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Introduction: The New Brunswick Trauma Registry is a database of injury admissions from eight hospitals throughout the province. Data tracks individuals in-hospital. By linking this information with vital statistics, we are able to observe outcomes post-discharge and can model health outcomes for participants. We want to know how outcomes for trauma patients compare with the general population post discharge. Methods: Using data from 2014-15, we followed over 2100 trauma registry observations for one year and tracked mortality rate per 1,000 people by age-group. We also compared the outcomes of this group to all Discharge Abstract Database (DAD) entries in the province (circa. 7500 total). We tracked mortality in-hospital, at six months, and one year after discharge. We truncated age into groups aged 40-64, 65-84, and 85 or older. Results: In-hospital mortality among those in the trauma registry is approximately 20 per 1,000 people for those age 40-64, 50 per 1,000 people for those aged 65-84, and 150 per 1,000 people aged 85 or older. For the oldest age group this is in line with the expected population mortality rate, for the younger two groups these estimates are approximately 2-4 times higher than expected mortality. The mortality at six-month follow-up for both of the younger groups remains higher than expected. At one-year follow-up, the mortality for the 65-84 age group returns to the expected population baseline, but is higher for those age 40-64. Causes of death for those who die in hospital are injury for nearly 50% of observations. After discharge, neoplasms and heart disease are the most common causes of death. Trends from the DAD are similar, with lower mortality overall. Of note, cardiac causes of death account for nearly as many deaths in the 6 months after the injury in the 40 -64 age group as the injury itself. Conclusion: Mortality rates remain high upon discharge for up to a year later for some age groups. Causes of death are not injury-related. Some evidence suggests that the injury could have been related to the eventual cause of death (e.g., dementia), but questions remain about the possibility for trauma-mitigating care increasing the risk of mortality from comorbidities. For example, cardiac death, which is largely preventable, is a significant cause of death in the 40-64 age group after discharge. Including an assessment of Framingham risk factors as part of the patients rehabilitation prescription may reduce mortality.
Introduction: Patients presenting to the emergency department (ED) with hypotension have a high mortality rate and require careful yet rapid resuscitation. The use of cardiac point of care ultrasound (PoCUS) in the ED has progressed beyond the basic indications of detecting pericardial fluid and activity in cardiac arrest. We examine if finding left ventricular dysfunction (LVD) on emergency physician performed PoCUS reliably predicts the presence of cardiogenic shock in hypotensive ED patients. Methods: We prospectively collected PoCUS findings performed in 135 ED patients with undifferentiated hypotension as part of an international study. Patients with clearly identified etiologies for hypotension were excluded, along with other specific presumptive diagnoses. LVD was defined as identification of a generally hypodynamic LV in the setting of shock. PoCUS findings were collected using a standardized protocol and data collection form. All scans were performed by PoCUS-trained emergency physicians. Final shock type was defined as cardiogenic or non-cardiogenic by independent specialist blinded chart review. Results: All 135 patients had complete follow up. Median age was 56 years, 53% of patients were male. Disease prevalence for cardiogenic shock was 12% and the mortality rate was 24%. The presence of LVD on PoCUS had a sensitivity of 62.50% (95%CI 35.43% to 84.80%), specificity of 94.12% (88.26% to 97.60%), positive-LR 10.62 (4.71 to 23.95), negative-LR 0.40 (0.21 to 0.75) and accuracy of 90.37% (84.10% to 94.77%) for detecting cardiogenic shock. Conclusion: Detecting left ventricular dysfunction on PoCUS in the ED may be useful in confirming the underlying shock type as cardiogenic in otherwise undifferentiated hypotensive patients.
Introduction: Bleeding in the first trimester of pregnancy is a common presentation to the Emergency Department (ED) with half going on to miscarry. Currently there is no local consensus on key quality markers of care for such cases. Point of Care Ultrasound (PoCUS) is increasingly utilized in the ED to detect life threating pathology such as an ectopic pregnancy or fetal viability. PoCUS leads to improved patient satisfaction, quicker diagnosis and treatment. The purpose for this study was to examine the rates of formal ultrasound and PoCUS when compared to reported and recommended rates, and also to understand the use of other diagnostic tests. Methods: A retrospective cohort study of pregnant females presenting to the ED with first trimester bleeding over one year (June 2016 – June2017) was completed. A sample size of 108 patients was required to detect a moderate departure from baseline reported rates (67.8 – 77.6%). The primary outcome was the PoCUS rate in the ED. The main secondary outcome was the formal ultrasound rate. The literature recommends PoCUS in all early pregnancy bleeding in the ED, with a target of 100% of patients receiving PoCUS. Additional data recorded included the live birth rate, pelvic and speculum examination rate and lab tests. There is no clearly defined ideal practice for the additional data so these rates will be recorded without comparison. Results: Records of 168 patients were screened for inclusion. 65 cases were excluded because they were not pregnant or had confirmed miscarriage or other, leaving a total of 103 patients included in the analysis. The PoCUS rate was 51.5% (95% CI 42%-61%), lower than previously reported PoCUS rates of 73% (67.8 – 77.6%). The formal ultrasound rate was 67% (57%-75%). Both approaches were significantly lower than the recommended rate of 100% (95.7 – 100%). Rates for other key markers of care will also be presented. Conclusion: Fewer PoCUS exams were performed at our centre compared with reported and recommended rates for ultrasound. Further results will explore our current practice in the management of first trimester pregnancy complications. We plan to use this information to suggest improvements in the management of this patient population.
Background: Chest tube insertion is a time and safety critical procedure with a significant complication rate (up to 30%). Industry routinely uses Lean and ergonomic methodology to improve systems. This process improvement study used best evidence review, small group consensus, process mapping and prototyping in order to design a lean and ergonomically mindful equipment solution. Aim Statement: By simplifying and reorganising chest tube equipment, we aim to provide users with adequate equipment, reduce equipment waste, and wasted effort locating equipment. Measures & Design: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Necessary equipment was identified. Next, two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student) to refine the equipment list and packaging. A final equipment storage system was produced and evaluated by an interprofessional team during cadaver training using a survey and Likert scales. Evaluation/Results: There were 47 equipment items in the pre-intervention ED chest tube tray. After prototyping 21 items were removed while nine critical items were added. The nine items missing from the original design were found in four different locations in the department. Six physicians and seven RNs participated in cadaver testing and completed an evaluation survey of the new layout. Participants preferred the new storage design (Likert median 5, IQR of 1) over the current storage design (median of 1, IQR of 1). Discussion/Impact: The results suggest that the lean equipment storage is preferred by ED staff compared to the current set-up, may reduce time finding missing equipment, and will reduce waste. Future simulation work will quantitatively understand compliance with safety critical steps, user stress, wasted user time and cost.
Introduction: Improving public access and training for epinephrine auto-injectors (EAIs) can reduce time to initial treatment in anaphylaxis. Effective use of EAIs by the public requires bystanders to respond in a timely and proficient manner. We wished to examine optimal methods for assessing effective training and skill retention for public use of EAIs, including the use of microskills lists. Methods: In this prospective, stratified randomized study, 154 participants at 15 sites receiving installation of public EAIs were randomized to one of three experimental education interventions: A) didactic poster (POS) teaching; B) poster with video teaching (VID), and C) Poster, video, and simulation training (SIM). Participants were tested by participation in a standardized simulated anaphylaxis scenario at 0-months, immediately following training, and again at follow-up at 3 months. Participants’ responses were videoed and assessed by two blinded raters using microksills checklists. The microskills lists were derived from the best available evidence and interprofessional process mapping using a skills trainer. The interobserver reliability was assessed for each item in a 14 step microskill checklist composed of 3-point and 5-point Likert scale questions around EpiPen use, expressed as Kappa Values. Results: Overall there was poor agreement between the two raters. Being composed or panicked had the highest level of agreement K = 0.7, but a result that did not reach statistical significance (substantial agreement, p = 0.06) calling for EMS support has the second highest level of agreement, K = 0.6 (moderate agreement, p = 0.01), the remainder of the items had very low to moderate agreement with a Kappa value range of -103 to 0.48. Conclusion: Although microskills chesklists have been shown to identify areas where learners and interprofessional teams require deliberate practice, these results support previously published evidence that the use of microskills checklists to assess skills has poor reproducibility. Performance will be further assessed in this study using global rating scales, which have shown higher levels of agreement in other studies.
Introduction: Chest tube insertion, a critical procedure with a published complication rate (30%), is a required competency for emergency physicians. Microskills training has been shown to identify steps that require deliberate practice. Objectives were: 1. Develop a chest tube insertion microskills checklist to facilitate IPE, 2. Compare the microskills checklist with published best available evidence, 3. Develop an educational video based on the process map, 4. Evaluate the video in an interprofessional team prior to cadaver training as a proof of concept. Methods: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student). A final microskills list was produced and compared to the procedural steps described in consensus publications. An educational video was produced and evaluated by an interprofessional team prior to cadaver training using a survey and Likert scales as a proof of concept. Participants were 7 EM RNs and 6 ATLS trained physicians. Participants were asked to fill out a nine-question survey, using a 5-point Likert Scale (1-strongly disagree to 5 strongly agree). Results: The final process map contained 54 interdisciplinary steps, compared to ATLS that describes 14 main steps and peer reviewed articles that describe 9 main steps. The microskills checklist described, in more detail, the steps that relate to team interaction and the operational environment. Physicians rated the training video were able to apply what they learned in the video with an average of 4.67 (median of 5, mode of 5, and an IQR of 0.75). Conclusion: The development of the process maps and microkills checklists provides interprofessional teams with more information about chest tube insertion than instructions described in commonly available courses and procedural steps derived by consensus.
Introduction: Although use of point of care ultrasound (PoCUS) protocols for patients with undifferentiated hypotension in the Emergency Department (ED) is widespread, our previously reported SHoC-ED study showed no clear survival or length of stay benefit for patients assessed with PoCUS. In this analysis, we examine if the use of PoCUS changed fluid administration and rates of other emergency interventions between patients with different shock types. The primary comparison was between cardiogenic and non-cardiogenic shock types. Methods: A post-hoc analysis was completed on the database from an RCT of 273 patients who presented to the ED with undifferentiated hypotension (SBP <100 or shock index > 1) and who had been randomized to receive standard care with or without PoCUS in 6 centres in Canada and South Africa. PoCUS-trained physicians performed scans after initial assessment. Shock categories and diagnoses recorded at 60 minutes after ED presentation, were used to allocate patients into subcategories of shock for analysis of treatment. We analyzed actual care delivered including initial IV fluid bolus volumes (mL), rates of inotrope use and major procedures. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: Although there were expected differences in the mean fluid bolus volume between patients with non-cardiogenic and cardiogenic shock, there was no difference in fluid bolus volume between the control and PoCUS groups (non-cardiogenic control 1878 mL (95% CI 1550 – 2206 mL) vs. non-cardiogenic PoCUS 1687 mL (1458 – 1916 mL); and cardiogenic control 768 mL (194 – 1341 mL) vs. cardiogenic PoCUS 981 mL (341 – 1620 mL). Likewise there were no differences in rates of inotrope administration, or major procedures for any of the subcategories of shock between the control group and PoCUS group patients. The most common subcategory of shock was distributive. Conclusion: Despite differences in care delivered by subcategory of shock, we did not find any significant difference in actual care delivered between patients who were examined using PoCUS and those who were not. This may help to explain the previously reported lack of outcome difference between groups.
Introduction: Point of care ultrasound has been reported to improve diagnosis in non-traumatic hypotensive ED patients. We compared diagnostic performance of physicians with and without PoCUS in undifferentiated hypotensive patients as part of an international prospective randomized controlled study. The primary outcome was diagnostic performance of PoCUS for cardiogenic vs. non-cardiogenic shock. Methods: SHoC-ED recruited hypotensive patients (SBP < 100 mmHg or shock index > 1) in 6 centres in Canada and South Africa. We describe previously unreported secondary outcomes relating to diagnostic accuracy. Patients were randomized to standard clinical assessment (No PoCUS) or PoCUS groups. PoCUS-trained physicians performed scans after initial assessment. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses including shock category were recorded at 0 and 60 minutes. Final diagnosis was determined by independent blinded chart review. Standard statistical tests were employed. Sample size was powered at 0.80 (α:0.05) for a moderate difference. Results: 273 patients were enrolled with follow-up for primary outcome completed for 270. Baseline demographics and perceived category of shock were similar between groups. 11% of patients were determined to have cardiogenic shock. PoCUS had a sensitivity of 80.0% (95% CI 54.8 to 93.0%), specificity 95.5% (90.0 to 98.1%), LR+ve 17.9 (7.34 to 43.8), LR-ve 0.21 (0.08 to 0.58), Diagnostic OR 85.6 (18.2 to 403.6) and accuracy 93.7% (88.0 to 97.2%) for cardiogenic shock. Standard assessment without PoCUS had a sensitivity of 91.7% (64.6 to 98.5%), specificity 93.8% (87.8 to 97.0%), LR+ve 14.8 (7.1 to 30.9), LR- of 0.09 (0.01 to 0.58), Diagnostic OR 166.6 (18.7 to 1481) and accuracy of 93.6% (87.8 to 97.2%). There was no significant difference in sensitivity (-11.7% (-37.8 to 18.3%)) or specificity (1.73% (-4.67 to 8.29%)). Diagnostic performance was also similar between other shock subcategories. Conclusion: As reported in other studies, PoCUS based assessment performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test. However performance was similar to standard (non-PoCUS) assessment, which was excellent in this study.
Infants with prenatally diagnosed CHD are at high risk for adverse outcomes owing to multiple physiologic and psychosocial factors. Lack of immediate physical postnatal contact because of rapid initiation of medical therapy impairs maternal–infant bonding. On the basis of expected physiology, maternal–infant bonding may be safe for select cardiac diagnoses.
This is a single-centre study to assess safety of maternal–infant bonding in prenatal CHD.
In total, 157 fetuses with prenatally diagnosed CHD were reviewed. On the basis of cardiac diagnosis, 91 fetuses (58%) were prenatally approved for bonding and successfully bonded, 38 fetuses (24%) were prenatally approved but deemed not suitable for bonding at delivery, and 28 (18%) were not prenatally approved to bond. There were no complications attributable to bonding. Those who successfully bonded were larger in weight (3.26 versus 2.6 kg, p<0.001) and at later gestation (39 versus 38 weeks, p<0.001). Those unsuccessful at bonding were more likely to have been delivered via Caesarean section (74 versus 49%, p=0.011) and have additional non-cardiac diagnoses (53 versus 29%, p=0.014). There was no significant difference regarding the need for cardiac intervention before hospital discharge. Infants who bonded had shorter hospital (7 versus 26 days, p=0.02) and ICU lengths of stay (5 versus 23 days, p=0.002) and higher survival (98 versus 76%, p<0.001).
Fetal echocardiography combined with a structured bonding programme can permit mothers and infants with select types of CHD to successfully bond before ICU admission and intervention.
The effect of transportation and lairage on the faecal shedding and post-slaughter contamination of carcasses with Escherichia coli O157 and O26 in young calves (4–7-day-old) was assessed in a cohort study at a regional calf-processing plant in the North Island of New Zealand, following 60 calves as cohorts from six dairy farms to slaughter. Multiple samples from each animal at pre-slaughter (recto-anal mucosal swab) and carcass at post-slaughter (sponge swab) were collected and screened using real-time PCR and culture isolation methods for the presence of E. coli O157 and O26 (Shiga toxin-producing E. coli (STEC) and non-STEC). Genotype analysis of E. coli O157 and O26 isolates provided little evidence of faecal–oral transmission of infection between calves during transportation and lairage. Increased cross-contamination of hides and carcasses with E. coli O157 and O26 between co-transported calves was confirmed at pre-hide removal and post-evisceration stages but not at pre-boning (at the end of dressing prior to chilling), indicating that good hygiene practices and application of an approved intervention effectively controlled carcass contamination. This study was the first of its kind to assess the impact of transportation and lairage on the faecal carriage and post-harvest contamination of carcasses with E. coli O157 and O26 in very young calves.
Introduction: Electrocardiographic (ECG) rhythms are used during resuscitation (ACLS) to guide resuscitation, and often to determine futility. Survival rates to hospital discharge have been reported to be higher for patients with PEA than asystole in out-of-hospital cardiac arrest. This study examines how well the initial ECG cardiac rhythm represents actual cardiac activity as determined by point of care ultrasound (PoCUS). Methods: A database review was completed for patients arriving to a tertiary ED in asystole or PEA arrest, from 2010 to 2014. Patients under 19y or with a previous DNR were excluded. Patients were grouped into those with cardiac activity (PEA) and asystole on ECG; as well as whether cardiac activity was seen on PoCUS during the arrest. Data was analyzed for visualized cardiac activity on PoCUS. Results: 186 patients met the study criteria. Those with asystole on ECG were more likely to have no cardiac activity than those with PEA (Odds 7.21 for initial PoCUS; 5.45 for any PoCUS). The sensitivity of ECG rhythm was 80.49% and 82.12%, specificity was 77.91% and 54.28%, positive predictive value was 94.28% and 88.57%, and negative predictive value was 30.43% and 41.30% for cardiac activity on initial PoCUS and on any PoCUS respectively. The positive and negative likelihood ratios for ECG were 3.47 and 0.25 for activity on initial PoCUS. The positive and negative likelihood ratios for activity on any PoCUS were 1.78 and 0.33. Conclusion: Our results suggest that although most patients with asystole on ECG demonstrate no cardiac activity, a small number actually had activity on PoCUS. This supports the use of PoCUS during cardiac arrest, in addition to ECG, to identify patients with ongoing mechanical cardiac activity.
Introduction: Situational Awareness is the ability to identify, process, and comprehend the critical elements of information about the patient condition, stability, the operational environment and an appropriate clinical course. The Situational Awareness Global Assessment Tool (SAGAT) is a validated tool for measuring situational awareness. The SAGAT tool was measured during a series of standardized high fidelity advanced airway management simulations in multidisciplinary teams in New Brunswick Emergency Departments delivered by two simulation programs Methods: Thirty eight simulated emergency airway cases were performed in situ in Emergency Departments and in learning centers in Southern New Brunswick from September 2015 to October 2017. Eight standardized cases were used whose educational objectives were to develop the optimization of critically ill patients prior to induction, to deliver patient-centered anesthesia and to choose an appropriate airway strategy. Learner profiles collected. Cases were divided into two groups; those that contained critical errors and those that did not based on video assessment. Critical errors were defined as failure of 1) Oxygenation 2) Shock correction 3) Induction dose estimation 4) Choice of airway management paradigm. The SAGAT has a maximum score of 13 and was assessed by research nurses after each case for all participants. SAGAT scores were non-normally distributed, so results were expressed as medians with interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. Results: Results. Of the 38 cases, 14 contained one more critical errors. The median SAGAT score in the group that contained critical errors was 8 +/− 2 (IQR). The median SAGAT Score in the group that contained no critical errors was 11 +/− 2 (IQR). The median scores we significantly different with a p-value of 0.02. Conclusion: In this study in simulated emergency cases, higher SAGAT scores were associated with teams leaders that did not commit safety critical errors. This work is the initial analysis to develop standards for Simulated team performance in Emergency Department teams.
Introduction: Improving public access and training for epinephrine auto-injectors (EAIs) can reduce time to initial treatment in anaphylaxis. Effective use of EAIs by the public requires bystanders to respond in a timely and proficient manner. We wished to examine optimal methods for effective training and skill retention for public use of EAIs. Methods: In this prospective, stratified randomized study, 154 participants at 15 sites receiving installation of public EAIs were randomized to one of three experimental education interventions: A) didactic poster (POS) teaching; B) poster with video teaching (VID), and C) Poster, video, and simulation training (SIM). Participants were tested by participation in a standardized simulated anaphylaxis scenario at 0-months, immediately following training, and again at follow-up at 3 months. Participants responses were videoed and assessed by blinded raters. Patient recorded experience measures (PREMs) assessed participant-patient interaction for every scenario. Data that was non-normally distributed was analyzed using non-parametric testing (Kruskall-Wallis-Rank Sum-Test). Results: Initial analysis showed differences between group baseline characteristics for age and first aid training; with a multivariable analysis providing the effect size of these differences. PREM data and video assessment data were not normally distributed. Analysis of PREM data revealed significantly higher scores in the SIM group at 0-months (median=6.5, IQR=5; p=0.05) and 3-months (median=5, IQR=3; p<0.01), compared to those groups that did not receive SIM. Video assessment performance scores show trends in higher skills and knowledge retention for SIM participants at 3-months; full data analysis will be performed at a later date. Final video assessment analysis will involve a weighted scoring system, using a consensus process, and an inter-rater agreement analysis. Conclusion: Simulation training improves interaction, essential skills, and retention of knowledge in simulated anaphylaxis response with public EAIs compared to non-simulation-based training.
Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Microskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Surgical cricothyrotomy is a rarely performed safety critical task. Methods: Two doctors and three nurses developed stepwise team microskills checklists from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 30 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. Commonly available airway trainers were retrofitted with the 3-D printed larynx. The microskills checklist was used in four phases: 1. Group discussion of each microskill step; 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback - changes are recorded; 3. Total task run through without interruption - changes are recorded; 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 12/21, RNs 6/12. The commonest changes in practice were equipment preparation (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 5/5). Conclusion: Microskills checklists facilitate cricothyrotomy skill development in interprofessional teams in this provisional analysis.
Introduction: The decision as to whether to end resuscitation for pre-hospital cardiac arrest (CA) patients in the field or in the emergency department (ED) is commonly made based upon standard criteria. We studied the reliability of several easily determined criteria as predictors of resuscitation outcomes in a population of adults in CA transported to the ED. Methods: A retrospective database and chart analysis was completed for patients arriving to a tertiary ED in cardiac arrest, between 2010 and 2014. Patients were excluded if aged under 19. Multiple data were abstracted from charts using a standardized form. Regression analysis was used to compare criteria that predicted return of spontaneous circulation (ROSC) and survival to hospital admission (SHA). Results: 264 patients met the study inclusion criteria. Logistic regression was used to identify predictors of ROSC and SHA. The criteria that emerged as significant predictors for ROSC included; longer ED resuscitation time (Odds ratio 1.11 (1.06- 1.18)), witnessed arrest (Odds ratio 9.43 (2.58- 53.0)) and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 3.23 (1.07-9.811)) over Asystole. Receiving point of care ultrasound (PoCUS; Odds ratio 0.22 (0.07-0.69)); and having an initial cardiac rhythm of Pulseless Electrical Activity (Odds Ratio 4.10 (1.43-11.88)) were the significant predictors for SHA. Longer times for ED resuscitation was close to reaching significance for predicting SHA Conclusion: Our results suggest that both fixed and adaptable factors, including increasing resuscitation time, and PoCUS use in the ED were important independent predictors of successful resuscitation. Several commonly used criteria were unreliable predictors.
Introduction: Deliberate practice (DP) is the evolution of practice using continually challenging and focused practice on a particular task. DP involves immediate feedback, time for problem-solving and evaluation, and opportunities for repeated performance. Mircroskills training breaks down larger tasks into multiple smaller subtasks and then adds opportunities for feedback and adjustment for each subtask. Microskills training is routinely used to achieve excellence in competitive sports, martial arts, military operations, and music. Endotracheal intubation is a complex task with a clinically significant complication and failure rate. Methods: Two doctors and three nurses developed stepwise team microskills checklist from case review, simulations and published evidence. The checklist was tested, evaluated and developed during four days of simulation faculty team training. The final 36 item checklist was used to facilitate skills training for doctors, nurses, respiratory therapists and ACPs in one level 2, and two level 3 trauma centers from April 2017 to October 2017. The microskills checklist was used in four phases: 1. Group discussion of each microskill step 2. Groups of three team members; operator, assistant and microskill facilitator (using the checklist) to enable the deliberate analysis of the teams current performance. Each subtask is performed with immediate peer and where necessary faculty feedback. Changes are recorded. 3. Total task run though without interruption. Changes are recorded. 4. Repetition and feedback using different team members, manikins, including time pressure. User satisfaction surveys were collected after the skills training session Results: Results. Teams were composed of Registered Nurses (8), Physicians (9), and Respiratory Therapists (2). All of the teams experienced a change in practice. The median number of microskills changed for MDs 13/30, RNs 7/16. The commonest changes in practice were patient positioning (all teams). All professions agreed strongly that the approach produces a positive change in practice (median score 4.8/5). Conclusion: Microskills checklist facilitate endotracheal intubation with a bougie skill development in interprofessional teams in this provisional analysis.
Introduction: Traditionally, out of hospital cardiac arrests (CA) have poor outcomes. Incorporation of extracorporeal cardiopulmonary resuscitation (ECPR) is being used increasingly to supplement ACLS to provide better outcomes for patients. Current literature suggests potentially improved outcomes, including neurological function. We assessed the feasibility of introduction of ECPR to a regional hospital using a 4-phase study. We report phase-1, an estimation of the number of potential candidates for ECPR in our setting. Methods: Following development and agreement on local criteria for selection of patients for ECPR using a modified Delphi Technique, inclusion and exclusion criteria were applied retrospectively, to a database comprising 4 years of emergency department (ED) cardiac arrests (n=395). This provided estimates of the number of patients who would have qualified for EMS transport for ECPR and initiation of ECPR in the ED. Results: Application of criteria would result in 20.0% (95% CI 16.2-24.3%) of CA being transported to the ED for ECPR (mean 18.5 patients per year). In the ED 4.6% (95% CI 2.83-7.26%) would be eligible to receive ECPR (4.3 patients per year). Incorporating downtime criteria, 3.0% (95% CI 1.6-5.3%) qualify. After considering local in-house cardiac catheterization hours 9.4% (95% CI 6.8-12.9%) and 5.4% (95% CI 3.5-8.2%), without and with EMS rhythm assumptions respectively, would be eligible for transport. For placement on pump, 3.0% (95% CI 1.6-5.3%) and 2.4% (95% CI 1.2-4.6%), without and with use of total downtime respectively, were eligible. Conclusion: If historical patterns of CA were to continue, we believe that an ECPR program may be feasible in our regional hospital setting, with a small number of selected cardiac arrest patients meeting eligibility for transportation and initiation of ECPR. These numbers suggest that an ECPR program would not be resource intensive, yet would be sufficiently busy to maintain adequate team competency.
Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR), a method of cardiopulmonary bypass, is increasingly being used to supplement traditional CPR to improve outcomes for cardiac arrest (CA). CA and particularly out of hospital CA (OHCA) have poor outcomes. Prior to development of a 3 phase ECPR program in a Canadian regional hospital, we wished to identify and optimize a practical selection process (inclusion and exclusion criteria) for patients who may benefit from ECPR. Methods: Using a locally modified Delphi technique, we followed a literature review to construct a proposed set of evidence based criteria with a questionnaire, where inclusion and exclusion criteria were scored by a selected group of 13 experts. Following 3 rounds, and additional review by an international expert in the field of ECPR, consensus was achieved for patient selection criterion. Results: First round responses achieved 87.5% agreement for selection of exclusion criteria. Inclusion criteria had agreement 62.5%. Responses to the second round for selection of inclusion criteria were unanimous at 100% with the exception of age parameters (<65 years vs. <70 years). The third and final set of criteria achieved 100% consensus though subsequent expert review refined a single exclusion criteria (asystole). Agreed inclusion criteria were: witnessed CA, age <70, refractory arrest, no flow time <10min, total downtime <60min, and a cardiac or select non-cardiac etiology (PE, drug OD, poisoning, hypothermia). Exclusion criteria were : unwitnessed arrest, asystole, certain etiologies (uncontrolled bleeding, irreversible brain damage, trauma), and comorbidities (severe disability limiting ADLs, standing DNR, palliation). Simplified criteria for EMS transport included witnessed OHCA, age, and no flow time. Conclusion: Selection criteria of candidates for ECPR are important components for any program. Expert consensus review of current evidence is an effective method for development of ECPR selection criteria.
Introduction: Situational awareness (SA) is the team understanding patient stability, presenting illness and future clinical course. Losing SA has been shown to increase safety-critical events in multiple industries. SA can be measured by the previously validated Situational Awareness Global Assessment Tool (SAGAT). Checklists are used in many safety-critical industries to reduce errors of omission and commission. An RSI checklist was developed from case review and published evidence.The New Brunswick Trauma Program supports an inter-professional simulation-based medical education program Methods: Simulations were facilitated in three hospitals in New Brunswick from April 2017 to October 2017. Learner profiles were collected. The SAGAT tool was completed by a research nurse at the end of each scenario. SAGAT scores were non-normally distributed, so results were expressed as medians and interquartile ranges. Mann Whitney U tests were used to calculate statistical significance. To understand the effect of the of an RSI checklist a comparison was made between SAGAT scores at baseline in scenario 1, and the same first scenario completed after a washout period. A Poisson regression analysis will be used to account for the effect of confounding variables in further analyses. Results: The group was composed of Registered Nurses (8), Physicians (7), and Respiratory Therapists (2). Situational awareness increased significantly with the use of an RSI checklist after 1 day of 4 simulations. The washout period ranged between 5 weeks and 8 weeks. The baseline situational awareness of the whole group during scenario 1 was 9 +/− 0.5 (median, IQR), and with the RSI checklist was 12 +/−1 (median, IQR). The difference was highly statistically significant, p=< 0.001. This level of situational awareness using checklist is comparable to the SAGAT scores after 10 scenarios. Conclusion: In this provisional analysis, the use of an RSI checklist was associated with an increase in measured situational awareness. Higher levels of situational awareness are associated with greater patient safety. A Poisson regression model will be used to understand the confounding effects of user expertise and the likely interaction with simulation exposure.
Introduction: With hospital occupancy rates frequently approaching 100%, even small variations in daily admission numbers can have a large impact. The ability to predict variance in emergency admission rates would provide administrators with a significant advantage in managing hospital daily bed requirements. There is a growing interest in patterns of hospital admissions, and many EDs utilize historical admission patterns to attempt to predict daily bed requirements. Previous studies have utilized patient demographics and past medical history to develop an admission likelihood model. We wished to examine the predictive strength of individual CEDIS presenting complaints (PC) on admission likelihood Methods: Using a database analysis of over 285,000 ED presentations (2013-2017), we calculated visit frequencies and admission rates by PC. Using a logistic regression analysis PCs were ordered from high to medium predictive strength. Results: Of 285,155 presentations, there were 38,090 hospital admissions, a rate of 13.36%. Based on the number of visit frequencies and admission rates, the PCs demonstrating high predictive strength were Direct Referral (effect=0.36, binomial CI: 0.28 to 0.44); Shortness of Breath (0.32: 0.26 to 0.41); General Weakness; Weakness/Query CVA; & Chest Pain Cardiac Features (each 0.30: 0.25 to 0.42); Altered level of consciousness (0.24: 0.16 to 0.31); and Confusion (0.18: 0.08 to 0.26). With our sample size, all remaining CEDIS PCs had low predictive value (the effect is <0.1), or were not predictive at all. Conclusion: We have demonstrated that, for our population, certain PCs are associated with an increased likelihood of admission and have quantified this effect using logistic regression analysis. Variance from the average daily admission rate may be predicted, in our population, by identifying these PCs at registration.We plan to develop a tool, based on this data and implemented at registration, to predict cumulative likely daily admission requirements as patients present over a 24hr period.