Search

BackgroundIt is postulated that early determination of the need for admission can improve flow through EDs. There are several scoring systems which have been developed for predicting patient admission at triage, although they have not been directly compared. In addition, it is not known if these scoring systems perform better than clinical judgement. Therefore, the aim of this study was to validate existing tools in predicting hospital admission during triage and then compare them with the clinical judgement of triage nurses.MethodsTo conduct this prospective, single-centre observational study, we enrolled consecutive adult patients who presented between 30 September 2019 and 25 October 2019 at the ED of a large teaching hospital in Milan, Italy. For each patient, triage nurses recorded all of the variables needed to perform Ambulatory (AMB), Glasgow Admission Prediction (GAP) and Sydney Triage to Admission Risk Tool (START) scoring. The probability of admission was estimated by the triage nurses using clinical judgement and expressed as a percentage from 0 to 100 with intervals of 5. Nurse estimates were dichotomised for analysis, with ≥50% likelihood being a prediction of admission. Receiver operating characteristic curves were generated for accuracy of the predictions. Area under the curve (AUC) with 95% CI for each of the scores and for the nursing judgements was also calculated.ResultsA total of 1710 patients (844 men; median age, 54 years (IQR: 34–75)) and 35 nurses (15 men; median age, 37 years (IQR: 33–48)) were included in this study. Among these patients, 310 (18%) were admitted to hospital from the ED. AUC values for AMB, GAP and START scores were 0.77 (95% CI: 0.74 to 0.79), 0.72 (95% CI: 0.69 to 0.75) and 0.61 (95% CI: 0.58 to 0.64), respectively. The AUC for nurse clinical judgement was 0.86 (95% CI: 0.84 to 0.89).ConclusionAMB, GAP and START scores provided moderate accuracy in predicting patient admission. However, all of the scores were significantly worse than the clinical judgement of the triage nurses.

I pazienti sottoposti alla circolazione extracorporea (ECMO) necessitano di elevati dosaggi di anticoagulante per il buon funzionamento del circuito e ciò li espone ad un alto rischio emorragico. Le sedi più comuni di sanguinamento sono i siti di inserzione delle cannule, la cute e le mucose. Meno frequenti, ma potenzialmente fatali sono invece i sanguinamenti maggiori (polmonari, gastrointestinali, retroperitoneali e del sistema nervoso centrale).

Background At the height of the coronavirus disease 2019 (COVID-19) pandemic, Italy had the highest number of deaths in Europe; most occurred in the Lombardy region. Up to 4% of patients with COVID-19 required admission to an intensive care unit because they developed a critical illness (eg, acute respiratory distress syndrome). Numerous patients with acute respiratory distress syndrome who had been admitted to the intensive care unit required rescue therapy like prone positioning. Objective To describe the respiratory management of and the extensive use of prone positioning in patients with COVID-19 at the intensive care unit hub in Lombardy, Italy. Methods A total of 89 patients (67% male; median age, 59 years [range, 23-80 years]) with confirmed COVID-19 who were admitted between February 23 and March 31, 2020, were enrolled in this quality improvement project. Results Endotracheal intubation was required in 86 patients (97%). Prone positioning was used as rescue therapy in 43 (48%) patients. Significantly more younger patients (age ≤ 59 years) were discharged alive (43 of 48 [90%]) than were older patients (age ≥ 60 years; 26 of 41 [63%]; P < .005). Among the 43 patients treated with prone ventilation, 15 (35% [95% CI, 21%-51%]) died in the intensive care unit, of which 10 (67%; P < .001) were older patients. Conclusions Prone positioning is one strategy available for treating acute respiratory distress syndrome in patients with COVID-19. During this pandemic, prone positioning can be used extensively as rescue therapy, per a specific protocol, in intensive care units.

BackgroundRespiratory physiotherapy is reported as safe and feasible in mechanically ventilated patients with severe Coronavirus Disease (COVID-19) admitted to Intensive Care Unit (ICU), but the short-term benefits remain unclear.MethodsWe performed a retrospective observational study in four ICUs in Northern Italy. All patients with COVID-19 admitted to ICU and under invasive mechanical ventilation (MV) between March 1st and May 30th, 2020, were enrolled into the study. Overlap weighting based on the propensity score was used to adjust for confounding in the comparison of patients who had or had not been treated by physiotherapists. The primary outcome was the number of days alive and ventilator-free (VFDs). The secondary outcomes were arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio (P/F) at ICU discharge, ICU length of stay, ICU and hospital mortality, and survival at 90 days. The trial protocol was registered on clinicaltrials.gov (NCT 05067907).ResultsA total of 317 patients were included in the analysis. The median VFDs was 18 days [interquartile range (IQR) 10; 24] in patients performing physiotherapy and 21 days (IQR 0; 26) in the group without physiotherapy [incidence rate ratio (IRR) 0.86, 95% confidence interval (CI): 0.78; 0.95]. The chance of 0 VFDs was lower for patients treated by physiotherapists compared to those who were not [odds ratio (OR) = 0.36, 95% CI: 0.18–0.71]. Survival at 90 days was 96.0% in the physiotherapy group and 70.6% in patients not performing physiotherapy [hazard ratio (HR) = 0.14, 95% CI: 0.03–0.71]. Number of VFDs was not associated with body mass index (BMI), sex, or P/F at ICU admission for individuals with at least 1 day off the ventilator.ConclusionIn patients with COVID-19 admitted to ICU during the first pandemic wave and treated by physiotherapists, the number of days alive and free from MV was lower compared to patients who did not perform respiratory physiotherapy. Survival at 90 days in the physiotherapy group was greater compared to no physiotherapy. These findings may be the starting point for further investigation in this setting.

Background In the last decade, access to national palliative care programs have improved, however a large proportion of patients continued to die in hospital, particularly within internal medicine wards. Objectives To describe treatments, symptoms and clinical management of adult patients at the end of their life and explore whether these differ according to expectation of death. Methods Single-centre cross-sectional study performed in the medical and surgical wards of a large tertiary-level university teaching hospital in the north of Italy. Data on nursing interventions and diagnostic procedure in proximity of death were collected after interviewing the nurse and the physician responsible for the patient. Relationship between nursing treatments delivered and patients’ characteristics, quality of dying and nurses’ expectation about death was summarized by means of multiple correspondence analysis (MCA). Results Few treatments were found statistically associated with expectation of death in the 187 patients included. In the last 48 h, routine (70.6%) and biomarkers (41.7%) blood tests were performed, at higher extent on patients whose death was not expected. Many symptoms classified as severe were reported when death was highly expected, except for agitation and respiratory fatigue which were reported when death was moderately expected. A high Norton score and absence of anti-bedsore mattress were associated with unexpected death and poor quality of dying, as summarized by MCA. Quality of dying was perceived as good by nurses when death was moderately and highly expected. Physicians rated more frequently than nurses the quality of dying as good or very good, respectively 78.6 and 57.8%, denoting a fair agreement between the two professionals (k = 0.24, P Conclusion Staff in medical and surgical wards still deal inadequately with the needs of dying people. Presence of hospital-based specialist palliative care could lead to improvements in the patients’ quality of life.

Objective To evaluate the muscle strength and functional level of patients discharged from intensive care unit (ICU) in relation to the swimmer position as a nurse intervention during pronation. Methods Prospective study conducted in the hub COVID-19 center in Milan (Italy), between March and June 2020. All patients with COVID-19 discharged alive from ICU who received invasive mechanical ventilation were included. Forward continuation ratio model was fitted to explore the statistical association between muscle strength grades and body positioning during ICU stay. Results Over the 128 patients admitted to ICU, 87 patients were discharged alive from ICU, with available follow-up measures at hospital discharge. Thirty-four patients (39.1%) were treated with prone positioning as rescue therapy, for a total of 106 pronation cycles with a median duration of 72 hours (IQR 60–83). Prone positioning did not influence the odds of showing particular level of muscle strength, in any of the evaluated districts, namely shoulder (OR 1.34, 95%CI:0.61–2.97), elbow (OR 1.10, 95%CI:0.45–2.68) and wrist (OR 0.97, 95%CI:0.58–1.63). Only in the shoulder district, age showed evidence of association with strength (OR 1.06, 95%CI:1.02–1.10), affecting people as they get older. No significant sequalae related to swimmer position were reported by physiotherapists or nurses. Conclusion Swimmer position adopted during prone ventilation is not associated with worse upper limb strength or poor mobility level in COVID-19 survivors after hospital discharge.

Background Careful hand hygiene of healthcare workers is recommended to reduce transmission of pathogenic microorganisms to patients. Mobile phones are commonly used during work shifts and may act as vehicles of pathogens. Objective To assess the colonizsation rate of intensive care unit healthcare workers’ mobile phones before and after work shifts. Methods Prospective observational study conducted in an academic, tertiary-level intensive care unit. Healthcare workers (including doctors, nurses and healthcare assistants) had their mobile phones sampled for microbiology before and after work shifts. Samples were taken with a swab in a standardizsed modality. Results Fifty healthcare workers participated in the study (91% of the department staff). One hundred swabs were taken from 50 mobile phones. Forty-three healthcare workers (86%) reported a habitual use of their phones during the work shift. All phones (100%) were positive for bacteria. The most frequently isolated bacteria were Coagulase Negative Staphylococci, Bacillus sp. and Methicillin-resistant Staphylococcus aureus (97%, 56%, 17%, respectively). No patient admitted to the intensive care unit during the study period was positive for bacteria found on healthcare workers’ mobile phones. No difference in bacteria types and burden was found between the beginning and the end of work shifts. Conclusion Healthcare workers’ mobile phones are colonized even before the work shift and irrespective of the patients’ microbiological flora.

In early March 2020, Italy became the epicenter of the Coronavirus Disease 2019 (COVID-19) pandemic in Europe. A different organization of hospital units was required to take care of patients affected by acute respiratory failure caused by COVID-19. This study aimed to evaluate the prevalence of burnout in two sub-intensive care units (SICUs) of the COVID-19 hub center of the Lombardia region in Milan (Italy). All nurses and healthcare assistants working in the SICUs during June 2020 were included in the study. Burnout was assessed via the Maslach Burnout Inventory questionnaire. One hundred and five (84%) SICU staff participated in the study. The prevalence of high burnout for nurses and healthcare assistants was 61.9% for emotional exhaustion, 47.6% for depersonalization and 34.3% for personal accomplishment. Depersonalization was significantly more frequent in younger nurses (p = 0.009). Nurses were 4.5 times more likely to have burnout than healthcare assistants. Burnout was a common condition among healthcare workers operating in SICUs during the pandemic. Urgent actions are needed, especially for nurses, as well as preventive strategies for future pandemic scenarios.

During the Coronavirus disease 2019 (COVID-19), a general decrease in the presentations to emergency departments (ED) was reported. However, we suspect that there was a lower number but an unchanged pattern of ED visits for urgent conditions in 2020 compared to 2019. This retrospective study assessed the change in the number of presentations in the ED of a tertiary level university hospital in Milano (Lombardia, Italy). Compared to 2019, a significant drop in ED presentations occurred (−46.4%), and we recorded a −15.7% difference in the proportion of patients admitted with white codes. The pattern of hourly presentations to the ED was unchanged, with overcrowding during the working daytime. COVID-19 changed ED flows, likely causing an overall reduction in the number of deferrable conditions. However, the pattern associated with urgent conditions did not change abruptly in 2020.

The prediction fo Hospitalization in triage: a comparison of instruments and methods of evaluation. A systematic revision.Overcrowding in the emergency department causes called-boarding, in addition to the increase of the waiting times, high costs and unsatisfied patients. Boarded patients are those admitted to an inpatient unit in the hospital that continue to wait in the emergency department for a bed to become available. The adoption of tools and methods to help the clinician to predict the admission in the triage phase could significantly improve patients flow.To analyze and compare different tools and methods and to predict the hospitalization in the triage phase for adult patients.A systematic review was conducted by querying the PubMed and Cochrane databases, limited to the last 10 years articles.Ten longitudinal observational studies analyzed the variables associated with admission, predictive ability of the clinical judgment of the triage nurse, predictive ability of validated objective scores, and cross compared the various methods of predicting admission. The variable most associated with admission was advanced age; both the clinical judgment of the triage nurse and the various scores showed a good predictive ability; the association of the clinical judgment of the triage nurse with one of the scores would offer more accurate predictions.The ability to predict admission in the triage, through the use of validated scores and the clinical judgment of the triage nurse, could be the first step to reduce the boarding phenomenon and to improve the flow in the emergency department.

During COVID-19 pandemic, the recruitment of new personnel was necessary to guarantee an adequate healthcare level to all patients affected by SARS-CoV-2 virus. In order to deal with the sanitary emergency, unusual selection procedures have been adopted inside the public health system by searching for new healthcare personnel. The recruitment of new candidates with a short self-introduction was very effective and permitted to select 65 nurses.

To investigate the association between time to active sitting position and clinical features in people with COVID-19 admitted to intensive care unit (ICU) and referred to physiotherapists.Prospective study conducted in the largest temporary ICU in Lombardy (Italy) between April 2020 and June 2021. All individuals with COVID-19 who received physiotherapy were included. Multivariable Cox proportional hazard model was fitted to explore the statistical association between active sitting position and characteristics of patients referred to physiotherapists, also accounting for the different multidisciplinary teams responsible for patients.284 individuals over 478 (59.4%) had access to physiotherapy, which was performed for a median of 8 days, without difference between multidisciplinary teams (P = 0.446). The active sitting position was reached after a median of 18 (IQR: 10.0-32.0) days. Sex was the only characteristic associated with the time to active sitting position, with males showing a reduced hazard by a factor of 0.65 (95% CI: 0.48-0.87; P = 0.0042) compared to females. At ICU discharge, nearly 50% individuals increased Manchester Mobility Score by 3 points. During physiotherapy no major adverse event was recorded.Individuals with COVID-19 take long time to reach active sitting position in ICU, with males requiring longer rehabilitation than females.

Objective To determine the prevalence of complications in patients with COVID-19 undergone prone positioning, focusing on the development of prone-related pressure ulcers. Methods Cross-sectional study conducted in the hub COVID-19 center in Milan (Italy), between March and June 2020. All patients with COVID-19 admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning were included. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. Results A total of 219 proning cycles were performed on 63 patients, aged 57.6 (10.8) and predominantly obese males (66.7%). The main complications recorded were: prone-related pressure ulcers (30.2%), bleeding (25.4%) and medical device displacement (12.7%), even if none unplanned extubation was recorded. Bleeding of upper airways represented the most common site (17.5%). Only 15 prone positioning cycles (6.8%) were interrupted, requiring staff to roll the patient back in the supine position. The likelihood of pressure ulcers development was independently associated with the duration of prone positioning, once adjusting for age, hypoxemic level, and nutritional status (OR 1.9, 95%CI 1.04 to 3.6). Conclusion The use of prone positioning in patients with COVID-19 was a safe and feasible treatment, also in obese patients, who might deserve more surveillance and active prevention by intensive care unit staff.

Background The high-flow nasal cannula (HFNC) delivers up to 60 l/min of humidified air/oxygen blend at a temperature close to that of the human body. In this study, we tested whether higher temperature and flow decrease patient comfort. In more severe patients, instead, we hypothesized that higher flow might be associated with improved comfort. Methods A prospective, randomized, cross-over study was performed on 40 acute hypoxemic respiratory failure (AHRF) patients (PaO2/FiO2 ≤ 300 + pulmonary infiltrates + exclusion of cardiogenic edema) supported by HFNC. The primary outcome was the assessment of patient comfort during HFNC delivery at increasing flow and temperature. Two flows (30 and 60 l/min), each combined with two temperatures (31 and 37 °C), were randomly applied for 20 min (four steps per patient), leaving clinical FiO2 unchanged. Toward the end of each step, the following were recorded: comfort by Visual Numerical Scale ranging between 1 (extreme discomfort) and 5 (very comfortable), together with respiratory parameters. A subgroup of more severe patients was defined by clinical FiO2 ≥ 45%. Results Patient comfort was reported as significantly higher during steps at the lower temperature (31 °C) in comparison to 37 °C, with the HFNC set at both 30 and 60 l/min (p

Background Positive end-expiratory pressure (PEEP) is a key element of mechanical ventilation. It should optimize recruitment, without causing excessive overdistension, but controversy exists on the best method to set it. The purpose of the study was to test the feasibility of setting PEEP with electrical impedance tomography in order to prevent lung de-recruitment following a recruitment maneuver. We enrolled 16 patients undergoing mechanical ventilation with PaO2/FiO2

Risk factors for delirium in intensive care unit in liver transplant patients.Delirium is a disorder of the state of consciousness characterized by acute onset and temporal variability of cognitive abilities. It is frequent in intensive care unit (ICU) and it is associated with worst outcomes.To identify risk factors for the development of delirium in patients in intensive care unit (ICU) after orthotopic liver transplantation (OLTx).Observational retrospective study on all the patients undergoing OLTx between January 2014 and December 2015. The daily assessment for delirium was performed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), by nemed nurses.Of the 123 patients included, 15 (12.2%) developed post-operative delirium. The main risk factor was preoperative hepatic encephalopathy (OR = 8.80, 95% CI 2.70-28.59): the deterioration of the state of consciousness (GCS pre-OLTx score15) increased the risk of developing delirium (OR 6.18; IC 95% 1.51 - 25.31). A high Acute Physiologic and Health Evaluation (APACHE II) score (OR=1.29, IC 95%: 1.12-1.47) showed how patients with a more severe clinical situation at ICU admission were more likely to develop delirium.The risk factors identified predict the development of delirium in ICU. Its prevention with the implementation of pharmacological or other strategies may reduce the onset of delirium and improve the quality of care.

Background: Urinary tract infections (UTIs) are the most common type of healthcare associated infection in acute care hospitals. Most involve urinary drainage devices, such as urinary catheter. The objective of this study was to investigate the prevalence of catheter-associated urinary tract infections in adult patients of a tertiary level university hospital.Methods: The point prevalence study was conducted in one single day and included all adult patients admitted in medical, surgical wards and intensive care units. The Centre for Disease Control (CDC) criteria were adopted to classify the different type of UTIs.Results: Out of a total of 497 adult inpatients, 94 patients had a urinary catheter for at least 48 hours. The prevalence of symptomatic urinary tract infection (SUTI) in this sample is 17%. Escherichia coli (31.2%), Enterococcus faecium (25.0%) and Enterococcus faecalis (12.5%) are the most common pathogens found.Conclusions: The main isolated uropathogens in this study are Gram-negative and Escherichia coli remains one of the most frequent cause of UTIs in human. Gram-negative pathogens have multiple virulent factors responsible for their adherence to uroepithelium and urinary catheter positioning facilitates the transmission of these pathogens to urinary tract. Urinary catheterization is frequently used as solution to facilitate continence and maintain skin integrity in elderly patients. Urinary incontinence frequently is an example of inappropriate use of urinary catheter: for that reason, urinary catheter should be considered as the last option if other solution, like incontinence pads, are not indicated.