encounters, mean (SD) age was 75.1 (10.5), and the population was 44% female. Thirty-day mortality was 10.4% (39 112/376 062) among patients without DNRs, 43.1% (26 181/60 719) in those with present-on-admission DNR, and 72.1% (21 984/30 478) in those with postadmission DNR. Among 9.2% (43 090/467 259) of encounters with palliative care, there was a 76.9% mortality rate (33 151/43 090). Hazard ratios for mortality were 5.25 (95% CI, 5.17–5.33) for present-on-admission DNR and 10.73 (95% CI, 10.55–10.91) for postadmission DNR as compared with encounters without DNRs. Among n=24 AMI mortalities at our institution, 71% (17/24) had DNRs, and 33% (8/24) met the unpreventable death criteria. CONCLUSIONS: The validity of 30-day AMI mortality metrics may be undermined by their inclusion of high-acuity, end-of-life patients, which may disincentivize hospitals from delivering appropriate, patient-centered care. Removal of DNR or palliative cases from performance measures should be explored to better identify opportunities for reducing preventable deaths.

The Omicron variant of SARS-CoV-2 is associated with milder symptoms and lower hospitalization and mortality rates than Delta variants, although the impact of Omicron on immunocompromised patients, especially solid organ transplant (SOT) recipients, is still unclear. This study compares the hospitalization rate and outcomes between immunocompromised, immunocompetent, and SOT patients during the Delta and Omicron periods. We included adult patients who tested positive for SARS-CoV-2 on PCR or nasopharyngeal antigen test between 26 June 2021 to 8 September 2022, at our institution. A total of 12,401 COVID-19 patients were included, of which 11,055 were immunocompetent, and 1346 were immunocompromised (375 SOT recipients). Throughout the Delta and Omicron outbreaks, immunocompromised patients exhibited higher comorbidities and 30-day hospitalizations, but rates of mechanical ventilation and ICU-level care were like immunocompetent patients. During the Omicron wave, immunocompromised patients had higher unadjusted relative risk estimates (RR = 2.37, 95% CI 1.96–2.87, p < 0.05) than Delta (RR = 1.58, 95% CI 1.24–2.01, p < 0.05), with higher adjusted relative risk for hospitalization in Omicron (RR = 1.50, 95% CI 1.10–2.03, p = 0.01). Analyses show increased hospitalization risk in immunocompromised during the Omicron wave compared to the Delta wave, with no significant difference in hospitalization outcomes. The relative risk of hospitalization for SOT patients was higher in both waves.

Background Ketamine has demonstrated efficacy in treatment-resistant depression, primarily in psychiatric or outpatient populations. Its use in ICU patients remains underexplored, with limited data beyond case reports and small series. This study evaluated the association between subanesthetic ketamine infusions and improvement in depressive symptoms and hemodynamic changes in ICU patients. Methods We conducted a retrospective study of adults admitted to the ICU who received IV ketamine (0.3-0.75 mg/kg over 40 min on three consecutive days) for depressive symptoms. Changes in depressive symptoms were assessed using routine clinical documentation by physicians, nurses, and occupational and physical therapists. Hemodynamic parameters (blood pressure and heart rate) were recorded before and up to 120 min after infusion. The primary outcome was to evaluate depressive symptoms while the secondary outcome was to assess hemodynamic changes post transfusion. Results Thirty-four patients met criteria, including 18 solid organ transplant recipients. Median age was 59 years; 61.8% were male. Ketamine was associated with improvement in apparent sadness (90.0% vs 52.2%, P < .05) and reported sadness (95.0% vs 59.1%, P < .05). In transplant recipients, improvement in apparent sadness remained significant (80.0% vs 41.7%, P < .05). Hemodynamic parameters remained stable; heart rate increased transiently at 15-30 min post-infusion, returning to baseline by 60-90 min. Adverse effects observed were anxiety (12.5%), restlessness and/or agitation (10.4%), and dissociation (8.16%). Conclusion Subanesthetic ketamine improved specific depressive symptoms in critically ill ICU patients without significant hemodynamic instability. These findings support its potential as a rapid-acting antidepressant in the ICU, warranting further prospective trials.

Purpose Despite the need for advanced hemodynamic monitoring, the role of the pulmonary artery catheter (PAC) in cardiogenic shock (CS) remains controversial due to conflicting evidence from previous studies. Material and Methods This single-center retrospective study utilized the MIMIC-IV database to assess the impact of PAC use on 30-day in-hospital mortality and clinical outcomes in CS patients admitted between 2008 and 2019. Propensity score matching (PS) and inverse propensity treatment weighting (IPTW) were employed to adjust for baseline differences. The primary outcome was 30-day in-hospital mortality; secondary outcomes included hospital and ICU length of stay and complications. Cox proportional hazard ratio analyses were performed to evaluate the association between PAC use and mortality outcomes. Results The final cohort consisted of 1940 adult CS patients, with 134 receiving PAC and 1806 not. PAC use significantly reduced 30-day in-hospital mortality (PS-matched HR 0.57, 95% CI: 0.39-0.83; IPTW HR 0.58, 95% CI: 0.35-0.96) but was associated with longer hospital stays (16.47 vs 12.37 days) and ICU stays (9.26 vs 7.52 days). Conclusion PAC use in CS patients was associated with improved short-term survival but also with longer hospitalization and potential complications, underscoring the need for careful patient selection and further research.

AbstractNational performance metrics ultimately enhance patient decision‐making and promote meaningful improvements in health care delivery, which makes having valid and reliable measures essential. This study examined US News and World Report metrics from 2019 to 2012 and used electronic health record data, combined with detailed chart review across 3 in‐system hospitals, to assess the provision of care compared to the attribution of patients assigned to the ear, nose, and throat (ENT) mortality group. Of the initial 47 ENT‐attributed deaths, 23 of those were verified, dimensioning the mortality rate from 1.7% to just 0.8%. These results underscore the necessity of rethinking measures and mortality attribution methodologies to be more accurate. Current methods use Medicare Severity Diagnosis Related Group billing coding to map the attribution. We suggest transitioning away from specialty ranking approaches and towards a procedure and condition “rating” approach to ensure that these ranking types capture data about the provision of care within a given encounter.

Aim This study aims to evaluate the impact of frailty on the outcomes of older patients with pulmonary embolism (PE). Methods Using the National Inpatient Sample database, we identified 288 070 patients aged 65 or older who were admitted with a primary diagnosis of PE from 2017 to 2019. Frailty was assessed using the Hospital Frailty Risk Score (HFRS), and patients were categorized into low‐, intermediate‐, and high‐frailty‐risk groups. Multivariate logistic regression was used to calculate adjusted odds ratios for all outcomes. Results These patients were categorized into low‐risk (57.6%, 161 420), medium‐risk (39.9%, 111 805), and high‐risk (2.5%, 7075) groups. High‐risk patients, predominantly females with multiple comorbidities, exhibited significantly higher mortality rates and adverse outcomes. The HFRS showed a good discriminating ability in predicting mortality (area under the receiver operating characteristic curve = 0.7796). Frailty was associated with increased use of advanced therapeutic interventions and critical care resources such as thrombolysis, catheter‐directed therapies, inferior vena cava filter placement, mechanical ventilation, vasopressor use, and intensive care unit admission. Conclusion Frailty markedly affects outcomes in older PE patients. The HFRS offers a valuable prognostic tool in this population, suggesting that integrating frailty assessments into clinical practice could enhance care strategies and improve patient outcomes. Our findings underscore the need for further research to refine frailty‐based care paradigms. Geriatr Gerontol Int 2024; 24: 924–929 .

AbstractPurposeBy assessing longitudinal associations between COVID‐19 census burdens and hospital characteristics, such as bed size and critical access status, we can explore whether pandemic‐era hospital quality benchmarking requires risk‐adjustment or stratification for hospital‐level characteristics.MethodsWe used hospital‐level data from the US Department of Health and Human Services including weekly total hospital and COVID‐19 censuses from August 2020 to August 2023 and the 2021 American Hospital Association survey. We calculated weekly percentages of total adult hospital beds containing COVID‐19 patients. We then calculated the number of weeks each hospital spent at Extreme (≥20% of beds occupied by COVID‐19 patients), High (10%–19%), Moderate (5%–9%), and Low (<5%) COVID‐19 stress. We assessed longitudinal hospital‐level COVID‐19 stress, stratified by 15 hospital characteristics including joint commission accreditation, bed size, teaching status, critical access hospital status, and core‐based statistical area (CBSA) rurality.FindingsAmong n = 2582 US hospitals, the median(IQR) weekly percentage of hospital capacity occupied by COVID‐19 patients was 6.7%(3.6%–13.0%). 80,268/213,383 (38%) hospital‐weeks experienced Low COVID‐19 census stress, 28% Moderate stress, 22% High stress, and 12% Extreme stress. COVID‐19 census burdens were similar across most hospital characteristics, but were significantly greater for critical access hospitals.ConclusionsUS hospitals experienced similar COVID‐19 census burdens across multiple institutional characteristics. Evidence‐based inclusion of pandemic‐era outcomes in hospital quality reporting may not require significant hospital‐level risk‐adjustment or stratification, with the exception of rural or critical access hospitals, which experienced differentially greater COVID‐19 census burdens and may merit hospital‐level risk‐adjustment considerations.

Computer vision (CV), a type of artificial intelligence (AI) that uses digital videos or a sequence of images to recognize content, has been used extensively across industries in recent years. However, in the healthcare industry, its applications are limited by factors like privacy, safety, and ethical concerns. Despite this, CV has the potential to improve patient monitoring, and system efficiencies, while reducing workload. In contrast to previous reviews, we focus on the end-user applications of CV. First, we briefly review and categorize CV applications in other industries (job enhancement, surveillance and monitoring, automation, and augmented reality). We then review the developments of CV in the hospital setting, outpatient, and community settings. The recent advances in monitoring delirium, pain and sedation, patient deterioration, mechanical ventilation, mobility, patient safety, surgical applications, quantification of workload in the hospital, and monitoring for patient events outside the hospital are highlighted. To identify opportunities for future applications, we also completed journey mapping at different system levels. Lastly, we discuss the privacy, safety, and ethical considerations associated with CV and outline processes in algorithm development and testing that limit CV expansion in healthcare. This comprehensive review highlights CV applications and ideas for its expanded use in healthcare.

AbstractBackgroundPatient Safety Indicator (PSI)‐12, a hospital quality measure designed by Agency for Healthcare Research and Quality (AHRQ) to capture potentially preventable adverse events, captures perioperative venous thromboembolism (VTE). It is unclear how COVID‐19 has affected PSI‐12 performance.ObjectiveWe sought to compare the cumulative incidence of PSI‐12 in patients with and without acute COVID‐19 infection.Design, Setting, and ParticipantsThis was a retrospective cohort study including PSI‐12‐eligible events at three Mayo Clinic medical centers (4/1/2020‐10/5/2021).Exposure, Main Outcomes, and MeasuresWe compared the unadjusted rate and adjusted risk ratio (aRR) for PSI‐12 events among patients with and without COVID‐19 infection using Fisher's exact χ2 test and the AHRQ risk‐adjustment software, respectively. We summarized the clinical outcomes of COVID‐19 patients with a PSI‐12 event.ResultsOur cohort included 50,400 consecutive hospitalizations. Rates of PSI‐12 events were significantly higher among patients with acute COVID‐19 infection (8/257 [3.11%; 95% confidence interval {CI}, 1.35%–6.04%]) compared to patients without COVID‐19 (210/50,143 [0.42%; 95% CI, 0.36%–0.48%]) with a PSI‐12 event during the encounter (p < .001). The risk‐adjusted rate of PSI‐12 was significantly higher in patients with acute COVID‐19 infection (1.50% vs. 0.38%; aRR, 3.90; 95% CI, 2.12–7.17; p < .001). All COVID‐19 patients with PSI‐12 events had severe disease and 4 died. The most common procedure was tracheostomy (75%); the mean (SD) days from surgical procedure to VTE were 0.12 (7.32) days.ConclusionPatients with acute COVID‐19 infection are at higher risk for PSI‐12. The present definition of PSI‐12 does not account for COVID‐19. This may impact hospitals' quality performance if COVID‐19 infection is not accounted for by exclusion or risk adjustment.