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Angotti LB, Richards JB, Fisher DF, Sankoff JD, Seigel TA, Al Ashry HS, Wilcox SR. Duration of Mechanical Ventilation in the Emergency Department. West J Emerg Med 2017; 18:972-979. [PMID: 28874952 PMCID: PMC5576636 DOI: 10.5811/westjem.2017.5.34099] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS). METHODS This was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort. RESULTS We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator. CONCLUSION In a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.
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Affiliation(s)
- Lauren B Angotti
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina
| | - Jeremy B Richards
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina
| | - Daniel F Fisher
- Massachusetts General Hospital, Respiratory Care Services, Boston, Massachusetts
| | - Jeffrey D Sankoff
- University of Colorado at Denver, School of Medicine, Department of Emergency Medicine, Denver, Colorado
| | - Todd A Seigel
- Kaiser Permanente East Bay, Oakland and Richmond Medical Centers, Department of Emergency Medicine and Critical Care, Oakland, California
| | - Haitham S Al Ashry
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina
| | - Susan R Wilcox
- Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina.,Medical University of South Carolina, Division of Emergency Medicine, Charleston, South Carolina
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Protective lung strategies: A cross sectional survey of nurses knowledge and use in the emergency department. ACTA ACUST UNITED AC 2017; 20:87-91. [PMID: 28268159 DOI: 10.1016/j.aenj.2017.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Mechanical ventilation (MV) is commonly used in emergency departments (EDs). Protective lung strategies (PLS), comprising of low tidal volume (6mL/kg), control of oxygen and plateau pressures, and administration of positive end expiratory pressure (PEEP) has been shown to reduces the risks associated with MV but there is little evidence exists about nurses' knowledge or application of PLS. Our aim was to explore nurses knowledge and application of PLS in Australian EDs. METHODS Descriptive, exploratory design utilising an online questionnaire. A convenience sample was recruited via the College of Emergency Nursing Australasia mailing list and secondary snowball sampling was used to optimise response rate. RESULTS There were 157 participants. PLS are being used in most EDs (n=104, 75%) and clinical practice guidelines (CPG) are often available (n=86, 62%). Most ED ventilators are capable of implementing PLS, but measurement of plateau pressures was infrequent (n=46%). Participants demonstrate appropriate knowledge, but reported varying levels of confidence and perceived autonomy when implementing PLS in the ED. CONCLUSION PLS are being used in Australian EDs, aligning with best available evidence. Nursing staff have good levels of PLS knowledge. Development of an evidence-based CPG may improve confidence when implementing PLS and may pave the way for ED nurses to expand their scope of practice.
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Tallo FS, de Campos Vieira Abib S, de Andrade Negri AJ, Filho PC, Lopes RD, Lopes AC. Evaluation of self-perception of mechanical ventilation knowledge among Brazilian final-year medical students, residents and emergency physicians. Clinics (Sao Paulo) 2017; 72:65-70. [PMID: 28273238 PMCID: PMC5304362 DOI: 10.6061/clinics/2017(02)01] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 08/08/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE: To present self-assessments of knowledge about mechanical ventilation made by final-year medical students, residents, and physicians taking qualifying courses at the Brazilian Society of Internal Medicine who work in urgent and emergency settings. METHODS: A 34-item questionnaire comprising different areas of knowledge and training in mechanical ventilation was given to 806 medical students, residents, and participants in qualifying courses at 11 medical schools in Brazil. The questionnaire's self-assessment items for knowledge were transformed into scores. RESULTS: The average score among all participants was 21% (0-100%). Of the total, 85% respondents felt they did not receive sufficient information about mechanical ventilation during medical training. Additionally, 77% of the group reported that they would not know when to start noninvasive ventilation in a patient, and 81%, 81%, and 89% would not know how to start volume control, pressure control and pressure support ventilation modes, respectively. Furthermore, 86.4% and 94% of the participants believed they would not identify the basic principles of mechanical ventilation in patients with obstructive pulmonary disease and acute respiratory distress syndrome, respectively, and would feel insecure beginning ventilation. Finally, 77% said they would fear for the safety of a patient requiring invasive mechanical ventilation under their care. CONCLUSION: Self-assessment of knowledge and self-perception of safety for managing mechanical ventilation were deficient among residents, students and emergency physicians from a sample in Brazil.
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Affiliation(s)
- Fernando Sabia Tallo
- Universidade Federal de São Paulo (UNIFESP), Departamento de Cirurgia, São Paulo/SP, Brazil
- *Corresponding author. E-mail:
| | | | | | | | - Renato Delascio Lopes
- Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, United States
| | - Antônio Carlos Lopes
- Universidade Federal de São Paulo (UNIFESP), Departamento de Cirurgia, São Paulo/SP, Brazil
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Wilcox SR, Strout TD, Schneider JI, Mitchell PM, Smith J, Lutfy-Clayton L, Marcolini EG, Aydin A, Seigel TA, Richards JB. Academic Emergency Medicine Physicians' Knowledge of Mechanical Ventilation. West J Emerg Med 2016; 17:271-9. [PMID: 27330658 PMCID: PMC4899057 DOI: 10.5811/westjem.2016.2.29517] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 01/19/2016] [Accepted: 02/05/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction Although emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings’ education, experience, and knowledge regarding mechanical ventilation in the emergency department. Methods We developed a survey of academic EM attendings’ educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings’ scores on the assessment instrument and their training, education, and comfort with ventilation. Results Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0–1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one’s own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians’ comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education. Conclusion EM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0–1 hour. Physicians’ performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical ventilation.
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Affiliation(s)
- Susan R Wilcox
- Medical University of South Carolina, Divisions of Emergency Medicine and Pulmonary, Critical Care and Sleep Medicine, Charleston, South Carolina
| | - Tania D Strout
- Maine Medical Center, Department of Emergency Medicine, Portland, Maine
| | - Jeffrey I Schneider
- Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Patricia M Mitchell
- Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Jessica Smith
- Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | | | - Evie G Marcolini
- Yale University School of Medicine, Departments of Emergency Medicine and Neurology, Divisions of Neurocritical Care and Emergency Neurology and Surgical Critical Care, New Haven, Connecticut
| | - Ani Aydin
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Todd A Seigel
- Department of Emergency Medicine and Critical Care, Kaiser Permanente East Bay, Oakland and Richmond Medical Centers, California
| | - Jeremy B Richards
- Medical University of South Carolina, Division of Pulmonary, Critical Care and Sleep Medicine, Charleston, South Carolina
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Wilcox SR, Richards JB, Fisher DF, Sankoff J, Seigel TA. Initial mechanical ventilator settings and lung protective ventilation in the ED. Am J Emerg Med 2016; 34:1446-51. [PMID: 27139256 DOI: 10.1016/j.ajem.2016.04.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/18/2016] [Accepted: 04/17/2016] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Mechanical ventilation with low tidal volumes has been shown to improve outcomes for patients both with and without acute respiratory distress syndrome. This study aims to characterize mechanically ventilated patients in the emergency department (ED), describe the initial ED ventilator settings, and assess for associations between lung protective ventilation strategies in the ED and outcomes. METHODS This was a multicenter, prospective, observational study of mechanical ventilation at 3 academic EDs. We defined lung protective ventilation as a tidal volume of less than or equal to 8 mL/kg of predicted body weight and compared outcomes for patients ventilated with lung protective vs non-lung protective ventilation, including inhospital mortality, ventilator days, intensive care unit length of stay, and hospital length of stay. RESULTS Data from 433 patients were analyzed. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Two hundred sixty-one patients (60.3%) received lung protective ventilation, but most patients were ventilated with a low positive end-expiratory pressure, high fraction of inspired oxygen strategy. Patients were ventilated in the ED for a mean of 5 hours and 7 minutes but had few ventilator adjustments. Outcomes were not significantly different between patients receiving lung protective vs non-lung protective ventilation. CONCLUSIONS Nearly 40% of ED patients were ventilated with non-lung protective ventilation as well as with low positive end-expiratory pressure and high fraction of inspired oxygen. Despite a mean ED ventilation time of more than 5 hours, few patients had adjustments made to their ventilators.
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Affiliation(s)
- Susan R Wilcox
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Division of Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Jeremy B Richards
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Daniel F Fisher
- Respiratory Care Services, Massachusetts General Hospital, Boston, MA, USA.
| | - Jeffrey Sankoff
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO, USA.
| | - Todd A Seigel
- Department of Emergency Medicine and Critical Care, Kaiser Permanente East Bay, Oakland and Richmond Medical Centers, CA, USA.
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Wilcox SR, Seigel TA, Strout TD, Schneider JI, Mitchell PM, Marcolini EG, Cocchi MN, Smithline HA, Lutfy-Clayton L, Mullen M, Ilgen JS, Richards JB. Emergency medicine residents' knowledge of mechanical ventilation. J Emerg Med 2014; 48:481-91. [PMID: 25497896 DOI: 10.1016/j.jemermed.2014.09.059] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 08/15/2014] [Accepted: 09/30/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although Emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) residency curricula. OBJECTIVES The objective of this study was to quantify EM residents' education, experience, and knowledge regarding mechanical ventilation. METHODS We developed a survey of residents' educational experiences with ventilators and an assessment tool with nine clinical questions. Correlation and regression analyses were performed to evaluate the relationship between residents' scores on the assessment instrument and their training, education, and comfort with ventilation. RESULTS Of 312 EM residents, 218 responded (69.9%). The overall correct response rate for the assessment tool was 73.3%, standard deviation (SD) ± 22.3. Seventy-seven percent (n = 167) of respondents reported ≤ 3 h of mechanical ventilation education in their residency curricula over the past year. Residents reported frequently caring for ventilated patients in the ED, as 64% (n = 139) recalled caring for ≥ 4 ventilated patients per month. Fifty-three percent (n = 116) of residents endorsed feeling comfortable caring for mechanically ventilated ED patients. In multiregression analysis, the only significant predictor of total test score was residents' comfort with caring for mechanically ventilated patients (F = 10.963, p = 0.001). CONCLUSIONS EM residents report caring for mechanically ventilated patients frequently, but receive little education on mechanical ventilation. Furthermore, as residents' performance on the assessment tool is only correlated with their self-reported comfort with caring for ventilated patients, these results demonstrate an opportunity for increased educational focus on mechanical ventilation management in EM residency training.
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Affiliation(s)
- Susan R Wilcox
- Department of Emergency Medicine, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Todd A Seigel
- Department of Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island; University of California San Francisco, San Francisco, California
| | - Tania D Strout
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine
| | - Jeffrey I Schneider
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts
| | - Patricia M Mitchell
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts
| | - Evie G Marcolini
- Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut
| | - Michael N Cocchi
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Howard A Smithline
- Department of Emergency Medicine, Baystate Medical Center, Springfield, Massachusetts
| | | | - Marie Mullen
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jonathan S Ilgen
- Division of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jeremy B Richards
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Rose L, Ramagnano S. Emergency Nurse Responsibilities for Mechanical Ventilation: A National Survey. J Emerg Nurs 2013; 39:226-32. [DOI: 10.1016/j.jen.2012.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 07/06/2012] [Accepted: 08/21/2012] [Indexed: 10/27/2022]
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Archambault PM, St-Onge M. Invasive and Noninvasive Ventilation in the Emergency Department. Emerg Med Clin North Am 2012; 30:421-49, ix. [DOI: 10.1016/j.emc.2011.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rose L. Management of critically ill patients receiving noninvasive and invasive mechanical ventilation in the emergency department. Open Access Emerg Med 2012; 4:5-15. [PMID: 27147858 PMCID: PMC4753973 DOI: 10.2147/oaem.s25048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients requiring noninvasive and invasive ventilation frequently present to emergency departments, and may remain for prolonged periods due to constrained critical care services. Emergency clinicians often do not receive the same education on management of mechanical ventilation or have similar exposure to these patients as do their critical care colleagues. The aim of this review was to synthesize the evidence on management of patients requiring noninvasive and invasive ventilation in the emergency department including indications, clinical applications, monitoring priorities, and potential complications. Noninvasive ventilation is recommended for patients with acute exacerbation of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. Less evidence supports its use in asthma and other causes of acute respiratory failure. Use of noninvasive ventilation in the prehospital setting is relatively new, and some evidence suggests benefit. Monitoring priorities for noninvasive ventilation include response to treatment, respiratory and hemodynamic stability, noninvasive ventilation tolerance, detection of noninvasive ventilation failure, and identification of air leaks around the interface. Application of injurious ventilation increases patient morbidity and mortality. Lung-protective ventilation with low tidal volumes based on determination of predicted body weight and control of plateau pressure has been shown to reduce mortality in patients with acute respiratory distress syndrome, and some evidence exists to suggest this strategy should be used in patients without lung injury. Monitoring of the invasively ventilated patient should focus on assessing response to mechanical ventilation and other interventions, and avoiding complications, such as ventilator-associated pneumonia. Several key aspects of management of noninvasive and invasively ventilated patients are discussed, with a particular emphasis on initiation and ongoing monitoring priorities focused on maintaining patient safety and improving patient outcomes.
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Affiliation(s)
- Louise Rose
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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