Project description:BackgroundThe establishment of a resuscitation room management for nontraumatic critically ill children appears to make sense. This study collected data of pediatric patients suffering from nontraumatic critically ill conditions treated in a resuscitation room.MethodsThe retrospective OBSERvE-DUS-PED study (November 2019-October 2022) recorded pediatric patients (age < 18 years) who were admitted to the emergency department (ED) for resuscitation room care. The routinely documented data on treatment were taken from the hospital information system MEDICO® and the patient data management system COPRA® in accordance with the OBSERvE dataset. The study was approved by the Ethics Committee of the Medical Faculty of the Heinrich Heine University (2023-2377).ResultsThe study included 52 pediatric resuscitation room patients. Adolescents aged 14-17 years were the most frequent in the cohort representing 37% of the total and neonates/infants (0-1 year) were lowest at 8%. The most common symptoms categorized according to ABCDE problems were disturbance of consciousness (D) at 61%, cardiovascular failure (C) at 25%, respiratory insufficiency (B) at 6%, airway obstruction (A) and exposure/environment (E) problems each at 4%. The out-of-hospital and in-hospital emergency procedures were performed with the following frequencies: venous (58% vs. 65%), intraosseous (14% vs. 2%) and central venous access (0% vs. 12%), invasive airway management (35% vs. 8%), cardiopulmonary resuscitation (21% vs. 10%), vasopressors (15% vs. 17%), and intra-arterial pressure measurement (0% vs. 17%). The mean duration of resuscitation room management was 70 ± 43 min. The 30-day mortality was 17%.ConclusionThe OBSERvE-DUS-PED study demonstrates the major challenges in the care of critically ill nontraumatic pediatric patients, both in out-of-hospital and in-hospital management. The variety and complexity of the referral diagnoses as well as the immediate vital threat to the patients make it appear sensible to treat such patients primarily in a resuscitation room of the ED due to the available material, infrastructural and personnel resources.

Project description:ObjectivesEmergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes.Data sources and study selectionReview article.Data extraction and data synthesisEmergency department-based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department-based interventions, hospital-based interventions, and emergency department-based resuscitation care units.ConclusionsEmergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department-based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.

Project description:Study objectiveEmergency physicians are frequently responsible for making time-sensitive decisions around the provision of life-sustaining treatment. These decisions can involve goals of care or code status discussion, which will often substantially alter a patient's care pathway. A central part of these conversations that has received relatively little attention are recommendations for care. By proposing a best course of action or treatment via a recommendation, a clinician can ensure that their patients receive care that is concordant with their values. The objective of this study is to explore emergency physicians' attitudes toward recommendations about resuscitation in critically ill patients in the emergency department (ED).MethodsWe recruited Canadian emergency physicians via multiple recruitment strategies to ensure maximum variation sampling. Semi-structured qualitative interviews were conducted until thematic saturation occurred. Participants were asked about their perspectives and experiences with respect to recommendation-making in critically ill patients and to identify areas for improvement in this process in the ED. We used a qualitative descriptive approach and thematic analysis to identify themes around recommendation-making in the ED for critically ill patients.ResultsSixteen emergency physicians agreed to participate. We identified four themes and multiple subthemes. Major themes included identification of the roles and responsibilities of the emergency physician (EP) with respect to making a recommendation, the logistics or process of making a recommendation, barriers to making a recommendation, and how to improve recommendation-making and goals of care conversations in the ED.ConclusionEmergency physicians provided a range of perspectives on the role of recommendation-making in critically ill patients in the ED. Several barriers to the inclusion of a recommendation were identified and many physicians provided ideas on how to improve goals of care conversations, the recommendation-making process, and ensure that critically ill patients receive care that is concordant with their values.

Project description:BackgroundLittle is known about the factors that influence physicians' admission decisions, especially among lower acuity patients. For the purpose of our study, non-medical refers to all of the factors-other than the patient's clinical condition-that could potentially influence admission decisions.ObjectiveTo describe the influence of non-medical factors on physicians' decisions to admit non-critically ill patients presenting to the ED.DesignCross-sectional study of hospital admissions at a single academic medical center.ParticipantsNon-critically ill adult patients admitted to the hospital (n = 297) and the admitting emergency medicine physicians (n = 34).Main measuresA patient survey assessed non-medical factors, including primary care access and utilization. A physician survey assessed clinical and non-medical factors influencing the decision to admit. Based on physician responses, admissions were characterized as "strongly acuity-driven," "moderately acuity-driven," or "weakly acuity-driven." Among these admission types, we compared length of stay, cost, and readmission within 30 days to the hospital or ED.Key resultsBased on the admitting physician's assessment, we categorized the motivation for admission as strongly acuity-driven in 185 (62 %) admissions, moderately acuity-driven in 92 (31 %), and weakly acuity-driven in 20 (7 %). Per the physician surveys, 51 % of hospitalizations were strongly or moderately influenced by one or more non-medical factors, including lack of information about baseline conditions (23 %); inadequate access to outpatient specialty care (14 %); need for a diagnostic testing or procedure (12 %); a recent ED visit (11 %); and inadequate access to primary care (10 %). Compared with strongly-acuity driven admissions, admissions that were moderately or weakly acuity-driven were shorter and less costly but were associated with similar rates of ED (35 %) and hospital (27 %) readmission.ConclusionsNon-medical factors are influential in the admission decisions for many patients presenting to the emergency department. Moderately and weakly acuity-driven admissions may represent a feasible target for alternative care pathways.

Project description:BackgroundPneumonia is the most common hospital-acquired infection affecting patients in the intensive care unit (ICU). However, current national guidelines for the treatment of hospital-acquired pneumonia (HAP) are several years old and the diagnosis of pneumonia in mechanically ventilated patients (VAP) has been subject to considerable recent attention. The optimal duration of antibiotic therapy for HAP in the critically ill is uncertain.ObjectivesTo assess the effectiveness of short versus prolonged-course antibiotics for HAP in critically ill adults, including patients with VAP.Search methodsWe searched CENTRAL (2015, Issue 5), MEDLINE (1946 to June 2015), MEDLINE in-process and other non-indexed citations (5 June 2015), EMBASE (2010 to June 2015), LILACS (1982 to June 2015) and Web of Science (1955 to June 2015).Selection criteriaWe considered all randomised controlled trials (RCTs) comparing a fixed 'short' duration of antibiotic therapy with a 'prolonged' course for HAP (including patients with VAP) in critically ill adults.Data collection and analysisTwo review authors conducted data extraction and assessment of risk of bias. We contacted trial authors for additional information.Main resultsWe identified six relevant studies involving 1088 participants. This included two new studies published after the date of our previous review (2011). There was substantial variation in participants, in the diagnostic criteria used to define an episode of pneumonia, in the interventions and in the reported outcomes. We found no evidence relating to patients with a high probability of HAP who were not mechanically ventilated. For patients with VAP, overall a short seven- or eight-day course of antibiotics compared with a prolonged 10- to 15-day course increased 28-day antibiotic-free days (two studies; N = 431; mean difference (MD) 4.02 days; 95% confidence interval (CI) 2.26 to 5.78) and reduced recurrence of VAP due to multi-resistant organisms (one study; N = 110; odds ratio (OR) 0.44; 95% CI 0.21 to 0.95), without adversely affecting mortality and other recurrence outcomes. However, for cases of VAP specifically due to non-fermenting Gram-negative bacilli (NF-GNB), recurrence was greater after short-course therapy (two studies, N = 176; OR 2.18; 95% CI 1.14 to 4.16), though mortality outcomes were not significantly different. One study found that a three-day course of antibiotic therapy for patients with suspected HAP but a low Clinical Pulmonary Infection Score (CPIS) was associated with a significantly lower risk of superinfection or emergence of antimicrobial resistance, compared with standard (prolonged) course therapy.Authors' conclusionsOn the basis of a small number of studies and appreciating the lack of uniform definition of pneumonia, we conclude that for patients with VAP not due to NF-GNB a short, fixed course (seven or eight days) of antibiotic therapy appears not to increase the risk of adverse clinical outcomes, and may reduce the emergence of resistant organisms, compared with a prolonged course (10 to 15 days). However, for patients with VAP due to NF-GNB, there appears to be a higher risk of recurrence following short-course therapy. These findings do not differ from those of our previous review and are broadly consistent with current guidelines. There are few data from RCTs comparing durations of therapy in non-ventilated patients with HAP, but on the basis of a single study, short-course (three-day) therapy for HAP appears not to be associated with worse clinical outcome, and may reduce the risk of subsequent infection or the emergence of resistant organisms when there is low probability of pneumonia according to the CPIS.

Project description:Introduction:Associations between air pollutants, meteorological conditions and respiratory diseases have been extensively shown. The aim of this study was to investigate associations between daily meteorological data, data on air pollution and emergency department (ED) visits depending on the day of the week, season and year (study period from 2013 to 2015). Methods:Highly correlated environmental data entered a categorical principal components analysis (CATPCA). We analysed cross-correlation functions between the time series of the respective daily environmental factors and daily ED visits. Time lags with peak correlations of environmental variables obtained by the CATPCA on ED visits together with day of the week, year, running day (linear, quadratic and cubic), season and interaction terms entered the univariate analysis of variance (UNIANOVA) model. Results:The analyses demonstrated main effects on ED visits for the day of the week with highest admission rates on Mondays (B=10.69; ?2=0.333; p<0.001). A significant time trend could be observed showing increasing numbers of ED visits per each year (p<0.001). The variable 'running day' (linear, quadratic and cubic) indicated a significant non-linear effect over time. The variable season showed significant results with winter, spring and summer recording fewer ED visits compared with the reference season autumn. Environmental variables showed no direct associations with respiratory ED visits. Discussion:ED visits were significantly associated with temporal variables. Our data did not show direct associations between environmental variables and ED visits.In times of rapid urbanisation, increases in respiratory diseases, temperature and air pollution, our analyses can help focus future studies and enhance strategies to reduce increasing numbers of respiratory diseases and ED visits. Because the potential costs of medical care in hospitals can be high compared with physicians, public health recommendations for reducing the increasing ED visits should be promoted and evaluated.

Project description:ObjectivesIn mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence.DesignAn a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial.SettingThe ED of three academic medical centers.PatientsMechanically ventilated adult patients that received neuromuscular blockers.InterventionsNone.Measurements and main resultsAll data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01).ConclusionsAWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.

Dataset Information

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

Background

Methods

Results

Conclusion

Publications

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

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