Incidence of delirium in the critical care unit and risk factors in the Central Region,Saudi Arabia

Objectives:To determine the incidence and risk factors of delirium in the cardiac care unit (CCU) and intensive care unit (ICU).Methods:This multicenter prospective observational study was conducted between July 2019 and November 2019 in the central region of Saudi Arabia. All patients admitted to the critical care units were enrolled, and their demographic data and risk factors of delirium were reported.Results:A total of 165 patients were included: 76 (46.1%) admitted to the CCU and 89 (53.9%) admitted to the ICU. The mean age was 55.1±18 years, and 45 (27.3%) were women. We found that 24/165 (14.5%) patients developed delirium during admission. Importantly, variables significantly associated with delirium group were female gender: (24.5% versus 10.8%, p=0.028), malnutrition (29.2% versus 5%, p<0.001), the presence of urinary catheter (75% versus 30.5%, p=0.001), septicemia (50% versus 14.9%, p<0.001), intubation (41.7% versus 10.6%, p=0.001), low hemoglobin (10.79±2.91 versus 12.05±2.77, p=048), and prolonged prothrombin time (PT) (15.87±5.17 versus 13.60±3.28, p=0.011).Conclusion:The incidence of delirium was 14.5% among patients admitted to critical care units in the central region of Saudi Arabia. Septicemia, prolonged PT, malnutrition, and urinary catheter are significant predictors of delirium.     

Quality metrics and outcomes among critically ill patients in China: results of the national clinical quality control indicators for critical care medicine survey 2015–2019

Background:It is crucial to improve the quality of care provided to ICU patient, therefore a national survey of the medical quality of intensive care units (ICUs) was conducted to analyze adherence to quality metrics and outcomes among critically ill patients in China from 2015 to 2019.Methods:This was an ICU-level study based on a 15-indicator online survey conducted in China. Considering that ICU care quality may vary between secondary and tertiary hospitals, direct standardization was adopted to compare the rates of ICU quality indicators among provinces/regions. Multivariate analysis was performed to identify potential factors for in-hospital mortality and factors related to ventilator-associated pneumonia (VAP), catheter-related bloodstream infections (CRBSIs), and catheter-associated urinary tract infections (CAUTIs).Results:From the survey, the proportions of structural indicators were 1.83% for the number of ICU inpatients relative to the total number of inpatients, 1.44% for ICU bed occupancy relative to the total inpatient bed occupancy, and 51.08% for inpatients with Acute Physiology and Chronic Health Evaluation II scores ≥15. The proportions of procedural indicators were 74.37% and 76.60% for 3-hour and 6-hour surviving sepsis campaign bundle compliance, respectively, 62.93% for microbiology detection, 58.24% for deep vein thrombosis prophylaxis, 1.49% for unplanned endotracheal extubations, 1.99% for extubated inpatients reintubated within 48 hours, 6.38% for unplanned transfer to the ICU, and 1.20% for 48-hour ICU readmission. The proportions of outcome indicators were 1.28‰ for VAP, 3.06‰ for CRBSI, 3.65‰ for CAUTI, and 10.19% for in-hospital mortality. Although the indicators varied greatly across provinces and regions, the treatment level of ICUs in China has been stable and improved based on various quality control indicators in the past 5 years. The overall mortality rate has dropped from 10.19% to approximately 8%.Conclusions:The quality indicators of medical care in China''s ICUs are heterogeneous, which is reflected in geographic disparities and grades of hospitals. This study is of great significance for improving the homogeneity of ICUs in China.     

Acute kidney injury in the pediatric intensive care unit at a tertiary care hospital of the Armed Forces: a cross-sectional observational study

BackgroundAcute kidney injury (AKI) is shown to be the commonest complication in critically ill children admitted to the pediatric intensive care unit (PICU). Kidney Disease: Improving Global Outcomes (KDIGO) classification and definition are now used universally. We undertook prospective observational study to study the etiology and maximum stage of AKI as defined by KDIGO and its complications and outcomes.MethodsAll children admitted to the PICU were included in the study. The diagnosis of sepsis and multiorgan dysfunction syndrome (MODS) was made according to the standard international guidelines. The patients were followed up till discharge/death. All children were screened for AKI at admission and subsequently using serum creatinine measured by modified Jaffe's method and urine output measurement.ResultsA total of 197 children were admitted to the PICU. 38 (19.28%) developed AKI, and 6 (15.78%) developed stage III AKI. Malignancies, serious neurological and renal disorders, and postsurgery complications accounted for most of the cases with AKI. Six were admitted with primary renal condition. Sepsis with or without MODS was seen in 12 patients with AKI and in 8 without AKI. Twenty-one children with AKI and 3 children without AKI were exposed to nephrotoxic drugs. Twenty-three children with AKI required inotropic support. The average length of stay (ALOS) of children with AKI in the PICU was 9.86 days, whereas ALOS of children without AKI was 6.23 days. Eighteen children with AKI (47.36%) and 36 (21.38%) with no AKI died.ConclusionsAKI in children in the PICUs of referral hospitals in the armed forces have varied etiologies and presentations. These children require early identification and management with close monitoring to prevent long-term renal morbidity and mortality.     

Economic burden of routine hematologic tests and intensive care unit observation for elective anterior cervical discectomy and fusion

BackgroundAnterior cervical discectomy and fusion is one of the most common surgical interventions performed by spine surgeons. As efforts are made to control healthcare spending because of the limited or capped resources offered by the National Health Insurance, surgeons are faced with the challenge of offering high-level patient care while minimizing associated healthcare expenditures. Routine ordering of postoperative hematologic tests and observational intensive care unit (ICU) stay might be areas of potential cost containment. This study was designed to determine the necessity of routine postoperative hematologic tests and ICU stay for patients undergoing elective anterior cervical discectomy and fusion and to investigate whether the elimination of unnecessary postoperative laboratory blood studies and ICU stay inhibits patient care.MethodsThe necessity for postoperative blood tests was determined if there were needs for a postoperative blood transfusion and hospital readmission within 1 month after surgery. The necessity for postoperative ICU observation was decided if immediate surgical intervention was required when any kind of complications occurred during the ICU stay.ResultsThere were 168 patients collected in the study. Among them, all had routine preoperative and postoperative blood tests and were transferred to ICU for observation. No need for blood transfusion was observed, and no patient required immediate surgical intervention when the complications occurred during the ICU stay.ConclusionCost savings per admission amounted to approximately 10% of the hospitalization cost by the elimination of unnecessary postoperative routine laboratory blood studies and observational ICU stay without waiving patient care in the current volatile, cost-conscious healthcare environment in Taiwan.     

Prescribers’ Responses to Alerts During Medication Ordering in the Long Term Care Setting

ObjectiveComputerized physician order entry with clinical decision support has been shown to improve medication safety in adult inpatients, but few data are available regarding its usefulness in the long-term care setting. The objective of this study was to examine opportunities for improving medication safety in that clinical setting by determining the proportion of medication orders that would generate a warning message to the prescriber via a computerized clinical decision support system and assessing the extent to which these alerts would affect prescribers’ actions.DesignThe study was set within a randomized controlled trial of computerized clinical decision support conducted in the long-stay units of a large, academically-affiliated long-term care facility. In March 2002, a computer-based clinical decision support system (CDSS) was added to an existing computerized physician order entry (CPOE) system. Over a subsequent one-year study period, prescribers ordering drugs for residents on three resident-care units of the facility were presented with alerts; these alerts were not displayed to prescribers in the four control units.MeasurementsWe assessed the frequency of drug orders associated with various categories of alerts across all participating units of the facility. To assess the impact of actually receiving an alert on prescriber behavior during drug ordering, we calculated separately for the intervention and control units the proportion of the alerts, within each category, that were followed by an appropriate action and estimated the relative risk of an appropriate action in the intervention units compared to the control units.ResultsDuring the 12 months of the study, there were 445 residents on the participating units of the facility, contributing 3,726 resident-months of observation time. During this period, 47,997 medication orders were entered through the CPOE system—approximately 9 medication orders per resident per month. 9,414 alerts were triggered (2.5 alerts per resident-month). The alert categories most often triggered were related to risks of central nervous system side-effects such as over-sedation (20%). Alerts for risk of drug-associated constipation (13%) or renal insufficiency/electrolyte imbalance (12%) were also common. Twelve percent of the alerts were related to orders for warfarin. Overall, prescribers who received alerts were only slightly more likely to take an appropriate action (relative risk 1.11, 95% confidence interval 1.00, 1.22). Alerts related to orders for warfarin or central nervous system side effects were most likely to engender an appropriate action, such as ordering a recommended laboratory test or canceling an ordered drug.ConclusionLong-term care facilities must implement new system-level approaches with the potential to improve medication safety for their residents. The number of medication orders that triggered a warning message in this study suggests that CPOE with a clinical decision support system may represent one such tool. However, the relatively low rate of response to these alerts suggests that further refinements to such systems are required, and that their impact on medication errors and adverse drug events must be carefully assessed.     

Morbidity,mortality, and emerging drug resistance in Device-associated infections (DAIs) in intensive care patients at a 1000-bedded tertiary care teaching hospital

BackgroundDevice-associated infections (DAIs) such as ventilator associated pneumonia (VAP), central line–associated blood stream infection (CLABSI), and catheter-related urinary tract infection (CAUTI) are principal contributors to health hazard and a major preventable threat to patient safety. Robust surveillance of DAI delineates infections, pathogens, resistograms, and facilitates antimicrobial therapy, infection-control, antimicrobial stewardship, and improvement in quality of care.MethodsThis prospective outcome surveillance study was conducted amongst 2067 ICU patients in a 1000-bedded teaching hospital. Clinical, laboratory, and environmental surveillance, as well as screening of health care professionals (HCPs) were conducted using the modified US Centers for Disease Control and Prevention–National Healthcare Safety Network definitions and methods. Morbidity, mortality, and health-care indices were analyzed and two-tier infection prevention and control was promulgated.ResultsMean occupancy was 95.34% for 2061 patients of 7381 patients/bed/ICU days. One hundred seventeen episodes of DAI occurred in 1258 patients of 12,882 device-days with mean device utilization ratio of 1.79. Mean rate of DAI was 7.40 per 1000 device days. Multiresistant Pseudomonas aeruginosa was most commonly followed by Acinetobacter. Mean all-cause mortality in ICU was 24.85%, whereas all-cause mortality after DAI was 9.79%. Methicillin-resistant Staphylococcus aureus prevalence was 38.46% amongst health-care professionals.ConclusionMean rates of VAP, CLABSI, and CAUTI were 20.69, 2.53, and 2.23 per 1000 device days comparable with Indian and global ICUs. Resolute conviction and sustained momentum in infection prevention and control is an essential step toward patient safety.     

Coronavirus Disease 2019 (COVID-19) in pediatric emergency. Presentation and disposition

Objectives:To examine the demographics and common presentations of pediatric coronavirus disease 2019 patients in the emergency department (ED), as well as their contact with positive COVID-19 cases, return visits, and patients’ disposition from the ED.Methods:A retrospective chart review of confirmed cases of COVID-19 presenting to the Pediatric ED from March 2020 until June 2020 was conducted.Results:Fifty-two patients were identified, with a higher frequency of male patients. Forty-four (85%) patients were discharged from the ED, and 8 (15%) required admission. Three patients were admitted to the pediatric intensive care unit and 2 died, resulting in a mortality rate of 3.8%. The most frequent presentations were fever (85%), cough (48%), and diarrhea (23%).Conclusion:In our study, the second most affected system after the respiratory tract was the gastrointestinal tract, which was also the system responsible for the most return visits due to diarrhea. Coronavirus disease 2019 poses clinical and operational challenges given its variable clinical presentations.     

Methicillin-resistant Staphylococcus aureus development in intensive care patients: A case-control study

Objectives:To determine the factors associated with the development of methicillin-resistant Staphylococcus aureus (MRSA), hospital stay and mortality, and early versus late MRSA infection.Methods:Cases (n=44) were intensive care unit (ICU) patients admitted to King Fahd Specialist Hospital, Al-Qassim, Saudi Arabia between 2015 and 2019 who developed MRSA during their hospital stay. Controls (n=48) were patients from the same place and period who did not develop MRSA. Data were abstracted from hospital records.Results:Admission with sepsis (case: 46% vs. control: 2%, p<0.001) and having at least one comorbid condition (case: 95% vs. control: 46%, p<0.001) were significantly associated with the development of MRSA. Age (mean ± SD: case: 65±18, control: 64±18, p=0.7) and gender (% male, case: 52%, control: 56%, p=0.70) were not associated with the development of MRSA. Approximately 73% of all MRSA cases developed within the first 2 weeks of admission. Among the early cases, 44% died during their ICU stay; the corresponding percentage among the late cases was 42% (p=0.69). There was no difference between early and late MRSA cases in terms of non-sepsis admissions (50% vs. 67%, p=0.32) or comorbid status (at least one: 97% vs. 92%, p=0.17).Conclusion:Sepsis and comorbid conditions were significant risk factors for MRSA development among hospital patients.     

The prevalence of hypocalcemia following total thyroidectomy: A retrospective study based at King Abdulaziz University Hospital,Jeddah, Saudi Arabia

Objectives:To estimate the prevalence of hypocalcemia following total thyroidectomy (TT) at a tertiary center.Methods:This retrospective study was conducted between 2014 and 2019 at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. The study was based at the Department of General Surgery and was approved by the Research Ethics Committee of KAUH. Medical records of 154 patients who had undergone TT were reviewed. Data such as age, gender, level of postoperative calcium at 24 and 48 hours after surgery, parathyroid hormone (PTH) levels, central neck dissection (CCND), histological diagnosis were entered into Microsoft Excel sheets.Results:Hypocalcemia occurred more on the second day after surgery in 67.4% of patients. Among them, 83.9% were female and 16.1% were male. The majority of patients were asymptomatic and benign thyroid disease was the most common. There was a significant association between hypocalcemia and the PTH level (p<0.001).Conclusion:There was a high prevalence of hypocalcemia on the second day after surgery. Presence of hypocalcemia association with the PTH level. Meticulous surgical technique and preservation of parathyroid vascularity are important in preventing postoperative hypocalcemia.     

Efficiency of intensive care. A comparative analysis of eight pediatric intensive care units

To calculate overall pediatric intensive care unit (PICU) efficiency rates, 1668 patients representing 6962 patient-days were studied in eight PICUs. The contributions to inefficiency by two patient groups--low-risk monitored patients and potential early-discharge patients--were quantified using measures of daily mortality risk and therapeutic assessments. Low-risk monitored patients never received a unique PICU therapy and had daily mortality risks less than 1%. Potential early-discharge patients were similar to the low-risk monitored patients except that their unnecessary PICU use came only on their last consecutive day(s) of PICU stay. Efficiency ratings ranged from 0.894 to 0.547 in the eight PICUs. Low-risk monitored patients constituted from 16% to 58% of the PICU patient populations and used from 5.4% to 34.5% of the total days of care. Potential early-discharge patients constituted from 12% to 29% of the populations and the potential early-discharge days of care ranged from 5.1% to 17.2% of the total days of care. These results indicate that large disparity exists in efficiency among PICUs. Efficiency rates of greater than 0.80 seem to be a reasonable goal.     

An audit of acute psychiatric admission bed occupancy in Northern Ireland.

The Northern Ireland Section (Irish Division) of the Royal College of Psychiatrists were requested to investigate apparent increasing pressures on acute psychiatric beds. Information on bed occupancy and associated service activity was collected by clinicians on site in every psychiatric unit in Northern Ireland over the past eight years. Three separate years (1987, 1991 and 1995) were studied. Bed occupancy rose across these three years. There was an associated reduction in the number of acute psychiatric beds, reduction in adult continuing care beds, increased recorded referrals to psychiatric units and evidence of considerable numbers of new long-stay patients and difficulties with community placements. Acute bed occupancy in Northern Ireland is high, frequently over 100% and rising. Occupancy rose between each of the years studied. The problem is not confined to urban areas and several associated service factors may be contributing. Without change, acute bed provision will inevitably fail to match mental health needs.     

Frequency and appropriateness of antipsychotic medication use in older people in long-term care

Background  Many studies have reported excessive use of antipsychotic medications in long stay institutions in Britain and America. Aim  We examined the frequency and appropriateness of antipsychotic prescribing in a variety of extended care settings in the west of Ireland. Methods  Clinical details of 345 residents (211 public and 134 private) were obtained from medication sheets and medical notes and by interviewing nursing staff. American prescribing guidelines were applied for those residents taking antipsychotic medications. Results  Of the 345 residents, 80 (23%) were prescribed regular antipsychotic medications of whom 41 (51%) were deemed to be receiving these agents inappropriately. There was no difference in the use of antipsychotic drugs (21.3% vs. 26.1%, Chi-sq = 1.1, p = 0.3) between residents of public and private units. However, inappropriate antipsychotic use was more common among those in private care (23/35 (66%) vs. 18/45 (40%); Chi-sq = 5.2, p = 0.02). Prominent inappropriate indications for antipsychotic use were: restlessness (26/41 (63%) patients); history of very intermittent aggression (23 (56%) patients); and wandering (19 (46%) patients). Conclusions  Inappropriate use of antipsychotic medications, as judged by American legislative guidelines, is common in long-stay units in the west of Ireland.     

儿科重症监护病房抗菌药使用的多中心流行病学调查

【目的】了解并评估中国5家教学儿童医院儿科重症监护病房（pediatric intensive care unit,PICU）抗菌药使用情况,建立适合我国国情的儿科医院PICU抗菌药使用初步评估体系。【方法】首先调查2002-2006年5家教学儿童医院PICU所有12 743患儿的情况,然后抽查北京、重庆以及复旦儿童医院PICU,均观察以下指标：一般情况、临床资料、抗菌药使用、细菌学检查等。【结果】5家儿童医院2002-2006年收住患儿的住院时间没有明显变化;PICU抗菌药使用的费用占总的药物使用费用的比率均有下降的趋势。在抗菌药使用指征上,各医院PICU还是以经验性治疗为主,但从2002-2006年,经验性治疗在逐年降低,而针对性治疗在逐年升高。540份抽查病例显示：524（97%）例患儿至少使用了一种抗菌药,经验性治疗占71.6%。第三代头孢菌素使用最多（31%）。北京、重庆、复旦的病原菌分离率分别为29%,66%和67%。其中,6种常见的细菌占分离菌的77.2%。大肠埃希菌耐头孢噻肟的耐药率在北京、重庆、复旦分别为73.8%、58.3%和49.2%,北京儿童医院均高于其他2家儿童医院（P=0.00）。【结论】本研究调查得出了5家儿童医院PICU抗菌药使用的基本数据。所抽查的3家医院PICU在抗菌药使用上均存在不同程度的不合理性;由于送检标本的检出率低,所以病原学的结果在指导抗菌药针对性使用上也受到限制。     

Imaging trend and disease course in admitted COVID-19 patients

Objectives:To describe radiographic imaging findings and disease course in admitted Coronavirus disease 2019 (COVID-19) patients.Methods:This retrospective study was carried in the Radiology Department, King Fahad Military Medical Complex, Dhahran between March to August 2020 (6 months). All laboratory confirmed COVID-19 admitted cases were evaluated for their symptoms, duration of hospital stays (in a ward or intensive care unit [ICU]), and imaging findings (ground-glass opacity [GGO], air-space shadowing/consolidation, and others such as atelectasis, reticulation, peribronchovascular thickening, lymphadenopathy and pleural effusion) on chest radiograph (CXR) and computed tomography (CT) studies. Cavitation, nodularity, bronchiectasis, and embolism detected on CT scans were considered as complications. Disease course in terms of recovery (radiographic regression or resolution of findings), worsening (shifting from ward to ICU), and unfavorable outcome (persistent ICU stay or death) were recorded. Imaging findings were interpreted by 2 experienced radiologists and consensus reporting was made. Chi-square test was used to determine association.Results:Out of 106 patients, majority were males (n=82, 77.4%). Forty-six patients (43.3%) had abnormal imaging with mostly peripheral GGO (56.5%), followed by consolidations (34.7%), and others (26%). Complications were detected in 6 ICU patients. All patients with unfavorable outcomes were above 60 years having comorbidities or complications (p<0.0005). Fatality rate was calculated as 2.8.Conclusion:Coronavirus disease 2019 is seen mostly affecting males, with peripheral opacities as common imaging findings. Elderly patients with co-morbidities may show unfavorable outcomes.     

Intensive care in a general hospital: demographics,utilization and outcomes

Introduction

Intensive care units (ICU) in Irish academic centres are known to fare as well as their international counterparts. Our aim in this study was to characterise the role and outcomes of an ICU in a smaller Irish hospital and to compare these to international best practice.

Methods

We reviewed admissions of patients to the ICU of St. Luke’s Hospital, Kilkenny. Patient demographics, indications for admission, and outcomes were all recorded and analysed. Sequential organ failure assessment (SOFA) scores were calculated.

Results

Forty-three patients were included in our study, 33 (76.7 %) of which were emergency admissions. Median length of stay was 2 days. The observed mortality rate in our cohort was 20.9 %. The median SOFA score in patients admitted was 7. Higher median SOFA scores on admission were predictive of mortality. The ICU occupancy rate during the duration of our study was 98 %, with only 15 (35.7 %) of admissions to ICU occurring within core working hours.

Conclusion

Critical care can be provided safely and in line with current best practice in smaller Irish hospitals. There is a cohort of patients for whom care may be best provided in a tertiary centre, how best to provide for these patients will likely be achieved by early identification (e.g. with SOFA score). Bed capacity issues remain problematic.     

Clinical characteristics and outcomes of children with COVID-19 in Saudi Arabia

Objectives:To determine the demographic and clinical characteristics, underlying comorbidities, and outcomes of children with coronavirus disease 2019 (COVID-19) infection.Methods:In this retrospective study, we reported 62 pediatric patients (age <14 years) with confirmed COVID-19 between March 2 and July 1, 2020, at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.Results:Comorbid conditions, including cardiac, neurological, respiratory, and malignant disorders, were reported in 9 patients (14.5%). The most prominent presenting complaints were fever (80.6%) and cough (48.4%). Most of our patients (80.6%) had mild disease, 11.3% had moderate disease, and 8.1% exhibited severe and critical illness. Twenty-one patients (33.9%) were hospitalized, with 4 patients (6.5%) admitted to the pediatric intensive care unit, and 3 (4.8%) patients died.Conclusion:All pediatric age groups are susceptible to COVID-19, with no gender difference. COVID-19 infection may result in critical illness and even mortality in subsets of pediatric patients.     

结直肠癌患者围术期静脉血栓栓塞症风险筛查与管理路径的应用效果分析

目的 探讨围术期静脉血栓栓塞症风险筛查与管理路径的构建与应用对结直肠癌患者深静脉血栓的预防作用.方法 选取2019年1月至2020年4月在安徽省肿瘤医院行结直肠癌根治术的190例患者为研究对象.基于文献回顾与小组会议形成初稿,选取8名专家进行2轮德尔菲专家咨询,形成终版血栓风险筛查与管理路径.将实施风险筛查和管理路径前(2019年1月～6月)的95例患者设为对照组;实施后(2019年7月～2020年4月)的95例患者设为干预组.比较两组患者术前、术后3天、2周的凝血酶原时间(PT)、血浆纤维蛋白原(FIB)、D-二聚体、血小板计数、深静脉血栓发生率、住院天数及住院费用.结果 对照组术后发生血栓13例(13.69％),多于干预组的4例(4.21％),差异有统计学意义(P<0.05).两组患者的PT、FIB、血小板计数、D-二聚体水平不同时间点差异有统计学意义(P<0.05);组间PT、FIB、D-二聚体水平差异有统计学意义(P<0.05);其中D-二聚体存在干预和时间的交互效应(P<0.05).干预组住院时间及住院费用均低于对照组,差异有统计学意义(P<0.05).结论 静脉血栓栓塞症风险筛查与管理路径的应用可有效降低结直肠癌术后患者发生深静脉血栓的风险、缩短住院时间,降低治疗费用.     

Computerized Clinical Decision Support During Medication Ordering for Long-term Care Residents with Renal Insufficiency

Objective

To determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency.

Design

Randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units.

Measurement

The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information.

Results

The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units—relative risk 1.2 (1.0, 1.4).

Conclusions

Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions.Trial Registration: http://clinicaltrials.gov Identifier: NCT00599209     

Global Burden of Cardiovascular Disease Attributable to High Temperature in 204 Countries and Territories from 1990 to 2019

Objective This study aimed to estimate spatiotemporal variations of global heat-related cardiovascular disease(CVD) burden from 1990 to 2019.Methods Data on the burden of heat-related CVD were derived from the Global Burden of Disease Study 2019. Deaths and disability-adjusted life years(DALYs) were used to quantify heat-induced CVD burden. We calculated the age-standardized mortality rate(ASMR) and DALY rate(ASDR) per 100,000population to compare this burden across regions. Generalized linear m...