Critical Discharge Research Articles

Quality of Care Transition During Hospital Discharge, Patient Safety, and Weight Regain After Bariatric Surgery: a Cross-Sectional Study

PurposeBariatric surgery is established as the gold standard in the treatment of severe obesity. However, a significant proportion of patients experience a substantial weight regain afterwards. Previous research focused predominantly on patients’ personal factors. Yet, critical discharge process factors that contribute to patient’s adherence after surgical interventions are rarely examined. This study investigated whether high quality of care transitions in discharge management influences weight regain and the likelihood of experiencing adverse patient safety incidents.Materials and MethodsA cross-sectional study with 578 patients after bariatric surgery was conducted. Participants answered a standardized assessment on the quality of care transition from hospital to home-, surgery-, and nutrition-related characteristics as well as patient safety incidents.ResultsSignificant weight regain was observed 24 months after surgery. The association between time since surgery and weight regain was weaker in patients with high quality of care transitions (B = 2.27, p < .001). Higher quality of care transition was also significantly related to a lower likelihood of unplanned hospital readmissions (OR = 0.67) and fewer medication complications (OR = 0.48) after surgery.ConclusionThis study sheds first light on the key influence of high quality of care transitions after bariatric surgery. Improvement efforts into effective discharge processes may establish smoother care transitions and help patients to assume responsibility and compliance with behavioral recommendations after surgery. Moreover, adverse patient safety incidents are less frequent after high quality care transitions indicating both high quality of health services for patients and reducing costs for the health care system.Graphical

Flashover Prediction of Polymer Insulators Based on Dynamic Modeling of Pollution Layer Resistance Using ANN

In this article, a novel dynamic approach is proposed to analyze pollution layer resistance of polymer insulators. One of the main challenges in dynamic modeling of pollution layer resistance is the effects of pollution layer conduction and pollution layer thickness on discharge length due to change in pollution layer thickness and wetting rate in real outdoor conditions. The represented approach investigates the effects of such parameters on variation of discharge length. Then, an artificial intelligence (AI) algorithm based on artificial neural network (ANN) is developed to predict flashover voltage (FOV) of polluted insulators according to the prediction of critical discharge length. Calculations are done based on experimental data of leakage current (LC) and voltage of insulators in different pollution conditions. Obtained results by the proposed approach show a close correlation with experimental results. In addition, various validation tests are performed to investigate the effects of hydrophobicity class (HC) of polymeric surface and pollution type on the quality of the represented analysis. Results of the validation also show a close correlation between calculations and real data.

Analysis of ozone generation in a planar atmospheric pressure air dielectric barrier discharge reactor

This work investigates O3 production in a planar atmospheric pressure air dielectric barrier discharge reactor numerically and experimentally. The surface temperature of the reactor is measured by an infrared (IR) thermal imager, and the O3 densities of cases in the reactive zone are measured by ultraviolet absorption spectroscopy. The 1.5D plasma fluid model (PFM) with transverse convection is employed to capture the average properties of a single microdischarge (MD) generated in the reactor. The concept of equivalent reaction is proposed to calculate spatial-cyclic average species sources obtained by the 1.5D PFM and provided to the chemical model of a 3D gas flow model (GFM) for obtaining density distributions of reactive species generated by MDs in the reactive zone. The simulated temperature distribution of the reactor surface is validated by that measured with the IR thermal imager since the gas temperature was reported as a critical discharge parameter for O3 generation. The simulated O3 densities show the same trend as the flow rate changes, which demonstrates the proposed model captures the average discharge dynamics in different operating conditions. In the 1.5D PFM, the simulated results show that the O3 molecules produced in the case of 4 SLM are much more than those produced in the case of 1 SLM though the O atoms produced in the case of 1 SLM are around 20% more than those produced in the case of 4 SLM. In the case of 1 SLM, more than 48% of O3 molecular generated are destructed, while only around 14% of O3 molecules are destructed in the case of 4 SLM. The analysis shows that around 73% of O atoms generated in the 1.5D PFM are consumed in the formation of O3 molecules in the case of 4 SLM, while only 18% of O atoms generated in the case of 1 SLM are consumed in the formation of O3 molecules. In the 3D GFM, the O3 destructed is around 24% of that destructed in the 1.5D PFM in the case of 4 SLM due to the oxidation reaction of NO, while only 11% of O3 molecules destructed as that destructed in the 1.5D PFM in the case of 1 SLM. The amounts of O3 molecules generated in the 3D GFM are minor if they are compared with those generated in the 1.5D PFM in all cases. The overall O3 yield efficiency reaches 97 g kWh−1 with the O3 concentration increasing up to 2700 ppm in the case of 4 SLM, while the O3 yield efficiency decreases to 10 g kWh−1 and O3 concentration drops to 1400 ppm in the case of 1 SLM.

Assessing 1D Hydrodynamic Modeling of Júcar River Behavior in Mancha Oriental Aquifer Domain (SE Spain)

In times of population growth, climate change, and increasing water scarcity around the world, it is important to take an objective look at water, a fundamental resource for life. Hydrodynamic modeling makes possible the research of different aspects of the water cycle and the evaluation of different hydrological and hydrogeological forecasting scenarios in the short and medium terms. The present research offers a more detailed scope at the hydrodynamic processes and their space-time distributions on a UE pilot in the Júcar River Basin, providing a calibrated and validated hydrodynamic model of 121 km river reach for 45 years period (1974–2019) on a daily scale. The obtained information is about discharge and water depths along the Júcar River reach within the hydrogeological boundaries of the Mancha Oriental Aquifer (MOA). The river–aquifer interactions have been represented as dynamic boundary conditions expressed as a difference between observed discharges measured in 3 gauging stations. The obtained calibration error performance evaluations of observed and simulated values cover two periods, according to observed data availability from gauging station 08036 with resulting R2 for both discharges and water depths over 0.96. The model validation results were obtained for a different gauge 08132 and the determination coefficients R2 also perform very well with value of 0.90. The model developed might be useful for decision making in water resources management and can be used to generate simulated time series of water depths, levels, discharges, and velocities in reaches where gauging measurements are not available with a desired space-time resolution (from meter/second to kilometer/month). Estimation of critical discharge value (1.973 m3s−1) for system equilibrium, based on the balance between losing and gaining sub-reaches of the river, is also made with a statistical significance at 95% for hydrologic years 2007–2010, period influenced by restrictions in groundwater withdrawals. The results of the present research are important for the proper and objective management of the scarce water resources on a watershed scale in Júcar River Basin, a complex case study representing semiarid climate, growing anthropogenic pressures, and complex river–aquifer interactions. The used approach of dynamic representation of the river–aquifer interactions as distributed source boundary condition in the one-dimensional hydrodynamic model might be applied in another study case on similar scale.

Testing Bed Load Transport Formulas: A Case Study Of The Lower Amur Using Bed Load Yield Data Obtained With Multi-Beam Echo-Sounders (Mbes)

The development of bed load calculation methods directly depends on the reliability of the measurement data. The most reliable measurement data remains the data obtained by the volumetric method when observing the filling of reservoirs, borrows, ditches etc. Nevertheless these data are the rarest. In this paper on the base of the data obtained when observing the process of filling of a ditch across the Amur River a comparison of a number of bed load calculation methods is performed. The observations were carried out with a multi-beam echo-sounder during summer floods of 2018, from 21st of July to 22nd of August. Over this time 5 surveys were performed, that allows to have 4 calculation periods for determining bed load yield. The total number of the measurements at different calculation verticals is 108. These data are used for verification of 80 bed load formulas. Four methodological approaches are considered: bed form approach, critical velocity approach, critical water discharge approach and regression approach. The bed form approach has shown the greatest accuracy: 17 formulas out of 26 gave the error less than 60%. For the other 56 methods which were considered only 5 formulas showed the error less than 60%, all of them correspond to the critical velocity approach.

Lightning-induced smoldering ignition of peat: Simulation experiments by an electric arc with long continuing current

Lightning is one of the essential causes of wildfires. However, the ignition criteria for lightning-caused wildfires have significant limitations due to a lack of understanding of the ignition mechanism. This work aims to reveal the mechanism of lightning-induced smoldering ignition of wildland fuels and explore a more reasonable ignition criterion by experimental means. The solidified peat cake samples were ignited by the electric arcs with different discharge currents (from 100 to 220 A with a step of 30 A) and durations (from 40 to 480 ms with an interval of 40 ms). The observations show that the ignition process follows a unique flaming-to-smoldering mode consisting of three stages: discharge heating (Stage I), thermal feedback (Stage II), and sustaining smoldering (Stage III) stages. The flame column that appears in Stage I is attributed to intense gasification and burnup of the peat, and seems to have little contribution to the ignition outcome. The carbonized region formed in Stage I, not the sample gasified in the discharge channel, is the main energy deposition to drive the successful smoldering ignition. It is found that the discharge duration required for smoldering ignition decreases with increasing discharge current (Iarc) when Iarc<160 A, but weakly depends on the discharge current when Iarc≥160 A. Critical discharge energy is also required when Iarc<160 A. A segmented ignition criterion is proposed based on the critical discharge duration and energy. For the peat cake sample, a minimum size, initial temperature, and absorbed energy of the carbonized zone are required for a sustaining smoldering ignition.

An evaluation of standardised pharmaceutical handover on critical care units

Abstract Introduction Patients cared for in the Critical Care unit are severely ill and may require multiple changes to their usual medication and new medicines to manage their current clinical condition. Due to pharmacist working patterns at University Hospital Southampton (UHS) patients on the Critical Care unit will receive pharmaceutical care from more than one pharmacist. It is vital that any changes are communicated between members of the pharmacy team as deliberate clinical decisions and not accidental omissions or errors. It is recognised that transfer of patients between professionals or teams caring for them is “one of the very high-risk transactions of health care service” 1. Errors of omission in medication for chronic conditions on Critical Care may lead to continuing omission of this therapy following discharge from hospital.2 Aim To assess the impact on pharmacist time and patient care of a formalised pharmaceutical handover for Critical Care patients at UHS. Methods Handovers are part of routine pharmaceutical care and ethics approval was not required. A pharmacist handover tool was developed within the existing Microsoft Access database used on Critical Care at UHS. Prior to the implementation a cohort of patients were identified and followed up on Critical Care discharge. Data were collected regarding pharmacist documented pre-Critical care medication, changes to this medication, ITU prophylaxis therapies. Following implementation, a second cohort was identified and a further data set collected. Data was analysed using a series of chi-squared tests and two-sample t-tests. Qualitative data were collected about ward pharmacist perceptions of pharmaceutical handover issues from Critical Care and regarding the Critical Care pharmacists’ use of the system and perceptions following its introduction. Ethical approval was not required for this service development initiative and evaluation. Results Favourable trends were detected following the introduction of the standardised handover tool: these did not reach statistical significance in most of the outcomes measured. There wasa statistical difference in the number of changes to pre-ITU medication detected following the handover introduction (p=0.028). The ward pharmacists consulted often had queries about medication changes. Within the critical care team the system was regarded as easy to use and useful. Discussion/Conclusion The standardised handover was well received by the Critical Care team who considered it to be simple to use and a useful tool. Statistical significance was not reached for the majority of measures although a positive trend was detected, probably due to the small sample size. Further standardisation handover system will ensure consistency of pharmaceutical care for this group of complex patients. Since this project was completed, the tool developed has been incorporated into the clinical information system now used within the Trust and has been developed further as an integrated part of the system. The tool is also used within other areas who use the clinical information system and will be reviewed and developed for their specialist areas including neonatal and paediatric intensive care where the information hand over may require different priority areas to be highlighted. Ward pharmacists are also able to access the clinical information handover tool and has led to a reduction in post-critical care queries.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Implications of Rigid Bronchoscopy: An Eight-Year Review in a Pediatric Intensive Care Unit.

Rigid bronchoscopy is an endoscopic technique used to visualize the airway, and rigid bronchoscopy is performed for both diagnostic and therapeutic indications. We defined the clinical characteristics of pediatric intensive care unit (PICU) patients undergoing bronchoscopy to establish a predictive model for early discharge from the PICU. Prediction can provide tangible aid in managing PICU patients. The primary objectives of this research are to evaluate the impact of different bronchoscopic procedures on the duration of PICU stay and to determine the Predictors of PICU discharge. We retrospectively reviewed records of 451 PICU admissions from 2012 to 2019 at our institution. In total, 36 pediatric patients under 12 years of age undergoing interventional rigid bronchoscopy during their PICU stay were studied. This study examined the impact of bronchoscopic procedures on the duration of PICU stays. Patients were categorized into three groups according to the number of bronchoscopic interventions used to evaluate the implications of different bronchoscopic procedures on the duration of PICU stay. Multiple linear regression analysis was used to test the predictors of PICU discharge. Tracheostomy and gender were significant predictors (p = 0.072 and 0.060, respectively), but first bronchoscopy showed strong significance (p = 0.002). Our findings have shown that early bronchoscopic interventions assisted in early critical care unit discharge, and most patients who did not benefit from the first bronchoscopy were complicated cases that could explain the long stay in the PICU.

The mechanics of diurnal thermal stratification in river pools: Implications for water management and species conservation

AbstractWe examined conditions that form or prevent thermal stratification in river pools using field measurements, statistical modelling, and three‐dimensional (3D) computational fluid dynamics (CFD) modelling. Our motivation is to identify variables that control stratification for exploitation to enhance or prevent thermal gradients as needed to benefit species in rivers. One study pool (UT) is located above water storage reservoirs and receives natural flows, and the other pool (PT) is regulated and receives unnaturally high, cold water in summer; both pools are on the Trinity River, California. Thermal stratification formed in UT pool in spring at a critical flow of 1.01 m3/s, peaked at 8.1°C in summer, and exhibited diurnal formation and destruction under sub‐critical flows until fall. At PT pool, the 14.2 m3/s baseflow caused mixing that prevented stratification and formed a spatially homogenous thermal environment. Statistical analyses indicated the daily range in air and inlet water temperature at UT pool best correlated with the occurrence and strength of stratification but were progressively irrelevant as flows increased above the critical value. The validated CFD model was used to reproduce the diurnal stratification and explain the processes involved. The CFD model correctly predicted the observed critical flow and replicated the dynamics of stratification at UT pool and isohyets observed at PT pool. The CFD results also confirmed that low flows are the main variable for stratification to form, and the daily range in inlet water temperature drives the strength of the thermal gradient. The model estimated a critical discharge at PT pool of 2.0 m3/s, twice that for UT pool owing to its 2.6‐times larger area, suggesting critical flows scale with pool size. Results showed that releasing critical and lower flows in summer on regulated streams may conserve water and provide thermal gradients that benefit poikilothermic species; alternately, higher than critical flows can prevent stratification where needed to improve water quality.

Modeling Non-Point Source Nutrient Loads with Different Cropping Systems in an Agricultural Lake Watershed in Southwestern China: From Field to Watershed Scale

Understanding the influence of cropping systems on non-point source pollution (NPSP) is crucial, since NPSP has become the major nutrient source of lake eutrophication. How to identify the characteristics of the N and P balance at different spatial and temporal scales remains a challenge in pollution control and decision-making. In this study, we built a soil and water assessment tool (SWAT) model coupled with an export coefficient model for a NPSP simulation in the North of Erhai Lake Basin (NELB). A method was proposed to study the N and P transport from fields and the individual sub-basins to Erhai Lake using SWAT simulation. The results showed that the N and P loss fields were mainly situated in the vicinity of the Fengyu river and along the mainstream of the Miju and Mici rivers. N and P loss fields were mainly occupied by rice–broad bean/rice–rapeseed crops and vegetables. While the critical N and P load contribution areas were situated in the vicinity of downstream of the Miju, Yong’an, and Luoshi rivers. The effects of different cropping systems on the N and P export to the watershed were insignificant in the NELB and decreased by 4–9% when changing cropping system compared to the original crops. The NPSP discharged from the critical areas was retained and purified by the flow and the reservoirs scattered along the rivers, and it was noticed that the N and P loss was mainly from the critical pollution discharge areas located downstream of Miju river. This study can provide an important simulation method for understanding NPSPs and, therefore, can help authorities improve agricultural land use and reduce lake pollution.

Delivery decision in pregnant women rescued by ECMO for severe ARDS: a retrospective multicenter cohort study

BackgroundAlthough rarely addressed in the literature, a key question in the care of critically pregnant women with severe acute respiratory distress syndrome (ARDS), especially at the time of extracorporeal membrane oxygenation (ECMO) decision, is whether delivery might substantially improve the mother’s and child’s conditions. This multicenter, retrospective cohort aims to report maternal and fetal short- and long-term outcomes of pregnant women with ECMO-rescued severe ARDS according to the timing of the delivery decision taken before or after ECMO cannulation.MethodsWe included critically ill women with ongoing pregnancy or within 15 days after a maternal/child-rescue-aimed delivery supported by ECMO for a severe ARDS between October 2009 and August 2021 in four ECMO centers. Clinical characteristics, critical care management, complications, and hospital discharge status for both mothers and children were collected. Long-term outcomes and premature birth complications were assessed.ResultsAmong 563 women on venovenous ECMO during the study period, 11 were cannulated during an ongoing pregnancy at a median (range) of 25 (21–29) gestational weeks, and 13 after an emergency delivery performed at 32 (17–39) weeks of gestation. Pre-ECMO PaO2/FiO2 ratio was 57 (26–98) and did not differ between the two groups. Patients on ECMO after delivery reported more major bleeding (46 vs. 18%, p = 0.05) than those with ongoing pregnancy. Overall, the maternal hospital survival was 88%, which was not different between the two groups. Four (36%) of pregnant women had a spontaneous expulsion on ECMO, and fetal survival was higher when ECMO was set after delivery (92% vs. 55%, p = 0.03). Among newborns alive, no severe preterm morbidity or long-term sequelae were reported.ConclusionContinuation of the pregnancy on ECMO support carries a significant risk of fetal death while improving prematurity-related morbidity in alive newborns with no difference in maternal outcomes. Decisions regarding timing, place, and mode of delivery should be taken and regularly (re)assess by a multidisciplinary team in experienced ECMO centers.

Retention of discharge instructions using an interdisciplinary model for at-risk children with cancer: A quality improvement initiative.

We sought to improve caregiver retention of critical initial hospital discharge instructions using a multidisciplinary, team-based intervention for newly diagnosed pediatric cancer patients at high risk for unfavorable outcomes. A multidisciplinary team of pediatric residents, nurses, social workers, pharmacists and hematology/oncology faculty implemented practices to optimize teaching of key discharge material as part of four Plan-Do-Study-Act intervention cycles. An 11-question survey distributed at the first post-discharge clinic visit assessed the efficacy of the intervention, as defined by caregiver retention of critical home instructions. Thirty-nine caregivers of pediatric cancer patients in an urban academic tertiary-care children's hospital took part in this project. Overall retention of key discharge information was greater in the post-intervention cohort compared to the baseline cohort (median total scores: 89 and 63, respectively; p=.001). Improvements in the proportions of correct responses post-intervention were also observed across all subject matters: from 0.57 to 0.88 for fever guidelines (p=.059), from 0.71 to 0.78 for signs of sepsis (p=.65), from 0.57 to 1.00 for accurate choice of on-call number (p=.004), and from 0.71 to 0.94 for antiemetic management (p=.14). Initiation of our comprehensive cancer-specific program to improve caregiver retention of discharge instructions at the first post-hospitalization clinic visit has been successful and sustainable. This project demonstrated that a multi-disciplinary collaborative team effort increases caregiver retention of critical health information, and this has potential to lead to improved outcomes for patients.

Proposed treatment to reduce salinity intrusion into the Shatt Al-Arab estuary by using temporary storage in a convergent of channel in the context of tide

ABSTRACT The Shatt Al-Arab estuary is the lifeline of the Basrah city, as it is the source of water for various uses of irrigation, industry, agriculture and human use, in addition to being the navigational passage towards the Arabian Gulf throughout history. Nowadays, the estuary suffers from the deterioration of its water quality due to the increase in salinity values as a result of the intrusion of salinity from the Arabian Gulf due to the lack of freshwater flows from the Tigris and Euphrates rivers. To reduce the risks of water quality deterioration and the lack of natural solutions represented in the provision of freshwater, the idea of building an artificial structure to narrow the channel came to give the ability to resist the impact of the tide and the intrusion of marine salinity. Two hypothetical sites were chosen to build the structure: i.e. in Dweeb and Faw sites, to test the feasibility of this artificial estuary structure. A one-dimensional mathematical model was adopted, which is the Mike 11 software package. The model was run according to a set of scenarios using the critical water discharge values of 10 and 20 m3/s. The results showed through simulation of the model for a period of six months that the structure is useful on improving the water quality by reducing salinity in the river, in addition, there is a delay in the time of arrival of the intrusion of salts.

Availability of opioid agonist treatment and critical incidents in Forensic Clinics for Dependency Diseases in Germany

BackgroundPrevalence of substance use disorders, especially opioid use disorders, is high in patients admitted into forensic psychiatric settings. Opioid agonist treatment is a safe, well-established, and effective treatment option for patients that suffer from opioid dependence. Surprisingly, data on the availability and practice of opioid agonist treatment (OAT) options in German Forensic Clinics for Dependency Diseases is rare. Furthermore, essential data on the prevalence of critical incidents such as violent behavior, relapse, or escape from the clinic are missing for this particular treatment setting.Materials and methodsWe conducted an observational study on all forensic addiction treatment units in Germany (Sect. 64 of the German Criminal Code). A questionnaire on the availability and practice of OAT was sent to all Forensic Clinics for Dependency Diseases in Germany. Following items were assessed: availability and the total number of patients that received an OAT in 2018, available medication options, specific reasons for start and end of OAT, number of treatments terminated without success, number of successful treatments, and critical incidents such as violent behavior, relapse, escape and reoffending. We compared the forensic clinics that offered OAT with those that did not offer this treatment option. The data were analyzed descriptively. Mean and standard deviation was calculated for metric scaled variables. For categorical variables, absolute and relative frequencies were calculated. The two groups (OAT vs. Non-OAT institutions) were compared concerning the given variables by either using Fishers exact test (categorical variables), t-test (normally distributed metric variables), or Wilcoxon-test (metric variables not normally distributed).ResultsIn total, 15 of 46 Forensic Clinics for Dependency Diseases participated in the study (33%). In total, 2,483 patients were treated in the participating clinics, 18% were relocated into prison due to treatment termination, and 15% were discharged successfully in 2018. 275 critical incidents were reported: violence against a patient (4%), violence against staff (1.6%), escape (4.7%) and reoffending in (0.5%). In seven clinics treating 1,153 patients, an OAT was available. OAT options in forensic clinics were buprenorphine/naloxone, buprenorphine, methadone, and levomethadone. Regarding critical incidents and successful discharge, no differences were detected in the clinics with or without an OAT. In the clinics that offered an OAT, we found a significantly higher rate of treatment termination without success (p < 0.007) in comparison to clinics without an OAT program. Ninety-nine patients received an OAT, and this treatment was ended due to illegal drug abuse (57%), refusal to give a urine drug sample (71%), and cases where the OAT was given away to other patients (85%).ConclusionIn Forensic Clinics for Dependency Diseases in Germany, OAT is not available in every institution, and thus, access is limited. Critical incidents such as violent behavior against staff or patients and escape are not uncommon in these forensic treatment settings. Further studies are needed to enhance the understanding of OAT practice and the risks for patients and staff.

Riprap Protection Exposed to Overtopping Phenomena: A Review of Laboratory Experimental Models

There are increasing demands from dam safety regulations and guidelines to upgrade the rockfill dams, especially in Norway where over 180 large rockfill dams are present. To protect the hydraulic structure against overtopping events or leakages, it is important to use defence mechanisms such as a protective layer of riprap on the downstream slope. In this article, we display 9 experimental setups of riprap, conducted at the hydraulic laboratory of NTNU (Trondheim) and subjected to overtopping phenomena with increasing water discharge, until the complete failure of the model. These tests were performed on models with dumped and placed riprap, with or without toe support, with or without the downstream rockfill shoulder, and finally on models with a full dam profile. The models with downstream rockfill shoulder as well as with full dam profiles allowed for throughflow. The model behaviour during these experimental tests is described and discussed, according to their respective critical discharge values and associated failure mechanisms. Limitations are also discussed. The results bring to light the benefit of placed riprap compared to dumped riprap structures. As the results show a placed riprap can withstand a significantly higher overtopping discharge than a dumped riprap. Also, the use of toe support enables a significant increase of resistance against overtopping of placed riprap structures. However, toe supports have not proven any significant improvement in stability for dumped riprap structures. This research also puts forward that dumped riprap undergoes a surface erosion process with smaller slides. Placed riprap undergoes a sliding failure mechanism when unsupported at the toe, and a buckling deformation when supported.

Double choking characteristics of three-dimensional steam ejector with non-equilibrium condensing

The phenomenology of double choking in a supersonic steam ejector which plays an influential role in the performance is not fully understood because the non-equilibrium condensing and three-dimensional effects are neglected in most numerical simulations. In this paper, a non-equilibrium condensation model was combined with the k-ω SST turbulence model to simulate three-dimensional supersonic steam ejectors with different working conditions and different structures. The internal relationship between the ejector performance and the double choking characteristics was revealed. The influence of the characteristics of double choking on the shock waves in the ejector was also investigated. Results show that when the minimum distance between the sonic velocity line in the diffuser and the wall is equal to the critical minimum distance which is 0.21 mm, the steam ejector is in a double choking mode. 4 mm downstream of the diffuser entrance is the critical second choking position. The deviations between discharge pressure and critical discharge pressure are getting greater with the increase of the second choking length. The intensity and number of shock waves in the diffuser are positively related to the second choking length with certain working conditions. Three-dimensional effects bring non-negligible differences to both the flow field and the ejector performance.

Predictors of health-related quality of life in patients undergoing extracorporeal membrane oxygenation for acute severe respiratory failure.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a form of life support used in severe respiratory failure. While the short-term complications of VV-ECMO are well described, impacts on health-related quality of life (HRQOL) are less well characterised. This study aims to assess the HRQOL of patients who underwent VV-ECMO for acute severe respiratory failure and explore predictors of poor HRQOL. We performed a retrospective, observational study of a large cohort of adults who underwent VV-ECMO for acute severe respiratory failure in a single tertiary centre (June 2013-March 2019). Patients surviving critical care discharge were invited to a six-month clinic, where they completed an EQ-5D-5L questionnaire assessing HRQOL. Multivariate analysis was performed to assess prognostic factors for HRQOL. Among the 245 consecutive patients included in this study (median age 45years), 187 (76.3%) survived until ECMO decannulation and 172 (70.2%) until hospital discharge. Of those, 98 (57.3%) attended a follow-up clinic at a mean (±SD) of 204 (±45)days post-discharge. Patients reported problems with pain/discomfort (56%), usual daily activities (53%), anxiety/depression (49%), mobility (46%), and personal care (21%). Multivariate analysis identified limb ischaemia (-0.266, 95% C.I. [-0.116; -0.415], p = 0.0005), renal replacement therapy (-0.149, [-0.046; -0.252], p = 0.0044), and having received more than four platelet units (-0.157, [-0.031; -0.283], p = 0.0146) as predictors of poor HRQOL. We report that survivors of VV-ECMO have reduced HRQOL in multiple domains at 6months, with pain reported most frequently. Patients who had limb ischaemia, renal replacement therapy or were transfused more than four units of platelets are particularly at risk of poor HRQOL and may benefit from added support measures.

Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Therapy on Liberation From Respiratory Support in Acutely Ill Children Admitted to Pediatric Critical Care Units

The optimal first-line mode of noninvasive respiratory support for acutely ill children is not known. To evaluate the noninferiority of high-flow nasal cannula therapy (HFNC) as the first-line mode of noninvasive respiratory support for acute illness, compared with continuous positive airway pressure (CPAP), for time to liberation from all forms of respiratory support. Pragmatic, multicenter, randomized noninferiority clinical trial conducted in 24 pediatric critical care units in the United Kingdom among 600 acutely ill children aged 0 to 15 years who were clinically assessed to require noninvasive respiratory support, recruited between August 2019 and November 2021, with last follow-up completed in March 2022. Patients were randomized 1:1 to commence either HFNC at a flow rate based on patient weight (n = 301) or CPAP of 7 to 8 cm H2O (n = 299). The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which a participant was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio of 0.75. Seven secondary outcomes were assessed, including mortality at critical care unit discharge, intubation within 48 hours, and use of sedation. Of the 600 randomized children, consent was not obtained for 5 (HFNC: 1; CPAP: 4) and respiratory support was not started in 22 (HFNC: 5; CPAP: 17); 573 children (HFNC: 295; CPAP: 278) were included in the primary analysis (median age, 9 months; 226 girls [39%]). The median time to liberation in the HFNC group was 52.9 hours (95% CI, 46.0-60.9 hours) vs 47.9 hours (95% CI, 40.5-55.7 hours) in the CPAP group (absolute difference, 5.0 hours [95% CI -10.1 to 17.4 hours]; adjusted hazard ratio 1.03 [1-sided 97.5% CI, 0.86-∞]). This met the criterion for noninferiority. Of the 7 prespecified secondary outcomes, 3 were significantly lower in the HFNC group: use of sedation (27.7% vs 37%; adjusted odds ratio, 0.59 [95% CI, 0.39-0.88]); mean duration of critical care stay (5 days vs 7.4 days; adjusted mean difference, -3 days [95% CI, -5.1 to -1 days]); and mean duration of acute hospital stay (13.8 days vs 19.5 days; adjusted mean difference, -7.6 days [95% CI, -13.2 to -1.9 days]). The most common adverse event was nasal trauma (HFNC: 6/295 [2.0%]; CPAP: 18/278 [6.5%]). Among acutely ill children clinically assessed to require noninvasive respiratory support in a pediatric critical care unit, HFNC compared with CPAP met the criterion for noninferiority for time to liberation from respiratory support. ISRCTN.org Identifier: ISRCTN60048867.

A Web-Based, Provider-Driven Mobile App to Enhance Patient Care Coordination Between Dialysis Facilities and Hospitals: Development and Pilot Implementation Study.

BackgroundWe piloted a web-based, provider-driven mobile app (DialysisConnect) to fill the communication and care coordination gap between hospitals and dialysis facilities.ObjectiveThis study aimed to describe the development and pilot implementation of DialysisConnect.MethodsDialysisConnect was developed iteratively with focus group and user testing feedback and was made available to 120 potential users at 1 hospital (hospitalists, advanced practice providers [APPs], and care coordinators) and 4 affiliated dialysis facilities (nephrologists, APPs, nurses and nurse managers, social workers, and administrative personnel) before the start of the pilot (November 1, 2020, to May 31, 2021). Midpilot and end-of-pilot web-based surveys of potential users were also conducted. Descriptive statistics were used to describe system use patterns, ratings of multiple satisfaction items (1=not at all; 3=to a great extent), and provider-selected motivators of and barriers to using DialysisConnect.ResultsThe pilot version of DialysisConnect included clinical information that was automatically uploaded from dialysis facilities, forms for entering critical admission and discharge information, and a direct communication channel. Although physicians comprised most of the potential users of DialysisConnect, APPs and dialysis nurses were the most active users. Activities were unevenly distributed; for example, 1 hospital-based APP recorded most of the admissions (280/309, 90.6%) among patients treated at the pilot dialysis facilities. End-of-pilot ratings of DialysisConnect were generally higher for users versus nonusers (eg, “I can see the potential value of DialysisConnect for my work with dialysis patients”: mean 2.8, SD 0.4, vs mean 2.3, SD 0.6; P=.02). Providers most commonly selected reduced time and energy spent gathering information as a motivator (11/26, 42%) and a lack of time to use the system as a barrier (8/26, 31%) at the end of the pilot.ConclusionsThis pilot study found that APPs and nurses were most likely to engage with the system. Survey participants generally viewed the system favorably while identifying substantial barriers to its use. These results inform how best to motivate providers to use this system and similar systems and inform future pragmatic research in care coordination among this and other populations.