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Dünser MW, Noitz M, Tschoellitsch T, Bruckner M, Brunner M, Eichler B, Erblich R, Kalb S, Knöll M, Szasz J, Behringer W, Meier J. Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission. Wien Klin Wochenschr 2024:10.1007/s00508-024-02374-w. [PMID: 38755419 DOI: 10.1007/s00508-024-02374-w] [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: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024]
Abstract
Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.
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Affiliation(s)
- Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria.
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4020, Linz, Austria.
| | - Matthias Noitz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Thomas Tschoellitsch
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Bruckner
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Brunner
- Ambulance and Disaster Relief Services, Oberösterreichisches Rotes Kreuz, 4020, Linz, Austria
| | - Bernhard Eichler
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Romana Erblich
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Stephan Kalb
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Marius Knöll
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | | | - Wilhelm Behringer
- Department of Emergency Medicine, Vienna General Hospital, 1090, Vienna, Austria
| | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
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Vergnano B, Signori D, Benini A, Calcinati S, Bettini F, Verga L, Borin LM, Cavalca F, Gambacorti-Passerini C, Bellani G, Foti G. Safety and Effectiveness of Intensive Treatments Administered Outside the Intensive Care Unit to Hematological Critically Ill Patients: An Intensive Care without Walls Trial. J Clin Med 2023; 12:6281. [PMID: 37834926 PMCID: PMC10573388 DOI: 10.3390/jcm12196281] [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: 09/02/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Historically, the admission of hematological patients in the ICU shortly after the start of a critical illness is associated with better survival rates. Early intensive interventions administered by MET could play a role in the management of hematological critically ill patients, eventually reducing the ICU admission rate. In this retrospective and monocentric study, we evaluate the safety and effectiveness of intensive treatments administered by the MET in a medical ward frame. The administered interventions were mainly helmet CPAP and pharmacological cardiovascular support. Frequent reassessment by the MET at least every 8 to 12 h was guaranteed. We analyzed data from 133 hematological patients who required MET intervention. In-hospital mortality was 38%; mortality does not increase in patients not immediately transferred to the ICU. Only three patients died without a former admission to the ICU; in these cases, mortality was not related to the acute illness. Moreover, 37% of patients overcame the critical episode in the hematological ward. Higher SOFA and MEWS scores were associated with a worse survival rate, while neutropenia and pharmacological immunosuppression were not. The MET approach seems to be safe and effective. SOFA and MEWS were confirmed to be effective tools for prognostication.
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Affiliation(s)
- Beatrice Vergnano
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Davide Signori
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Annalisa Benini
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Serena Calcinati
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Francesca Bettini
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Luisa Verga
- Department of Hematology, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Lorenza Maria Borin
- Department of Hematology, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Fabrizio Cavalca
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Carlo Gambacorti-Passerini
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
- Department of Hematology, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
| | - Giacomo Bellani
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
| | - Giuseppe Foti
- Department of Anesthesia and Intensive Care Medicine, Asst Monza, San Gerardo Hospital, 20900 Monza, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Piazza Ateneo Nuovo 1, 20126 Milano, Italy
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Systematized and efficient: organization of critical care in the future. Crit Care 2022; 26:366. [PMID: 36443764 PMCID: PMC9707068 DOI: 10.1186/s13054-022-04244-1] [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: 06/09/2022] [Accepted: 11/15/2022] [Indexed: 11/30/2022] Open
Abstract
Since the advent of critical care in the twentieth century, the core elements that are the foundation for critical care systems, namely to care for critically ill and injured patients and to save lives, have evolved enormously. The past half-century has seen dramatic advancements in diagnostic, organ support, and treatment modalities in critical care, with further improvements now needed to achieve personalized critical care of the highest quality. For critical care to be even higher quality in the future, advancements in the following areas are key: the physical ICU space; the people that care for critically ill patients; the equipment and technologies; the information systems and data; and the research systems that impact critically ill patients and families. With acutely and critically ill patients and their families as the absolute focal point, advancements across these areas will hopefully transform care and outcomes over the coming years.
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Sivajohan A, Krause SC, Hegazy A, Slessarev M. Protocol for a systematic review on effective patient positioning for rapid sequence intubation. BMJ Open 2022; 12:e062988. [PMID: 36332945 PMCID: PMC9639087 DOI: 10.1136/bmjopen-2022-062988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Rapid sequence intubation (RSI) is an advanced airway technique to perform endotracheal intubation in patients at high risk of aspiration. Although RSI is recognised as a life-saving technique and performed by many physicians in various settings (emergency departments, intensive care units), there is still a lack of consensus on various features of the procedure, most notably patient positioning. Previously, experts have commented on the unique drawbacks and benefits of various positions and studies have been published comparing patient positions and how it can affect endotracheal intubation in the context of RSI. The purpose of this systematic review is to compile the existing evidence to understand and compare how different patient positions can potentially affect the success of RSI. METHODS AND ANALYSIS We will use MEDLINE, EMBASE and the Cochrane Library to source studies from 1946 to 2021 that evaluate the impact of patient positioning on endotracheal intubation in the context of RSI. We will include randomised control trials, case-control studies, prospective/retrospective cohort studies and mannequin simulation studies for consideration in this systematic review. Subsequently, we will generate a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram to display how we selected our final studies for inclusion in the review. Two independent reviewers will complete the study screening, selection and extraction, with a third reviewer available to address any conflicts. The reviewers will extract this data in accordance with our outcomes of interest and display it in a table format to highlight patient-relevant outcomes and difficulty airway management outcomes. We will use the Risk of Bias tool and the Newcastle-Ottawa Scale to assess included studies for bias. ETHICS AND DISSEMINATION This systematic review does not require ethics approval, as all patient-centred data will be reported from published studies. PROSPERO REGISTRATION NUMBER CRD42022289773.
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Affiliation(s)
| | - Sarah Ct Krause
- Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Ahmed Hegazy
- Department of Anaesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
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5
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Batista Filho LAC, Randhawa VK, Maciel AT, Coimbra MR. We need to talk about critical care in Brazil. Clinics (Sao Paulo) 2022; 77:100096. [PMID: 36049323 PMCID: PMC9422924 DOI: 10.1016/j.clinsp.2022.100096] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/27/2022] [Indexed: 11/20/2022] Open
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Abiodun MT, Sadoh WE. Socio-demographic characteristics and pre-hospital care of children with circulatory failure in a children's emergency room in southern Nigeria. Pan Afr Med J 2021; 40:65. [PMID: 34804333 PMCID: PMC8590251 DOI: 10.11604/pamj.2021.40.65.30003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/20/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction circulatory failure is a major childhood emergency. Several disease-related and patient-related factors can predispose children to shock. Early detection of such factors will improve its prevention, management and outcome. This study aimed to evaluate the incidence, socio-demographic characteristics and pre-hospital care of children presenting with circulatory failure (shock) in children´s emergency room (CHER). Methods this study adopted cross-sectional design in CHER of the University of Benin Teaching Hospital, Nigeria, from October 2018 to March 2019. Data were collected using a semi-structured questionnaire eliciting demography, socio-economic status, pre-hospital care and presence of shock. In a sub-analysis, multiple logistic regression identified variables that are independently associated with circulatory failure in the participants, using adjusted odds ratio (OR) and 95% confidence intervals (CI). Results a total of 554 acutely-ill children participated in the study. Their median age was 60 (IQR: 24-132) months. Shock was present in 79 (14.3%) of the children on arrival at CHER. Children referred from private clinics were more likely to arrive CHER in shock compared to those coming directly from home (OR = 2.67, 95%CI: 1.07-6.69; p = 0.036) while children from lower socio-economic class families presented more frequently with shock than those from higher class (OR = 14.39, 95% CI: 2.61-79.44; p = 0.002). Also, children that received oral rehydration solution as pre-hospital care seemed more likely to present with shock in CHER (OR = 6.63, 95% CI: 2.15-20.46; p =0.001). Conclusion quality of pre-hospital care and parental socio-economic status influence the presence of shock in children seen at the emergency unit. Focused health education and prevention of finance-related delays in emergency care are needed.
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Affiliation(s)
- Moses Temidayo Abiodun
- Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria.,School of Medicine, University of Benin, Benin City, Edo State, Nigeria
| | - Wilson Ehidiamen Sadoh
- Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria.,School of Medicine, University of Benin, Benin City, Edo State, Nigeria
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Shaparin N, Mann GE, Streiff A, Kiyatkin ME, Choice C, Ramachandran S, Delphin E, Adams DC. Adaptation and restructuring of an academic anesthesiology department during the COVID-19 pandemic in New York City: Challenges and lessons learned. Best Pract Res Clin Anaesthesiol 2021; 35:425-435. [PMID: 34511230 PMCID: PMC7728432 DOI: 10.1016/j.bpa.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 10/29/2022]
Abstract
The novel SARS-CoV-2 pandemic starting in 2019 profoundly changed the world, and thousands of residents of New York City were affected, leading to one of the most acute surges in regional hospital capacity. As the largest academic medical center in the Bronx, Montefiore Medical Center was immediately impacted, and the entire hospital was mobilized to address the needs of its community. In this article, we describe our experiences as a large academic anesthesiology department during this pandemic. Our goals were to maximize our staff's expertise, maintain our commitment to wellness and safety, and preserve the quality of patient care. Lessons learned include the importance of critical care training presence and leadership, the challenges of converting an ambulatory surgery center to an intensive care unit (ICU), and the management of effective communication. Lastly, we provide suggestions for institutions facing an acute surge, or subsequent waves of COVID-19, based on a single center's experiences.
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Affiliation(s)
- Naum Shaparin
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA.
| | - Glenn E Mann
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Agathe Streiff
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | | | - Curtis Choice
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | | | - Ellise Delphin
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - David C Adams
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
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8
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Avery P, Morton S, Raitt J, Lossius HM, Lockey D. Rapid sequence induction: where did the consensus go? Scand J Trauma Resusc Emerg Med 2021; 29:64. [PMID: 33985541 PMCID: PMC8116824 DOI: 10.1186/s13049-021-00883-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/28/2021] [Indexed: 12/15/2022] Open
Abstract
Background Rapid Sequence Induction (RSI) was introduced to minimise the risk of aspiration of gastric contents during emergency tracheal intubation. It consisted of induction with the use of thiopentone and suxamethonium with the application of cricoid pressure. This narrative review describes how traditional RSI has been modified in the UK and elsewhere, aiming to deliver safe and effective emergency anaesthesia outside the operating room environment. Most of the key aspects of traditional RSI – training, technique, drugs and equipment have been challenged and often significantly changed since the procedure was first described. Alterations have been made to improve the safety and quality of the intervention while retaining the principles of rapidly securing a definitive airway and avoiding gastric aspiration. RSI is no longer achieved by an anaesthetist alone and can be delivered safely in a variety of settings, including in the pre-hospital environment. Conclusion The conduct of RSI in current emergency practice is far removed from the original descriptions of the procedure. Despite this, the principles – rapid delivery of a definitive airway and avoiding aspiration, are still highly relevant and the indications for RSI remain relatively unchanged.
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Affiliation(s)
- Pascale Avery
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
| | - Sarah Morton
- Essex & Herts Air Ambulance, Flight House, Earls Colne, Colchester, Essex, CO6 2NS, UK
| | - James Raitt
- Thames Valley Air Ambulance Stokenchurch House, Oxford Rd, Stokenchurch, High Wycombe, HP14 3SX, UK
| | | | - David Lockey
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.,Blizard Institute, Queen Mary University, Whitechapel, London, E1 2AT, UK
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Mermiri M, Mavrovounis G, Chatzis D, Mpoutsikos I, Tsaroucha A, Dova M, Angelopoulou Z, Ragias D, Chalkias A, Pantazopoulos I. Critical emergency medicine and the resuscitative care unit. Acute Crit Care 2021; 36:22-28. [PMID: 33508185 PMCID: PMC7940106 DOI: 10.4266/acc.2020.00521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/23/2020] [Indexed: 01/08/2023] Open
Abstract
Critical emergency medicine is the medical field concerned with management of critically ill patients in the emergency department (ED). Increased ED stay due to intensive care unit (ICU) overcrowding has a negative impact on patient care and outcome. It has been proposed that implementation of critical care services in the ED can negate this effect. Two main Critical Emergency Medicine models have been proposed, the "resource intensivist" and "ED-ICU" models. The resource intensivist model is based on constant presence of an intensivist in the traditional ED setting, while the ED-ICU model encompasses the notion of a separate ED-based unit, with monitoring and therapeutic capabilities similar to those of an ICU. Critical emergency medicine has the potential to improve patient care and outcome; however, establishment of evidence-based protocols and a multidisciplinary approach in patient management are of major importance.
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Affiliation(s)
- Maria Mermiri
- Department of Emergency Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Georgios Mavrovounis
- Department of Emergency Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | | | | | - Maria Dova
- Medical School, European University of Cyprus, Nicosia, Cyprus
| | - Zacharoula Angelopoulou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Ragias
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Ioannis Pantazopoulos
- Department of Emergency Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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10
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Four Walls Should Not Define an ICU. Pediatr Crit Care Med 2020; 21:504-505. [PMID: 32358335 DOI: 10.1097/pcc.0000000000002261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Critical Care Surge Management: A Role for ICU Telemedicine and Emergency Department Collaboration. Crit Care Med 2020; 47:1271-1273. [PMID: 31415312 DOI: 10.1097/ccm.0000000000003881] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Al-Qahtani SM, Baffoe-Bonnie H, El-Saed A, Alshamrani M, Algwizani A, Alaklabi A, AlJoudi K, Albaalharith N, Mohammed A, Hussain S, Balkhy HH. Appropriateness of antimicrobial use among septic patients managed by the critical care response team: an opportunity for improvement through de-escalation. Antimicrob Resist Infect Control 2019; 8:186. [PMID: 31832186 PMCID: PMC6869254 DOI: 10.1186/s13756-019-0609-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/21/2019] [Indexed: 01/09/2023] Open
Abstract
Background Most septic patients managed by critical care response teams (CCRT) are prescribed antimicrobials. Nevertheless, data evaluating their appropriateness are lacking both locally and internationally. The objective was to assess antimicrobial use among septic and non-septic patients managed by CCRT. Setting Case-control design was used to compare septic (cases) and non-septic (controls) CCRT patients at tertiary care setting. The frequency of antimicrobial use was assessed before and after CCRT activation. The appropriateness of antimicrobial use was assessed at day four post-CCRT, based on standard recommendations, clinical assessment, and culture results. Main results A total of 157 cases and 158 controls were included. The average age was 61.1 ± 20.4 years, and 54.6% were males, with minor differences between groups. The use of any antimicrobial was 100.0% in cases and 87.3% in controls (p < 0.001). The use of meropenem (68.2% versus 34.8%, p < 0.001) and vancomycin (56.7% versus 25.9%, p < 0.001) were markedly higher in cases than controls. The overall appropriateness was significantly lower in cases than controls (50.7% versus 59.6%, p = 0.047). Individual appropriateness was lowest with meropenem (16.7%) and imipenem (25.0%), and highest with piperacillin/tazobactam (87.1%) and colistin (78.3%). Only 48.5% of antimicrobials prescribed by CCRT were de-escalated by a primary team within four days. Individual appropriateness and de-escalations were not different between groups. Conclusions Empiric use and inadequate de-escalation of broad-spectrum antimicrobials were major causes for inappropriate antimicrobial use in CCRT patients. Our findings highlight the necessity of urgent implementation of an antimicrobial stewardship program, including training and auditing of antimicrobial prescriptions.
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Affiliation(s)
- Saad M Al-Qahtani
- 1Intensive Care Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Henry Baffoe-Bonnie
- 3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Aiman El-Saed
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Majid Alshamrani
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Ali Alaklabi
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,5Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Khuloud AlJoudi
- 6Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nahlah Albaalharith
- 1Intensive Care Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Azzam Mohammed
- 3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Sajid Hussain
- 1Intensive Care Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hanan H Balkhy
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,7King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Kim J, Kim YD, Lee DR, Kim KM, Lee WY, Lee S. Analysis of the characteristics of unplanned admission to the intensive care unit after general surgery. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.2.230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jaesuk Kim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Yeong-deok Kim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Dong-reul Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Kye-Min Kim
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sangseok Lee
- Department of Anesthesiology and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Lalova V, Petrova G, Merdzhanova E. Assessment of various aspects of using protocols in intensive care units in Plovdiv, Bulgaria. MEDICAL SCIENCE PULSE 2019. [DOI: 10.5604/01.3001.0013.1586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Since 1950 intensive care has become a separate and independent specialty. Significant technological
advances have allowed the Intensive Care Unit (ICU)s to be monitored through the centralized work of a
multidisciplinary team of specialists. ICUs provide cares at different levels of support. To provide patient access
to this highly specialized cares, the “Critical care without walls” or “Intensive Care without Borders” theories
have emerged, involving reanimation nurses offering highly specialized care and support. Protocols for nurses
have been developed, with the aim of facilitating their day-to-day activities, improving outcomes and safety of
patients and all staff. Utilizing this concept, the role of intensive care has rapidly expanded over the past 20 years.
Aim of the study: To understand the effectiveness and benefits derived from organisation of the working process.
Material and methods: We used documentary and survey methods and analysed the data using the software
package SPSS v. 21.0. Graphics were prepared using Microsoft Excel 2013. Numbers from 1 to 5 refer to the
answers “no”, “not really”, “cannot judge”, “closer to yes” and “yes”, respectively.
Results: Nurses’ performance, as an integral part of multidisciplinary ICU teams, is evidence that mortality
and morbidity can be improved thanks to the early recognition of patient deterioration and rapid resuscitation.
The better healing process is accomplished by optimising the content and evaluation of the desired results, in
association with good doctor practices. Respondents’ opinions about outcomes of protocol use differed significantly
between professions in regard to making their job easier, improving patient outcomes, providing consistency
in care, and preventing patient harm.
Conclusions: A more flexible and standard framework for nurses should be developed to improve quality of
care. The rapidly growing lack of ICU nurses in Bulgaria is concerning.
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Affiliation(s)
- Valentina Lalova
- Department of Nursing, Faculty of Public Health, Medical University of Plovdiv, Bulgaria
| | - Gergana Petrova
- Department of Nursing, Faculty of Public Health, Medical University of Plovdiv, Bulgaria
| | - Elena Merdzhanova
- Department of Nursing, Faculty of Public Health, Medical University of Plovdiv, Bulgaria
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Wheeler DS, Stalets EL. A day in the life. Transl Pediatr 2018; 7:242-245. [PMID: 30460174 PMCID: PMC6212388 DOI: 10.21037/tp.2018.09.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Wheeler DS, Dewan M, Maxwell A, Riley CL, Stalets EL. Staffing and workforce issues in the pediatric intensive care unit. Transl Pediatr 2018; 7:275-283. [PMID: 30460179 PMCID: PMC6212383 DOI: 10.21037/tp.2018.09.05] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.
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Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Maxwell
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carley L Riley
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Levkovich BJ, Bingham G, Jones D, Kirkpatrick CM, Cooper DJJ, Dooley MJ. Understanding how medications contribute to clinical deterioration and are used in rapid response systems: A comprehensive scoping review. Aust Crit Care 2018; 32:256-272. [PMID: 30005938 DOI: 10.1016/j.aucc.2018.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 05/23/2018] [Accepted: 05/29/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In hospitals, rapid response systems (RRSs) identify patients who deteriorate and provide critical care at their bedsides to stabilise and escalate care. Medications, including oral and parenteral pharmaceutical preparations, are the most common intervention for hospitalised patients and the most common cause of harm. This connection between clinical deterioration and medication safety is poorly understood. OBJECTIVES To inform improvements in prevention and management of clinical deterioration, this review aimed to examine how medications contributed to clinical deterioration and how medications were used in RRSs. REVIEW METHODS A scoping review was undertaken of medication data reported in studies of clinical deterioration or RRSs in diverse hospital settings between 2005 and 2017. Bibliographic database searches used permutations of "rapid response system," "medical emergency team," and keyword searching with medication-related terms. Independent selection, quality assessment, and data extraction informed mapping against four medication themes: causes of deterioration, predictors of deterioration, RRS use, and management. RESULTS Thirty articles were reviewed. Quality was low: limited by small samples, observational, single-centre designs and few primary medication-related outcomes. Adverse drug reactions and potentially preventable medication errors, involving sedatives, analgesics, and cardiovascular agents, contributed to clinical deterioration. While sparsely reported, outcomes included death and escalation of care. In children, administration of antibiotics or nebulised medications appeared to predict subsequent deterioration. Cardiovascular medications, sedatives, and analgesics commonly were used to manage deterioration but further detail was lacking. Despite reported potential for patient harm, evaluation of medication management systems was limited. CONCLUSIONS Medications contributed to potentially preventable clinical deterioration, with considerable harm, and were common interventions for its management. When assessing deteriorating patients or caring for patients who require escalation to critical care, clinicians should consider medication errors and adverse reactions. Studies with more specific medication-related, patient-centred end points could reduce medication-related deterioration and refine RRS medication use and management.
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Affiliation(s)
- Bianca J Levkovich
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia.
| | - Gordon Bingham
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Daryl Jones
- Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, The Austin Hospital, Heidelberg, Victoria, Australia.
| | - Carl M Kirkpatrick
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.
| | - D J Jamie Cooper
- Australia and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia.
| | - Michael J Dooley
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia.
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McGaughey J, O'Halloran P, Porter S, Blackwood B. Early warning systems and rapid response to the deteriorating patient in hospital: A systematic realist review. J Adv Nurs 2017; 73:2877-2891. [DOI: 10.1111/jan.13398] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Jennifer McGaughey
- School of Nursing & Midwifery; Medical Biology Centre; Queen's University Belfast; Belfast UK
| | - Peter O'Halloran
- School of Nursing & Midwifery; Queen's University of Belfast; Belfast UK
| | - Sam Porter
- Department of Social Sciences and Social Work; Bournemouth University; Poole UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry & Biomedical Sciences; Centre for Experimental Medicine; Queen's University Belfast; Belfast UK
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Abstract
Noting that a variety of pre-hospital interventions can now be applied to treat traumatic injury, David J Lockey calls for research to determine which of these actually improve survival and reduce morbidity.
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García-Gigorro R, de la Cruz Vigo F, Andrés-Esteban EM, Chacón-Alves S, Morales Varas G, Sánchez-Izquierdo JA, Montejo González JC. Impact on patient outcome of emergency department length of stay prior to ICU admission. Med Intensiva 2016; 41:201-208. [PMID: 27553889 DOI: 10.1016/j.medin.2016.05.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/29/2016] [Accepted: 05/31/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The favorable evolution of critically ill patients is often dependent on time-sensitive care intervention. The timing of transfer to the intensive care unit (ICU) therefore may be an important determinant of outcomes in critically ill patients. The aim of this study was to analyze the impact upon patient outcome of the length of stay in the Emergency Care Department. DESIGN A single-center ambispective cohort study was carried out. SETTING A general ICU and Emergency Care Department (ED) of a single University Hospital. PATIENTS We included 269 patients consecutively transferred to the ICU from the ED over an 18-month period. INTERVENTIONS Patients were first grouped into different cohorts based on ED length of stay (LOS), and were then divided into two groups: (a) ED LOS ≤5h and (b) ED LOS >5h. VARIABLES Demographic, diagnostic, length of stay and mortality data were compared among the groups. RESULTS Median ED LOS was 277min (IQR 129-622). Patients who developed ICU complications had a longer ED LOS compared to those who did not (349min vs. 209min, p<0.01). A total of 129 patients (48%) had ED LOS >5h. The odds ratio of dying for patients with ED LOS >5h was 2.5 (95% CI 1.3-4.7). Age and sepsis diagnosis were the risk factors associated to prolongation of ED length of stay. CONCLUSIONS A prolonged ED stay prior to ICU admission is related to the development of time-dependent complications and increased mortality. These findings suggest possible benefit from earlier ICU transfer and the prompt initiation of organ support.
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Affiliation(s)
- R García-Gigorro
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain.
| | - F de la Cruz Vigo
- Servicio de Cirugía General, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain
| | - E M Andrés-Esteban
- Servicio de Epidemiología e Investigación Clínica, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain
| | - S Chacón-Alves
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain
| | - G Morales Varas
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain
| | - J A Sánchez-Izquierdo
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain
| | - J C Montejo González
- Jefe del Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Avenida de Córdoba, s/n, 28041 Madrid, Spain
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Gouda AM, Alqahtani SM. Do not resuscitate: An expanding role for critical care response team. Indian J Crit Care Med 2016; 20:146-9. [PMID: 27076725 PMCID: PMC4810891 DOI: 10.4103/0972-5229.178177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Do not resuscitate (DNR) order is an important aspect of medical practice. Since the implementation of critical care response team (CCRT), frequently we have encountered with patients in the wards that should have been made DNR. Initiating DNR became an important part of CCRT activity. We were obliged to extended the role of CCRT - beyond managing seriously ill patients - in addressing the code status for patients after discussion with the managing teams. PURPOSE We compare the trend of initiation of DNR orders in the regular ward before and after implementing CCRT. METHODS Our hospital is 1200 bed tertiary care center. CCRT has been launched in January 1, 2008. The CCRT is 24/7 service led by in-house North American certified intensivists. Cohort analysis of prospectively collected data of 5406 CCRT activation from January 1, 2008, to September 30, 2013. Data before implementation of CCRT was available for 299 patients from the period of June 1, 2007, to December 31, 2007. A comparison made between the two groups (before and after implementation of CCRT) for demographic data and percentage of patients in whom DNR order initiated. RESULTS Before CCRT implementation, 299 patients were attended by Intensive Care Unit physician for regular consultation, 41.1% were females and 52.4% were males with mean of age 58.44 ± 18.47 standard deviation (SD). DNR was initiated in 2.7% of patients. After CCRT implementation, 5904 CCRT activations, 47.6% females and 52.4% males with mean of age 59.17 ± 20.07 SD DNR initiated in 468 (7.9%) of cases. There was 5.2% increase in DNR orders initiation and completion after CCRT introduced to our institute.
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Affiliation(s)
- Alaa M Gouda
- Department of Intensive Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Saad M Alqahtani
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Abstract
A significant number of medical admissions and inpatients on general wards are unstable or have unmet medical or nursing needs. Ward-based physiological scoring (early warning scores) and similar innovations aim to identify those who may merit enhanced care, and initiatives such as 'comprehensive critical care' describe a whole system approach to this group. While the recommendations in this 15-year-old document have been largely accepted and implemented, the Future Hospital Report recognises that close cooperation between acute medicine and critical care is essential but lacking in many institutions. Much of what follows is opinion and conjecture as there is little hard data to refer to. Although an anaesthetically trained intensivist, I have been a member of the Society for Acute Medicine since its inception and have sat on Council since then as critical care representative. I was also the clinical director for acute medicine in Norwich for three years.
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Affiliation(s)
- Simon Fletcher
- Norfolk and Norwich University Foundation Trust, Norwich, UK
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Hubner P, Schober A, Sterz F, Stratil P, Wallmueller C, Testori C, Grassmann D, Lebl N, Ohrenberger I, Herkner H, Weiser C. Surveillance of Patients in the Waiting Area of the Department of Emergency Medicine. Medicine (Baltimore) 2015; 94:e2322. [PMID: 26705221 PMCID: PMC4697987 DOI: 10.1097/md.0000000000002322] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Many patients visiting an emergency department are in reduced general condition of health and at risk of suffering further deterioration during their stay. We wanted to test the feasibility of a new monitoring system in a waiting area of an emergency department.In an observational cross-sectional single-center study, patients with acute cardiac or pulmonary symptoms or in potentially life-threatening conditions were enrolled. Monitoring devices providing vital signs via short range radio (SRR) at certain time points and compliance evaluation forms were used.Out of 230 patients, 4 wanted to terminate their participation prematurely. No data was lost due to technical difficulties. Over a median monitoring period of 178 (118-258) min per patient, 684 h of vital sign data were collected and used to assist managing those patients. Linear regression analysis between clinical symptom category groups of patients showed significant differences in the respiratory rate and noninvasive blood pressure courses. Feedback from patients and users via questionnaires showed overall very good acceptance and patients felt that they were given better care.To assist medical staff of an emergency department waiting area to rapidly response to potentially life-threatening situations of its patients, a new monitoring system proved to be feasible and safe.
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Affiliation(s)
- Pia Hubner
- From the Department of Emergency Medicine, Medical University of Vienna, Austria
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RCoA spring symposium: perioperative medicine. Br J Anaesth 2015. [DOI: 10.1093/bja/aev138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Carlisle JB, White SM, Tobin AE. The anaesthetist and peri-operative medicine: migration and evolution. Anaesthesia 2015; 71 Suppl 1:1-2. [DOI: 10.1111/anae.13339] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- J. B. Carlisle
- Anaesthesia and Peri-operative Medicine; Torbay Hospital; Torquay Devon UK
| | - S. M. White
- Brighton and Sussex University Hospitals, NHS Trust; Brighton East Sussex UK
| | - A. E. Tobin
- Intensive Care; St Vincent's Hospital; Melbourne Victoria Australia
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Lockey DJ, Crewdson K, Lossius HM. Pre-hospital anaesthesia: the same but different. Br J Anaesth 2014; 113:211-9. [PMID: 25038153 DOI: 10.1093/bja/aeu205] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.
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Affiliation(s)
- D J Lockey
- North Bristol NHS Trust, Bristol BS16 1LE, UK London's Air Ambulance, Barts Health NHS Trust, London E1 1BB, UK
| | - K Crewdson
- London's Air Ambulance, Barts Health NHS Trust, London E1 1BB, UK
| | - H M Lossius
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Holterveien 24, PO Box 94, N-1441 Drøbak, Norway Field of Pre-hospital Critical Care, Network for Medical Sciences, University of Stavanger, Kjell Arholmsgate 41, Stavanger 4036, Norway
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HILLMAN KM. Failure to recognise patients at the end of life in acute hospitals. Acta Anaesthesiol Scand 2014; 58:1-2. [PMID: 24341690 DOI: 10.1111/aas.12231] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- K. M. HILLMAN
- Liverpool Hospital; South West Sydney Clinical School; The Simpson Centre for Health Services Research affiliated with the Australian Institute of Health Innovation; University of New South Wales; Liverpool BC NSW Australia
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Harrison OJ, Lockey D. Should resuscitative thoracotomy be performed in the pre-hospital phase of care? TRAUMA-ENGLAND 2013. [DOI: 10.1177/1460408613488481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Penetrating thoracic trauma is increasing in the UK and elsewhere and immediate transfer to a Major Trauma Centre with cardio-thoracic expertise is usually optimal management. Pre-hospital traumatic cardiac arrest has an extremely poor prognosis. Performing thoracotomy before arrival in hospital has produced neurologically intact survivors in several case series. The technique described involves rapid clamshell thoracotomy and release of pericardial tamponade. Favourable outcomes appear to be associated with a single stab wound to the heart causing cardiac tamponade. Pre-hospital thoracotomy is described in the current European Resuscitation Guidelines and courses for non-surgeons are now taught at the Royal College of Surgeons of England and at the Surgical Skills Training Centre at Newcastle Freeman Hospital. It is likely that further survivors will be reported as the technique becomes more widely used. Alternatives to pre-hospital thoracotomy in the future for patients with hypovolaemic cardiac arrest may include resuscitative endovascular balloon occlusion of the aorta and pre-hospital extended preservation and resuscitation.
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Affiliation(s)
| | - David Lockey
- North Bristol NHS Trust, Bristol, UK
- Barts Health NHS Trust, UK
- School of Clinical Sciences, University of Bristol, UK
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Lockey DJ, Weaver AE, Davies GE. Practical translation of hemorrhage control techniques to the civilian trauma scene. Transfusion 2013; 53 Suppl 1:17S-22S. [PMID: 23301967 DOI: 10.1111/trf.12031] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This article examines how established and innovative techniques in hemorrhage control can be practically applied in a civilian physician-based prehospital trauma service. A "care bundle" of measures to control hemorrhage on scene are described. Interventions discussed include the implementation of a system to achieve simple endpoints such as shorter scene times, appropriate triage, careful patient handling, use of effective splints and measures to control external hemorrhage. More complex interventions include prehospital activation of massive hemorrhage protocols and administration of on-scene tranexamic acid, prothrombin complex concentrate, and red blood cells. Radical resuscitation interventions, such as prehospital thoracotomy for cardiac tamponade, and the potential future role of other interventions are also considered.
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Affiliation(s)
- David J Lockey
- London's Air Ambulance, Royal London Hospital, London, UK.
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O'Callaghan DJP, Jayia P, Vaughan-Huxley E, Gribbon M, Templeton M, Skipworth JRA, Gordon AC. An observational study to determine the effect of delayed admission to the intensive care unit on patient outcome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R173. [PMID: 23025890 PMCID: PMC3682272 DOI: 10.1186/cc11650] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 10/01/2012] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Delayed patient admission to the intensive care unit (ICU) due to lack of bed availability is a common problem, but the effect on patient outcome is not fully known. METHODS A retrospective study was performed using departmental computerised records to determine the effect of delayed ICU admission and temporary management within the operating theatre suite on patient outcome. Emergency surgical and medical patients admitted to the ICU (2003 to 2007) were divided into delay (more than three hours from referral to admission) and no-delay (three or fewer hours from referral to admission) groups. Our primary outcome measure was length of ICU stay. Secondary outcome measures were mortality rates and duration of organ support. RESULTS A total of 1,609 eligible patients were included and 149 (9.3%) had a delayed admission. The delay and no-delay groups had similar baseline characteristics. Median ICU stay was 5.1 days (delay) and 4.5 days (no-delay) (P = 0.55) and ICU mortality was 26.8% (delay) and 24.2% (no-delay) (P = 0.47). Following adjustment for demographic and baseline characteristics there was no difference in either length of ICU stay or mortality rates between groups. ICU admission delay was associated with both an increased requirement for advanced respiratory support (92.3% delay vs. 76.4% no-delay, P <0.01) and a longer time spent ventilated (median four days delay vs. three days no-delay, P = 0.04). CONCLUSIONS No significant difference in length of ICU stay or mortality rate was demonstrated between the delay and no-delay cohorts. Patients within the delay group had a significantly greater requirement for advanced respiratory support and spent a longer time ventilated.
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Hillman K. Outreach Systems – Where Next? J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ken Hillman
- Professor of Intensive Care, Liverpool Hospital, University of New South Wales (SWS Clinical School), Sydney, Australia. Director of The Simpson Centre for Health Services Research, affiliated with the Australian Institute of Health Innovation, University of New South Wales
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Wheeler DS. Once more unto the breach, dear friends, once more. World J Crit Care Med 2012; 1:1-3. [PMID: 24701394 PMCID: PMC3956062 DOI: 10.5492/wjccm.v1.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 12/20/2011] [Accepted: 12/26/2011] [Indexed: 02/06/2023] Open
Abstract
The first issue of the World Journal of Critical Care Medicine (WJCCM), whose preparatory work was initiated on December 16, 2010, will be published on February 4, 2012. The WJCCM Editorial Board has now been established and consists of 105 distinguished experts from 27 countries. Our purpose of launching the WJCCM is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.
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Affiliation(s)
- Derek S Wheeler
- Derek S Wheeler, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
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Al-Qahtani S, Al-Dorzi HM. Rapid response systems in acute hospital care. Ann Thorac Med 2011; 5:1-4. [PMID: 20351953 PMCID: PMC2841802 DOI: 10.4103/1817-1737.58952] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2009] [Accepted: 08/20/2009] [Indexed: 01/26/2023] Open
Affiliation(s)
- Saad Al-Qahtani
- Department of Intensive Care Unit, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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Abstract
Severe sepsis is defined as organ dysfunction in the setting of systemic inflammatory response due to infection. With changes in population age, comorbidity and the delivery of medical care, severe sepsis is increasingly common, and can present in every area of the hospital. The major obstacles to improved outcomes in severe sepsis are deficiencies in healthcare staffing and education, haphazard recognition and response to early clinical deterioration and deviation from optimal management as defined by international guidelines. Major treatment errors were identified in 30% of patients with bacteraemia in one recent investigation. Against this, substantial reductions in mortality can be achieved by improving recognition, urgent care and resuscitation. With a view to improving survival in sepsis, collaborative efforts are required to measure outcomes, implement guidelines and secure adequate funding for ongoing practice improvement, education and research.
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Affiliation(s)
- P J Huggan
- Divisions of General Medicine and Infectious Disease, National University Health System, Singapore.
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Abstract
PURPOSE OF REVIEW This review outlines the way the specialty of intensive care has expanded over the last decade in response to the changing population of hospital patients, being older with more comorbidities and having more complex interventions. The previous disjointed professional and geographical silos, providing patient care, are being challenged and a more patient focussed continuum of care is replacing it. RECENT FINDINGS There have been many reports over the last few years, describing patient centred systems, constructed around the needs of the seriously ill, at-risk patient, including trauma systems and Medical Emergency Team-type systems. There is now general agreement that in most settings these systems are responsible for a significant reduction in mortality and serious adverse events such as cardiac arrest rates. SUMMARY The implications for the move towards systems to improve patient outcome and decrease mortality in hospitals are having a significant impact on the way we practise medicine, resulting in an emphasis, among other things, of constructing our care around the needs of patients, rather than rigidly practice medicine from within our own tribal boundaries, for example professional boundaries, medical specialty boundaries and geographical boundaries.
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Intensive Care Medicine: Where We Are and Where We Want To Go? ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2011 2011. [PMCID: PMC7121679 DOI: 10.1007/978-3-642-18081-1_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Intensive care medicine can be defined as the science and art of detecting and managing patients with impending or established critical illness, in order to prevent further deterioration and revert the disease process or its consequences, so as to achieve the best possible outcomes.
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Abstract
Intensive care offers a standard of monitoring, intervention, and organ support that cannot be readily delivered in a general ward. Its expansion in the past few decades, including the creation of emergency and outreach teams, emphasises that intensive care has an increasingly prominent role within the hospital. Although outcomes are clearly improving, intensive care remains a nascent specialty in which we are still learning how to harness a powerful ability to manipulate physiology, biochemistry, and immunology to achieve best outcomes for the patient. The results of many multicentre studies have not lent support to, or have even confounded, expectations, drawing attention to several issues related to patient heterogeneity, trial design, and elucidation of underlying pathophysiological processes. However, these results have generated constructive introspection and reappraisal of treatments and management strategies that have benefited the patient. In addition to the medical, financial, and logistical challenges in the future, exciting opportunities will arise as new developments in diagnostic tests, therapeutic interventions, and technology are used to exploit an increasing awareness of how critical illness should be managed.
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Durand M, Hutchings A, Black N, Green J. 'Not quite Jericho, but more doors than there used to be'. Staff views of the impact of 'modernization' on boundaries around adult critical care services in England. J Health Serv Res Policy 2010; 15:229-35. [PMID: 20660533 DOI: 10.1258/jhsrp.2010.009135] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To explore staff perceptions of the impact of 'modernization' on the organization, delivery and culture of adult critical care services in England. 'Modernization' policies aimed to alter the boundaries around critical care and create a comprehensive, seamless service. METHODS Seven hospitals (three teaching and four district general hospitals) in three critical care networks participated. In-depth interviews were conducted with a purposive sample of 45 critical care staff. Data were analysed thematically. RESULTS The boundaries around critical care were generally perceived to be less fixed than previously. The re-framing of 'internal walls' within hospitals was associated with the introduction of outreach teams, new hospital-wide remits for intensive care unit (ICU) staff and the greater integration of allied health professionals into the critical care team. Transformation of services was challenged by practicalities including the need for additional staff, and a 'them and us' attitude between ICU and ward staff. 'External walls' between hospitals were breached where local clinical networks were perceived to have successfully improved communication and joint working. This was facilitated by effective leadership, availability of network-associated funds, the identification of common problems and evidence of benefit from cooperation. However, barriers existed and there was some scepticism among staff as to whether critical care can ever be entirely 'without walls'. CONCLUSIONS Policies to remove boundaries around adult critical care are perceived to have had a dramatic impact on the organization of the service. Considerable progress was reported towards developing comprehensive critical care services both within and between hospitals.
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Affiliation(s)
- Mary Durand
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London, UK.
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Affiliation(s)
- Chris Brunker
- neurosciences, St George's Hospital, Tooting, London
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Boniatti MM, Azzolini N, da Fonseca DLO, Ribeiro BSP, de Oliveira VM, Castilho RK, Raymundi MG, Coelho RS, Filho EMR. Prognostic value of the calling criteria in patients receiving a medical emergency team review. Resuscitation 2010; 81:667-70. [DOI: 10.1016/j.resuscitation.2010.01.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2009] [Revised: 01/14/2010] [Accepted: 01/28/2010] [Indexed: 10/19/2022]
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Código rojo, un ejemplo de sistema de respuesta rápida. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2010. [DOI: 10.1016/s0120-3347(10)81006-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Jones L, King L, Wilson C. A literature review: factors that impact on nurses’ effective use of the Medical Emergency Team (MET). J Clin Nurs 2009; 18:3379-90. [DOI: 10.1111/j.1365-2702.2009.02944.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Piagnerelli M, Van Nuffelen M, Maetens Y, Lheureux P, Vincent JL. A 'shock room' for early management of the acutely ill. Anaesth Intensive Care 2009; 37:426-31. [PMID: 19499862 DOI: 10.1177/0310057x0903700307] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Our 850-bed, academic, tertiary care hospital uses a four-bed dedicated 'shock room' situated between the Departments of Emergency Medicine and Intensive Care to stabilise all acutely ill patients from outside or inside the hospital before transfer to the intensive care unit or other department. Admitted patients stay a maximum of four hours in the shock room. In this article we describe our experiences using this shock room by detailing the demographic data, including time and source of admission, diagnosis and outcome, for the 2514 patients admitted to the shock room in 2006. The most common reasons for admission were cardiac (33%) and neurological (21%) diagnoses. After diagnosis and initial treatment, 54% of patients were transferred to an intensive care unit or a coronary care unit; 2.5% of patients died in the shock room. The shock room provides a useful area of collaboration between emergency department and intensive care unit staff and enables acutely ill patients to be assessed and treated rapidly to optimise outcomes.
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Affiliation(s)
- M Piagnerelli
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Hill AD, Fan E, Stewart TE, Sibbald WJ, Nauenberg E, Lawless B, Bennett J, Martin CM. Critical care services in Ontario: a survey-based assessment of current and future resource needs. Can J Anaesth 2009; 56:291-7. [PMID: 19296190 DOI: 10.1007/s12630-009-9055-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 01/15/2009] [Accepted: 01/22/2009] [Indexed: 11/28/2022] Open
Abstract
PURPOSE In response to the challenges of an aging population and decreasing workforce, the provision of critical care services has been a target for quality and efficiency improvement efforts. Reliable data on available critical care resources is a necessary first step in informing these efforts. We sought to describe the availability of critical care resources, forecast the future requirement for the highest-level critical care beds and to determine the physician management models in critical care units in Ontario, Canada. METHODS In June 2006, self-administered questionnaires were mailed to the Chief Executive Officers of all acute care hospitals, identified through the Ontario government's hospital database. The questionnaire solicited information on the number and type of critical care units, number of beds, technological resources and management of each unit. RESULTS Responses were obtained from 174 (100%) hospitals, with 126 (73%) reporting one or more critical care units. We identified 213 critical care units in the province, representing 1789 critical care beds. Over half (59%) of these beds provided mechanical ventilation on a regular basis, representing a capacity of 14.9 critical care and 8.7 mechanically ventilated beds per 100,000 population. Sixty-three percent of units with capacity for mechanical ventilation involved an intensivist in admission and coordination of care. Based on current utilization, the demand for mechanically ventilated beds by 2026 is forecast to increase by 57% over levels available in 2006. Assuming 80% bed utilization, it is estimated that an additional 810 ventilated beds will be needed by 2026. CONCLUSION Current utilization suggests a substantial increase in the need for the highest-level critical care beds over the next two decades. Our findings also indicate that non-intensivists direct care decisions in a large number of responding units. Unless major investments are made, significant improvements in efficiency will be required to maintain future access to these services.
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Affiliation(s)
- Andrea D Hill
- University Health Network, Toronto General Hospital, and Department of Health Policy Management and Evaluation, University of Toronto, 200 Elizabeth Street, 11C-1165, Toronto, ON, Canada, M5G 2C4.
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Chen J, Hillman K, Bellomo R, Flabouris A, Finfer S, Cretikos M. The impact of introducing medical emergency team system on the documentations of vital signs. Resuscitation 2009; 80:35-43. [DOI: 10.1016/j.resuscitation.2008.10.009] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 08/21/2008] [Accepted: 10/05/2008] [Indexed: 11/24/2022]
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Smith GB, Prytherch DR, Schmidt PE, Featherstone PI, Higgins B. A review, and performance evaluation, of single-parameter “track and trigger” systems. Resuscitation 2008; 79:11-21. [DOI: 10.1016/j.resuscitation.2008.05.004] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 05/03/2008] [Indexed: 11/27/2022]
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Baker-McClearn D, Carmel S. Impact of critical care outreach services on the delivery and organization of hospital care. J Health Serv Res Policy 2008; 13:152-7. [PMID: 18573764 DOI: 10.1258/jhsrp.2008.008003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate the impact of critical care outreach services on the delivery and organization of hospital care from the perspective of staff working in acute hospitals. METHODS One hundred semi-structured interviews were undertaken with hospital staff who were either members of, or who came into contact with, the outreach service in eight hospitals in England. RESULTS Outreach services had two main impacts on the delivery and organization of hospital care, reflecting the organizational and educational aims of the policy. First, on the organization of patient care: it was suggested that care was more timely, there were fewer referrals to the intensive care unit (ICU) and ICUs felt more able to discharge patients to hospital wards. There were also perceived to be improved links between ward nurses and medical teams and improved morale among ICU nurses. Second, on the confidence and skills of ward staff (nurses and junior doctors): increased contact on the wards resulted in more opportunities to share critical care skills. However, there remained concerns about the sustainability of improved skills and some respondents felt that junior doctors were becoming de-skilled. CONCLUSION Critical care outreach services have had a positive impact on the delivery and organization of hospital care. In attempting to share critical care skills, however, these services can experience a tension between the aims of service delivery and education - a tension which is partly resolved by sharing skills in the clinical and organizational context of direct patient care.
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