Matthew E. Lissauer

BACKGROUND: Hospital-based violence intervention programs (HVIPs) effectively reduce recidivism and improve outcomes, but their impact on posthospitalization service utilization for patients with penetrating injuries is unclear. OBJECTIVE: The aim of this article is to evaluate the impact of an HVIP on posthospitalization service utilization among patients with penetrating injuries. METHODS: A retrospective cohort study was conducted at our urban academic Level I trauma center in the Northeastern United States to assess posthospitalization service utilization, including inpatient rehabilitation and home health services, among patients with gunshot or stab wounds during the first year of HVIP implementation (October 2022–September 2023). Comparisons between the HVIP and non-HVIP groups were made using Mann–Whitney U and Chi-square/Fisher’s exact tests. Multivariate logistic regression evaluated predictors of posthospitalization service utilization. RESULTS: Of the 192 patients, 62 were HVIP, and 130 were non-HVIP. The HVIP patients were younger (31 vs. 35 years; p = .010) and more likely to be injured by gunfire (77.4% vs. 45.4%; p < .001), with a higher median Injury Severity Score (4 vs. 1; p = .029). Posthospitalization service utilization was significantly higher in HVIP patients (25.8% vs. 9.2%; p = .002). Predictors of posthospitalization service utilization included hospital admission (OR: 10.5, p = .033), Hispanic ethnicity (OR: 3.2, p = .035), and higher Injury Severity Score (OR: 1.2, p < .001). The HVIP involvement had a positive but nonsignificant association (OR: 2.5, p = .078). CONCLUSIONS: Hospital-based violence intervention programs may increase posthospitalization service utilization and promote health equity for patients with penetrating injuries. Larger studies are needed to confirm these findings.

Background: Recent literature suggests respiratory system compliance (Crs) based phenotypes exist among COVID-19 ARDS patients. We sought to determine whether these phenotypes exist and whether Crs predicts mortality. Methods: A retrospective observational cohort study of 111 COVID-19 ARDS patients admitted March 11-July 8, 2020. Crs was averaged for the first 72-hours of mechanical ventilation. Crs<30ml/cmH2 O was defined as poor Crs(phenotype-H) whereas Crs≥30ml/ cmH2 O as preserved Crs(phenotype-L). Results: 111 COVID-19 ARDS patients were included, 40 phenotype-H and 71 phenotype-L. Both the mean PaO2/FiO2 ratio for the first 72-hours of mechanical ventilation and the PaO2/FiO2 ratio hospital nadir were lower in phenotype-H than L(115[IQR87] vs 165[87], p=0.016), (63[32] vs 75[59], p=0.026). There were no difference in characteristics, diagnostic studies, or complications between groups. Twenty-seven (67.5%) phenotype-H patients died vs 37(52.1%) phenotype-L(p=0.115). Multivariable regression did not reveal a mortality difference between phenotypes; however, a 2-fold mortality increase was noted in Crs50ml/cmH2 O when analyzing ordinal Crs groups. Moving up one group level (ex. Crs30-39.9ml/cmH2 O to 40-49.9ml/cmH2 O), was marginally associated with 14% lower risk of death(RR=0.86, 95%CI 0.72, 1.01, p=0.065). This attenuated (RR=0.94, 95%CI 0.80, 1.11) when adjusting for pH nadir and PaO2/FiO2 ratio nadir. Conclusion: We identified a spectrum of Crs in COVID-19 ARDS similar to Crs distribution in non-COVID-19 ARDS. While we identified increasing mortality as Crs decreased, there was no specific threshold marking significantly different mortality based on phenotype. We therefore would not define COVID-19 ARDS patients by phenotypes-H or L and would not stray from traditional ARDS ventilator management strategies.

While fever may be a presenting symptom of COVID-19, fever at hospital admission has not been identified as a predictor of mortality. However, hyperthermia during critical illness among ventilated COVID-19 patients in the ICU has not yet been studied. We sought to determine mortality predictors among ventilated COVID-19 ICU patients and we hypothesized that fever in the ICU is predictive of mortality. We conducted a retrospective cohort study of 103 ventilated COVID-19 patients admitted to the ICU between March 14 and May 27, 2020. Final follow-up was June 5, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded. 103 patients were included, 40 survived and 63(61.1%) died. Deceased patients were older {66 years[IQR18] vs 62.5[IQR10], (p = 0.0237)}, more often male {48(68%) vs 22(55%), (p = 0.0247)}, had lower initial oxygen saturation {86.0%[IQR18] vs 91.5%[IQR11.5], (p = 0.0060)}, and had lower pH nadir than survivors {7.10[IQR0.2] vs 7.30[IQR0.2] (p < 0.0001)}. Patients had higher peak temperatures during ICU stay as compared to hospital presentation {103.3°F[IQR1.7] vs 100.0°F[IQR3.5], (p < 0.0001)}. Deceased patients had higher peak ICU temperatures than survivors {103.6°F[IQR2.0] vs 102.9°F[IQR1.4], (p = 0.0008)}. Increasing peak temperatures were linearly associated with mortality. Febrile patients who underwent targeted temperature management to achieve normothermia did not have different outcomes than those not actively cooled. Multivariable analysis revealed 60% and 75% higher risk of mortality with peak temperature greater than 103°F and 104°F respectively; it also confirmed hyperthermia, age, male sex, and acidosis to be predictors of mortality. This is one of the first studies to identify ICU hyperthermia as predictive of mortality in ventilated COVID-19 patients. Additional predictors included male sex, age, and acidosis. With COVID-19 cases increasing, identification of ICU mortality predictors is crucial to improve risk stratification, resource management, and patient outcomes.

Acute care surgery (ACS) services have evolved in an effort to provide 24-h surgical services for a wide array of general surgical emergencies. The formation of ACS services has been shown to improve outcomes and lead to more expeditious care. Despite the advances of ACS, the etiology and timing of patient mortality has yet to be described. We hypothesized that infectious complications occur more frequently in ACS patients that die during their hospitalization.

Background. No randomized trials have examined the effect of contact precautions or universal glove and gown use on adverse events. We assessed if wearing gloves and gowns during all patient contact in the intensive care unit (ICU) changes adverse event rates. Methods. From January 2012 to October 2012, intervention ICUs of the 20-site Benefits of Universal Gloving and Gowning cluster randomized trial required that healthcare workers use gloves and gowns for all patient contact. We randomly sampled 1800 medical records of adult patients not colonized with antibiotic-resistant bacteria and reviewed them for adverse events using the Institute for Healthcare Improvement Global Trigger Tool. Results. Four hundred forty-seven patients (24.8%) had 1 or more ICU adverse events. Adverse events were not associated with universal glove and gown use (incidence rate ratio [IRR], 0.81; 95% confidence interval [CI], .48–1.36). This did not change with adjustment for ICU type, severity of illness, academic hospital status, and ICU size, (IRR, 0.91; 95% CI, .59–1.42; P = .68). Rates of infectious adverse events also did not differ after adjusting for the same factors (IRR, 0.75; 95% CI, .47–1.21; P = .24). Conclusions. In ICUs where healthcare workers donned gloves and gowns for all patient contact, patients were no more likely to experience adverse events than in control ICUs. Concerns of adverse events resulting from universal glove and gown use were not supported. Similar considerations may be appropriate regarding use of contact precautions. Clinical Trials Registration. NCT0131821.

Introduction. Vascular surgery patients have multiple risk factors for renal dysfunction, but acute kidney injury (AKI) is poorly studied in this group. The purpose of this study was to define the incidence, risk factors and outcomes of AKI in high risk vascular patients. Methods. Critically ill vascular surgery patients admitted during January – December 2012 were retrospectively analyzed with 1-year follow-up. The endpoint was AKI by established RIFLE creatinine criteria. The primary analysis was between patients with or without AKI, with secondary analysis of postoperative AKI. Outcomes were inpatient and 1-year mortality, inpatient lengths of stay, and discharge renal function. Results. 136 vascular surgery patients were included, representing 27% of all vascular surgery admissions during the study period. 65 (48%) developed AKI. Independent global risk factors for AKI were diabetes, increasing critical illness severity, and sepsis. While intraoperative blood loss and hypotension were associated with subsequent renal dysfunction, postoperative AKI rates were similar for patients undergoing aortic, carotid, endovascular, or peripheral vascular procedures, All RIFLE grades of AKI were associated with worse outcomes. Overall, patients with AKI had significantly increased short and long-term mortality, longer inpatient lengths of stay, and worse discharge renal function. Conclusions. AKI is common among critically ill vascular surgery patients. Importantly, the type of surgical procedure appears to be less important than intra- and perioperative management in determining renal dysfunction. Regardless of its severity, AKI is a clinically significant complication that is associated with substantially worse patient outcomes.