Intrahospital transport of critically ill patients

Assessment of the comparative agreement between chest radiographs and CT scans in intensive care units

PURPOSE

Chest radiographs in critically ill patients can be difficult to interpret due to technical and clinical factors. We sought to determine the agreement of chest radiographs and CT scans, and the inter-observer variation of chest radiograph interpretation, in intensive care units (ICUs).

METHODS

Chest radiographs and corresponding thoracic computerised tomography (CT) scans (as reference standard) were collected from 45 ICU patients. All radiographs were analysed by 20 doctors (radiology consultants, radiology trainees, ICU consultants, ICU trainees) from 4 different centres, blinded to CT results. Specificity/sensitivity were determined for pleural effusion, lobar collapse and consolidation/atelectasis. Separately, Fleiss' kappa for multiple raters was used to determine inter-observer variation for chest radiographs.

RESULTS

The median sensitivity and specificity of chest radiographs for detecting abnormalities seen on CTs scans were 43.2% and 85.9% respectively. Diagnostic sensitivity for pleural effusion was significantly higher among radiology consultants but no specialty/experience distinctions were observed for specificity. Median inter-observer kappa coefficient among assessors was 0.295 ("fair").

CONCLUSIONS

Chest radiographs commonly miss important radiological features in critically ill patients. Inter-observer agreement in chest radiograph interpretation is only "fair". Consultant radiologists are least likely to miss thoracic radiological abnormalities. The consequences of misdiagnosis by chest radiographs remain to be determined.

Pupillometry in the follow-up of patients undergoing EVT - prediction of space-occupying hemispheric infarction

BACKGROUND

Despite benefits of endovascular treatment (EVT) for large vessel occlusion (LVO) ischemic stroke, space-occupying brain edema (BE) represents a detrimental complication. In critical-care settings, CT-imaging is needed for monitoring these patients. Yet, bed-side techniques with the potential to predict whether patients develop BE or not would facilitate a time- and cost-efficient patient care. We assessed clinical significance of automated pupillometry in the follow-up of patients undergoing EVT.

METHODS

From 10/2018 to 10/2021, neurocritical-care-unit patients were retrospectively enrolled after EVT of anterior circulation LVO. We monitored parameters of pupillary reactivity [light-reflex-latency (Lat), constriction- and redilation-velocities (CV, DV), percentage-change-of-apertures (per-change); NeurOptics-pupilometer®] up to every hour on day 1-3 of ICU stay. BE was defined as midline shift ≥ 5 mm on follow-up imaging 3-5 days after EVT. We calculated mean values of intra-individual differences between successive pairs of parameters (mean-deltas), determined best discriminative cut-off values for BE development (ROC-analyses), and evaluated prognostic performance of pupillometry for BE development (sensitivity/specificity/positive-/negative-predictive-values).

RESULTS

3241 pupillary assessments of 122 patients [67 women, 73 years (61.0-85.0)] were included. 13/122 patients developed BE. Patients with BE had significantly lower CVs, DVs, and smaller per-changes than patients without BE. On day 1 after EVT mean-deltas of CV, DV, and per-changes were significantly lower in patients with than without BE. Positive-predictive-values of calculated thresholds to discriminate both groups were considerably low, yet, we found high negative-predictive-values for CV, DV, per-changes, and mean-deltas (max.: 98.4%).

CONCLUSION

Our data suggest associations between noninvasively detected changes in pupillary reactivity and BE early after LVO-EVT. Pupillometry may identify patients who are unlikely to develop BE and may not need repetitive follow-up-imaging or rescue-therapy.

Adverse Events during Intrahospital Transport of Critically Ill Patients: A Multicenter, Prospective, Observational Study (I-TOUCH Study)

Background

Critically ill patients are frequently transported to various locations within the hospital for diagnostic and therapeutic purposes, which increases the risk of adverse events (AEs). This multicenter prospective observational study was undertaken to determine the incidence of AEs related to intrahospital transport, their severity, and their effects on patient outcomes.

Patients and methods

We included consecutive unstable critically ill patients requiring intrahospital transport, across 15 Indian tertiary care centers over 5 months (October 11, 2022-February 20, 2023). Apart from the demographics and severity of illness, data related to transport itself, such as indications and destination, incidence of AEs, their category and treatment required, and patient outcomes, were recorded in a standard form.

Results

Eight hundred and ninety-three patients were transported on 1065 occasions out of the intensive care unit (ICU). The mean (SD) acute physiology and chronic health evaluation II score of the patients was 15.38 (±7.35). One hundred and two AEs occurred, wherein cardiovascular instability was the most common occurrence (31, 30.4%). Two patients had cardiac arrest immediately after transport. Acute physiology and chronic health evaluation II [odds ratio (OR): 1.02, 95% confidence interval (CI) - 1.00-1.05, p = 0.04], emergent transport (OR: 5.11, 95% CI - 3.32-7.88, p = 0.00), and team composition (OR: 5.34, 95% CI - 1.63-17.5, p = 0.00) during transport were found to be independent predictors of AEs.

Conclusion

We found a high incidence of AEs during intrahospital transport of critically ill patients. These events were more common during emergent transports and when the patients were transported by doctors. Transport by itself was not related to ICU mortality. We feel that stabilization of the patients before transport and adherence to a standardized protocol may help in minimizing the AEs, thereby enhancing patient safety.

How to cite this article

Zirpe KG, Tiwari AM, Kulkarni AP, Govil D, Dixit SB, Munjal M, et al. Adverse Events during Intrahospital Transport of Critically Ill Patients: A Multicenter, Prospective, Observational Study (I-TOUCH Study). Indian J Crit Care Med 2023;27(9):635-641.

Serum biomarkers for risk assessment of intrahospital transports in neurosurgical intensive care unit patients

BACKGROUND

Intrahospital transport (IHT) of Neurosurgical Intensive Care Unit (NICU) patients for cranial computed tomography (CCT) scans is associated with a high rate of complications. The potential of serum biomarkers to estimate the risk for complications associated with IHT and improve their safety remains underexplored. The present study investigated the influence of several serum biomarkers on IHT-associated complications in brain-injured NICU patients.

METHODS

A total of 523 IHTs in 223 NICU patients were prospectively analyzed (05/2019-05/2020). Hemoglobin, hematocrit, serum sodium, and albumin levels were evaluated as serum biomarkers. Each patient's demographic data, CCT scan, NICU parameters and modified Rankin Scale at discharge as well as indications, consequences, and complications of IHTs were analyzed.

RESULTS

In 58.7% of all IHTs, at least one IHT-associated complication was observed with 60.1% of all IHTs having no therapeutic consequence. Significantly lower rates of increased intracranial pressure (ICP; P<0.0001), decreased cerebral perfusion pressure (CPP; P=0.03) as well as hemodynamic (P<0.0001) and pulmonary events (P=0.01) were observed in patients with higher hemoglobin levels prior to IHT. Additionally, higher hematocrit levels before IHT were associated with a fewer rate of hemodynamic (P<0.0001), pulmonary (P=0.006), ICP (P<0.0001), and CPP (P=0.01) events.

CONCLUSIONS

Higher levels of hemoglobin and hematocrit are associated with less complications with respect to ICP, CPP, hemodynamic and pulmonary events during IHT in NICU patients. Therefore, these biomarkers may be helpful for risk assessment of potential complications prior to IHT.

MRI and the Critical Care Patient: Clinical, Operational, and Financial Challenges

Neuroimaging in conjunction with a neurologic examination has become a valuable resource for today's intensive care unit (ICU) physicians. Imaging provides critical information during the assessment and ongoing neuromonitoring of patients for toxic-metabolic or structural injury of the brain. A patient's condition can change rapidly, and interventions may require imaging. When making this determination, the benefit must be weighed against possible risks associated with intrahospital transport. The patient's condition is assessed to decide if they are stable enough to leave the ICU for an extended period. Intrahospital transport risks include adverse events related to the physical nature of the transport, the change in the environment, or relocating equipment used to monitor the patient. Adverse events can be categorized as minor (e.g., clinical decompensation) or major (e.g., requiring immediate intervention) and may occur in preparation or during transport. Regardless of the type of event experienced, any intervention during transport impacts the patient and may lead to delayed treatment and disruption of critical care. This review summarizes the commentary on the current literature on the associated risks and provides insight into the costs as well as provider experiences. Approximately, one-third of patients who are transported from the ICU to an imaging suite may experience an adverse event. This creates an additional risk for extending a patient's stay in the ICU. The delay in obtaining imaging can negatively impact the patient's treatment plan and affect long-term outcomes as increased disability or mortality. Disruption of ICU therapy can decrease respiratory function after the patient returns from transport. Because of the complex care team needed for patient transport, the staff time alone can cost $200 or more. New technologies and advancements are needed to reduce patient risk and improve safety.

Benchmarking Hospital Practices and Policies on Intrahospital Neurocritical Care Transport: The Safe-Neuro-Transport Study

An electronic survey was administered to multidisciplinary neurocritical care providers at 365 hospitals in 32 countries to describe intrahospital transport (IHT) practices of neurocritically ill patients at their institutions. The reported IHT practices were stratified by World Bank country income level. Variability between high-income (HIC) and low/middle-income (LMIC) groups, as well as variability between hospitals within countries, were expressed as counts/percentages and intracluster correlation coefficients (ICCs) with a 95% confidence interval (CI). A total of 246 hospitals (67% response rate; n = 103, 42% HIC and n = 143, 58% LMIC) participated. LMIC hospitals were less likely to report a portable CT scanner (RR 0.39, 95% CI [0.23; 0.67]), more likely to report a pre-IHT checklist (RR 2.18, 95% CI [1.53; 3.11]), and more likely to report that intensive care unit (ICU) physicians routinely participated in IHTs (RR 1.33, 95% CI [1.02; 1.72]). Between- and across-country variation were highest for pre-IHT external ventricular drain clamp tolerance (reported by 40% of the hospitals, ICC 0.22, 95% CI 0.00-0.46) and end-tidal carbon dioxide monitoring during IHT (reported by 29% of the hospitals, ICC 0.46, 95% CI 0.07-0.71). Brain tissue oxygenation monitoring during IHT was reported by only 9% of the participating hospitals. An IHT standard operating procedure (SOP)/hospital policy (HP) was reported by 37% (n = 90); HIC: 43% (n= 44) vs. LMIC: 32% (n = 46), p = 0.56. Amongst the IHT SOP/HPs reviewed (n = 13), 90% did not address the continuation of hemodynamic and neurophysiological monitoring during IHT. In conclusion, the development of a neurocritical-care-specific IHT SOP/HP as well as the alignment of practices related to the IHT of neurocritically ill patients are urgent unmet needs. Inconsistent standards related to neurophysiological monitoring during IHT warrant in-depth scrutiny across hospitals and suggest a need for international guidelines for neurocritical care IHT.

Lung ultrasound monitoring: impact on economics and outcomes

PURPOSE OF REVIEW

This review aims to summarize the impact of lung ultrasonography (LUS) on economics and possible impact on patients' outcomes, proven its diagnostic accuracy in patients with acute respiratory failure.

RECENT FINDINGS

Despite some previous ethical concerns on LUS examination, today this technique has showed several advantages. First, it is now clear that the daily use of LUS can provide a relevant cost reduction in healthcare of patients with acute respiratory failure, while reducing the risk of transport of patients to radiological departments for chest CT scan. In addition, LUS reduces the exposition to x-rays since can replace the bedside chest X-ray examination in many cases. Indeed, LUS is characterized by a diagnostic accuracy that is even superior to portable chest X-ray when performed by well trained personnel. Finally, LUS examination is a useful tool to predict the course of patients with pneumonia, including the need for hospitalization and ICU admission, noninvasive ventilation failure and orotracheal intubation, weaning success, and mortality.

SUMMARY

LUS should be implemented not only in Intensive Care Units, but also in other setting like emergency departments. Since most data comes from the recent coronavirus disease 2019 pandemic, further investigations are required in Acute Respiratory Failure of different etiologies.

Establishment of a simplified score for predicting risk during intrahospital transport of critical patients: A prospective cohort study

AIMS AND OBJECTIVES

To establish a simple score that enables nurses to quickly, conveniently and accurately identify patients whose condition may change during intrahospital transport.

BACKGROUND

Critically ill patients may experience various complications during intrahospital transport; therefore, it is important to predict their risk before they leave the emergency department. The existing scoring systems were not developed for this population.

DESIGN

A prospective cohort study.

METHODS

This study used convenience sampling and continuous enrolment from 1 January, 2019, to 30 June, 2021, and 584 critically ill patients were included. The collected data included vital signs and any condition change during transfer. The STROBE checklist was used.

RESULTS

The median age of the modelling group was 74 (62, 83) years; 93 (19.7%) patients were included in the changed group, and 379 (80.3%) were included in the stable group. The five independent model variables (respiration, pulse, oxygen saturation, systolic pressure and consciousness) were statistically significant (p < .05). The above model was simplified based on beta coefficient values, and each variable was assigned 1 point, for a total score of 0-5 points. The AUC of the simplified score in the modelling group was 0.724 (95% CI: 0.682-0.764); the AUC of the simplified score in the validation group (112 patients) was 0.657 (95% CI: 0.566-0.741).

CONCLUSIONS

This study preliminarily established a simplified scoring system for the prediction of risk during intrahospital transport from the emergency department to the intensive care unit. It provides emergency nursing staff with a simple assessment tool to quickly, conveniently and accurately identify a patient's transport risk.

RELEVANCE TO CLINICAL PRACTICE

This study suggested the importance of strengthening the evaluation of the status of critical patients before intrahospital transport, and a simple score was formed to guide emergency department nurses in evaluating patients.

Comparison of image quality between a novel mobile CT scanner and current generation stationary CT scanners

PURPOSE

Point-of-care imaging with mobile CT scanners offers several advantages, provided that the image quality is satisfactory. Our aim was to compare image quality of a novel mobile CT to stationary scanners for patients in a neurosurgical intensive care unit (ICU).

METHODS

From November 2020 to April 2021, all patients above 18 years of age examined by a mobile CT scanner at a neurosurgical ICU were included if they also had a stationary head CT examination during the same hospitalization. Quantitative image quality parameters included attenuation and noise in six predefined regions of interest, as well as contrast-to-noise ratio between gray and white matter. Subjective image quality was rated on a 4-garde scale, by four radiologists blinded to scanner parameters.

RESULTS

Fifty patients were included in the final study population. Radiation dose and image attenuation values were similar for mobCT and stationary CTs. There was a small statistically significant difference in subjective quality rating between mobCT and stationary CT images. Two radiologists favored the stationary CT images, one was neutral, and one favored mobCT images. For overall image quality, 14% of mobCT images were rated grade 1 (poor image quality) compared to 8% for stationary CT images.

CONCLUSION

Point-of-care brain CT imaging was successfully performed on clinical neurosurgical ICU patients with small reduction in image quality, predominantly affecting the posterior fossa, compared to high-end stationary CT scanners.

Patient care during interfacility transport: a narrative review of managing diverse disease states

BACKGROUND

When critically ill patients require specialized treatment that exceeds the capability of the index hospitals, patients are frequently transferred to a tertiary or quaternary hospital for a higher level of care. Therefore, appropriate and efficient care for patients during the process of transport between two hospitals (interfacility transfer) is an essential part of patient care. While medical adverse events may occur during the interfacility transfer process, there have not been evidence-based guidelines regarding the equipment or the practice for patient care during transport.

METHODS

We conducted searches from the PubMed, Cumulative Index of Nursing and Allied Health (CINAHL), and Scopus databases up to June 2022. Two reviewers independently screened the titles and abstracts for eligibility. Studies that were not in the English language and did not involve critically ill patients were excluded.

RESULTS

The search identified 75 articles, and we included 48 studies for our narrative review. Most studies were observational studies.

CONCLUSION

The review provided the current evidence-based management of diverse disease states during the interfacility transfer process, such as proning positioning for respiratory failure, extracorporeal membrane oxygenation (ECMO), obstetric emergencies, and hypertensive emergencies (aortic dissection and spontaneous intracranial hemorrhage).

Enhancement of Intra-hospital patient transfer in medical center hospital using discrete event system simulation

The intra-hospital transfer of critically ill patients are associated with complications at up to 70%. Numerous issues can be avoided with optimal pre-transport planning and communication. Simulation models have been demonstrated to be an effective method for modeling processes and enhancing on-time service and queue management. Discrete-event simulation (DES) models are acceptable for general hospital systems with increased variability. Herein, they are used to improve service effectiveness. A prospective observational study was conducted on 13 official day patient transfers, resulting in a total of 827 active patient transfers. Patient flow was simulated using discrete-event simulation (DES) to accurately and precisely represent real-world systems and act accordingly. Several patient transfer criteria were examined to create a more realistic simulation of patient flow. Waiting times were also measured to assess the efficiency of the patient transfer process. A simulation was conducted to identify 20 scenarios in order to discover the optimal scenario in which where the number of requests (stretchers or wheelchairs) was increased, while the number of staff was decreased to determine mean waiting times and confidence intervals. The most effective approach for decreasing waiting times involved prioritizing patients with the most severe symptoms. After a transfer process was completed, staff attended to the next transfer process without returning to base. Results show that the average waiting time was reduced by 21.78% which is significantly important for emergency cases. A significant difference was recorded between typical and recommended patient transfer processes when the number of requests increased. To decrease waiting times, the patient transfer procedure should be modified according to our proposed DES model, which can be used to analyze and design queue management systems that achieve optimal waiting times.

Case report: A comatose patient with pregabalin overdose successfully treated with continuous renal replacement therapy

Pregabalin (PB) overdose causes mild symptoms and coma is rarely seen unless the patient has also ingested sedatives and/or has preexisting renal disease. We present a case report of a suicide attempt with PB where the patient presented in a comatose state that was successfully treated with continuous renal replacement therapy (CRRT). Treatment of PB overdose is usually supportive. However, previous reports of PB overdose have been treated with intermittent hemodialysis (IHD) in patients with preexisting renal disease. The problem with IHD is that it is only available in specialist centers and unsuitable for unstable patients. In the following case report, the patient presented to the emergency department (ED) unconscious and hypotensive. It was thought that the patient tried to commit suicide by taking an overdose of zopiclone tablets, as empty packets of zopiclone tablets were found beside the patient. There was no effect with flumazenil treatment, so the patient was intubated, mechanically ventilated, and admitted to the intensive care unit (ICU) where inotropic support was started. Despite supportive therapy, there was no improvement in the patient's condition. Further investigation into the patient's medical records uncovered prescriptions of PB. Based on this finding, plasma PB levels were measured and found to be 20 times the upper limit of the therapeutic reference range. CRRT was instituted and after 6 h of treatment the patient woke up. Hospitals with ICUs often have CRRT available in their units whereas IHD is less readily available. This case report demonstrates that CRRT is an effective method for treating PB overdose in an unconscious unstable patient that was unsuitable for transfer to another hospital.

Quantitative pupillometry and radiographic markers of intracranial midline shift: A pilot study

Background

Asymmetric pupil reactivity or size can be early clinical indicators of midbrain compression due to supratentorial ischemic stroke or primary intraparenchymal hemorrhage (IPH). Radiographic midline shift is associated with worse functional outcomes and life-saving interventions. Better understanding of quantitative pupil characteristics would be a non-invasive, safe, and cost-effective way to improve identification of life-threatening mass effect and resource utilization of emergent radiographic imaging. We aimed to better characterize the association between midline shift at various anatomic levels and quantitative pupil characteristics.

Methods

We conducted a multicenter retrospective study of brain CT images within 75 min of a quantitative pupil observation from patients admitted to Neuro-ICUs between 2016 and 2020 with large (>1/3 of the middle cerebral artery territory) acute supratentorial ischemic stroke or primary IPH > 30 mm³. For each image, we measured midline shift at the septum pellucidum (MLS-SP), pineal gland shift (PGS), the ratio of the ipsilateral to contralateral midbrain width (IMW/CMW), and other exploratory markers of radiographic shift/compression. Pupil reactivity was measured using an automated infrared pupillometer (NeurOptics^®, Inc.), specifically the proprietary algorithm for Neurological Pupil Index^® (NPi). We used rank-normalization and linear mixed-effects models, stratified by diagnosis and hemorrhagic conversion, to test associations of radiographic markers of shift and asymmetric pupil reactivity (Diff NPi), adjusting for age, lesion volume, Glasgow Coma Scale, and osmotic medications.

Results

Of 53 patients with 74 CT images, 26 (49.1%) were female, and median age was 67 years. MLS-SP and PGS were greater in patients with IPH, compared to patients with ischemic stroke (6.2 v. 4.0 mm, 5.6 v. 3.4 mm, respectively). We found no significant associations between pupil reactivity and the radiographic markers of shift when adjusting for confounders. However, we found potentially relevant relationships between MLS-SP and Diff NPi in our IPH cohort (β = 0.11, SE 0.04, P = 0.01), and PGS and Diff NPi in the ischemic stroke cohort (β = 0.16, SE 0.09, P = 0.07).

Conclusion

We found the relationship between midline shift and asymmetric pupil reactivity may differ between IPH and ischemic stroke. Our study may serve as necessary preliminary data to guide further prospective investigation into how clinical manifestations of radiographic midline shift differ by diagnosis and proximity to the midbrain.

Imaging in the Intensive Care Unit

Radiology plays an important role in the management of the most seriously ill patients in the hospital. Over the years, continued advances in imaging technology have contributed to an improvement in patient care. However, even with such advances, the portable chest radiograph (CXR) remains one of the most commonly requested radiographic examinations. While they provide valuable information, CXRs remain relatively insensitive at revealing abnormalities and are often nonspecific. Chest computed tomography (CT) can display findings that are occult on CXR and is particularly useful at identifying and characterizing pleural effusions, detecting barotrauma including small pneumothoraces, distinguishing pneumonia from atelectasis, and revealing unsuspected or additional abnormalities which could result in increased morbidity and mortality if left untreated. CT pulmonary angiography is the modality of choice in the evaluation of pulmonary emboli which can complicate the hospital course of the ICU patient. This article will provide guidance for interpretation of CXR and thoracic CT images, discuss some of the invasive devices routinely used, and review the radiologic manifestations of common pathologic disease states encountered in ICU patients. In addition, imaging findings and complications of more specific clinical scenarios in which the incidence has increased in the ICU setting, such as patients who are immunocompromised, have interstitial lung disease, or COVID-19, will also be discussed. Communication between the radiologist and intensivist, particularly on complicated cases, is important to help increase diagnostic accuracy and leads to an improvement in the management of the most critically ill patients.

Preparing the Patient for ICU Transfer: What Is the Anesthesiologist’s Role?

Purpose of Review

This review summarizes the anesthesiologist’s role in transferring critically ill surgical patients at different phases of care.

Recent Findings

Early recognition of patients at high intraoperative and postoperative risk is one of the most important first steps, followed by preoperative and intraoperative stabilization measures depending on the individual needs. It mainly is the anesthesiologist’s responsibility to decide on postoperative ICU admission. The transfer of the critically ill should be planned; the ICU staff has to be informed as early as possible. Locally developed checklists should be used during the preparation of patient transport. Trained, dedicated staff should be made available in every institution. A detailed handover using dedicated institutional flowcharts should ensure patient safety upon arrival to the ICU.

Summary

Transfer of critically ill patients from the OR to the ICU is an interdisciplinary task with a high probability of eventual incidents. Anesthesiologists should play a key role in all phases of the procedure to improve patient outcomes.

Safety during interhospital helicopter transfer of ventilated COVID-19 patients. No clinical relevant changes in vital signs including non-invasive cardiac output

Background

During the COVID-19 pandemic in The Netherlands, critically ill ventilated COVID-19 patients were transferred not only between hospitals by ambulance but also by the Helicopter Emergency Medical Service (HEMS). To date, little is known about the physiological impact of helicopter transport on critically ill patients and COVID-19 patients in particular. This study was conducted to explore the impact of inter-hospital helicopter transfer on vital signs of mechanically ventilated patients with severe COVID-19, with special focus on take-off, midflight, and landing.

Methods

All ventilated critically ill COVID-19 patients who were transported between April 2020 and June 2021 by the Dutch ‘Lifeliner 5’ HEMS team and who were fully monitored, including noninvasive cardiac output, were included in this study. Three 10-min timeframes (take-off, midflight and landing) were defined for analysis. Continuous data on the vital parameters heart rate, peripheral oxygen saturation, arterial blood pressure, end-tidal CO₂ and noninvasive cardiac output using electrical cardiometry were collected and stored at 1-min intervals. Data were analyzed for differences over time within the timeframes using one-way analysis of variance. Significant differences were checked for clinical relevance.

Results

Ninety-eight patients were included in the analysis. During take-off, an increase was noticed in cardiac output (from 6.7 to 8.2 L min⁻¹; P < 0.0001), which was determined by a decrease in systemic vascular resistance (from 1071 to 739 dyne·s·cm⁻⁵, P < 0.0001) accompanied by an increase in stroke volume (from 88.8 to 113.7 mL, P < 0.0001). Other parameters were unchanged during take-off and mid-flight. During landing, cardiac output and stroke volume slightly decreased (from 8.0 to 6.8 L min⁻¹, P < 0.0001 and from 110.1 to 84.4 mL, P < 0.0001, respectively), and total systemic vascular resistance increased (P < 0.0001). Though statistically significant, the found changes were small and not clinically relevant to the medical status of the patients as judged by the attending physicians.

Conclusions

Interhospital helicopter transfer of ventilated intensive care patients with COVID-19 can be performed safely and does not result in clinically relevant changes in vital signs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02177-5.

Sonografisches Neuromonitoring auf der Stroke Unit und in der neurologischen Intensivmedizin

Hintergrund Der Artikel gibt einen Überblick über die aktuellen diagnostischen Einsatzmöglichkeiten sonographischer Anwendung in der neurologischen Intensivmedizin.

Methoden Selektive Literaturrecherche mit kritischer Beurteilung ab dem Jahr 1984 sowie nationaler und internationaler Leitlinien sowie Expertenmeinung.

Ergebnisse Neben der raschen validen Abklärung akuter Schlaganfälle bieten verschiedene neurosonografische Monitoring-verfahren gerade in der Intensivmedizin spezifische Vorteile wie die beliebig häufige Wiederholbarkeit am Patientenbett selbst und die Darstellung in Echtzeit. Innovative Entwicklungen machen die Neurosonografie auch wissenschaftlich zu einem interessanten Gebiet.

Schlussfolgerung Die neurosonografische Diagnostik nimmt seit Jahren einen wichtigen Stellenwert in der neurologischen Intensivmedizin ein. Weitere Anstrengungen sind notwendig, um die Verbreitung der Methode zu fördern und durch wissenschaftliche Evidenz zu stärken.

Portable, low-field magnetic resonance imaging enables highly accessible and dynamic bedside evaluation of ischemic stroke

Brain imaging is essential to the clinical management of patients with ischemic stroke. Timely and accessible neuroimaging, however, can be limited in clinical stroke pathways. Here, portable magnetic resonance imaging (pMRI) acquired at very low magnetic field strength (0.064 T) is used to obtain actionable bedside neuroimaging for 50 confirmed patients with ischemic stroke. Low-field pMRI detected infarcts in 45 (90%) patients across cortical, subcortical, and cerebellar structures. Lesions as small as 4 mm were captured. Infarcts appeared as hyperintense regions on T2-weighted, fluid-attenuated inversion recovery and diffusion-weighted imaging sequences. Stroke volume measurements were consistent across pMRI sequences and between low-field pMRI and conventional high-field MRI studies. Low-field pMRI stroke volumes significantly correlated with stroke severity and functional outcome at discharge. These results validate the use of low-field pMRI to obtain clinically useful imaging of stroke, setting the stage for use in resource-limited environments.

Non-contact physiological monitoring of post-operative patients in the intensive care unit

Prolonged non-contact camera-based monitoring in critically ill patients presents unique challenges, but may facilitate safe recovery. A study was designed to evaluate the feasibility of introducing a non-contact video camera monitoring system into an acute clinical setting. We assessed the accuracy and robustness of the video camera-derived estimates of the vital signs against the electronically-recorded reference values in both day and night environments. We demonstrated non-contact monitoring of heart rate and respiratory rate for extended periods of time in 15 post-operative patients. Across day and night, heart rate was estimated for up to 53.2% (103.0 h) of the total valid camera data with a mean absolute error (MAE) of 2.5 beats/min in comparison to two reference sensors. We obtained respiratory rate estimates for 63.1% (119.8 h) of the total valid camera data with a MAE of 2.4 breaths/min against the reference value computed from the chest impedance pneumogram. Non-contact estimates detected relevant changes in the vital-sign values between routine clinical observations. Pivotal respiratory events in a post-operative patient could be identified from the analysis of video-derived respiratory information. Continuous vital-sign monitoring supported by non-contact video camera estimates could be used to track early signs of physiological deterioration during post-operative care.

Bedside detection of intracranial midline shift using portable magnetic resonance imaging

Neuroimaging is crucial for assessing mass effect in brain-injured patients. Transport to an imaging suite, however, is challenging for critically ill patients. We evaluated the use of a low magnetic field, portable MRI (pMRI) for assessing midline shift (MLS). In this observational study, 0.064 T pMRI exams were performed on stroke patients admitted to the neuroscience intensive care unit at Yale New Haven Hospital. Dichotomous (present or absent) and continuous MLS measurements were obtained on pMRI exams and locally available and accessible standard-of-care imaging exams (CT or MRI). We evaluated the agreement between pMRI and standard-of-care measurements. Additionally, we assessed the relationship between pMRI-based MLS and functional outcome (modified Rankin Scale). A total of 102 patients were included in the final study (48 ischemic stroke; 54 intracranial hemorrhage). There was significant concordance between pMRI and standard-of-care measurements (dichotomous, κ = 0.87; continuous, ICC = 0.94). Low-field pMRI identified MLS with a sensitivity of 0.93 and specificity of 0.96. Moreover, pMRI MLS assessments predicted poor clinical outcome at discharge (dichotomous: adjusted OR 7.98, 95% CI 2.07–40.04, p = 0.005; continuous: adjusted OR 1.59, 95% CI 1.11–2.49, p = 0.021). Low-field pMRI may serve as a valuable bedside tool for detecting mass effect.

Methodology for Low-Field, Portable Magnetic Resonance Neuroimaging at the Bedside

Neuroimaging is a critical component of triage and treatment for patients who present with neuropathology. Magnetic resonance imaging and non-contrast computed tomography are the gold standard for diagnosis and prognostication of patients with acute brain injuries. However, these modalities require intra-hospital transport to strict, access-controlled environments, which puts critically ill patients at risk for complications and secondary injuries. A novel, portable MRI (pMRI) device that can be deployed at the patient's bedside provides a needed solution. In a dual-center investigation, Yale New Haven Hospital has obtained regular neuroimaging on patients using the pMRI as part of routine clinical care in the Emergency Department and Intensive Care Unit (ICU) since August of 2020. Massachusetts General Hospital has begun using pMRI in the Neuroscience Intensive Care Unit since January 2021. This technology has expanded the population of patients who can receive MRI imaging by increasing accessibility and timeliness for scan completion by eliminating the need for transport and increasing the potential for serial monitoring. Here we describe our methods for screening, coordinating, and executing pMRI exams and provide further detail on how to scan specific patient populations.

Adverse events during intrahospital transport of critically ill patients: A systematic review and meta-analysis

INTRODUCTION

Intrahospital transport of critically ill patients is often necessary for diagnostic procedures, therapeutic procedures, or admission to the intensive care unit. The aim of this study was to investigate and describe safety and adverse events during intrahospital transport of critically ill patients.

MATERIAL AND METHODS

A systematic search was performed of MEDLINE and the Cochrane Central Register of Controlled Trials for studies published up to June 3, 2020, and of the International Clinical Trials Platform Search Portal and ClinicalTrials.gov for ongoing trials. We selected prospective and retrospective cohort studies published in English on intrahospital transport of critically ill patients, and then performed a meta-analysis. The primary outcome was the incidence of all adverse events that occurred during intrahospital transport. The secondary outcomes were death due to intrahospital transport or life-threatening adverse events, minor events in vital signs, adverse events related to equipment, durations of ICU and hospital stay, and costs.

RESULTS

A total of 12,313 intrahospital transports and 1898 patients from 24 studies were included in the meta-analysis. Among 24 studies that evaluated the primary outcome, the pooled frequency of all adverse events was 26.2% (95% CI: 15.0-39.2) and the heterogeneity among these studies was high (I2 = 99.5%). The pooled frequency of death due to intrahospital transport and life-threatening adverse events was 0% and 1.47% each, but heterogeneity was also high.

CONCLUSIONS

Our findings suggest that adverse events can occur during intrahospital transport of critically ill patients, and that the frequency of critical adverse events is relatively low. The results of this meta-analysis could assist in risk-benefit analysis of diagnostic or therapeutic procedures requiring intrahospital transport of critically ill patients.

TRIAL REGISTRATION

UMIN000040963.

Insurance-based inequities in emergency interhospital transfers: an argument for the prioritisation of patient care

Currently there is an inequity in transfer rates of uninsured patients versus their insured counterparts. While this may vary by hospital system, studies indicate that this is a national trend, especially in emergency situations, and represents a prioritisation of profits over ethical obligations. This creates a variety of ethical issues for patients and society that generates a concordance between deontological and utilitarian viewpoints, two generally opposed schools of thought. The prioritisation of profit maximisation in order to provide better care for a select population is insufficient to justify deleterious health outcomes, stress and financial burden on patients. Current policy regarding patient transfers in the emergency department is insufficient to protect the uninsured and must be reevaluated.

Feasibility of the Ultrasound-Guided Insertion of the Peripherally Inserted Central Catheter (PICC) by the Vascular Surgeon at the Bedside in the Trauma Intensive Care Unit

BACKGROUND

This study analyzed the outcomes of the ultrasound-guided insertion of the peripherally inserted central venous catheter (PICC) by experienced vascular surgeons at the bedside of the trauma intensive care unit (ICU) and compared the outcomes with those of fluoroscopy-guided PICC performed by radiologists in the interventional suite.

METHODS

Between May 1, 2016, and April 30, 2021, 97 patients who were hospitalized in the trauma ICU and underwent PICC insertion were enrolled in the study. Forty-two out of the 97 patients underwent PICC insertion by interventional radiologists in the interventional radiology suite under fluoroscopy guidance, while the remaining 55 cases underwent ultrasound-guided PICC insertion by the vascular surgeon at the trauma ICU bedside.

RESULTS

The technical failure (P = 0.504) and malposition (P = 0.127) rates were not significantly different between the 2 groups. However, it took significantly less time for the vascular surgeon to complete the PICC insertion procedure (P < 0.001). Significantly more patients of the ultrasound-guided group required inotropes (P = 0.012) and mechanical ventilation (P = 0.003) at the time of the procedure. In addition, the ultrasound-guided group appeared to be in critical condition in terms of kidney function according to laboratory data (P = 0.014). Meanwhile, the ultrasound-guided group maintained the central line catheter for a shorter time (P < 0.001).

CONCLUSIONS

In trauma patients, ultrasound-guided PICC insertion at the bedside by experienced vascular surgeons at the trauma ICU was feasible compared to fluoroscopy-guided insertion performed by interventional radiologists.

Portable, bedside, low-field magnetic resonance imaging for evaluation of intracerebral hemorrhage

Radiological examination of the brain is a critical determinant of stroke care pathways. Accessible neuroimaging is essential to detect the presence of intracerebral hemorrhage (ICH). Conventional magnetic resonance imaging (MRI) operates at high magnetic field strength (1.5-3 T), which requires an access-controlled environment, rendering MRI often inaccessible. We demonstrate the use of a low-field MRI (0.064 T) for ICH evaluation. Patients were imaged using conventional neuroimaging (non-contrast computerized tomography (CT) or 1.5/3 T MRI) and portable MRI (pMRI) at Yale New Haven Hospital from July 2018 to November 2020. Two board-certified neuroradiologists evaluated a total of 144 pMRI examinations (56 ICH, 48 acute ischemic stroke, 40 healthy controls) and one ICH imaging core lab researcher reviewed the cases of disagreement. Raters correctly detected ICH in 45 of 56 cases (80.4% sensitivity, 95%CI: [0.68-0.90]). Blood-negative cases were correctly identified in 85 of 88 cases (96.6% specificity, 95%CI: [0.90-0.99]). Manually segmented hematoma volumes and ABC/2 estimated volumes on pMRI correlate with conventional imaging volumes (ICC = 0.955, p = 1.69e-30 and ICC = 0.875, p = 1.66e-8, respectively). Hematoma volumes measured on pMRI correlate with NIH stroke scale (NIHSS) and clinical outcome (mRS) at discharge for manual and ABC/2 volumes. Low-field pMRI may be useful in bringing advanced MRI technology to resource-limited settings.

Adverse events experienced with intrahospital transfer of critically ill patients: A national survey

ABSTRACT

Research that focuses on transfers to and from the intensive care unit (ICU) could highlight important patients' safety issues. This study aims to describe healthcare workers' (HCWs) practices involved in patient transfers to or from the ICU.This cross-sectional study was conducted among HCWs during the Saudi Critical Care Society's annual International Conference, April 2017. Responses were assessed using Likert scales and frequencies. Bivariate analysis was used to evaluate the significance of different indicators.Overall, 312 HCWs participated in this study. Regarding transfer to ICUs, the most frequently reported complications were deterioration in respiratory status (51.4%), followed by deterioration in hemodynamic status (46.5%), and missing clinical information (35.5%). Regarding transfers from ICUs to the general ward, the most commonly reported complications were changes in respiratory status (55.6%), followed by incomplete clinical information (37.9%), and change in hemodynamic conditions (29%). The most-used models for communicating transfers were written documents in electronic health records (69.3%) and verbal communication (62.8%). One-fourth of the respondents were not aware of the Situation, Background, Assessment, Recommendation (SBAR) method of patients' handover. Pearson's test of correlation showed that the HCW's perceived satisfaction with their hospital transfer guidelines showed significant negative correlation with their reported transfer-related complications (r = -0.27, P < .010).Hemodynamic and respiratory status deterioration is representing significant adverse events among patients transferred to or from the ICU. Factors controlling the perceived satisfaction of HCWs involved in patients, transfer to and from the ICU need to be addressed, focusing on their compliance to the hospital-wide transfer and handover policies. Quality improvement initiatives could improve patient safety to transfer patients to and from the ICU and minimize the associated adverse events.

The Effects of ICU Crisis Reorganization on Outcomes in Patients Not Infected With Coronavirus Disease 2019 During the Initial Surge of the Coronavirus Disease 2019 Pandemic

To determine if ICU reorganization due to the coronavirus disease 2019 pandemic affected outcomes in critically ill patients who were not infected with coronavirus disease 2019.

Design

This was a Before-After study, with coronavirus disease 2019-induced ICU reorganization as the intervention. A retrospective chart review of adult patients admitted to a reorganized ICU during the coronavirus disease 2019 surge (from March 23, 2020, to May 06, 2020: intervention group) was compared with patients admitted to the ICU prior to coronavirus disease 2019 surge (from January 10, 2020, to February 23, 2020: before group).

Setting

High-intensity cardiac, medical, and surgical ICUs of a community hospital in metropolitan Missouri.

PATIENTS

All patients admitted to the ICU during the before and intervention period were included. Patients younger than 18 years old and those admitted after an elective procedure or surgery were excluded. Patients with coronavirus disease 2019 were excluded.

Interventions

None.

Measurements and Main Results

We identified a total of 524 eligible patients: 342 patients in the before group and 182 in the intervention group. The 28-day mortality was 25.1% (86/342) and 28.6% (52/182), respectively (p = 0.40). The ICU length of stay, ventilator length of stay, and ventilator-free days were similar in both groups. Rates of patient adverse events including falls, inadvertent endotracheal tube removal, reintubation within 48 hours of extubation, and hospital acquired pressure ulcers occurred more frequently in the study group (20 events, 11%) versus control group (12 events, 3.5%) (p = 0.001).

Conclusions

Twenty-eight-day mortality, in patients who required ICU care and were not infected with coronavirus disease 2019, was not significantly affected by ICU reorganization during a pandemic.

Bedside surgery in the newborn infants: survey of the Italian society of pediatric surgery

Introduction

This is the report of the first official survey from the Italian Society of Pediatric Surgery (ISPS) to appraise the distribution and organization of bedside surgery in the neonatal intensive care units (NICU) in Italy.

Methods

A questionnaire requesting general data, staff data and workload data of the centers was developed and sent by means of an online cloud-based software instrument to all Italian pediatric surgery Units.

Results

The survey was answered by 34 (65%) out of 52 centers. NICU bedside surgery is reported in 81.8% of the pediatric surgery centers. A lower prevalence of bedside surgical practice in the NICU was reported for Southern Italy and the islands than for Northern Italy and Central Italy (Southern <Northern<Central, p < 0.03). The most frequent clinical characteristics of neonates was preterm neonates with birthweight < 1200 g, with cardiorespiratory instability and/or ventilatory dependence. The most frequently selected indications to surgery were pneumothorax, pleural effusion, pericardial effusion, central venous catheter (CVC) positioning, intestinal perforation, patent ductus arteriosus ligation and congenital diaphragmatic hernia. More than 60% of respondents report no institutional recommendations and dedicated informed consent on bedside surgical procedures. The lack of dedicated areas and infrastructures is considered a relative contraindication to the performance of bedside surgery.

Conclusion

Bedside surgery is performed in the majority of the Italian pediatric surgery centers included in this census. The introduction of a national set of surgery guidelines would be widely welcomed.

Dealing with the Sick Rural Surgery Patient in Need of Transfer

Care for rural and urban surgical patients is increasingly more complex due to advancing knowledge and technology. Interhospital transfers occur in approximately 10% of index encounters at rural hospitals secondary to mismatch of patient needs and local resources. Due to the recent expansion of air transport to rural areas, distance and geography are less of a barrier. The interhospital transfer process is understudied and far from standardized. Interhospital transfer status is associated with increase in mortality, complications, length of stay, and costs. The cost, price to patients, and safety of air ambulance transports cannot be ignored.

Critical events during intra-hospital transport of critically ill patients to and from intensive care unit

OBJECTIVES

Intensive care unit (ICU) patients are at an increased risk of many catastrophic events during intrahospital transport (IHT) for various procedures. This study was planned to determine the incidence and types of adverse events occurring during the transport of critically ill patients in a tertiary care hospital.

METHODS

This prospective observational study was conducted in the ICU of a tertiary care hospital for 8 months after ethical clearance from the institute ethics committee. All patients transported out of the ICU during the audit period for diagnostic or therapeutic procedures were included in the study. Vitals and several study parameters were recorded before, during, and after shifting patients to and from the ICU. Various critical events were noted during transport and classified into major and minor critical events based on the presence and absence of potential consequences that lead to a change of therapy during transport.

RESULTS

One hundred and sixty patients were studied for consecutive IHT to and from the ICU. The patients were transported for imaging studies (58.1%), minor surgery (31.8%), major surgery (2.5%), and other procedures (7.5%). A total of 248 critical events were observed in 104 IHTs (65%; 95% confidence interval [95% CI]: 57.4%-72.1%). Hence, an average of 2.38 critical events occurred per IHT. There were 31 major events among the 248 critical events (12.5%; 95% CI: 8.8%-17.1%).

CONCLUSIONS

Standard guidelines about the accompanying personnel and monitoring need to be followed during IHT. Conduct of minor surgical procedures in the ICU and better bedside diagnostic procedures may be considered for the future.

Incidents related to critical patient safety during in-hospital transfer

OBJECTIVE

To analyze the incidents related to patient safety (IRSP) and their risk factors during in-hospital transfer (IHT) of critical patients after the application of a protocol, and to evaluate safety during transfer using quality indicators.

DESIGN

A prospective, observational and non-intervention cohort study was carried out.

SETTING

A 10-bed multipurpose Intensive Care Unit (ICU) of a second level university hospital.

PATIENTS

All IHTs of critical patients in the ICU for diagnostic tests and to the operating room between March 2011 and March 2017 were included in the study.

MAIN MEASUREMENTS

Demographic variables, patient severity, transfer priority, moment of the day, reason and type of transfer team. Pre-transport checklist items and IRSP were collected. A biannual analysis was made of quality indicators designed for IHT.

RESULTS

A total of 805 transfers were registered, mostly of an urgent nature (53.7%) and for diagnostic tests (77%). In turn, 112 transfers (13.9%) presented some type of IRSP; 54% related to the equipment and 30% related to team and organization. Adverse events occurred in 19 (2.4%) transfers. Risk factors identified in the multivariate analysis were mechanical ventilation and the transport team. The evolution of the indicators related to transport was significantly favorable.

CONCLUSIONS

After the application of an IHT protocol, IRSP are low. The main risk factor is invasive mechanical ventilation. The experience of the team performing IHT influences the detection of a greater number of incidents.

Cone-beam CT for imaging of the head/brain: Development and assessment of scanner prototype and reconstruction algorithms

PURPOSE

Our aim was to develop a high-quality, mobile cone-beam computed tomography (CBCT) scanner for point-of-care detection and monitoring of low-contrast, soft-tissue abnormalities in the head/brain, such as acute intracranial hemorrhage (ICH). This work presents an integrated framework of hardware and algorithmic advances for improving soft-tissue contrast resolution and evaluation of its technical performance with human subjects.

METHODS

Four configurations of a CBCT scanner prototype were designed and implemented to investigate key aspects of hardware (including system geometry, antiscatter grid, bowtie filter) and technique protocols. An integrated software pipeline (c.f., a serial cascade of algorithms) was developed for artifact correction (image lag, glare, beam hardening and x-ray scatter), motion compensation, and three-dimensional image (3D) reconstruction [penalized weighted least squares (PWLS), with a hardware-specific statistical noise model]. The PWLS method was extended in this work to accommodate multiple, independently moving regions with different resolution (to address both motion compensation and image truncation). Imaging performance was evaluated quantitatively and qualitatively with 41 human subjects in the neurosciences critical care unit (NCCU) at our institution.

RESULTS

The progression of four scanner configurations exhibited systematic improvement in the quality of raw data by variations in system geometry (source-detector distance), antiscatter grid, and bowtie filter. Quantitative assessment of CBCT images in 41 subjects demonstrated: ~70% reduction in image nonuniformity with artifact correction methods (lag, glare, beam hardening, and scatter); ~40% reduction in motion-induced streak artifacts via the multi-motion compensation method; and ~15% improvement in soft-tissue contrast-to-noise ratio (CNR) for PWLS compared to filtered backprojection (FBP) at matched resolution. Each of these components was important to improve contrast resolution for point-of-care cranial imaging.

CONCLUSIONS

This work presents the first application of a high-quality, point-of-care CBCT system for imaging of the head/ brain in a neurological critical care setting. Hardware configuration iterations and an integrated software pipeline for artifacts correction and PWLS reconstruction mitigated artifacts and noise to achieve image quality that could be valuable for point-of-care detection and monitoring of a variety of intracranial abnormalities, including ICH and hydrocephalus.

Intrahospital critical patient transport from the emergency department

INTRODUCTION

Although intrahospital transportation of critical patients from the emergency department (ED) is inevitable, it could also result in life-threatening situations. These situations, referred to as unwanted or unexpected events, mainly happen during the transportation of patients for diagnostic imaging or invasive procedures and result in a wide spectrum from vital condition changes, mental condition changes to cardiopulmonary arrest and death. Emergency departments have a high risk of facing such situations because these units are the first admission door of critical patients.

MATERIAL AND METHODS

This cross-sectional study was conducted prospectively, after interviewing the doctors who work in the ED actively, and by filling out the forms which were already prepared by the participants. Statistical analysis was performed according to the data received, and results were compared to the literature.

RESULTS

Three hundred and forty-seven doctors from 52 hospitals were included in the study. 59.4% (n = 206) of them were working at EDs which had more than 500 patients admitted. 51.9% (n = 180) of doctors stated that they performed 10 or more critical patients' transport every day from their ED. 86.7% (n = 301) of the participants stated that usage of control checklists would decrease the rate of unwanted situations and stated that they wanted to use them.

CONCLUSIONS

Intrahospital transportation of critical patients from the emergency room is a subject that should require attention by emergency room doctors, and using educated personnel, proper equipment, standardized protocols and control checklists will decrease the frequency of unwanted situations effectively.

Serum Biomarkers for Risk Assessment of Intrahospital Transports in Mechanically Ventilated Neurosurgical Intensive Care Unit Patients

OBJECTIVE

Intrahospital transports (IHTs) of neurosurgical intensive care unit (NICU) patients can be hazardous. Increasing intracranial pressure (ICP) and/or decreasing cerebral perfusion pressure (CPP) as well as cardiopulmonary alterations are common complications of an IHTs, which can lead to secondary brain injury. This study was performed to assess several serum biomarkers concerning their potential to improve safety of IHTs in mechanically ventilated NICU patients.

METHODS

All IHTs of mechanically ventilated and sedated NICU patients from 03/2017 to 01/2018 were retrospectively analyzed. Intracranial pressure and CPP measurements were performed in all patients. Serum hemoglobin, hematocrit, and serum sodium were defined as serum biomarkers. Demographic data, computed tomography scan on admission, Simplified Acute Physiology Score and Acute Physiology and Chronic Health Evaluation II, modified Rankin Scale, indication and consequence of IHTs were analyzed. Alteration of ICP/CPP, hemodynamic and pulmonary events were defined as complications. The study population was stratified into patients with the occurrence of a complication and absence of a complication.

RESULTS

We analyzed a total number of 184 IHTs in 70 NICU patients with an overall complication rate of 57.6%. Of all, 32.1% IHTs had no direct therapeutic consequence. In patients with higher hemoglobin values prior to IHT less complications occurred, concerning ICP (P = .001), CPP (P = .001), hemodynamic (P = .005), and pulmonary (P < .0001) events. In addition, complications concerning ICP (P = .001), CPP (P = .001), hemodynamic (P = .005), and pulmonary problems (P = .002) were significantly lower in patients with higher hematocrit values before IHT.

CONCLUSION

Intrahospital transports of mechanically ventilated NICU patients carry a high risk of increased ICP and hemodynamic complications and should be performed restrictively. Higher values of hemoglobin and hematocrit prior to IHT were associated with less complications with regard to ICP, CPP as well as hemodynamic and pulmonary events and could be helpful to assess the potential risk of complications prior to IHTs.

Taking upstairs care outside

Background: Critical care is a clinically complex and resource intensive discipline, the world over. Consequently, the delivery of these services has been compounded by the need to sustain a specialized workforce, while maintaining consistent and high standards.1,2 The regionalization of critical care resources and the creation of referral networks has been one approach that has led to success in this area.2-7 However, as steps have been made towards regionalization, so too has the need to transfer patients between facilities in order to access these services. The effects of this are already apparent, where estimates in the United States have found that 1 in 20 patients requiring intensive and critical care resulted in transfer to another facility.2 The need for such transfers are equally varied as they are common and include: no critical care facilities at the referring facility; no staffed critical care bed availability at referring facility; requirements for expertise and/or specialists facilitates not available at referring site; and the repatriation of patients back to their original facility.6,8 An increase in the number of patients requiring the continuation of critical care in-transit has led to a need to expand the borders of traditional intensive care beyond the confines of the hospital. Such a concept fits with the assertions of Peter Safar, a pioneer of modern critical care, who proposed that critical care should not be defined by geographic location, but rather a set of principles designed to deliver appropriate and timely care to patients who need it.9 Specialised transfer services: The advent and implementation of critical care transfer and retrieval services has been the bridge to this divide, lying at the confluence of prehospital emergency care, in-hospital emergency medicine, and intensive care. Undertaking the transfer of a patient requiring the initiation or continuation of critical care is no simple task. Variations in patient type and severity of their medical condition, as well as the expectations of the transfer team are significant. Reports regarding the transfer of patients ranging from critical neonates, to the multi-comorbid geriatric; with complex underlying surgical and medical diagnoses; involving the concomitant administration of multiple vasoactive and sedative medications; with a variety of oxygenation and ventilation requirements, are commonplace in the literature.6,8,10-16 Consequently, moving these patients from the safety and security of one facility to another is an immense logistical challenge and fraught with risks. In addition to the severity of the patients underlying condition, limitations in space, personnel and equipment, as well an unpredictable operating environment are several of the potential hazards faced during the transfer of these patients. These hazards are evident in the incidence of adverse events found in the literature. Incorrect referral triage; inadequate transfer team; patients requiring stabilization prior to transfer; equipment and/or technical failures; adverse drug events and medication errors are amongst the most common reported events.6,8,10-17 Further to this, the movement of patients alone has in itself been shown to have an impact on a patient's baseline status, without the occurrence of negative or untoward events.10,13,15,16 As a result, patient safety and quality of care have become essential components of modern critical care transfer and retrieval services, with the role of clinical audit central to their ability to learn and improve from previous cases and events. The local solution: Despite the relatively small size of the State of Qatar, critical care transfer and retrieval has nonetheless become a necessity within the country's healthcare system. Figure 1 highlights the locations of the main hospitals. Starting in 2014, a dedicated program was initiated to facilitate the transfer and retrieval of critical care patients across the country.18 The Specialized High Acuity Adult Retrieval Program (SHAARP) is a joint initiative between the Hamad Medical Corporation Ambulance Service (HMCAS) and the Hamad Medical Corporation (HMC) Critical Care Network (CCN). It consists of a single dedicated purpose-built ambulance, manned and run 24 hours a day, seven days a week by a variety of staff from both HMCAS and the CCN and deployed primarily for the transfer and retrieval of critical care patients across Qatar.19 The program was further developed in 2016 and formalized under the Transfer and Retrieval division of the HMCAS, with dedicated HMCAS and CCN staff receiving bespoke training and continued education;18 the addition of specialized and dedicated communications staff for call taking, dispatch and monitoring; and focused governance and audit to maintain the highest quality of patient safety and quality of care. Since then, the program has seen considerable success and uptake within the country's health system. The activity of the unit echoes much of what can be found in the literature and further reinforces the need for such a specialized service, regardless of setting (Table 1). It further highlights the importance of the relationship and cooperation between the HMCAS and CCN regarding the expertise and resources that each component adds to the overall service. This is particularly evident in the expectations of the team regarding their duties of care whilst in transit. A significant proportion of the patients transferred by the program have required the maintenance of a high-level of care between facilities, under conditions that are far more challenging than that seen in any regular hospital ward or intensive care unit (Table 2). Conclusion: In modern healthcare, to deliver a consistent and high-level critical care service in any setting, the movement of patients is inevitable. However, in order to ensure the continuum of this level of care and maintain the highest standards of patient safety and quality of care in-transit, specialized transfer services are a necessity. The multidisciplinary nature of critical care transfer and retrieval dictates the cooperation between multiple in-hospital and out of hospital specialties and is a fundamental underlying concept in the success of such services.

From the ICU to the operating room: how to manage the patient?

PURPOSE OF REVIEW

To outline key points for perioperative ICU optimization of nutrition, airway management, blood product preparation and transfusion, antibiotic prophylaxis and transport.

RECENT FINDINGS

Optimization entails glycemic control for all, with specific attention to type-1 diabetic patients. Transport-related adverse events may be averted with surgery in the ICU. If moving the patient is unavoidable, transport guidelines should be followed and hemodynamic optimization, airway control, and stabilization of mechanical ventilation ensured before transport. Preinduction preparation includes assessment of the airway and the provision of high-flow oxygen to prolong apneic oxygenation. Postintubation, a protective positive ventilation strategy should be employed. Ideal transfusion thresholds are 7 g/dl for hemodynamically stable adult patients, 8 g/dl in orthopedic or cardiac surgery patients as well as those with underlying cardiovascular disease. Higher transfusions thresholds may be required in specific disease states. Antimicrobial prophylaxis within 120 min of incision prevents most surgical site infections. Antibiotic therapy depends on the antibiotics being received in the ICU, the time elapsed since ICU admission, local epidemiology and the type of surgery. Tailored antimicrobial regimens may be continued periprocedurally. If more than 70% of the nutritional requirement cannot be met enterally, parenteral nutrition should be initiated within 5-7 days of surgery or earlier if the patient is malnourished.

SUMMARY

ICU patients who require surgery may benefit from appropriate perioperative management.

Remote Surveillance Technologies: Realizing the Aim of Right Patient, Right Data, Right Time

The convergence of multiple recent developments in health care information technology and monitoring devices has made possible the creation of remote patient surveillance systems that increase the timeliness and quality of patient care. More convenient, less invasive monitoring devices, including patches, wearables, and biosensors, now allow for continuous physiological data to be gleaned from patients in a variety of care settings across the perioperative experience. These data can be bound into a single data repository, creating so-called data lakes. The high volume and diversity of data in these repositories must be processed into standard formats that can be queried in real time. These data can then be used by sophisticated prediction algorithms currently under development, enabling the early recognition of patterns of clinical deterioration otherwise undetectable to humans. Improved predictions can reduce alarm fatigue. In addition, data are now automatically queriable on a real-time basis such that they can be fed back to clinicians in a time frame that allows for meaningful intervention. These advancements are key components of successful remote surveillance systems. Anesthesiologists have the opportunity to be at the forefront of remote surveillance in the care they provide in the operating room, postanesthesia care unit, and intensive care unit, while also expanding their scope to include high-risk preoperative and postoperative patients on the general care wards. These systems hold the promise of enabling anesthesiologists to detect and intervene upon changes in the clinical status of the patient before adverse events have occurred. Importantly, however, significant barriers still exist to the effective deployment of these technologies and their study in impacting patient outcomes. Studies demonstrating the impact of remote surveillance on patient outcomes are limited. Critical to the impact of the technology are strategies of implementation, including who should receive and respond to alerts and how they should respond. Moreover, the lack of cost-effectiveness data and the uncertainty of whether clinical activities surrounding these technologies will be financially reimbursed remain significant challenges to future scale and sustainability. This narrative review will discuss the evolving technical components of remote surveillance systems, the clinical use cases relevant to the anesthesiologist's practice, the existing evidence for their impact on patients, the barriers that exist to their effective implementation and study, and important considerations regarding sustainability and cost-effectiveness.

Transport of Critically Ill Patients by the Anesthesia Versus the Intensive Care Unit Service: A Before-After Study of Operating Room Workflows

BACKGROUND

We implemented a new policy at our institution where the responsibility for intensive care unit (ICU) patient transports to the operating room (OR) was changed from the anesthesia to the ICU service. We hypothesized that this approach would be associated with increased on-time starts and decreased turnover times.

METHODS

In the historical model, intubated patients or those on mechanical circulatory assistance (MCA) were transported by the anesthesia service to the OR ("pre-ICU Pickup"). In our new model, these patients are transported by the ICU service to the preoperative holding area (Pre-op) where care is transferred to the anesthesia service ("post-ICU Transfer"). If judged necessary by the ICU or anesthesia attending, the patient was transported by the anesthesia service ("post-ICU Pickup"). We retrospectively reviewed case tracking data for patients undergoing surgery before (January 2014 to May 2015) and after implementation (July 2016 to June 2017) of the new policy. The primary outcome was the proportion of elective, weekday first-case, on-time starts. To adjust for confounders including comorbidities and time trends, we performed a segmented logistic regression analysis assessing the effect of our intervention on the primary outcome. Secondary outcomes were turnover times and compliance with preoperative checklist documentation.

RESULTS

We identified 95 first-start and 86 turnover cases in the pre-ICU Pickup, 70 first-start and 88 turnover cases in the post-ICU Transfer, and 6 turnover cases in the post-ICU Pickup group. Ignoring time trends, the crude proportion of on-time starts increased from 32.6% in the pre-ICU Pickup to 77.1% in the post-ICU Transfer group. After segmented logistic regression adjusting for age, sex, American Society of Anesthesiologists (ASA) physical status, Sequential Organ Failure Assessment (SOFA) score, respiratory failure, endotracheal intubation, MCA, congestive heart failure (CHF), valvular heart disease, and cardiogenic and hemorrhagic shock, the post-ICU Transfer group was more likely to have an on-time start at the start of the intervention than the pre-ICU Pickup group at the end of the preintervention period (odds ratio, 11.1; 95% confidence interval [CI], 1.3-125.7; P = .043). After segmented linear regression adjusting for the above confounders, the estimated difference in mean turnover times between the post-ICU Pickup and pre-ICU Transfer group was not significant (-6.9 minutes; 95% CI, -17.09 to 3.27; P = .17). In post-ICU Transfer patients, consent, history and physical examination (H&P), and site marking were verified before leaving the ICU in 92.9%, 93.2%, and 89.2% of the cases, respectively. No adverse events were reported during the study period.

CONCLUSIONS

A transition from the anesthesia to the ICU service for transporting ICU patients to the OR did not change turnover times but resulted in more on-time starts and high compliance with preoperative checklist documentation.

Is Tracheostomy Insertion an Indication for Gastrostomy Insertion?

The aim of the study was to determine the frequency of surgical patients who undergo tracheostomy and gastrostomy insertion during the same hospitalization. Secondary outcomes included ICU and hospital length of stay (LOS) for patients who underwent concomitant tracheostomy and gastrostomy versus those who did not. This study is a retrospective review of trauma and acute care surgery (ACS) patients between 2006 and 2015 who underwent tracheostomy. Patients who also underwent open gastrostomy or percutaneous endoscopic gastrostomy during the same hospitalization were identified. Data collected included patient demographics, hospital LOS, ICU LOS, and timing of tracheostomy and gastrostomy. Three hundred one trauma and ACS patients who underwent tracheostomy were identified. Seventy- three per cent of tracheostomy patients underwent gastrostomy during the same admission. Of patients who had both tubes inserted, 79 per cent (175) underwent gastrostomy with tracheostomy as the concomitant procedure, whereas 21 per cent received gastrostomy as a delayed procedure. Median hospital LOS for patients who underwent concomitant procedures was 25 days versus 22 days for those who had delayed or no gastrostomy ( P = 0.24). Eighty-four per cent of patients who had tracheostomy for prolonged or anticipated prolonged mechanical ventilation were receiving tube feeds at discharge, and 78 per cent had not been advanced to an oral diet at discharge. Most trauma/ACS patients who undergo tracheostomy also undergo gastrostomy during their hospitalization. Concomitant gastrostomy is not associated with a decrease in hospital LOS; however, most patients who undergo tracheostomy for prolonged mechanical ventilation are discharged receiving enteral nutrition. These patients may benefit from concomitant ICU gastrostomy as a way to improve efficiency and cost-saving.

The learning curve in blind bedside postpyloric placement of spiral tubes: data from a multicentre, prospective observational study

Objective

This study sought to quantify the learning curve for the blind bedside postpyloric placement of a spiral tube in critically ill patients.

Methods

We retrospectively analysed 127 consecutive experiences of three intensivists who performed comparable procedures of blind bedside postpyloric placement of a spiral tube subsequent to failed self-propelled transpyloric migration in a multicentre study. Each intensivist’s cases were divided chronologically into two groups for analysis. The assessment of the learning curve was based on efficiency and safety outcomes.

Results

All intensivists achieved postpyloric placement for over 80% of their patients. The junior intensivist showed major improvement in both efficiency and safety outcomes, and the learning curve for both outcomes was approximately 20 cases. The junior intensivist showed a significant increase in the success rate of proximal jejunum placement and demonstrated a substantial decrease in the major adverse tube-associated events rate. The time to insertion significantly decreased in each intensivist as case experience accumulated.

Conclusions

Blind bedside postpyloric placement of a spiral tube involves a significant learning curve, indicating that this technique could be readily acquired by intensivists with no previous experience using an adequate professional training programme.

Additional and repeated computed tomography in interfacility trauma transfers: Room for standardization

BACKGROUND

Despite the recommendations of the Advanced Trauma Life Support course of the American College of Surgeons, patients undergo computed tomography (CT) in local hospitals before transfer to a trauma center. The problem of repeat CTs caused by technical and protocol issues is ongoing. The objective is to measure the importance of repeat CTs and CTs involving other body regions.

METHODS

All secondary transfers to our level 1 facility with CT at the local hospital over 9 years were reviewed. Patients were considered to have had a repeat CT if the same body region or an another body region was scanned as a part of the initial assessment but not for reasons of clinical follow-up.

RESULTS

Of 6,292 patients received from local hospitals, 685 (12%) had undergone 1097 CT scans at the local hospitals. Patients being scanned in local hospitals were sicker (injury severity score: 21 vs 13) and required more intensive care unit admissions (38% vs 29%) and more ventilation (32% vs 22%). Thirty-nine percent of CTs were repeated, and 55% of these patients required imaging of another body part.

CONCLUSION

Repeat and additional images remain a major issue in trauma transfers. Improvement requires standardization of CT protocols and change in the approach of local hospitals from "finding and requiring need level 1 trauma center" to "not missing any injuries."

Diagnostic chest ultrasound for acute respiratory failure

Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying aetiologies. Diagnostic chest ultrasound provides accurate diagnosis of conditions that commonly cause ARF, and may improve overall diagnostic accuracy in critical care settings as compared to standard diagnostic approaches. Respiratory physicians are becoming increasingly familiar with ultrasound as a part of routine clinical practice, although the majority of data to date has focused on the emergency and intensive care settings. This review will examine the evidence for the use of diagnostic chest ultrasound, focusing on different levels of imaging efficacy; specifically ultrasound test attributes, impacts on clinician behaviour and impact on health outcomes. The evidence behind use of multi-modality ultrasound examinations in ARF will be reviewed. It is hoped that readers will become familiar with the advantages and potential issues with chest ultrasound, as well as evidence gaps in the field.

Cardiothoracic MRI in the ICU: A 10-Year Experience

RATIONALE AND OBJECTIVE

The objective of this study was to identify the feasibility and pitfalls of cardiothoracic magnetic resonance imaging (MRI) in intensive care unit (ICU) patients.

MATERIALS AND METHODS

This retrospective study identified adult ICU patients scheduled for cardiothoracic MRIs during a 10-year study period. ICU patients scheduled for brain MRIs served as a comparison group. A chart review was performed to identify factors impacting a patient's ability to undergo an MRI. Differences between completed and canceled examinations for both cardiothoracic and brain MRIs were evaluated. For the cardiothoracic group, clinical indications and the diagnostic value of the study performed were also identified.

RESULTS

A total of 143 cardiothoracic MRIs and 1011 brain MRIs were requested. Cardiothoracic MRI patients were less frequently completed (52% vs 62%), more frequently men (64% vs 43%), younger (55 vs 63 years), less likely mechanically ventilated (8% vs 29%), more likely to require intravenous contrast (83% vs 23%), and had longer examination times compared to brain MRI patients (64 vs 21 minutes). Successful completion of cardiothoracic MRI was associated with lower serum creatinine, higher glomerular filtration rate, and the absence of mechanical ventilation; significant differences were not seen with regard to gender and use of vasoactive agents. Cardiothoracic MRI results were diagnostic in 69% of examinations, most frequently when performed for myocardial disease (84%) and aortic disease (33%), and less frequently for viability (33%).

CONCLUSIONS

In an ICU population, successful completion of cardiothoracic MRI is challenging but feasible in patients with intact renal function and the absence of mechanical ventilation. Examinations were most frequently diagnostic for myocardial and aortic disease indications.

Pulmonary ultrasound scoring system for intubated critically ill patients and its association with clinical metrics and mortality: A prospective cohort study

PURPOSE

Pulmonary ultrasound (PU) examination at the point-of-care can rapidly identify the etiology of acute respiratory failure (ARF) and assess treatment response. The often-subjective classification of PU abnormalities makes it difficult to document change over time and communicate findings across providers. The study goal was to develop a simple, PU scoring system that would allow for standardized documentation, have high interprovider agreement, and correlate with clinical metrics.

METHODS

In this prospective study of 250 adults intubated for ARF, a PU examination was performed at intubation, 48-hours later, and at extubation. A total lung score (TLS) was calculated. Clinical metrics and final diagnosis were extracted from the medical record.

RESULTS

TLS correlated positively with mortality (P = .03), ventilator hours (P = .003), intensive care unit, and hospital length of stay (P = .003, P = .008), and decreasing PaO₂ /FiO₂ (P < .001). Agreement of PU findings was very good (kappa = 0.83). Baseline TLS and subscores differed significantly between ARF categories (nonpulmonary, obstructive, and parenchymal disease).

CONCLUSIONS

A quick, scored, PU examination was associated with clinical metrics, including mortality among a diverse population of patients intubated for ARF. In addition to diagnostic and prognostic information at the bedside, a standardized and quantifiable approach to PU provides objectivity in serial assessment and may enhance communication of findings between providers.

Blind bedside postpyloric placement of spiral tube as rescue therapy in critically ill patients: a prospective, tricentric, observational study

Background

Various special techniques for blind bedside transpyloric tube placement have been introduced into clinical practice. However, transpyloric spiral tube placement facilitated by a blind bedside method has not yet been reported. The objective of this prospective study was to evaluate the safety and efficiency of blind bedside postpyloric placement of a spiral tube as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients.

Methods

This prospective, tricentric, observational study was conducted in the intensive care units (ICUs) of three tertiary hospitals. A total of 127 consecutive patients with failed spontaneous transpyloric spiral tube migration despite using prokinetic agents and still required enteral nutrition for more than 3 days were included. The spiral tube was inserted postpylorically using the blind bedside technique. All patients received metoclopramide intravenously prior to tube insertion. The exact tube tip position was determined by radiography. The primary efficacy endpoint was the success rate of postpyloric spiral tube placement. Secondary efficacy endpoints were success rate of a spiral tube placed in the third portion of the duodenum (D3) or beyond, success rate of placement in the proximal jejunum, time to insertion, length of insertion, and number of attempts. Safety endpoints were metoclopramide-related and major adverse tube-associated events.

Results

In 81.9% of patients, the spiral feeding tubes were placed postpylorically; of these, 55.1% were placed in D3 or beyond and 33.9% were placed in the proximal jejunum, with a median time to insertion of 14 min and an average number of attempts of 1.4. The mean length of insertion was 95.6 cm. The adverse event incidence was 26.0%, and no serious adverse event was observed.

Conclusions

Blind bedside postpyloric placement of a spiral tube, as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients, is safe and effective. This technique may facilitate the early initiation of postpyloric feeding in the ICU.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-OPN-16008206. Registered on 1 April 2016.

Analysis of Adverse Events during Intrahospital Transportation of Critically Ill Patients

Purpose

To describe adverse events occurring during intrahospital transportation of adult patients hospitalized in an Intensive Care Unit (ICU) and to evaluate the association with morbidity and mortality.

Method

Prospective cohort study from July 2014 to July 2015. Data collection comprised clinical data, prognostic scores, length of stay, and outcome at hospital discharge. Data was collected on transport and adverse events. Adverse events were classified according to the World Health Organization following the degree of damage. The level of significance was set at 5%.

Results

A total of 293 patients were analyzed with follow-up of 143 patient transportations and records of 86 adverse events. Of these events, 44.1% were related to physiological alterations, 23.5% due to equipment failure, 19.7% due to team failure, and 12.7% due to delays. Half of the events were classified as moderate. The mean time of hospital stay of the group with adverse events was higher compared to patients without adverse events (31.4 versus 16.6 days, resp., p < 0.001).

Conclusions

Physiological alterations were the most frequently encountered events, followed by equipment and team failures. The degree of damage associated with adverse events was classified as moderate and associated with an increase in the length of hospital stay.