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Singh P, Lamine H, Sapkota S, Bahattab A, Eriksson A. Management of Mass-Casualty Incidents in Nepal: A Qualitative Case Study of Three District Hospitals in Nepal. Prehosp Disaster Med 2023; 38:606-611. [PMID: 37609893 PMCID: PMC10548016 DOI: 10.1017/s1049023x23006209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/22/2023] [Indexed: 08/24/2023]
Abstract
INTRODUCTION The frequency of disasters world-wide has significantly increased in recent years, leading to an increase in the number of mass-casualty incidents (MCIs). These MCIs can overwhelm health care systems, requiring hospitals to respond quickly and effectively, often with limited resources. While numerous studies have identified the challenges in managing MCIs and have emphasized the importance of hospital disaster preparedness, there is a research gap in the preparedness level and response capacities of district hospitals in Nepal. STUDY OBJECTIVE This study attempts to fill this gap by understanding the perception of hospital staff in managing MCIs in district hospitals of Nepal. METHODS A qualitative case study was conducted in three district hospitals in Nepal. Semi-structured interviews were conducted with the hospital personnel, using an interview guide. An inductive thematic analysis was carried out to understand their perception on the most recent MCI management. RESULTS Three themes emerged from the data analysis: enablers in MCI management, barriers in MCI management, and recommendations for the future. Use of multiple communication channels, mobilization of entire hospital teams, mobilization of police in crowd control, presence of disaster store, and pre-identified triage areas were the major enablers that facilitated successful MCI management. Nonetheless, the study also revealed challenges such as a lack of knowledge on MCI response among new staff, disruptions caused by media and visitors, and challenges in implementing triage. CONCLUSION This study emphasized the importance of hospital disaster preparedness in managing MCIs and highlighted the significance of overcoming barriers and utilizing enablers for an efficient response. The findings of this study can provide the basis for the Ministry of Health and Population Nepal and district hospitals to plan initiatives for the effective management of MCIs in the future.
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Affiliation(s)
- Prinka Singh
- Department of Global Public Health, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Hamdi Lamine
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università Del Piemonte Orientale, 28100Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università Del Piemonte Orientale, 13100Vercelli, Italy
| | - Sujan Sapkota
- HERD International, Sainbu Awas Cr-10 Marga, Bhaisepati, Lalitpur, Nepal
| | - Awsan Bahattab
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università Del Piemonte Orientale, 28100Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università Del Piemonte Orientale, 13100Vercelli, Italy
| | - Anneli Eriksson
- Department of Global Public Health, Karolinska Institutet, Solna, Stockholm, Sweden
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Martin-Loeches I, Torres A, Nagavci B, Aliberti S, Antonelli M, Bassetti M, Bos LD, Chalmers JD, Derde L, de Waele J, Garnacho-Montero J, Kollef M, Luna CM, Menendez R, Niederman MS, Ponomarev D, Restrepo MI, Rigau D, Schultz MJ, Weiss E, Welte T, Wunderink R. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Intensive Care Med 2023; 49:615-632. [PMID: 37012484 PMCID: PMC10069946 DOI: 10.1007/s00134-023-07033-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 12/01/2022] [Indexed: 04/05/2023]
Abstract
PURPOSE Severe community-acquired pneumonia (sCAP) is associated with high morbidity and mortality, and whilst European and non-European guidelines are available for community-acquired pneumonia, there are no specific guidelines for sCAP. METHODS The European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), and Latin American Thoracic Association (ALAT) launched a task force to develop the first international guidelines for sCAP. The panel comprised a total of 18 European and four non-European experts, as well as two methodologists. Eight clinical questions for sCAP diagnosis and treatment were chosen to be addressed. Systematic literature searches were performed in several databases. Meta-analyses were performed for evidence synthesis, whenever possible. The quality of evidence was assessed with GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Evidence to Decision frameworks were used to decide on the direction and strength of recommendations. RESULTS Recommendations issued were related to diagnosis, antibiotics, organ support, biomarkers and co-adjuvant therapy. After considering the confidence in effect estimates, the importance of outcomes studied, desirable and undesirable consequences of treatment, cost, feasibility, acceptability of the intervention and implications to health equity, recommendations were made for or against specific treatment interventions. CONCLUSIONS In these international guidelines, ERS, ESICM, ESCMID, and ALAT provide evidence-based clinical practice recommendations for diagnosis, empirical treatment, and antibiotic therapy for sCAP, following the GRADE approach. Furthermore, current knowledge gaps have been highlighted and recommendations for future research have been made.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation (MICRO), St James's Hospital, Dublin, Ireland.
- Trinity College Dublin, Dublin, Ireland.
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain.
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, Barcelona, Spain.
| | - Antoni Torres
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, Barcelona, Spain
| | - Blin Nagavci
- Faculty of Medicine, Institute for Evidence in Medicine, Medical Centre-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | | | - Matteo Bassetti
- Infectious Disease Clinic, Department of Health Sciences, Ospedale Policlinico San Martino IRCCS, University of Genoa, Genoa, Italy
| | - Lieuwe D Bos
- Department of Intensive Care and Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Lennie Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Carlos M Luna
- Neumonología, Hospital de Clínicas, UBA, Buenos Aires, Argentina
| | - Rosario Menendez
- Pneumology Service, Universitary and Politechnic Hospital La Fe, Valencia, Spain
| | - Michael S Niederman
- Pneumology Service, Universitary and Politechnic Hospital La Fe, Valencia, Spain
| | - Dmitry Ponomarev
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Intensive Care, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Marcos I Restrepo
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, and University of Texas Health, San Antonio, TX, USA
| | - David Rigau
- Centre Cochrane Iberoamericà-Institut d'Investigació Biomèdica Sant Pau, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Hôpital Beaujon, DMU PARABOL, AP-HP Nord and Université de Paris, Clichy, France
| | - Tobias Welte
- Department of Respiratory Medicine and Infectious Disease, Member of the German Center of Lung Research, Hannover School of Medicine, Hannover, Germany
| | - Richard Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Martin-Loeches I, Torres A, Nagavci B, Aliberti S, Antonelli M, Bassetti M, Bos L, Chalmers J, Derde L, de Waele J, Garnacho-Montero J, Kollef M, Luna C, Menendez R, Niederman M, Ponomarev D, Restrepo M, Rigau D, Schultz M, Weiss E, Welte T, Wunderink R. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Eur Respir J 2023; 61:13993003.00735-2022. [PMID: 37012080 DOI: 10.1183/13993003.00735-2022] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 12/01/2022] [Indexed: 04/05/2023]
Abstract
BACKGROUND Severe community-acquired pneumonia (sCAP) is associated with high morbidity and mortality, and while European and non-European guidelines are available for community-acquired pneumonia, there are no specific guidelines for sCAP. MATERIALS AND METHODOLOGY The European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Latin American Thoracic Association (ALAT) launched a task force to develop the first international guidelines for sCAP. The panel comprised a total of 18 European and four non-European experts, as well as two methodologists. Eight clinical questions for sCAP diagnosis and treatment were chosen to be addressed. Systematic literature searches were performed in several databases. Meta-analyses were performed for evidence synthesis, whenever possible. The quality of evidence was assessed with GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Evidence to Decision frameworks were used to decide on the direction and strength of recommendations. RESULTS Recommendations issued were related to diagnosis, antibiotics, organ support, biomarkers and co-adjuvant therapy. After considering the confidence in effect estimates, the importance of outcomes studied, desirable and undesirable consequences of treatment, cost, feasibility, acceptability of the intervention and implications to health equity, recommendations were made for or against specific treatment interventions. CONCLUSIONS In these international guidelines, ERS, ESICM, ESCMID and ALAT provide evidence-based clinical practice recommendations for diagnosis, empirical treatment and antibiotic therapy for sCAP, following the GRADE approach. Furthermore, current knowledge gaps have been highlighted and recommendations for future research have been made.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organisation (MICRO), St James's Hospital, Dublin, Ireland
- Trinity College Dublin, Dublin, Ireland
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, Barcelona, Spain
- Authors contributed equally to this work
| | - Antoni Torres
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
- Pulmonary Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, Barcelona, Spain
- Authors contributed equally to this work
| | - Blin Nagavci
- Faculty of Medicine, Institute for Evidence in Medicine, Medical Centre - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | | | - Matteo Bassetti
- Infectious Disease Clinic, Ospedale Policlinico San Martino IRCCS, Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Lieuwe Bos
- Department of Intensive Care and Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - James Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Lennie Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Carlos Luna
- Neumonología, Hospital de Clínicas, UBA, Buenos Aires, Argentina
| | - Rosario Menendez
- Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Michael Niederman
- Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Dimitry Ponomarev
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Intensive Care, E.N. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Marcos Restrepo
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, and University of Texas Health, San Antonio, TX, USA
| | - David Rigau
- Centre Cochrane Iberoamericà - Institut d'Investigació Biomèdica Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Marcus Schultz
- Department of Intensive Care and Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emmanuele Weiss
- Department of Anaesthesiology and Critical Care, Hôpital Beaujon, DMU PARABOL, AP-HP Nord and Université de Paris, Clichy, France
| | | | - Richard Wunderink
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Roca O, Caritg O, Santafé M, Ramos FJ, Pacheco A, García-de-Acilu M, Ferrer R, Schultz MJ, Ricard JD. Closed-loop oxygen control improves oxygen therapy in acute hypoxemic respiratory failure patients under high flow nasal oxygen: a randomized cross-over study (the HILOOP study). Crit Care 2022; 26:108. [PMID: 35422002 PMCID: PMC9008383 DOI: 10.1186/s13054-022-03970-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background We aimed to assess the efficacy of a closed-loop oxygen control in critically ill patients with moderate to severe acute hypoxemic respiratory failure (AHRF) treated with high flow nasal oxygen (HFNO). Methods In this single-centre, single-blinded, randomized crossover study, adult patients with moderate to severe AHRF who were treated with HFNO (flow rate ≥ 40 L/min with FiO2 ≥ 0.30) were randomly assigned to start with a 4-h period of closed-loop oxygen control or 4-h period of manual oxygen titration, after which each patient was switched to the alternate therapy. The primary outcome was the percentage of time spent in the individualized optimal SpO2 range. Results Forty-five patients were included. Patients spent more time in the optimal SpO2 range with closed-loop oxygen control compared with manual titrations of oxygen (96.5 [93.5 to 98.9] % vs. 89 [77.4 to 95.9] %; p < 0.0001) (difference estimate, 10.4 (95% confidence interval 5.2 to 17.2). Patients spent less time in the suboptimal range during closed-loop oxygen control, both above and below the cut-offs of the optimal SpO2 range, and less time above the suboptimal range. Fewer number of manual adjustments per hour were needed with closed-loop oxygen control. The number of events of SpO2 < 88% and < 85% were not significantly different between groups. Conclusions Closed-loop oxygen control improves oxygen administration in patients with moderate-to-severe AHRF treated with HFNO, increasing the percentage of time in the optimal oxygenation range and decreasing the workload of healthcare personnel. These results are especially relevant in a context of limited oxygen supply and high medical demand, such as the COVID-19 pandemic. Trial registration The HILOOP study was registered at www.clinicaltrials.gov under the identifier NCT04965844. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03970-w.
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Mass casualty medicine: time for a 21st century refresh. Br J Anaesth 2021; 128:e65-e67. [PMID: 34949438 DOI: 10.1016/j.bja.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 11/20/2022] Open
Abstract
Mass casualty events are on the rise globally, as we face increasing pressures from scarcity of resources, population growth, systemic inequalities, geopolitical instabilities, and polarised discourse. Although they are rare events for an individual practitioner, they are going to happen to someone, somewhere, this week, this month, this year. And whilst they are often the last consideration for healthcare systems under constant pressures from daily routine work, individuals, departments, hospitals, and systems have to step up effectively in times of crisis. Failure to do so can lead to suboptimal outcomes for casualties, and even perceived failures can have crippling consequences on staff, families, and communities for years.
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