Critical Care Team Research Articles

Implementing the Pediatric Ventilator Liberation Guidelines Using the Most Current Evidence.

Invasive mechanical ventilation is prevalent and associated with considerable morbidity. Pediatric critical care teams must identify the best timing and approach to liberating (extubating) children from this supportive care modality. Unsurprisingly, practice variation varies widely. As a first step to minimizing that variation, the first evidence-based pediatric ventilator liberation guidelines were published in 2023 and included 15 recommendations. Unfortunately, there is often a substantial delay before clinical guidelines reach widespread clinical practice. As such, it is important to consider barriers and facilitators using a systematic approach during implementation planning and design. In this narrative review, we will (1) summarize guideline recommendations, (2) discuss recent evidence and identify practice gaps relating to those recommendations, and (3) hypothesize about potential barriers and facilitators to their implementation in clinical practice.

Critical care management of acute ischemic stroke – An overview of current concepts

Acute ischemic stroke is a major cause of morbidity and mortality globally. Early recognition and prompt revascularisation are the cornerstones of treatment. Advances in the management of stroke, notably with the endovascular interventions has led to improved functional outcomes. Identification of stroke subtype, timely decision making, institution of specific therapy and periprocedural care in an intensive care unit make the difference between a favourable and an unfavourable outcome. To this effect, dedicated stroke centres, multidisciplinary teams with trained experts and critical care management play an important role. Improvements in the understanding of the disease process, ever expanding literature and development of promising novel therapeutic strategies, not withstanding, stroke is still a leading cause of acquired long term disability and mortality worldwide. End of life care and associated decision making precariousness, pose a significant prognostication challenge to the critical care team. The aim of this review is to discuss the current evidence regarding diagnosis, revascularisation modalities and optimal critical care management strategies.

Communication in the ICU: An Unintended Nocebo Effect?

To identify medical phrases utilized by the critical care team that may have an unintended impact on the critically ill patient, we administered an anonymous survey to multi-professional critical care team members. We elicited examples of imprecise language that may have a negative emotional impact on the critically ill. Of the 1600 providers surveyed, 265 offered 1379 examples (912 unique) which were clustered into 5 categories. Medical jargon (eg, "riding the vent") was most prevalent (n = 549). There were 217 negative suggestions (eg, "you will feel a stick and a burn"). Hyperboles (eg, "black cloud") were common (n = 198) while homonyms (ie "he fibbed") accounted for 150 examples. Phrases such as "code brown in there" were categorized as metonyms (n = 144). 121 metaphors/similes (eg, "rearranging deck chairs on the Titanic") were provided. Phrases that have the potential to negatively impact critically ill patient perceptions are commonplace in critical care practice. Whether these everyday communication habits lead to an unintended nocebo effect on mental health outcomes of the critically ill deserves further study.

Factors Associated With Desaturation in Prehospital Rapid Sequence Intubation in a Helicopter Emergency Medical Service

ObjectiveDesaturation during prehospital rapid sequence intubation (RSI) is common and is associated with patient morbidity. Past studies have identified oxygen saturations at induction, the grade of laryngoscopy, and multiple attempts to intubate as being associated with desaturation. This study aimed to investigate whether there are other factors, identifiable before RSI, associated with desaturation. MethodsThis was a study of a physician-paramedic critical care team operating as Aeromedical Operations, NSW Ambulance. Prehospital RSIs (using paralysis) were studied retrospectively via patient case notes, monitor data, and an airway database. The review occurred between April 1, 2016, and December 31, 2018. Desaturation was defined as monitor recordings of saturations ≤ 92%. Logistic regression was performed for factors likely to be associated with desaturation. ResultsDesaturation occurred in 67 of 350 (19.1%) RSIs. Factors significantly associated with desaturation included male sex, a chest injury, increased weight, and lower saturations pre-RSI. ConclusionIncreased weight, chest injuries, and lower oxygen saturations are associated with desaturation at RSI. The variable male sex may be a surrogate for other as-yet unidentified factors.

The association between geospatial and temporal factors and pre-hospital response to major trauma: a retrospective cohort study in the North of England

BackgroundMajor trauma is a leading cause of premature death and disability worldwide, and many healthcare systems seek to improve outcomes following severe injury with provision of pre-hospital critical care. Much research has focussed on the efficacy of pre-hospital critical care and advanced pre-hospital interventions, but less is known about how the structure of pre-hospital critical care services may influence response to major trauma. This study assessed the association between likelihood of pre-hospital critical care response in major trauma and factors important in the planning and development of those services: geographic isolation, time of day, and tasking mechanism.MethodsA local trauma registry, supported with data from the Trauma Audit and Research Network alongside additional information regarding pre-hospital management, identified patients sustaining major trauma admitted to Major Trauma Centres in the North of England. Data was extracted on location and time of incident, mechanism of injury, on-scene times, and presence or absence of pre-hospital critical care team. An isochrone map was constructed for 30-minute intervals to regional Major Trauma Centres, defining geographic isolation. Univariate logistic regression compared likelihood of pre-hospital critical care response to that of conventional ambulance response for varying degrees of geographic isolation, day or night period, and mechanism of injury, and multiple linear regression assessed the association between geographic isolation, service response and on-scene time.Results2619 incidents were included, with 23.3% attended by pre-hospital critical care teams. Compared to conventional ambulance services, pre-hospital critical care teams were more likely to respond major trauma in areas of greater geographic isolation (OR 1.42, 95% CI 1.30–1.55, p < 0.005). There were significant differences in the mechanism of injury attended and no significant difference in response by day or night period. Pre-hospital critical care team response and increasing geographic isolation was associated with longer on-scene times (p < 0.005).ConclusionPre-hospital critical care teams are more likely to respond to major trauma in areas of greater geographic isolation. Enhanced pre-hospital care may mitigate geographic inequalities when providing advanced interventions and transport of severely injured patients. There may be an unmet need for pre-hospital critical care response in areas close to major hospitals.

Relational skill training for patient engagement and the creation of a trauma-informed critical care.

Patients and families in critical care have a high likelihood of previous and re-experienced trauma. Unaddressed, physical, and psychological impacts of these traumas can worsen outcomes for patients and families. A trauma-informed care approach has been proposed for critical care; however, training programs do not include relational competencies or de-escalation techniques, risking the re-traumatization of patients and families in critical care and negatively impacting clinicians. This article describes a strategy that can be adopted by critical care teams towards the creation of a trauma-informed critical care unit including the use of a framework for relational training. Principles of relationship management and de-escalation are discussed with the use of a fictional exemplar scenario. Key messages include a call to action for relational training for care teams to enhance skilled relational engagement of patients and families. This article also highlights the foundational importance of policies supporting a trauma-informed approach in critical care.

Abstract 19115: In-situ Resuscitation Training in Cardiology Procedural Suites

Background: Critical Care Advanced Resuscitation Training (CC-ART) prepares critical care teams for emergency situations through training that occurs in a simulated clinical space. Simulated environments do not always accurately mirror the actual clinical environments. Simulations conducted in the actual clinical environment, also known as in-situ simulation, may overcome some of these challenges. Goal: To explored the impact of in situ, ART simulation in a Cardiac Catheterization Lab (CCL) and an Electrophysiology Lab (EPL) on the staff’s experience, confidence, and communication skills. Method: Key leadership and educator team members collaborated on the in-situ simulation set up. Coordination with Simulation Center and Central Supply Department was completed to arrange for delivery of high-fidelity manikins and training crash cart to the site. A team of physicians and nurse educators created CCL and EPL scenarios for the simulations and wrote a simulation evaluation survey for CCL and EPL nurses and technologists who attended. Results: . Simulations were run by both critical care anesthesiologist and clinical nurse educator. Pre-simulation and post-simulation surveys were collected immediately prior to and after the in-situ simulation. 38 staff completed pre and post surveys. Pre-simulation, 50.00% of staff strongly agreed that they were confident in their ability to care for a decompensated patient based on the prior CC-ART training versus, post-simulation, 84.21% strongly agreed. Pre-simulation, 26.32% strongly agreed that the simulation center training was similar to their actual work experience versus post-simulation, 78.95% agreed the in-situ simulation matched their actual work experience. Pre-simulation, 52.63% strongly agreed that they were confident in their ability to communicate their needs during emergencies or code blue situations versus post-simulation 86.84% agreed. Conclusion: This quality improvement project highlights the effectiveness of in situ resuscitation simulation in improving healthcare professionals' confidence, training realism, and communication skills . Analysis of patient outcomes is needed to determine the effectiveness and duration of impact of in situ training for clinical practice.

The 2023 American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine Pediatric and Adult Brain Death/Death by Neurologic Criteria Determination Consensus Guidelines: What the Critical Care Team Needs to Know.

Guidelines for brain death/death by neurologic criteria (BD/DNC) determination were revised to provide a consistent and updated approach to BD/DNC evaluation across all ages by the American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine. This article is intended to complement the guidelines and highlight aspects relevant to the critical care community; the actual guidelines should be used to update hospital protocols and dictate clinical practice. Because BD/DNC evaluations are conducted in the ICU, it is essential for members of the critical care community to familiarize themselves with these guidelines. The fundamental concept of BD/DNC has not changed; BD/DNC is permanent loss of function of the brain as a whole, including the brain stem, resulting in coma, brainstem areflexia, and apnea in the setting of an adequate stimulus. The BD/DNC evaluation requires a sufficient observation period to ensure there is no chance of recovery, followed by exclusion of potentially confounding conditions like hypothermia, hypotension, severe metabolic disturbances, or medication effects. Specific guidance is provided for patients who were treated with therapeutic hypothermia or medical or surgical interventions to manage intracranial hypertension. The guidelines outline a structured and meticulous neurologic examination and detail the responses consistent with BD/DNC. A protocol is provided for how to safely perform apnea testing, including modifications needed for patients on extracorporeal membrane oxygenation. Controversial issues such as consent, BD/DNC evaluation in pregnancy, preservation of neuroendocrine function, and primary posterior fossa injuries are addressed. The ultimate goal is to ensure a consistent and accurate approach to BD/DNC evaluation in patients of all ages, fostering public trust in the medical community's ability to determine death. By adhering to these guidelines, critical care clinicians can confidently navigate the challenging aspects of BD/DNC determination.

Virtual Reality simulation training improves health professionals’ knowledge in STEMI critical care

Abstract Background In Friuli-Venezia Giulia (FVG, Italy, 1.2M inhabitants), the STEMI network has been implemented with a regional educational programme since 2018. However, each step leading to a fast-track reperfusion needs specific interactions between critical care teams on the scene and in hospital that theoretical training cannot provide. Objectives A new educational tool, based on virtual reality (VR), was developed to train emergency nurses and doctors on the STEMI pathway. Each training session consisted of a VR simulation, dynamically driven by an instructor, where a nurse-doctor pair had to provide first aid to a patient with chest pain. A plenary debriefing followed each session. Before and after the training, all participants filled out a questionnaire on the STEMI pathway (21 multiple-choice items on technical and organizational issues) to evaluate the course theoretical effectiveness. This research is part of the EASY-NET program, co-funded by the Ministry of Health and the participating Regions (NET-2016-02364191). Results Between Oct ’22 and Jan ’23, 48 nurses and 14 doctors were trained and filled in both pre- and post-training questionnaires. Before the training, the median number of correct answers was 15 (IQR 13-16), after the course it rose to 16 (IQR 15-17, p &amp;lt; 0.0001); doctors performed better than nurses both at pre- (16, IQR 15-17 and 14.5, IQR 12.5-16, respectively; p = 0.017) and post-test (18, IQR 15-18 vs 16, IQR 15-17; p &amp;lt; 0,0001) but both categories significantly improved their scores (p = 0.019 and p = 0.0001). The main improvement was observed for items concerning the Case Manager's actions after ECG, (right answers: 58 post-test vs 45 pre, p = 0.0016), morphine administration, (37 vs 25, p = 0.0073), and therapy in vagal reaction (46 vs 35, p = 0.0116). Conclusions An innovative VR simulation training improves the theoretical knowledge of the critical care pathway of STEMI in healthcare teams, which may lead to a better approach to this disease. Key messages • A new Virtual Reality simulation tool is useful for the training of doctors and nurses in patients with STEMI. • Simulation tools based on Virtual Reality can improve health professionals’ theoretical knowledge in critical care pathways.

Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study

BackgroundPrehospital tracheal intubation is a potentially lifesaving intervention, but is associated with prolonged time on-scene. Some services strongly advocate performing the procedure outside of the ambulance or aircraft, while others also perform the procedure inside the vehicle. This study was designed as a non-inferiority trial registering the rate of successful tracheal intubation and incidence of complications performed by a critical care team either inside or outside an ambulance or helicopter. MethodsThis observational multicentre study was performed between March 2020 and September 2021 and involved 12 anaesthetist-staffed critical care teams providing emergency medical services by helicopter in Denmark, Norway, and Sweden. The primary outcome was first-pass successful tracheal intubations. ResultsOf the 422 drug-assisted tracheal intubations examined, 240 (57%) took place in the cabin of the ambulance or helicopter. The rate of first-pass success was 89.2% for intubations in-cabin vs 86.3% outside. This difference of 2.9% (confidence interval −2.4% to 8.2%) (two sided 10%, including 0, but not the non-inferiority limit Δ=−4.5) fulfils our criteria for non-inferiority, but not significant superiority. These results withstand after performing a propensity score analysis. The mean on-scene time associated with the helicopter in-cabin procedures (27 min) was significantly shorter than for outside the cabin (32 min, P=0.004). ConclusionsBoth in-cabin and outside the cabin, prehospital tracheal intubation by anaesthetists was performed with a high success rate. The mean on-scene time was shorter in the in-cabin helicopter cohort. Clinical trial registrationNCT04206566.

THU365 Diabetic Ketoacidosis Unmasking Acute Pancreatitis With A Hidden Surprise

Abstract Disclosure: Y. Arya: None. A. Syal: None. S. Teja Sathi: None. J.V. Mayrin: None. Background: Development of diabetic ketoacidosis (DKA) in acute pancreatitis is rare and requires high clinical suspicion, particularly in cases such as ours where it might lead to presentation and hence, unmasking of pancreatitis. Our case was also complicated by splenic vein thrombosis, making it a therapeutic dilemma. Case Presentation: We describe the case of a female in her mid-40s who presented to the emergency department with complaints of severe epigastric abdominal pain, associated with vomiting, for the past one day. She was hemodynamically stable, and her laboratory analysis revealed a lipase greater than twenty times the upper limits of normal. Patient was also noted to have a random capillary blood glucose of 500 mg/dL with positive urine beta hydroxybutyrate and an anion gap of thirty-five. She was diagnosed with DKA and managed with intravenous (IV) insulin along with IV fluids. Her abdominal pain failed to respond which triggered us to obtain imaging. She underwent a computed tomography (CT) scan of her abdomen and pelvis which showed extensive pancreatic inflammation and necrosis along with peripancreatic fluid collection extending into the mesentery. The patient was managed with a multidisciplinary approach involving endocrinology, gastroenterology, and critical care teams. Her abdominal pain initially improved, followed by worsening around the sixth hospital day. She underwent an MRI of her abdomen which revealed a new splenic vein thrombosis. Given the risk of bleeding from the peri-pancreatic fluid collection and non-occlusive nature of the thrombosis, clinical monitoring was preferred over anticoagulation. Extensive workup did not reveal an etiology of the pancreatitis, and it was deemed idiopathic. The patient became insulin dependent from her pancreatitis. She had a prolonged hospital course and was eventually discharged after three weeks of presentation with appropriate outpatient follow-up. Discussion: The incidence of diabetes mellitus after acute pancreatitis depends on the severity of pancreatic necrosis; the degree of insulin deficiency being directly proportional to the extent of necrosis.[1] The pathophysiology of splenic vein thrombosis revolves around necrosis, venous stasis, and activation of coagulation cascade, all in the background of the inflammatory state.[2] Anticoagulation in splenic vein thrombosis secondary to pancreatitis thus remains controversial, given the increased risk of hemorrhage and formation of pseudoaneurysms. Interestingly, therapeutic anticoagulation might prevent thrombosis progression by reducing portal pressure and thereby decreasing the risk of hemorrhage. Lower rates of hemorrhage have been documented in literature in patients receiving anticoagulation in this subset of patients, versus untreated cases.[3] Thus, an individual risk-benefit analysis is needed before initiating anticoagulation.

B-015 Magnesium Fractionation using Ultrafiltration System

Abstract Background Total magnesium (tMg) comprises 3 fractions: ionized (iMg), protein-bound (pbMg), and complexed magnesium (cMg). Serum iMg can be measured directly using ion-selective electrode method, but determination of pbMg and cMg has not been addressed. The aim of this study is to examine the efficiency of a newly introduced ultrafiltration system to fractionate tMg and validate proposed its reference intervals for Mg fractions. Methods Leftover whole blood samples were collected from 40 subjects. iMg and tMG were measured in whole blood using Stat Profile Prime® ES, and ultrafiltrate using VITROS 5600 Analyzer, respectively. Serum fractionation was done by ultrafiltration system (Centrifree®, Sigma-Aldrich, MA, USA). pbMg and cMG were calculated by subtracting tMg ultrafiltrate from tMg in whole blood, and subtracting iMg from tMg concentrations in the ultrafiltrate, respectively. Results Reference intervals of iMg, pbMg, and cMg were proposed as mean± 2 SD of 0.93–1.61 mg/dL, 0–0.85 mg/dL, and 0.07–0.57 mg/dl, respectively. iMg, pbMg, and cMg represented 65%, 20%, and 16% of the tMg concentration in normo-magnesemic subjects with slight variation in hypo- and hyper-magnesemic subjects. iMg showed weak positive correlation with tMg, (r = 0.5, 0.03, 0.005), in normo-magnesemic, hypo- and hyper-magnesemic subjects, respectively. iMg showed weak positive correlation with cMg (r = 0.11) and strongly with pbMg (r = 0.41) in hypermagnesemic subjects. iMg was not dependent on protein concentration or pH, however it correlated positively with blood sugar (r = 0.5 and 0.2) and serum creatinine levels (r = 0.3 and 0.5) in hypo- &amp; hyper-magnesemic subjects, respectively. Conclusions The ultrafiltration system was a promising means to assess cMg and pbMg in critical care patients. iMg measurement provides better discrimination in ill patients and was associated with lifestyle factors including alcohol consumption, hypertension and diabetes. Stat Profile Prime® ES point-of-care analyzer provides rapid and precise direct measurement comparable to current tMg standard method. Due to its rapid turnaround time, it can help to efficiently manage workload of high complexity laboratories, and alleviate the burden on the critical care team.

Implications of pediatric extracorporeal cardiopulmonary resuscitation simulation for intensive care team confidence and coordination: A pilot study.

Extracorporeal cardiopulmonary resuscitation (ECPR) is associated with improved outcomes in select populations, however, crisis resource management (CRM) in this setting is logistically challenging. This study evaluates the impact of ECPR simulation on self-perceived confidence and collaboration of intensive care unit team members. This is a prospective observational study analyzing data obtained between July 2018-December 2019. This study focused on non-surgical members of critical care team consisting of pediatric intensivists, resident physicians, registered nurses, respiratory therapists. Participants were expected to perform cardiopulmonary resuscitation (CPR) during the ECPR event, participate in code-team responsibilities and provide ancillary support during cannulation. Pre- and post-simulation surveys employed the Likert scale (1 = not at all confident, 5 = highly confident) to assess self-perceived scores in specified clinical competencies. Twenty-nine providers participated in the simulation; 38% had prior ECPR experience. Compared to mean pre-study Likert scores (2.4, 2.4, 2.5), post-simulation scores increased (4.2, 4.4, 4.3) when self-evaluating: confidence in assessing patients needing ECPR, confidence in participating in ECPR workflow and confidence in performing high-quality CPR, respectively. Post-simulation values of >3 were reported by 100% of participants in all domains (p < .0001). All participants indicated the clinical scenario and procedural environment to be realistic and appropriately reflective of situational stress. Additionally, 100% of participants reported the simulation to improve perceived team communication and teamwork skills. This study demonstrated preliminary feasibility of pediatric ECPR simulation in enhancing independent provider confidence and team communication. This self-perceived improvement may establish a foundation for cohesive CRM, in preparation for a real life ECPR encounter.

Quality Review of Prone Patient Transport Protocol

ObjectiveThis is a retrospective quality review of LifeFlight Nova Scotia's prone patient transport protocol. MethodsElectronic patient care records were queried for acute respiratory distress syndrome, prone position, proning, supine to prone, and prone to prone between February 2017 and June 2022. Eligible electronic patient care records were reviewed for demographics (sex, age, and weight); method of transports (ambulance, rotor wing, or fixed wing); duration of transports; mechanical ventilation parameters; medication infusions; arterial blood gases; occurrences of mild hypoxemia (any oxygen saturation [SpO2] < 88% or decrease in SpO2 > 5%); hypotension (any episode of MAP < 65 mm Hg); severe hypoxemia (any SpO2 < 80% or decrease in SpO2 > 10%); refractory hypotension (mean arterial pressure < 65 mm Hg not responsive to vasopressor/inotropes); cardiac arrests; and displacement of central lines, arterial lines, and endotracheal tubes. ResultsSeventeen prone patients were transported by ambulance, rotor wing, and fixed wing with 4 occurrences of mild hypotension, 4 occurrences of mild hypoxemia, and 1 occurrence of refractory hypotension. ConclusionInterfacility transfer of prone patients by a dedicated critical care team is feasible with minimal adverse occurrences while ensuring patients have access to the specialized lifesaving care they require.

Curative to palliative care transition challenges in the intensive care unit. A narrative review.

Abstract&#x0D; Introduction: The need for high quality palliative care services for critically ill patients and their families remains of high importance.&#x0D; Purpose: This review aims to present the benefits and barriers to implementing palliative care in Intensive Care Units and suggest ways to facilitate the shift from therapeutic to palliative care.&#x0D; Methods: PubMed, Scopus, and Google Scholar databases were searched online. Studies included were eligible for the provision of palliative care in the intensive care unit, published in English from 2012 through 2022.&#x0D; Review: Evidence shows that integrating palliative care impacts the quality of life in intensive care unit and increases rates of use of palliative care facilities. On the other hand decrease length of stay and impacts the cost and the opportunity cost of the intensive care unit. The data suggest that a large subset of intensive care units patients would benefit from palliative care, but palliative care remains underutilized in the ICU setting. Lack of training in palliative care, organizational factors, decisions about end of life, lack of defined criteria for inclusion, and life-saving culture of the intensive care unit are barriers to providing palliative care. Efforts should focus on education, support for effective communication and decision-making, early integration of a palliative approach, redesign of clinical protocols, and reallocation of resources to provide an environment conducive to quality at the end of life.&#x0D; Conclusion: Involving palliative care in critically ill patients has reduced intensive care unit resource use. Nurses need to define their essential management roles within the multidisciplinary critical care team and help develop systems by which these roles can be implemented.

When can an enhanced critical care team add value to equestrian related incidents? A retrospective observational study

BackgroundHelicopter Emergency Medical Services (HEMS) may be tasked to equestrian related incidents. Previous studies have suggested that majority of patients do not require HEMS specific interventions. No data has been published since 2015 so this article aims to establish the current incidence of equestrian incidents attended by one UK HEMS and identify trends that would aid the dispatch of HEMS to the patients who most need it. MethodsA retrospective review of the computerised record system for one UK HEMS was performed between 1st January 2015–30th June 2022. Demographic data, timings, suspected injury pattern and HEMS specific intervention details were extracted. The 20 patients with the highest confirmed injury burden were reviewed in detail. Results257 patients (229 female) were treated by HEMS (0.02% of all HEMS dispatches). Of those 124 dispatches were due to interrogation of the 999 calls by a clinician on the dispatch desk. Only 52% were conveyed to hospital by the HEMS team; 51% had no HEMS specific intervention. Of the 20 most severely injured patients their pathology included splenic, liver, spinal cord and traumatic brain injuries. ConclusionWhilst HEMS dispatches to equestrian incidents remain a small percentage, there are four mechanisms that may benefit due to potential injury burden: fall onto head with suggestion of hyper-extension or hyper-flexion injury; kick to the torso; horse fallen or repetitively rolled onto patient and, no movement of patient since incident. In addition, age >50 years should be considered as higher risk.

REBOA in Bleeding and Cardiac Arrest in Pre-Hospital Care by Helicopter Emergency Medical Service: The RIBCAP-HEMS Project

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) plays an important role in the most severe trauma and medical patients with cardiac arrest. Its use in pre-hospital emergency medicine in Germany does not yet regularly occur, and the vast majority of rapid response vehicles are not equipped with REBOA devices. In this article we will describe the introduction of REBOA for bleeding patients, as well as an adjunct for refractory out-of-hospital cardiac arrest (OHCA), in a German helicopter emergency medical service (HEMS).Methods: The DRF-Luftrettung HEMS base in Halle (Saale) Germany has incorporated REBOA in pre-hospital emergency medicine and will accompany this introduction with a feasibility study. We will describe the implementation of REBOA and the results of the training course. The training consists of theoretical and practical issues within different case scenarios. This was carried out before introducing REBOA into pre-hospital emergency medicine. Using a pre- and post-course exam and a self-assessment questionnaire the theoretical and practical knowledge and the performance of the critical care teams were determined.Results: The results of the pre-course exam in comparison with the post-course exam improved from 82% to 96%. Based on the self-assessment questionnaires, all participants felt a relevant improvement of their theoretical and practical knowledge. All physicians successfully performed REBOA under ongoing cardiopulmonary resuscitation in manikin simulators.Conclusions: The results from the training course indicate that there was a significant improvement of the theoretical and practical knowledge, as well as the performance of REBOA. The on-going feasibility study will show if it is worth introducing REBOA in a civilian HEMS for the patients in extremis.

The Role of Canadian respiratory therapists in adult critical care (ICURT-CAN): A scoping review

RATIONALE Respiratory therapists (RTs) are part of the critical care team, dedicated to providing specialized respiratory care. However, their role, regional practice variations and inclusion in the multidisciplinary team are not well described in the literature. OBJECTIVES The aim of this review was to describe: 1) the role and impact of RTs; 2) the recommendations for RT inclusion; and 3) regional differences in RT practices in adult critical care across Canada. METHODS AND MEASUREMENT A scoping review was performed. Eligible studies described the Canadian RT role in adult critical care. Data extraction was informed by the Respiratory Therapy Practice-Based Outcome Initiative Model (RT-PBOI), a conceptual model that outlines 5 domains of how RTs can contribute to patient care and resource utilization. MAIN RESULTS RTs’ roles across 22 studies were categorized into domains of the RT-PBOI model: Technical skills (n = 20), Approach to practice (n = 20), Leveraging capacity (n = 15), Strategic expertise (n = 16) and Growing value for the future (n = 17). The grey literature (n = 26) provided brief descriptions of the RT role across multiple practice settings, but common RT tasks in critical care were mechanical ventilation management and participation in specialized care teams. One grey literature report recommended RTs to participate as critical response team members and two studies briefly mentioned regional differences in RT roles. CONCLUSION There were minimal studies to report on the impact of RTs in Canadian, adult critical care. Future studies are needed to evaluate the RT role and their value in improving patient care and resource utilization.

P91: ECMO Education Initiative for Advanced Practice Providers.

Study: Our Adult ECMO program is supported by a rounding model where an ECMO Specialist is in house 24/7 and available to be called for bedside support. We are able to utilize this rounding model due to the high level of expertise from our multidisciplinary critical care teams. This expertise is maintained through a robust nursing competency program, as well as a credentialing process and accredited continuing medical education (CME) course for physicians. However, a gap in initial and ongoing competency was identified for Advanced Practice Providers (APP). Prior to 2021, a total of 19 APPs had received some form of initial ECMO education with no ongoing recompetency training. Our APPs serve as frontline providers and first responders in ECMO emergencies. Therefore, we aimed to develop an education program, including didactic and hands-on training, which provides them with necessary competencies in managing patients on ECMO support. Methods: Our team introduced the APP Adult ECMO Education Initiative in April 2021. The initiation of this program included the development of the Education & Training Policy for Multidisciplinary Critical Care Team, a policy outlining the educational requirements for RNs and APPs who care for patients requiring ECMO, the creation of the Adult ECMO APP Emergency In-Service and the creation of the Adult ECMO APP Initial Training Course. Additionally, our existing Adult ECMO Management CME Course was adjusted to better meet the competency needs of both APPs and physicians managing ECMO patients. Post-initiative, three institutional ECMO education options were available to APPs (Figure 1). Additionally, the newly created policy mandated initial and annual competency training for any APP who cares for a patient on ECMO. Results: 25 APPs attended at least one of our institution’s three ECMO education courses in Fiscal Year (FY) 2021, 33 APPs in FY 2022 and 31 APPs in FY 2023 (as of January 2023). This is compared to 15 or less in previous fiscal years (Figure 2). Post-test scores for our CME Course consistently show an increase in knowledge with an average score increase of 25 points, compared to the pre-test score, in the last three course offerings. For FY 2022, our ECMO survival rates included an 84% survival of ECMO with a 75% survival to discharge, compared to 78% survival of ECMO and 70% survival to discharge in FY 2021. In FY 2022, 54% of patients had zero ELSO-defined complications, compared to 47% in FY 2021 and 38% in FY 2020. Summary: Development and implementation of a structured training program for APPs has enabled our ECMO Program to improve upon our high-quality care by increasing APP’s proficiency in ECMO management.

P99: Progressive Mobilization Protocol for Patients Supported on ECMO Via Multidisciplinary Culture Change

Our project was aimed at changing the culture surrounding mobilization of the patient supported on ECMO. Due to the critical nature of patients supported on ECMO a multidisciplinary approach of ECMO trained staff members is essential. It is known that critically ill patients benefit from early mobilization. Culture around mobilizing patients supported on ECMO at our facility has been historically conservative and progressive mobility was met with resistance. Our goal was to initiate culture change to one in which progressive mobility is an expectation for the critically ill while designing and implementing a standardized formal protocol for mobilization of patients supported on VA/VV ECMO. This initiative required a multidisciplinary team of stakeholders and influencers to promote acceptance and willingness from nursing, perfusion, pulmonary critical care team and ICU lead physicians. Our team created a protocol with the following goals: 1) increase early and progressive mobilization of patients supported on ECMO 2) decrease time of eligibility to transplant listing of patients supported on ECMO 3) improve outcomes of patients supported on ECMO to include; earlier decannulation, decreased hospital length of stay and discharge to home or rehab vs skilled nursing facility or LTACH 4) change nursing culture to one where early and progressive mobilization is the expectation for patients supported on ECMO 5) increase confidence among healthcare staff regarding early and progressive mobility of the critically ill patient. For every ECMO patient on our unit, bedside nursing staff completes a daily checklist. The purpose of this list was to create ownership from nursing to allow them stake in the process. Checklist was created and vetted by all teams to allow input and to cultivate a multidisciplinary approach. The bedside nurse and physical therapist reviewed the patients’ case daily. Once the patient passes the suggested guidelines for mobility the multidisciplinary team, led by the physical therapist and consisting of the bedside nurse, perfusionist and respiratory therapist, initiates mobility per physical therapy protocol. If patients do not pass the safety checklist by nursing, a multidisciplinary conversation occurs to determine the appropriateness (risk/benefit) of mobilizing the patient, and session is either initiated or deferred. A specialized team and protocol are imperative to successful mobility for this patient population. This initiative created influencers who consisted of team leads targeted to implement change. Culture change has occurred and patients receiving ECMO support are mobilized daily without hesitation. Our future plans include modification of nursing checklists and physical therapy protocol, creation of post mobilization procedures to collect and analyze data, and the development and implementation of an ECMO competency for our PT/OT rehabilitation staff to ensure a high level of training and clinical competence.