Early in-hospital course of critically ill nontrauma patients in a resuscitation room of a German emergency department (OBSERvE2 study)

[Retrospective analysis of the resuscitation room management of nontraumatic critically ill children in a university emergency department (OBSERvE-DUS-PED study)]

BACKGROUND

The establishment of a resuscitation room management for nontraumatic critically ill children appears to make sense. This study collected data of pediatric patients suffering from nontraumatic critically ill conditions treated in a resuscitation room.

METHODS

The retrospective OBSERvE-DUS-PED study (November 2019-October 2022) recorded pediatric patients (age < 18 years) who were admitted to the emergency department (ED) for resuscitation room care. The routinely documented data on treatment were taken from the hospital information system MEDICO® and the patient data management system COPRA® in accordance with the OBSERvE dataset. The study was approved by the Ethics Committee of the Medical Faculty of the Heinrich Heine University (2023-2377).

RESULTS

The study included 52 pediatric resuscitation room patients. Adolescents aged 14-17 years were the most frequent in the cohort representing 37% of the total and neonates/infants (0-1 year) were lowest at 8%. The most common symptoms categorized according to ABCDE problems were disturbance of consciousness (D) at 61%, cardiovascular failure (C) at 25%, respiratory insufficiency (B) at 6%, airway obstruction (A) and exposure/environment (E) problems each at 4%. The out-of-hospital and in-hospital emergency procedures were performed with the following frequencies: venous (58% vs. 65%), intraosseous (14% vs. 2%) and central venous access (0% vs. 12%), invasive airway management (35% vs. 8%), cardiopulmonary resuscitation (21% vs. 10%), vasopressors (15% vs. 17%), and intra-arterial pressure measurement (0% vs. 17%). The mean duration of resuscitation room management was 70 ± 43 min. The 30-day mortality was 17%.

CONCLUSION

The OBSERvE-DUS-PED study demonstrates the major challenges in the care of critically ill nontraumatic pediatric patients, both in out-of-hospital and in-hospital management. The variety and complexity of the referral diagnoses as well as the immediate vital threat to the patients make it appear sensible to treat such patients primarily in a resuscitation room of the ED due to the available material, infrastructural and personnel resources.

[Indications and success rate of endotracheal emergency intubation in clinical acute and emergency medicine]

BACKGROUND

Securing the airway in the emergency department (ED) is a high-stakes procedure; however, the primary success and complication rate are largely unknown in Germany. The aim of this study was a retrospective analysis of prospectively collected resuscitation room data for endotracheal intubation (ETI) regarding indications, performance and complications.

METHOD

Between 1 January 2020 and 30 June 2023 all ETIs conducted in the ED (Kliniken Maria Hilf, Moenchengladbach, Germany) were analyzed following approval by the ethics committee (EK 23-369). Primary intubations performed by the anesthesiology department were excluded. The core medical team of the ED underwent a six-week training program including a two-week anesthesia rotation prior to performing ETI in the ED. There were standard operating procedures (SOP) for both rapid sequence induction (RSI) and airway exchange with a placed laryngeal tube (LT) utilizing video laryngoscopy (C-Mac, Storz), rocuronium for relaxation and primary intubation with an elastic bougie. The primary success rate, overall success rate and intubation-related complications were analyzed. Additionally, the factor of consultant ED staff and residents was evaluated with respect to the primary success rate.

RESULTS

During the study period 499 patients were intubated by the core ED team and 28 patients underwent airway exchange from LT to ETI. Primary success could be achieved in 489/499 (98.0%) ETI and in 25/28 (89.3%) LT exchange patients. Surgically achieved securing of the airway was carried out in 5/527 (0.9%) patients in a cannot intubate situation and 11/527 (2.2%) patients suffered cardiac arrest minutes after the ETI. The overall first pass success rate of endotracheal tube placement was 514/527 (97.4%). The comparison of the primary success of consultants (168/175; 96.0%) vs. residents 320/325 (98.5%) yielded no significant differences (p = 0.08).

CONCLUSION

In clinical acute and emergency medicine, a standardized approach utilizing video laryngoscopy and a bougie following a structured training concept, can achieve an above-average high primary success rate with simultaneous low severe complications in the high-risk collective of critically ill emergency patients in an intrahospital setting.

[End-of-life care in the emergency department-Indications for admission and spectrum of care-State of the art]

BACKGROUND

Emergency departments (EDs) and ED observation units provide care for a wide range of medical emergencies, serving patients of all ages and conditions. This includes palliative care for patients who are rapidly deteriorating. However, there is limited knowledge about the incidence, reasons for ED visits, modes of arrival, symptoms, leading diagnoses, and the emergency care provided to these patients until the time of death.

METHOD

This retrospective, exploratory study was conducted at the 754-bed Kliniken Maria Hilf academic teaching hospital in Moenchengladbach, Germany. It included patients who died in the ED resuscitation rooms or ED observation unit between 1st of July 2018 and 30th of June 2023. We utilized routine data to analyze the reasons for ED visits, modes of arrival, symptoms, diagnoses and the medical care provided. We also examined differences between oncologic and non-oncologic patients as well as between those requiring cardiopulmonary resuscitation (CPR) and those who did not. The study was approved by an ethics committee and categorical data were analyzed using the χ2-test with Yates correction. P-values < 0.05 were considered significant due to the exploratory nature of the study.

RESULTS

During the study period 168,328 patients were treated in the ED, with 43% admitted to the hospital. Of these, 262 died in the ED or ED observation unit. The primary mode of arrival was emergency medical services for 234 patients (89%). The most common symptoms were impaired consciousness (n = 198; 76%) and dyspnea (n = 83; 32%), among a range of others. Comparing non-oncologic (n = 214) and oncologic patients (n = 48), the former showed significantly higher rates of impaired consciousness (174/214 vs. 24/48; p = 0.0001), while dyspnea was more prevalent in oncologic patients (57/214 vs. 26/48; p = 0.0002). Among patients who underwent CPR (n = 147) and those who did not (n = 115), no statistical differences were found in levels of consciousness but a significant difference in dyspnea (prior to cardiac arrest) was noted (31/147 vs. 52/115; p = 0.0001). Palliative status was documented in 88 cases (34%), with palliative care initiated in only 58 (21%). Only three patients (1%) were receiving specialized outpatient palliative care (SAPV). The most common medical interventions were invasive ventilation (n = 160; 61%), opioid administration (n = 145; 55%), CPR (n = 143; 55%), and crystalloid administration (n = 90; 34%). Structured communication with relatives occurred in 188 cases (72%).

CONCLUSION

The incidence of death in a large German ED was approximately one patient per week. These patients typically presented with symptoms common in critically ill non-trauma cases. The low incidence of SAPV patients (1%) suggests its potential to reduce ED admissions. Oncologic patients were a minority, possibly due to effective outpatient care and lower mortality within the first 24 h after ED admission. Emergency palliative care in the ED could alleviate the burden on intensive care units. Training ED staff in acute palliative care and establishing procedural standards for such care are essential to maintain high-quality treatment, given the frequency of palliative cases in the ED.

Resuscitation room management of patients with non-traumatic critical illness in the emergency department (OBSERvE-DUS-study)

BACKGROUND

Few studies address the care of critically ill non-traumatic patients in the emergency department (ED). The aim of this study was to assess the epidemiology, management, and outcome of these patients.

METHODS

In this retrospective study, we identified and analyzed data from all consecutive adult critically ill non-traumatic ED patients treated from March 2018 to February 2019. Patient characteristics, major complaint leading to admission, out-of-hospital, and in-hospital interventions and 30-day mortality were extracted from medical records of the electronic patient data management system.

RESULTS

During the study period, we analyzed 40,764 patients admitted to the ED. Of these, 621 (1.5%) critically ill non-traumatic patients were admitted for life-threatening emergencies to the resuscitation room (age: 70 ± 16 years, 52% male). Leading problem on admission was disability/unconsciousness (D), shock (C), respiratory failure (B), airway obstruction (A), and environment problems (E) in 41%, 31%, 25%, 2%, and 1%, respectively. Out-of-hospital and in-hospital measures included: intravenous access (61% vs. 99%), 12-lead ECG (55% vs. 87%), invasive airway management (21% vs. 34%) invasive ventilation (21% vs. 34%), catecholamines (9% vs. 30%), arterial access (0% vs. 52%), and cardiopulmonary resuscitation (11% vs. 6%). The underlying diagnoses were mainly neurological (29%), followed by cardiological (28%), and pulmonological (20%) emergencies. The mean length of stay (LOS) in the resuscitation room and ED was 123 ± 122 and 415 ± 479 min, respectively. The 30-day mortality was 18.5%.

CONCLUSION

The data describe the care of critically ill non-traumatic patients in the resuscitation room. Based on these data, algorithms for the structured care of critically ill non-traumatic patients need to be developed.

[Acute dyspnea]

ACUTE DYSPNEA

The leading symptom "acute dyspnea" and the causal underlying diseases have a high risk potential for an unfavorable course of treatment with a high letality. This overview of possible causes, diagnostic procedures and guideline-based therapy is intended to help implement a targeted and structured emergency medical care in the emergency department. The leading symptom "acute dyspnea" is present in 10% of prehospital and 4-7% of patients in the emergency department. The most common conditions in the emergency department with the leading symptom "acute dyspnea" are heart failure in 25%, COPD in 15%, pneumonia in 13%, respiratory disorders in 8%, and pulmonary embolism in 4%. In 18% of cases, the leading symptom "acute dyspnea" is sepsis. The in-hospital letality is high and amounts to 9%. In critically ill patients in the non-traumatologic resuscitation room, respiratory disorders (B-problems) are present in 26-29%. In addition to cardiovascular disease, noncardiovascular disease may underlie "acute dyspnea" and requires differential diagnostic consideration. A structured approach can contribute to a high degree of certainty in the clarification of the leading symptom "acute dyspnea".

Development of the Interdisciplinary and Interprofessional Course Concept “Advanced Critical Illness Life Support”

The Advanced Critical Illness Life Support (ACiLS) course was developed on behalf of the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA). The goal of the ACiLS course is to provide a nationally recognized and certified life support course that teaches medical professionals the key principles of initial care of critically ill patients in the emergency department, including the (PR_E-)AUD2IT-algorithm. It is designed for interdisciplinary and multi-professional staff in the resuscitation room to optimize patient safety and outcome. ACiLS includes a new blended learning concept with a theoretical part as comprehensive e-learning and a two-day practical part with strong focus on team training in scenarios and workshops. The course format was conceived to balance best teaching practices within the limited instructional time and resources available. This article describes the development of the ACiLS course and provides an overview of its future implementation.

[Management of Critically Ill Non-traumatic Patients in the Emergency Department]

Resuscitation room management of non-traumatic critically ill patients in the emergency department comprises approximately 1.5% of all emergency department visits. Critically ill patients are usually brought to the hospital by emergency medical services, where they are first examined, given initial treatment, stabilized and then transported for further in-hospital treatment. Resuscitation room management plays a key role at the interface of the out-of-hospital and in-hospital treatment chains. While the structured care of traumatological patients has been established at a very high level for decades, the care of non-traumatic critically ill patients within the framework of resuscitation room care has only come into focus in recent years and is only now being implemented in some places with professional concepts. Emergency departments at all levels of care are equipped to provide structured care for non-traumatologic shock room patients. To professionalize non-traumatic resuscitation room management, the creation of uniform standards from alerting criteria, to equipment and staffing, as well as the establishment of a uniform resuscitation room management algorithm is required. The (PRE_E-)AUD2IT-algorithm provides a structure for the non-traumatic care of critically ill patients in the resuscitation room and includes preparation, resource retrieval, handover, initial care, diagnostics, differential diagnoses and the interpretation of examination findings. This overview focuses on the management of critically ill non-traumatic patients in respect to the resuscitation room care concept.

Interdisziplinäre Notaufnahme: Geben Symptome und Zuweisungsweg Auskunft über den Bettenbedarf?

Hintergrund

Das größte Nadelöhr in der Patientenbehandlung in der Notaufnahme ist meist die stationäre Bettenkapazität bei stationärer Aufnahmeindikation des Patienten. Im Gegensatz zu den interdisziplinären Notaufnahmen sind die aufnehmenden Kliniken meist fachspezifisch organisiert. Ziel unserer Studie ist es, den Bedarf an Betten bei Patienten in der zentralen Notaufnahme in Abhängigkeit von Zuweisungsweg und zu Clustern zugeteilten Symptomen zu erfassen.

Methoden

Retrospektiv wurden Daten aller Patienten, die sich innerhalb von drei Jahren in der Notaufnahme am Klinikum Großhadern vorstellten (n = 113.693) analysiert.

Ergebnisse

Die meisten Patienten wurden mit Symptomen aus den Bereichen Innere Medizin (28 %), Unfallchirurgie (24 %) und Neurologie (15 %) behandelt, gefolgt von Allgemeinchirurgie (11 %), HNO (7 %), Urologie (5 %), Orthopädie (5 %), Gynäkologie (3 %) und Neurochirurgie (2 %). Patienten, die über den Rettungsdienst vorgestellt wurden, mussten am häufigsten (67 %) aufgenommen werden, verglichen mit Zuweisungen über niedergelassene Ärzte (47 %) und Selbstzuweisungen (23 %). Am häufigsten stationär und auf Intensivstation aufgenommen wurden zudem Patienten mit Symptomen, die auf ein neurochirurgisches (69 % stationär, davon 12 % auf Intensivstation), internistisches (56 %; 5 %) oder neurologisches (46 %; 4 %) Krankheitsbild hinwiesen.

Diskussion

Unsere Daten legen nahe, dass Zuweisungsweg und fachspezifische Symptomzuordnung bei Patienten einer interdisziplinären Notaufnahme zu einer frühzeitigen Abschätzung der im Verlauf benötigten stationären Ressourcen beitragen können.

[Management of critically ill nontrauma patients in a nonuniversity emergency department]

Purpose

Today there exists only limited knowledge regarding the care of critically ill nontrauma (CINT) patients in the resuscitation room (RR) in Germany. The goal of this observational study was to describe the management of CINT patients in the RR of a nonuniversity emergency department.

Methods

Data of adult nontrauma patients in the RR were prospectively collected in this study from 26 January 2019 to 18 May 2021 using the OBSERvE‑2 evaluation protocol.

Results

In all, 213 patients were included in the study (age: 70 ± 15 years, 55% male; admission to the RR by emergency medical service 93%). 28% were brought in after out-of-hospital cardiac arrest. Leading admission causes were C (47%) and B problems (39%). Diagnoses at the end of RR treatment were 30% pulmonary and 26% cardiovascular diseases without myocardial infarction as well as pulmonary embolism (8% and 5%, respectively). Measures performed were airway protection (20%), invasive (46%) and noninvasive ventilation (25%), cardiopulmonary resuscitation (13%), catecholamine therapy (34%), emergency ultrasound (62%). The initial treatment lasted for 41 ± 22 min. Computed tomography was subsequently performed in 51%. On average 4-5 persons were involved in the treatment during the RR period. In total, 9% of the patients died during RR treatment and 40% in the hospital.

Conclusion

Patients in a nonuniversity nontrauma RR are resource-intensive and have a high in-hospital lethality. RR care can be completed within 60 min. In order to achieve better comparability between patient populations of different locations, it is necessary to uniformly define admission criteria for the nontrauma resuscitation room.

Liegetrauma: retrospektive Analyse einer Patientenkohorte aus einer universitären Notaufnahme

Hintergrund

Bisher fehlen Versorgungsdaten für Patienten mit Liegetrauma (LT).

Methode

Deskriptive retrospektive Analyse aller rettungsdienstlich mit einem LT der Notaufnahme des Universitätsklinikums Köln von 07.2018 bis 12.2020 zugeführten Patienten.

Ergebnis

Insgesamt konnten 50 Patienten mit LT (Altersmedian 76 Jahre, Liegedauer im Median 13,5 h) im Untersuchungszeitraum identifiziert werden. Die zugrunde liegende Ursache für das LT war in 40 % primär neurologisch (ischämischer Schlaganfall: 20 %, intrakranielle Blutung: 16 %, Epilepsie: 4 %), in 12 % eine Intoxikation und in 10 % ein häusliches Trauma. Häufige assoziierte Diagnosen waren Infektionen (52 %), Traumafolgen (22 %), Exsikkose (66 %), akute Nierenfunktionsstörung (20 %), schwere Rhabdomyolyse (Kreatininkinase ≥ 5000 U/l, 21 %) und schwere Hypothermie < 32 °C (20 %). Insgesamt wurden 69 % der Patienten auf einer Intensivstation aufgenommen und die Krankenhausletalität betrug 50 %.

Schlussfolgerung

Das LT beschreibt einen Patientenzustand, bei dem infolge vielfältiger Ursachen plötzlich die eigenständige Mobilisierung und ein selbstständiges Hilfeholen verhindert werden und dadurch weitere Gesundheitsschäden entstehen. Bei diesem Syndrom sind Gewebsschäden als Folge des Liegens keine notwendige Voraussetzung für das Vorliegen eines LT. Aufgrund der hohen Morbidität und Letalität sollten diese Patienten in einem nichttraumatologischen Schockraum aufgenommen werden.

["B problems" in non-traumatic resuscitation room management]

In the primary survey of resuscitation room management in critically ill nontrauma patients, the ABCDE (airway, breathing, circulation, disability, exposure) approach is used for immediate recognition and treatment of life-threatening conditions. "B problems" are associated with respiratory failure and require immediate treatment. The pathogenesis is diverse, especially in the nontrauma resuscitation room. Clinical examination, emergency sonography and knowledge of oxygenation techniques and ventilation are important components of diagnosis and therapy. Standardized procedures and regular training in the emergency room are of fundamental importance.

Identification and validation of objective triggers for initiation of resuscitation management of acutely ill non-trauma patients: the INITIATE IRON MAN study

Background

While there are clear national resuscitation room admission guidelines for major trauma patients, there are no comparable alarm criteria for critically ill nontrauma (CINT) patients in the emergency department (ED). The aim of this study was to define and validate specific trigger factor cut-offs for identification of CINT patients in need of a structured resuscitation management protocol.

Methods

All CINT patients at a German university hospital ED for whom structured resuscitation management would have been deemed desirable were prospectively enrolled over a 6-week period (derivation cohort, n = 108). The performance of different thresholds and/or combinations of trigger factors immediately available during triage were compared with the National Early Warning Score (NEWS) and Quick Sequential Organ Failure Assessment (qSOFA) score. Identified combinations were then tested in a retrospective sample of consecutive nontrauma patients presenting at the ED during a 4-week period (n = 996), and two large external datasets of CINT patients treated in two German university hospital EDs (validation cohorts 1 [n = 357] and 2 [n = 187]).

Results

The any-of-the-following trigger factor iteration with the best performance in the derivation cohort included: systolic blood pressure < 90 mmHg, oxygen saturation < 90%, and Glasgow Coma Scale score < 15 points. This set of triggers identified > 80% of patients in the derivation cohort and performed better than NEWS and qSOFA scores in the internal validation cohort (sensitivity = 98.5%, specificity = 98.6%). When applied to the external validation cohorts, need for advanced resuscitation measures and hospital mortality (6.7 vs. 28.6%, p < 0.0001 and 2.7 vs. 20.0%, p < 0.012) were significantly lower in trigger factor-negative patients.

Conclusion

Our simple, any-of-the-following decision rule can serve as an objective trigger for initiating resuscitation room management of CINT patients in the ED.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00973-4.

„C-Probleme“ des nichttraumatologischen Schockraummanagements

Im Rahmen des nichttraumatologischen Schockraummanagements zur Versorgung kritisch kranker Patienten werden akute Störungen der Vitalfunktionen rasch detektiert und behandelt. Beim „primary survey“ (Erstversorgung) dient das etablierte ABCDE-Schema der strukturierten Untersuchung aller relevanten Vitalparameter. Akute Störungen werden hierbei unmittelbar detektiert und therapiert. „C-Probleme“ stellen den größten Anteil der ABCDE-Störungen bei nichttraumatologischen Schockraumpatienten dar und zeichnen sich durch eine hämodynamische Instabilität infolge hypovolämischer, obstruktiver, distributiver oder kardiogener Schockformen aus. Abhängig von den lokalen Versorgungsstrukturen umfasst die nichttraumatologische Schockraumversorgung hierbei auch die Stabilisierung von Patienten mit akutem Koronarsyndrom oder nach prähospitaler Reanimation (Cardiac Arrest Center).