Hospital Variation in Management and Outcomes of Acute Respiratory Distress Syndrome Due to COVID-19

Johnson, Samantha; Garcia, Michael A.; Sisson, Emily; Sheldrick, R. Christopher; Kumar, Vishakha; Boman, Karen; Bolesta, Scott; Bansal, Vikas; Lal, Amos; Domecq, J. P.; Melamed, Roman; Christie, A.B.; Husain, Abdurrahman; Yus, S.; Gajic, Ognjen; Kashyap, Rahul; Walkey, Allan J.

doi:10.1097/cce.0000000000000638

Cited by 14 publications

(14 citation statements)

References 30 publications

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“…Despite well established, evidence-based principles for lung protective ventilation, 4 , 5 wide variation in the management of ARDS across hospitals continues in practice, with up to half of patients not receiving care consistent with guideline recommendations during the first year of the COVID-19 pandemic. 80 The identification of driving pressure as an important prognostic factor, based on high-certainty evidence, is consistent with existing evidence showing that this ventilation variable is strongly associated with mortality in patients with ARDS. 81 , 82 Additionally, we found that a longer duration of invasive mechanical ventilation (most commonly defined by a 7-day threshold) and a higher PaCO 2 are poor prognostic signs.…”

Section: Discussionsupporting

confidence: 83%

Prognostic factors associated with mortality among patients receiving venovenous extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis

Tran¹,

Fernando²,

Rochwerg³

et al. 2023

The Lancet Respiratory Medicine

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Section: Discussionsupporting

confidence: 83%

Prognostic factors associated with mortality among patients receiving venovenous extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis

Tran¹,

Fernando²,

Rochwerg³

et al. 2023

The Lancet Respiratory Medicine

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“…Our study captured intensivist workload, measured as the number of patients cared for. Study ICUs were primarily recruited through SCCM’s Discovery Network and were similar to ICUs and patients represented in other Discovery network studies ( 32 , 33 ). The overall prevalence of burnout in our cohort of ICU physicians was 26.4%, and there was no difference in the prevalence of burnout between physicians with high workload (>14 patients per physician) versus low workload (≤14 patients per physician).…”

Section: Discussionmentioning

confidence: 99%

SWEAT ICU—An Observational Study of Physician Workload and the Association of Physician Outcomes in Academic ICUs

Agarwal

Chen

Coopersmith

et al. 2022

Critical Care Explorations

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OBJECTIVES: The optimal staffing model for physicians in the ICU is unknown. Patient-to-intensivist ratios may offer a simple measure of workload and be associated with patient mortality and physician burnout. To evaluate the association of physician workload, as measured by the patient-to-intensivist ratio, with physician burnout and patient mortality. DESIGN: Cross-sectional observational study. SETTING: Fourteen academic centers in the United States from August 2020 to July 2021. SUBJECTS: We enrolled ICU physicians and collected data on adult ICU patients under the physician’s care on the single physician-selected study day for each physician. MEASUREMENTS and MAIN RESULTS: The primary exposure was workload (self-reported number of patients’ physician was responsible for) modeled as high (>14 patients) and low (≤14 patients). The primary outcome was burnout, measured by the Well-Being Index. The secondary outcome measure was 28-day patient mortality. We calculated odds ratio for burnout and patient outcomes using a multivariable logistic regression model and a binomial mixed effects model, respectively. We enrolled 122 physicians from 62 ICUs. The median patient-to-intensivist ratio was 12 (interquartile range, 10–14), and the overall prevalence of burnout was 26.4% ( n = 32). Intensivist workload was not independently associated with burnout (adjusted odds ratio, 0.74; 95% CI, 0.24–2.23). Of 1,322 patients, 679 (52%) were discharged alive from the hospital, 257 (19%) remained hospitalized, and 347 (26%) were deceased by day 28; 28-day outcomes were unknown for 39 of patients (3%). Intensivist workload was not independently associated with 28-day patient mortality (adjusted odds ratio, 1.33; 95% CI, 0.92–1.91). CONCLUSIONS: In our cohort, approximately one in four physicians experienced burnout on the study day. There was no relationship be- tween workload as measured by patient-to-intensivist ratio and burnout. Factors other than the number of patients may be important drivers of burnout among ICU physicians.

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“…During the COVID-19 pandemic, some studies suggested that 25-62% of patients with COVID-19associated ARDS were managed with prone positioning (14)(15)(16)(17)(18)(19). However, whether this greater use of proning was concordant with evidence-based recommendations (i.e., proning sessions of at least 12-16 consecutive hours (hr) in early moderate-to-severe ARDS) (1,4) is unknown.…”

mentioning

confidence: 99%

Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome

Hochberg

Psoter

Sahetya

et al. 2022

Critical Care Explorations

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IMPORTANCE:Use of prone positioning in patients with acute respiratory distress syndrome (ARDS) from COVID-19 may be greater than in patients treated for ARDS before the pandemic. However, the magnitude of this increase, sources of practice variation, and the extent to which use adheres to guidelines is unknown. OBJECTIVES:To compare prone positioning practices in patients with COVID-19 ARDS versus ARDS treated before the pandemic. DESIGN, SETTING, AND PARTICIPANTS:We conducted a multicenter retrospective cohort study of mechanically ventilated patients with early moderateto-severe ARDS from COVID-19 (2020COVID-19 ( -2021 or ARDS from non-COVID-19 pneumonia (2018)(2019) across 19 ICUs at five hospitals in Maryland. MAIN OUTCOMES AND MEASURES:The primary outcome was initiation of prolonged prone positioning (≥ 16 hr) within 48 hours of meeting oxygenation criteria. Comparisons were made between cohorts and within subgroups including academic versus community hospitals, and medical versus nonmedical ICUs. Other outcomes of interest included time to proning initiation, duration of prone sessions and temporal trends in proning frequency. RESULTS:Proning was initiated within 48 hours in 227 of 389 patients (58.4%) with COVID-19 and 11 of 123 patients (8.9%) with historic ARDS (49.4% absolute increase [95% CI for % increase, 41.7-57.1%]). Comparing COVID-19 to historic ARDS, increases in proning were similar in academic and community settings but were larger in medical versus nonmedical ICUs. Proning was initiated earlier in COVID-19 versus historic ARDS (median hours (hr) from oxygenation criteria, 12.9 vs 30.6; p = 0.002) and proning sessions were longer (median hr, 43.0 vs 28.0; p = 0.01). Proning frequency increased rapidly at the beginning of the pandemic and was sustained. CONCLUSIONS AND RELEVANCE:We observed greater overall use of prone positioning, along with shorter time to initiation and longer proning sessions in ARDS from COVID-19 versus historic ARDS. This rapid practice change can serve as a model for implementing evidence-based practices in critical care.

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Hospital Variation in Management and Outcomes of Acute Respiratory Distress Syndrome Due to COVID-19

Cited by 14 publications

References 30 publications

Prognostic factors associated with mortality among patients receiving venovenous extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis

Prognostic factors associated with mortality among patients receiving venovenous extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis

SWEAT ICU—An Observational Study of Physician Workload and the Association of Physician Outcomes in Academic ICUs

Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome

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