Annals of the American Thoracic Society
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Rationale: A small but growing number of hospitals are experimenting with emergency department-embedded critical care units (CCUs) in an effort to improve the quality of care for critically ill patients with sepsis and acute respiratory failure (ARF). Objectives: To evaluate the potential impact of an emergency department-embedded CCU at the Hospital of the University of Pennsylvania among patients with sepsis and ARF admitted from the emergency department to a medical ward or intensive care unit (ICU) from January 2016 to December 2017. Methods: The exposure was eligibility for admission to the emergency department-embedded CCU, which was defined as meeting a clinical definition for sepsis or ARF and admission to the emergency department during the intervention period on a weekday. ⋯ Conclusions: The emergency department-embedded CCU was not associated with clinical outcomes among patients admitted with sepsis or ARF. Among less sick patients with sepsis, the emergency department-embedded CCU was initially associated with reduced rates of direct ICU admission from the emergency department. Additional research is necessary to further evaluate the impact and utility of the emergency department-embedded CCU model.
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The COVID-19 pandemic struck an immunologically naïve, globally interconnected population. In the face of a new infectious agent causing acute respiratory failure for which there were no known effective therapies, rapid, often pragmatic trials were necessary to evaluate potential treatments, frequently starting with medications that are already marketed for other indications. Early in the pandemic, hydroxychloroquine and azithromycin were two such candidates. ⋯ This trial was prospectively registered (NCT04329832) before enrollment of the first patient.
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Rationale: Prior approaches to measuring healthcare capacity strain have been constrained by using individual care units, limited metrics of strain, or general, rather than disease-specific, populations. Objectives: We sought to develop a novel composite strain index and measure its association with intensive care unit (ICU) admission decisions and hospital outcomes. Methods: Using more than 9.2 million acute care encounters from 27 Kaiser Permanente Northern California and Penn Medicine hospitals from 2013 to 2018, we deployed multivariable ridge logistic regression to develop a composite strain index based on hourly measurements of 22 capacity-strain metrics across emergency departments, wards, step-down units, and ICUs. ⋯ Strain was also not meaningfully associated with patient characteristics. Conclusions: Hospital strain, measured by a novel composite strain index, is strongly associated with ICU admission among patients with sepsis and/or ARF. This strain index fulfills the assumptions of a strong within-hospital instrumental variable for quantifying the net benefit of admission to the ICU for patients with sepsis and/or ARF.