OBJECTIVES

Clinical pathways (CPs) ensure adherence to heart failure (HF) management guidelines. To optimize quality care in a low resource setting, an evidence-based care pathway for the management of acute HF was implemented at the emergency department (ED) of the Philippine General Hospital (PGH), the designated national tertiary hospital and referral center. This study aimed to describe the characteristics of adults with acute HF admitted at the ED and evaluate the quality of care they received, measured using physician adherence to the hospital’s acute heart failure CP.

METHODS

This was a retrospective, descriptive cohort study. We reviewed the inpatient charts of all adult patients with acute HF admitted to the ED of the PGH and referred to the Division of Cardiovascular Medicine between December 1, 2022 and May 31, 2023. Quality of care was assessed based on adherence to quality indicators adapted from routine and conditional order sets detailed in the pathway. Descriptive statistics was utilized to describe patient characteristics, quality of care, and outcomes.

RESULTS

Two hundred thirty-six (236) patients were included, with a mean age of 51.8 years. Majority were male (53.4%); hypertension (61.4%) and ischemic heart disease (53.8%) were the most common comorbidities, and infection the most common precipitant of decompensation (60.6%). There were optimal adherence rates to routine orders, which included referrals to Internal Medicine and Cardiology, baseline vital signs monitoring, fluid intake and output monitoring, chest radiograph, complete blood count, blood urea nitrogen, sodium, potassium, prothrombin time, partial thromboplastin time, arterial blood gas, urinalysis, and N-terminal pro b-type natriuretic peptide. Conditional orders, such as oxygen support, focused echocardiography, thyroid - stimulating hormone, and the use of vasopressors, diuretics, and venous thromboembolism prophylactic agents, were optimally performed when warranted. However, we noted suboptimal adherence to certain resource-intensive conditional orders, such as hourly monitoring of urine output (61.4%), hooking to cardiac monitor (53.8%), and performance of 12-lead ECG within 10 minutes (56.8%). Further, only 43.9% of patients were referred to the intensive care unit. Troponin I, calcium, magnesium, and albumin were ordered in excess.

CONCLUSION

Overall adherence rate of physicians to the hospital’s Acute Heart Failure Pathway was satisfactory. Work is needed to improve adherence to hourly urine output monitoring, consistent hooking to cardiac monitor, and timely performance of 12-lead ECG – an effort that begins with expanding in-hospital diagnostic equipment and human resource supply. We recommend continuous pathway implementation with periodic evaluation and stakeholder feedback to further improve quality of care.

Human ; Male ; Female ; Middle Aged: 45-64 Yrs Old ; Adult ; Albumins ; Blood ; Blood Urea Nitrogen ; Calcium ; Cardiology ; Chart ; Charts ; Cohort Studies ; Critical Care ; Critical Pathways ; Diagnostic Equipment ; Disease ; Diuretics ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Equipment And Supplies ; Evaluation Studies As Topic ; Feedback ; Heart ; Heart Diseases ; Heart Failure ; Hormones ; Hospitals ; Hospitals, General ; Humans ; Hypertension ; Indicators And Reagents ; Infection ; Infections ; Inpatients ; Intensive Care Units ; Internal Medicine ; Lead ; Magnesium ; Male ; Medicine ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Natriuretic Peptides ; Nitrogen ; Overall ; Oxygen ; Partial Thromboplastin Time ; Patients ; Peptides ; Philippines ; Physicians ; Potassium ; Prothrombin ; Prothrombin Time ; Quality Of Health Care ; Referral And Consultation ; Sodium ; Statistics ; Tertiary Care Centers ; Thorax ; Thromboembolism ; Thromboplastin ; Thyroid Gland ; Time ; Troponin ; Troponin I ; Universities ; Urea ; Urinalysis ; Urine ; Venous Thromboembolism ; Vital Signs ; Work ; Workforce

PURPOSE: Septic shock is associated with high mortality and poor outcomes among sepsis patients with coagulopathy. Although traditional statistical methods or machine learning (ML) algorithms have been proposed to predict septic shock, these potential approaches have never been systematically compared. The present work aimed to develop and compare models to predict septic shock among patients with sepsis. METHODS: It is a retrospective cohort study based on 484 patients with sepsis who were admitted to our intensive care units between May 2018 and November 2022. Patients from the 908th Hospital of Chinese PLA Logistical Support Force and Nanchang Hongdu Hospital of Traditional Chinese Medicine were respectively allocated to training (n=311) and validation (n=173) sets. All clinical and laboratory data of sepsis patients characterized by comprehensive coagulation indexes were collected. We developed 5 models based on ML algorithms and 1 model based on a traditional statistical method to predict septic shock in the training cohort. The performance of all models was assessed using the area under the receiver operating characteristic curve and calibration plots. Decision curve analysis was used to evaluate the net benefit of the models. The validation set was applied to verify the predictive accuracy of the models. This study also used Shapley additive explanations method to assess variable importance and explain the prediction made by a ML algorithm. RESULTS: Among all patients, 37.2% experienced septic shock. The characteristic curves of the 6 models ranged from 0.833 to 0.962 and 0.630 to 0.744 in the training and validation sets, respectively. The model with the best prediction performance was based on the support vector machine (SVM) algorithm, which was constructed by age, tissue plasminogen activator-inhibitor complex, prothrombin time, international normalized ratio, white blood cells, and platelet counts. The SVM model showed good calibration and discrimination and a greater net benefit in decision curve analysis. CONCLUSION The SVM algorithm may be superior to other ML and traditional statistical algorithms for predicting septic shock. Physicians can better understand the reliability of the predictive model by Shapley additive explanations value analysis.
Humans ; Shock, Septic/blood* ; Machine Learning ; Male ; Female ; Retrospective Studies ; Middle Aged ; Aged ; Sepsis/complications* ; ROC Curve ; Cohort Studies ; Adult ; Intensive Care Units ; Algorithms ; Blood Coagulation ; Critical Illness

The establishment and development of neonatal intensive care unit(NICU)have significantly increased the survival rate of premature infants.However,the diagnosis,treatment,and surgeries performed in NICU may expose neonates to more noxious stimuli.As the neonatal period is crucial for brain development,these noxious stimuli may cause irreversible damage to the neonatal nervous system.Existing clinical studies have shown that repetitive noxious stimuli during the neonatal period can lead to poor brain development,persistent hyperalgesia,and various sequelae.However,the underlying mechanisms remain unclear,and effective treatment methods are lacking.This article summarizes the effects of repetitive noxious stimuli during the neonatal period on neural development and the complications,aiming to provide a basis for the neonatal analgesia management and the prevention and treatment of related sequelae.
Humans ; Infant, Newborn ; Brain/growth & development* ; Infant, Premature ; Intensive Care Units, Neonatal ; Hyperalgesia ; Pain

Human ; Intensive Care Units ; Critical Care ; Philippines

Objective: This study described clinicodemographic profiles of children with prolonged length of stay admitted at the regular service ward of Philippine Children’s Medical Center (January 2023 – December 2023).

Materials and Methods: A descriptive and retrospective clinical profiling of patients with prolonged length of stay at PCMC was done (January 2023 to December 2023). Included were patients aged 1-18 years old admitted at the regular service ward and discussed during the overstaying audit. Excluded were those admitted at Neonatal Intensive Care Unit and Newborn Service Ward. Patients with prolonged length of stay admitted under the Hematology and Oncology Service ward and those with incomplete chart information were also excluded. Data collected were age, sex, area of residence, presence of comorbidities, diagnosis, reason for prolonged length of stay, and clinical outcomes.

Results: 153 patients were included in this study. Majority of the patients with prolonged length of stay were adolescents (43.79%). Most of the patients identified in this study were female (78%). Those who overstayed were predominantly from Quezon City (27.45%). Comorbidities were present in 93.46% of patients. Neurologic conditions accounted for majority of the admissions (35.29%). Most common reason for overstaying of patients was due to a medical reason (91.5%). Furthermore, 93.46% of patients were discharged while 6.54% died.

Conclusion: This retrospective study presented the clinical profile of patients with prolonged length of stay who were mostly adolescents, with female predominance. Neurologic disease was the most common diagnosis identified among patients. Those patients who have prolonged length of stay were generally because of medical problems mostly due to the complexity and chronicity of their disease. Strengthening of ongoing service delivery network and prompt subspecialty referrals and involvement may be recommended to address discharge delays and maximize hospital resources.

Human ; Male ; Female ; Infant: 1-23 Months ; Child Preschool: 2-5 Yrs Old ; Child: 6-12 Yrs Old ; Adolescent: 13-18 Yrs Old ; Length Of Stay ; Critical Care ; Chart

The intelligent oxygen management system is a software designed with various algorithms to automatically titrate inhaled oxygen concentration according to specific patterns. This system can be integrated into various ventilator devices and used during assisted ventilation processes, aiming to maintain the patient's blood oxygen saturation within a target range. This paper employs a scoping review methodology, focusing on research related to intelligent oxygen management systems in neonatal intensive care units. It reviews the fundamental principles, application platforms, and clinical outcomes of these systems, providing a theoretical basis for clinical implementation.
Humans ; Intensive Care Units, Neonatal ; Infant, Newborn ; Oxygen/administration & dosage* ; Oxygen Inhalation Therapy/methods* ; Respiration, Artificial

Acute Care Surgery (ACS) is an emerging discipline of general surgery that integrates trauma, emergency surgery, critical care medicine, and surgical rescue. It is a modern model for the diagnosis and treatment of patients with acute and critical abdominal conditions. Compared to the traditional model, ACS integrates the theories and techniques of trauma, critical care, and surgery. It consolidates surgical wards and intensive care units into a single department for operational management. The care of acute care patients is led by physicians who are qualified in both critical care medicine and surgery. This model improves efficiency and significantly reduces morbidity and mortality of patients. Both international and domestic hospitals have had multiple surgical rescue teams that have embarked on exploratory work in the development of ACS, accumulating a certain amount of experience. The Expert Working Group of Acute Care Surgery, Chinese Medical Doctor Association Division of Surgeons has formed a preliminary guideline for the development of the Department of Acute Care Surgery based on the current experience and accomplishment in China for the reference of hospitals at all levels.
Critical Care ; Humans ; General Surgery ; Acute Care Surgery

OBJECTIVES: Prolonged invasive mechanical ventilation is associated with increased risks of severe complications such as retinopathy of prematurity and bronchopulmonary dysplasia. Although neonatal intensive care unit (NICU) follow the principle of early extubation, extubation failure rates remain high, and reintubation may further increase the risk of adverse outcomes. This study aims to identify risk factors and short-term prognosis associated with first extubation failure in neonates, to provide evidence for effective clinical intervention strategies. METHODS: Clinical data of neonates who received invasive ventilation in the NICU of Children's Hospital of Nanjing Medical University from January 1, 2019, to December 31, 2021, were retrospectively collected. Neonates were divided into a successful extubation group and a failed extubation group based on whether reintubation occurred within 72 hours after the first extubation. Risk factors and short-term outcomes related to extubation failure were analyzed. RESULTS: A total of 337 infants were included, with 218 males (64.69%). Initial extubation failed in 34 (10.09%) infants. Compared with the successful extubation group, the failed extubation group had significantly lower gestational age [(31.37±5.14) weeks vs (34.44±4.07) weeks], age [2.5 (1.00, 8.25) h vs 5 (1.00, 22.00) h], birth weight [(1 818.97±1128.80) g vs (2 432.18±928.94) g], 1-minute Apgar score (6.91±1.90 vs 7.68±2.03), and the proportion of using mask oxygenation after extubation (21% vs 46%) (all P<0.05). Conversely, compared with the successful extubation group, the failed extubation group had significantly higher rates of vaginal delivery (59% vs 32%), caffeine use during mechanical ventilation (71% vs 38%), dexamethasone use at extubation (44% vs 17%), the highest positive end-expiratory pressure level within 72 hours post-extubation [6(5.00, 6.00) cmH₂O vs 5 (0.00, 6.00) cmH₂O] (1 cmH₂O=0.098 kPa), the highest FiO₂ within 72 hours post-extubation [(34.35±5.95)% vs (30.22±3.58)%], and duration of noninvasive intermittent positive pressure ventilation after extubation [0.5 (0.00, 42.00) hours vs 0 (0, 0) hours] (all P<0.05). Multivariate analysis identified gestational age <28 weeks (OR=5.570, 95% CI 1.866 to 16.430), age at NICU admission (OR=0.959, 95% CI 0.918 to 0.989), and a maximum FiO₂≥35% within 72 hours post-extubation (OR=4.541, 95% CI 1.849 to 10.980) as independent risk factors for extubation failure (all P<0.05). Additionally, the failed extubation group exhibited significantly higher incidences of necrotizing enterocolitis grade II or above, moderate-to-severe bronchopulmonary dysplasia, severe bronchopulmonary dysplasia, retinopathy of prematurity, treatment abandonment due to poor prognosis, and discharge on home oxygen therapy (all P<0.05). Total hospital length of stay and total hospitalization costs were also significantly increased in the failed extubation group (all P<0.05). CONCLUSIONS Gestational age <28 weeks, younger age at NICU admission, and FiO₂≥35% after extubation are high-risk factors for first extubation failure in neonates. Extubation failure markedly increases the risk of adverse clinical outcomes.
Humans ; Infant, Newborn ; Male ; Female ; Airway Extubation/adverse effects* ; Risk Factors ; Retrospective Studies ; Respiration, Artificial/methods* ; Intensive Care Units, Neonatal ; Prognosis ; Gestational Age ; Bronchopulmonary Dysplasia ; Infant, Premature ; Treatment Failure ; Intubation, Intratracheal

The accurate and timely detection of biochemical coagulation indicators is pivotal in pulmonary and critical care medicine. Despite their reliability, traditional laboratories often lag in terms of rapid diagnosis. Point-of-care testing (POCT) has emerged as a promising alternative, which is awaiting rigorous validation. We assessed 226 samples from patients at the First Affiliated Hospital of Guangzhou Medical University using a Beckman Coulter AU5821 and a PUSHKANG POCT Biochemistry Analyzer MS100. Furthermore, 350 samples were evaluated with a Stago coagulation analyzer STAR MAX and a PUSHKANG POCT Coagulation Analyzer MC100. Metrics included thirteen biochemical indexes, such as albumin, and five coagulation indices, such as prothrombin time. Comparisons were drawn against the PUSHKANG POCT analyzer. Bland-Altman plots (MS100: 0.8206‒0.9995; MC100: 0.8318‒0.9911) evinced significant consistency between methodologies. Spearman correlation pinpointed a potent linear association between conventional devices and the PUSHKANG POCT analyzer, further underscored by a robust correlation coefficient (MS100: 0.713‒0.949; MC100: 0.593‒0.950). The PUSHKANG POCT was validated as a dependable tool for serum and whole blood biochemical and coagulation diagnostics. This emphasizes its prospective clinical efficacy, offering clinicians a swift diagnostic tool and heralding a new era of enhanced patient care outcomes.
Humans ; Point-of-Care Testing ; Critical Care ; Blood Coagulation Tests/methods* ; Male ; Blood Coagulation ; Female ; Middle Aged ; Reproducibility of Results ; Prothrombin Time ; Aged ; Adult ; Point-of-Care Systems

OBJECTIVES: To investigate the association of serum albumin level after human albumin infusion with 28-day mortality in critically ill patients with acute kidney injury (AKI) and its impact on 90-day outcomes of the patients. METHODS: We conducted a retrospective cohort study based on the MIMIC IV database (2008-2019), including 5918 AKI patients treated with albumin in the ICU. Based on serum albumin levels within 72 h after albumin infusion, the patients were divided into low (<30 g/L), medium (30-35 g/L), and high albumin (>35 g/L) groups. Restricted cubic spline regression and multivariate logistic regression were used to analyze the association of albumin levels with patient mortality, and the results were verified in a external validation cohort consisting of 110 sepsis-induced AKI patients treated in Nanfang Hospital between 2017 and 2022 using survival analysis and multivariate adjustment. RESULTS: In the MIMIC training cohort, multivariate logistic regression showed no significant differences in 28-day mortality of the patients with different albumin levels (P>0.05). However, restricted cubic spline analysis indicated a non-linear dose-response relationship between albumin levels and 28-day mortality (threshold effect: risk increased when albumin levels >3.6 g/dL). Secondary endpoint analysis revealed that the patients with high albumin levels had a shorter duration of mechanical ventilation (P<0.001) but a longer ICU stay (P<0.001). In the validation cohort, albumin levels ≥30 g/L were significantly associated with a reduced 28-day mortality rate (P<0.05). CONCLUSIONS The association between increased serum albumin levels following albumin infusion and 28-day mortality of critically ill patients with AKI exhibits a cohort dependency and can be influenced by multiple factors including disease type and severity, infusion strategies, and statistical methods.
Humans ; Acute Kidney Injury/therapy* ; Critical Illness/mortality* ; Retrospective Studies ; Serum Albumin/analysis* ; Male ; Female ; Intensive Care Units ; Middle Aged ; Logistic Models ; Aged