Browsing by Author "Lardaro, Thomas"

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    Assessing the Risk of Interfacility Transport in Pregnant Patients Due to Progression of Labor: Lessons From a Specialized Maternal-Fetal Transport Program
    (Springer Nature, 2024-09-30) Lardaro, Thomas; Balaji, Adhitya; Yang, David; Kuhn, Diane; Glober, Nancy; Brent, Christine M.; Couturier, Katherine; Breyre, Amelia; Vaizer, Julia; Hunter, Benton R.; Emergency Medicine, School of Medicine
    Background: Pregnant laboring patients sometimes require interfacility transfer to a higher level of care. There is a paucity of evidence to inform when it is safe to transfer a laboring patient and when delivery may be too imminent to transfer. Methods: This is a retrospective study of pregnant patients undergoing interfacility transfer with a specialized obstetric transport team deployed from a large Midwest regional healthcare system. The primary outcome was delivery prior to or within one hour of arrival at the receiving institution due to progression of labor. Data collected included basic demographics, vital signs, gravidity, parity, gestational age, contraction frequency if contractions were present, and cervical dilation. We sought to define the association between these variables and the primary outcome to inform risk assessment for precipitous delivery among patients being considered for interfacility transfer. Results: Of the 370 pregnant patients for whom the specialized transfer team was requested, 11 (3%) met the primary outcome. Those with more advanced cervical dilation and those who did not receive regular prenatal care were more likely to meet the criteria for the primary outcome. For every centimeter of cervical dilation, the odds of meeting the primary outcome increased 2.3-fold (95% CI: 1.5-3.4). Conclusions: We identified risk factors for early delivery among pregnant patients for whom an interfacility transfer was requested and described patients who were high-risk for obstetric interfacility transport due to the progression of labor. Our results can help inform risk assessments for transferring potentially high-risk laboring patients.
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    Can we predict which COVID-19 patients will need transfer to intensive care within 24 hours of floor admission?
    (Wiley, 2021) Wang, Alfred Z.; Ehrman, Robert; Bucca, Antonino; Croft, Alexander; Glober, Nancy; Holt, Daniel; Lardaro, Thomas; Musey, Paul; Peterson, Kelli; Trigonis, Russell; Hunter, Benton R.; Emergency Medicine, School of Medicine
    Background Patients with COVID‐19 can present to the emergency department (ED) at any point during the spectrum of illness, making it difficult to predict what level of care the patient will ultimately require. Admission to a ward bed, which is subsequently upgraded within hours to an intensive care unit (ICU) bed, represents an inability to appropriately predict the patient's course of illness. Predicting which patients will require ICU care within 24 hours would allow admissions to be managed more appropriately. Methods This was a retrospective study of adults admitted to a large health care system, including 14 hospitals across the state of Indiana. Included patients were aged ≥ 18 years, were admitted to the hospital from the ED, and had a positive polymerase chain reaction (PCR) test for COVID‐19. Patients directly admitted to the ICU or in whom the PCR test was obtained > 3 days after hospital admission were excluded. Extracted data points included demographics, comorbidities, ED vital signs, laboratory values, chest imaging results, and level of care on admission. The primary outcome was a combination of either death or transfer to ICU within 24 hours of admission to the hospital. Data analysis was performed by logistic regression modeling to determine a multivariable model of variables that could predict the primary outcome. Results Of the 542 included patients, 46 (10%) required transfer to ICU within 24 hours of admission. The final composite model, adjusted for age and admission location, included history of heart failure and initial oxygen saturation of <93% plus either white blood cell count > 6.4 or glomerular filtration rate < 46. The odds ratio (OR) for decompensation within 24 hours was 5.17 (95% confidence interval [CI] = 2.17 to 12.31) when all criteria were present. For patients without the above criteria, the OR for ICU transfer was 0.20 (95% CI = 0.09 to 0.45). Conclusions Although our model did not perform well enough to stand alone as a decision guide, it highlights certain clinical features that are associated with increased risk of decompensation.
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    Characteristics of COVID-19 Patients with Bacterial Co-infection Admitted to the Hospital from the Emergency Department in a Large Regional Healthcare System
    (Wiley, 2021) Lardaro, Thomas; Wang, Alfred Z.; Bucca, Antonino; Croft, Alexander; Glober, Nancy; Holt, Daniel B.; Musey, Paul I., Jr.; Peterson, Kelli D.; Trigonis, Russell A.; Hunter, Benton R.; Emergency Medicine, School of Medicine
    Introduction The rate of bacterial coinfection with SARS‐CoV‐2 is poorly defined. The decision to administer antibiotics early in the course of SARS‐CoV‐2 infection depends on the likelihood of bacterial coinfection. Methods We performed a retrospective chart review of all patients admitted through the emergency department with confirmed SARS‐CoV‐2 infection over a 6‐week period in a large healthcare system in the United States. Blood and respiratory culture results were abstracted and adjudicated by multiple authors. The primary outcome was the rate of bacteremia. We secondarily looked to define clinical or laboratory features associated with bacteremia. Results There were 542 patients admitted with confirmed SARS‐CoV‐2 infection, with an average age of 62.8 years. Of these, 395 had blood cultures performed upon admission, with six true positive results (1.1% of the total population). An additional 14 patients had positive respiratory cultures treated as true pathogens in the first 72 h. Low blood pressure and elevated white blood cell count, neutrophil count, blood urea nitrogen, and lactate were statistically significantly associated with bacteremia. Clinical outcomes were not statistically significantly different between patients with and without bacteremia. Conclusions We found a low rate of bacteremia in patients admitted with confirmed SARS‐CoV‐2 infection. In hemodynamically stable patients, routine antibiotics may not be warranted in this population.
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    Decreased racial disparities in sepsis mortality after an order set-driven initiative: An analysis of 8151 patients
    (Academic Emergency Medicine, 2025-04-25) Fernandez Olivera, Maria; Pafford, Carl; Lardaro, Thomas; Roumpf, Steven; Saysana, Michele; Hunter, Benton
    Background: Sepsis is a leading cause of hospital mortality and there is evidence that outcomes vary by patient demographics including race and gender. Our objectives were to determine whether the introduction of a standardized sepsis order set was associated with (1) changes in overall mortality or early antibiotic administration or (2) changes in outcome disparities based on race or gender. Methods: Patients seen in the emergency department and admitted to the hospital with a diagnosis code of sepsis were identified and divided into a preintervention co- hort seen during the 18 months prior to the initiation of a new sepsis order set and an intervention cohort seen during the 18 months after a quality initiative driven by in- troducing the order set. Associations between time period, race, gender, and mortality were assessed using univariate and multivariate logistic regression models. Other outcomes included early antibiotic administration (<3 h from arrival). Results: Overall mortality was unchanged during the intervention period (7.8% vs. 7.2%) in both univariate (relative risk [RR] 1.08, 95% confidence interval [CI] 0.93–1.26) and multivariate logistic regression (RR 1.11, 95% CI 0.93–1.28) models. Although male gender tended to have higher mortality, there was no statistically significant association between gender and mortality in either cohort. In the multivariable model, Black race was associated with increased risk of death in the preintervention period (RR 1.41, 95% CI 1.02–1.94), but this association was not present in the intervention period. Patients of color also saw significantly more improvement in early antibiotic administration during the intervention period than White patients. Conclusions: An order set–driven sepsis initiative was not associated with overall improved mortality but was associated with decreased racial disparities in sepsis mortality and early antibiotics.
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    Fluid Resuscitation and Progression to Renal Replacement Therapy in Patients With COVID-19
    (Elsevier, 2022-02) Holt, Daniel B.; Lardaro, Thomas; Wang, Alfred Z.; Musey, Paul I.; Trigonis, Russell; Bucca, Antonino; Croft, Alexander; Glober, Nancy; Peterson, Kelli; Schaffer, Jason T.; Hunter, Benton R.; Medicine, School of Medicine
    Background Coronavirus disease 2019 (COVID-19) is associated with respiratory symptoms and renal effects. Data regarding fluid resuscitation and kidney injury in COVID-19 are lacking, and understanding this relationship is critical. Objectives To determine if there is an association between fluid volume administered in 24 h and development of renal failure in COVID-19 patients. Methods Retrospective chart review; 14 hospitals in Indiana. Included patients were adults admitted between March 11, 2020 and April 13, 2020 with a positive test for severe acute respiratory syndrome coronavirus 2 within 3 days of admission. Patients requiring renal replacement therapy prior to admission were excluded. Volumes and types of resuscitative intravenous fluids in the first 24 h were obtained with demographics, medical history, and other objective data. The primary outcome was initiation of renal replacement therapy. Logistic regression modeling was utilized in creating multivariate models for determining factors associated with the primary outcome. Results The fluid volume received in the first 24 h after hospital admission was associated with initiation of renal replacement therapy in two different multivariate logistic regression models. An odds ratio of 1.42 (95% confidence interval 1.01–1.99) was observed when adjusting for age, heart failure, obesity, creatinine, bicarbonate, and total fluid volume. An odds ratio of 1.45 (95% confidence interval 1.02–2.05) was observed when variables significant in univariate analysis were adjusted for. Conclusions Each liter of intravenous fluid administered to patients with COVID-19 in the first 24 h of presentation was independently associated with an increased risk for initiation of renal replacement therapy, supporting judicious fluid administration in patients with this disease.
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    Out-of-hospital cardiac arrest volumes and characteristics during the COVID-19 pandemic
    (Elsevier, 2021-10) Glober, Nancy K.; Supples, Michael; Faris, Greg; Arkins, Thomas; Christopher, Shawn; Fulks, Tyler; Rayburn, David; Weinstein, Elizabeth; Liao, Mark; O'Donnell, Daniel; Lardaro, Thomas; Emergency Medicine, School of Medicine
    Aim The COVID-19 pandemic has significantly impacted Emergency Medical Services (EMS) operations throughout the country. Some studies described variation in total volume of out-of-hospital cardiac arrests (OHCA) during the pandemic. We aimed to describe the changes in volume and characteristics of OHCA patients and resuscitations in one urban EMS system. Methods We performed a retrospective cohort analysis of all recorded atraumatic OHCA in Marion County, Indiana, from January 1, 2019 to June 30, 2019 and from January 1, 2020 to June 30, 2020. We described patient, arrest, EMS response, and survival characteristics. We performed paired and unpaired t-tests to evaluate the changes in those characteristics during COVID-19 as compared to the prior year. Data were matched by month to control for seasonal variation. Results The total number of arrests increased from 884 in 2019 to 1034 in 2020 (p = 0.016). Comparing 2019 to 2020, there was little difference in age [median 62 (IQR 59–73) and 60 (IQR 47–72), p = 0.086], gender (38.5% and 39.8% female, p = 0.7466, witness to arrest (44.3% and 39.6%, p = 0.092), bystander AED use (10.1% and 11.4% p = 0.379), bystander CPR (48.7% and 51.4%, p = 0.242). Patients with a shockable initial rhythm (19.2% and 15.4%, p = 0.044) both decreased in 2020, and response time increased by 18 s [6.0 min (IQR 4.5–7.7) and 6.3 min (IQR 4.7–8.0), p = 0.008]. 47.7% and 54.8% (p = 0.001) of OHCA patients died in the field, 19.7% and 19.3% (p = 0.809) died in the Emergency Department, 21.8% and 18.5% (p = 0.044) died in the hospital, 10.8% and 7.4% (p = 0.012) were discharged from the hospital, and 9.3% and 5.9% (p = 0.005) were discharged with Cerebral Performance Category score ≤ 2. Conclusion Total OHCA increased during the COVID-19 pandemic when compared with the prior year. Although patient characteristics were similar, initial shockable rhythm, and proportion of patients who died in the hospital decreased during the pandemic. Further investigation will explore etiologies of those findings.