Critical Procedures Research Articles

107: CURRENT LANDSCAPE OF ADVANCED PRACTICE PROVIDERS IN CRITICAL CARE

Introduction: Advanced Practice Providers (APPs) are a well-established part of the multidisciplinary critical care team, but the scope and utilization of APPs vary dramatically between hospitals. This survey captures current demographic, workflow, and utilization trends in the Society of Critical Care (SCCM) APP community. Methods: This was a cross sectional REDCap survey emailed to 2775 SCCM physician assistant or nurse practitioner members in April 2021. There were 578 responses (20.8%) with 60 non-APP respondents excluded for a sample size of 518. Statistical analysis was performed via SPSS. Results: Of the 518 respondents, there were 149 (28.8%) physician assistants and 327 (63.1%) nurse practitioners. Most respondents (n=371, 72%) were female. 248 APPs (48.1%) worked for large hospitals (>500 beds) and most (n=343, 66.2%) worked in an academic setting. Of the surveyed, 447 (86.3%) reported greater than 2 years of ICU experience. Formal onboarding was common (n=354, 68.6%) and was most likely to occur in academic medical centers (n=233 of 354, p< 0.001). Onboarding was usually completed in under 6 months (n=310, 87.8%). Most APPs (n=409, 79.3%) did not pursue post-graduate fellowships. Most units had full time APP coverage (n=361, 70.1%) including weekends and holidays (n=427, 82.8%). Daytime APP to patient ratios were less than 1:10 (n=377, 75.7%); nighttime ratios were 1:11 or greater (n=328, 72.9%). The majority of APPs performed arterial lines (n=425, 82%), central venous catheters (n=410, 79.2%), temporary dialysis catheters (n=318, 62.4%), and point-of-care ultrasound (n=295, 56.9%). APPs most frequently billed critical care time (n=314, 60.6%) and procedures (n 333, 64.3%). A quarter of respondents (n=137, 26.4%) reported that they did not bill. APPs did not routinely have their billing measured (n=212, 41.5%) and many (n=106, 20.7%) did not know if productivity measures were utilized in their group. Conclusions: APPs are experienced members of the critical care team heavily utilized in large academic hospitals. Current APP roles are mostly clinical and unit-based, with emphasis on procedures and episodic care. Additional research will better quantify APP productivity and value since metrics are inconsistent and many APPs do not currently participate in billing.

Development and Validation of an Integrated Suite of Prediction Models for All-Cause 30-Day Readmissions of Children and Adolescents Aged 0 to 18 Years

Readmission is often considered a hospital quality measure, yet no validated risk prediction models exist for children. To develop and validate a tool identifying patients before hospital discharge who are at risk for subsequent readmission, applicable to all ages. This population-based prognostic analysis used electronic health record-derived data from a freestanding children's hospital from January 1, 2016, to December 31, 2019. All-cause 30-day readmission was modeled using 3 years of discharge data. Data were analyzed from June 1 to November 30, 2021. Three models were derived as a complementary suite to include (1) children 6 months or older with 1 or more prior hospitalizations within the last 6 months (recent admission model [RAM]), (2) children 6 months or older with no prior hospitalizations in the last 6 months (new admission model [NAM]), and (3) children younger than 6 months (young infant model [YIM]). Generalized mixed linear models were used for all analyses. Models were validated using an additional year of discharges. The derivation set contained 29 988 patients with 48 019 hospitalizations; 50.1% of these admissions were for children younger than 5 years and 54.7% were boys. In the derivation set, 4878 of 13 490 admissions (36.2%) in the RAM cohort, 2044 of 27 531 (7.4%) in the NAM cohort, and 855 of 6998 (12.2%) in the YIM cohort were followed within 30 days by a readmission. In the RAM cohort, prior utilization, current or prior procedures indicative of severity of illness (transfusion, ventilation, or central venous catheter), commercial insurance, and prolonged length of stay (LOS) were associated with readmission. In the NAM cohort, procedures, prolonged LOS, and emergency department visit in the past 6 months were associated with readmission. In the YIM cohort, LOS, prior visits, and critical procedures were associated with readmission. The area under the receiver operating characteristics curve was 83.1 (95% CI, 82.4-83.8) for the RAM cohort, 76.1 (95% CI, 75.0-77.2) for the NAM cohort, and 80.3 (95% CI, 78.8-81.9) for the YIM cohort. In this prognostic study, the suite of 3 prediction models had acceptable to excellent discrimination for children. These models may allow future improvements in tailored discharge preparedness to prevent high-risk readmissions.

Strain measurement based on cooperative operation with different smartphones

AbstractStrain measurement is one of the critical procedures in detecting failures and health monitoring for various structures in the field of civil engineering. This article demonstrates a smartphone‐based cooperative strain measurement method called micro image strain sensing (MISS) for widespread and low‐cost structural strain monitoring. The method relies on smartphones, the piston‐type sensor with a microscope fitted on it, and the Android platform with cloud computing. The detailed principle of the MISS method and fabrication of the MISS sensor and the comparison of measurement accuracy with fiber Bragg grating sensor are presented. The results show that the error is within 10 με., which satisfies the engineering requirement, and the sensor exhibits high flexibility, high reliability, and high linearity. The work highlights the potential of widespread usage and public participation in smartphone‐based strain measurement for the structural health monitoring of the next generation.

Composite torquing cantilever

Torque is the 3rd key of occlusion, described by Andrews. Achieving ideal torque is one of the most difficult and critical procedures performed during orthodontic treatment. A simple and easy method was used to construct a composite torquing cantilever which provides stability and maintains a high moment: force ratio for a single tooth to achieve labial or lingual root torque during finishing and detailing.

Pollution Evaluation and Health Risk Assessment of Trace Metals in Eleven Tissues of Mylopharyngodon piceus Collected from an Aquaculture Pond in Huzhou, near Southern Taihu Lake

Pollution evaluation and health risk assessment are critical procedures for residents consuming black carp (Mylopharyngodon piceus) contaminated with non-essential hazardous trace elements in an artificial wetland also known as an aquaculture pond. Samples were collected, dissected and digested to analyze the pollution status and health risk associated with four heavy metals present in eleven tissues of black carp fish based on the metal pollution index (MPI) and target hazard quotient (THQ). The results indicated that the concentrations of Cd, Cr, Cu and Pb were 1.36 ± 0.04 mg/kg, 13.70 ± 0.50 mg/kg, 2.85 ± 0.10 mg/kg, and 4.98 ± 0.18 mg/kg in large black carp, while the concentrations of Cd, Cr, Cu and Pb were 4.27 ± 0.08 mg/kg, 50.84 ± 0.82 mg/kg, 9.33 ± 0.18 mg/kg, and 22.49 ± 0.42 mg/kg in small specimens. The MPI values showed that the heavy metal pollution detected in small fish was much more significant than in large fish. Notably, the polluted metals were more likely to accumulate in the viscera (e.g., brain and heart) rather than in the external tissues (e.g., muscle and epidermis). In addition, the estimated THQ and HI values for three edible tissues demonstrated that the health risk associated with muscle tissue intake of both small and large black carp was within the acceptable range, while the contaminants were likely to pose health risks associated with the consumption of fish head tissue. Small black carp are generally not fit for human consumption, thus both the epidermis and muscle of the fish are often cooked in China. However, the ingestion of large black carp is relatively safe. The contributions to THQ values of these four heavy metals decreased in the following sequence: Cr &gt; Pb &gt; Cd &gt; Cu. Cr is the critical pollutant with its contribution to HI values measuring over 50%. We suggest that in artificial wetlands (e.g., aquaculture ponds) more attention should be paid to heavy metal pollution, the conservation of the aquaculture ecosystem, and effects on human health.

Patientensicherheit in der Kindernotfallversorgung

The treatment of critically ill children is a time-critical task that requires effective collaboration between different professional groups and specialist disciplines. Rapid recognition of the medical problem, establishment of a joint working hypothesis, coordinated implementation and regular re-evaluation of treatment are essential for patient safety. Several tools are in place to ensure that care is delivered safely. These include standardized emergency equipment that everyone can use, cognitive aids for safe medication administration and checklists for the preparation and performance of critical procedures. Furthermore, standardization of communication, a clear distribution of roles and tasks, and regular debriefings are helpful. The establishment of a safety culture and regular training are essential for the implementation of the measures.

WER-Net: A New Lightweight Wide-Spectrum Encoding and Reconstruction Neural Network Applied to Computational Spectrum.

The computational spectrometer has significant potential for portable in situ applications. Encoding and reconstruction are the most critical technical procedures. In encoding, the random mass production and selection method lacks quantitative designs which leads to low encoding efficiency. In reconstruction, traditional spectrum reconstruction algorithms such as matching tracking and gradient descent demonstrate disadvantages like limited accuracy and efficiency. In this paper, we propose a new lightweight convolutional neural network called the wide-spectrum encoding and reconstruction neural network (WER-Net), which includes optical filters, quantitative spectral transmittance encoding, and fast spectral reconstruction of the encoded spectral information. The spectral transmittance curve obtained by WER-net can be fabricated through the inverse design network. The spectrometer developed based on WER-net experimentally demonstrates that it can achieve a 2-nm high resolution. In addition, the spectral transmittance encoding curve trained by WER-Net has also achieved good performance in other spectral reconstruction algorithms.

One-Shot Multiple Object Tracking in UAV Videos Using Task-Specific Fine-Grained Features

Multiple object tracking (MOT) in unmanned aerial vehicle (UAV) videos is a fundamental task and can be applied in many fields. MOT consists of two critical procedures, i.e., object detection and re-identification (ReID). One-shot MOT, which incorporates detection and ReID in a unified network, has gained attention due to its fast inference speed. It significantly reduces the computational overhead by making two subtasks share features. However, most existing one-shot trackers struggle to achieve robust tracking in UAV videos. We observe that the essential difference between detection and ReID leads to an optimization contradiction within one-shot networks. To alleviate this contradiction, we propose a novel feature decoupling network (FDN) to convert shared features into detection-specific and ReID-specific representations. The FDN searches for characteristics and commonalities between the two tasks to synergize detection and ReID. In addition, existing one-shot trackers struggle to locate small targets in UAV videos. Therefore, we design a pyramid transformer encoder (PTE) to enrich the semantic information of the resulting detection-specific representations. By learning scale-aware fine-grained features, the PTE empowers our tracker to locate targets in UAV videos accurately. Extensive experiments on VisDrone2021 and UAVDT benchmarks demonstrate that our tracker achieves state-of-the-art tracking performance.

Critical Clearing Time and Angle for Power Systems Postfault Stability Assessment

Transient stability analysis is a very important tool to deal with many behaviors of electrical power systems during and after being subjected to various disturbances. this paper propose a method for electrical power systems transient stability assessment using phase plane trajectories. A methodology for computing the critical stability conditions of generators is proposed. The critical conditions such as critical clearing time (CCT) and critical clearing angle (CCA) were obtained. The computation of CCA and CCT is curried out step by step using the characteristics of the faulted and postfault trajectories from given initial conditions until their intersection point. The angle and time values founded represent, by definition, the critical conditions of the system. The proposed algorithm can be used for complex models since it is based on solving systems of differential equations by iterative methods in the phase plane. The advantage provided by this method is it's accurate and small time consuming. To demonstrate the effectiveness of the proposed method, first, critical conditions calculation procedures are given, then the process used in judging power system stability is provided, finally, simulation results for various test cases of a single machine infinite bus (SMIB) system highlight the proposed methodology.

Streamlining the External Ventricular Drain and Intracranial Pressure Monitor Procedural Setup: A Quality Improvement Initiative

External ventricular drain (EVD) and intracranial pressure (ICP) monitor placements are among the most common critical care procedures for severe brain injury. Quality improvement initiatives have streamlined similar processes. The aim of the project was to decrease the time to collect supplies for EVD or ICP monitor placement by 25% by April 1,2021. The project followed the define-measure-analyze-improve-control 6 sigma framework. Several quality gaps were identified: equipment stored separately, delays in replacing faulty items, and wasted resources. The team defined the process using the suppliers-inputs-processes-outputs-customers+requirements method, measured time to collect supplies, and analyzed data with an Ishikawa/fishbone diagram. The improve phase included a kaizen burst to generate solutions and an impact/effort grid to evaluate options. The team concluded that the optimal plan was to stock a mobile EVD cart and an ICP monitor pole with disposable go-bags. The average time for nurses to collect EVD placement supplies decreased from 411 to 63seconds (7-1minute), and the average time for nurses to collect ICP monitor placement supplies decreased from 418 to 53seconds (7-<1minute). Residents decreased the time to obtainEVD placement supplies from 330 to 56seconds (6-<1minute) and ICP monitor supplies from 489 to 77seconds (8-1minute). Feedback was overwhelmingly positive and focused on improved process efficiency and reduced waste. The time reduction and enthusiasm are likely associated with the simplicity and comprehensiveness of the intervention design. Including key stakeholders in decision-making and succinct communications reduced resistance to change.

Critical Procedure Identification Method Considering the Key Quality Characteristics of the Product Manufacturing Process

The product’s manufacturing process has an evident influence on product quality. In order to control the quality and identify the critical procedure of the product manufacturing process reasonably and effectively, a method combining genetic back-propagation (BP) neural network algorithm and grey relational analysis is proposed. Firstly, the genetic BP neural network algorithm is used to obtain the key quality characteristics (KQCs) in the product manufacturing process. At the same time, considering the three factors that have an essential impact on the quality of the procedures, the grey correlation analysis method is used to establish the correlation scoring matrix between the procedure and the KQCs to calculate the criticality of each procedure. Finally, taking the manufacturing process of the evaporator as a case, the application process of this method is introduced, and four critical procedures are identified. It provides a reference for the procedure quality control and improvement of enterprise in the future.

Honeywell Introduces New Blue Spectra Medical Grade Bio Fiber Designed to Improve Visual Contrast for Critical Surgical Procedures

Honeywell Introduces New Blue Spectra Medical Grade Bio Fiber Designed to Improve Visual Contrast for Critical Surgical Procedures

P-777 Traceability and accountability in a “Virus-Free” vitrification program during the Covid-19 pandemic. Description of the first application of Blockchain for an IVF laboratory procedure

Study questionTo date, no publications exist describing Blockchain in IVF (Hickman, 2020). Can Blockchain technology be used for traceability and accountability in IVF laboratory procedures?Summary answerBlockchain is an easy-to-implement technology for incorruptible traceability of a “Virus-Free” vitrification/warming procedure.What is known alreadyIn healthcare, Blockchain can become a tool to address challenges regarding sensitive data-sharing and traceability of medical and laboratory procedures. During the Covid-19 pandemic, many authors warned about the role of LN2 as a potential vector for virus contamination, and vitrification and warming were identified as critical procedures for risk of contamination for environments, surfaces, operators and cells. In this study we describe the first application of Blockchain in IVF for incorruptible traceability of a “Virus-Free” vitrification/warming procedure based on the combined use of UVC-Sterilized Liquid Nitrogen (LN2) and CE Medical Devices (CE-MD).Study design, size, durationReport on 2346 Ethereum Blockchain data transactions for IVF laboratory procedures mined from 01/10/2019 to 31/12/2021. The procedures were oocyte/embryo vitrification, warming or handling in LN2 after cryopreservation. For each vitrification, warming and handling a UVC-sterilized batch of LN2 was associated with the code assigned to the vitrification/warming procedure and with the lot number of the single-use sterile vitrification box (N-Sleeve). The clinical results obtained from warmed oocytes/embryos were observed as completion of this process.Participants/materials, setting, methodsA Blockchain trusted “Virus-Free” vitrification/warming programme was set up using a specifically designed CE-MD N-Bath-System (Nterilizer-Italy). Each procedure was traced by the CE-MD’s software and a dedicated web application. Finally, data were made incorruptible by Ethereum Blockchain transactions. Before oocyte/embryo warming, vitrification carrier washing with UVC-sterilized LN2 was performed in accordance with Parmegiani et al (2012) and recent international anti-Covid guidelines.Main results and the role of chanceOf the 2346 Blockchain transactions 1268 regarded vitrification and cryopreserved specimen handling procedures; 1078 transactions were frozen cell warmings (308 oocytes and 770 embryos) performed on 799 patients. To date, 445 pregnancies have been obtained (pregnancy rate: 41% per cycle; 56% per patient) and 219 babies have been born.Limitations, reasons for cautionEthereum is a decentralized, open-source blockchain with smart contract functionality. Ether is the native cryptocurrency which is highly susceptible to cost changes. Other public or private Blockchains may be used in future in healthcare with more stable transaction costs.Wider implications of the findingsThis is the first evidence of the application of Blockchain in IVF and many others will probably follow. Blockchain immutable records of LN2 sterilization combined with procedure codes and disposable lots represent incorruptible traces for “Virus-Free” vitrification/warming. During this pandemic 219 babies were born from cryopreservation procedures powered by Blockchain.Trial registration numberNot Applicable

Application of intracavitary ECG for positioning the totally implantable venous access port in the upper arm of cancer patients.

Accurate positioning of the catheter tip is one of the most critical procedures in central venous catheter insertion. The traditional surface measurement method frequently has a large deviation and increases the X-ray exposure of doctors and patients. In the present retrospective study, cancer patients who received a totally implantable venous access port (TIVAP) in the upper arm using intracavitary electrocardiogram (ECG) guidance were compared with those where the traditional surface measurement method was used in terms of the rate of correct placement of the catheter tip, the rate of achieving the best position, the operation time and the complications. The results indicated that the correct placement rate and the best position rate of the catheter tip at the first attempt were higher in the ECG-guided group than in the traditional surface measurement method group (95.65 vs. 82.91% and 90.58 vs. 68.38%, respectively). The mean operation time was shorter in the ECG-guided group than in the surface measurement group (46.28 vs. 63.26 min). The incidence of complications in the ECG-guided group was 6.52%, while that in the surface measurement group was 10.26%. This indicated that the intracavitary ECG-guided tip positioning technique may improve the accuracy of tip catheter placement and shorten the operation time, thus reducing ionizing radiation caused by repeated positioning. Therefore, the intracavitary ECG-guided tip positioning technique is able to effectively place the tip of the TIVAD in the upper arm, holding great promise as a clinical application.

A multimodal pipeline using NMR spectroscopy and MALDI-TOF mass spectrometry imaging from the same tissue sample.

NMR spectroscopy and matrix assisted laser desorption ionization mass spectrometry imaging (MALDI MSI) are both commonly used to detect large numbers of metabolites and lipids in metabolomic and lipidomic studies. We have demonstrated a new workflow, highlighting the benefits of both techniques to obtain metabolomic and lipidomic data, which has realized for the first time the combination of these two complementary and powerful technologies. NMR spectroscopy is frequently used to obtain quantitative metabolite information from cells and tissues. Lipid detection is also possible with NMR spectroscopy, with changes being visible across entire classes of molecules. Meanwhile, MALDI MSI provides relative measures of metabolite and lipid concentrations, mapping spatial information of many specific metabolite and lipid molecules across cells or tissues. We have used these two complementary techniques in combination to obtain metabolomic and lipidomic measurements from triple-negative human breast cancer cells and tumor xenograft models. We have emphasized critical experimental procedures that ensured the success of achieving NMR spectroscopy and MALDI MSI in a combined workflow from the same sample. Our data show that several phospholipid metabolite species were differentially distributed in viable and necrotic regions of breast tumor xenografts. This study emphasizes the power of combined NMR spectroscopy-MALDI imaging to advance metabolomic and lipidomic studies.

Baby-friendly hospitals in Turkey: evaluation of adherence to the Ten Steps to Successful Breastfeeding.

The Baby-Friendly Hospital Initiative (BFHI) is a World Health Organization and United Nations Children's Fund joint global programme to protect, promote and support breastfeeding. Sustainability of the BFHI standards is important for health facilities and country-level implementation. To analyse the 2018-2019 external reassessment results of baby-friendly hospitals (BFHs) in Turkey. We included 414 BFHs. The Ten Steps to Successful Breastfeeding were divided into 2 groups: critical management procedures (Steps 1 and 2) and key clinical practices (Steps 3-10). All 10 steps were fulfilled by 60.1% of the hospitals. Steps 3 and 2 had the lowest compliance rates (81.6% and 85.7%), and Steps 7 and 8 had the highest rates (97.1% and 98.1%). Caesarean section rates in the fourth quartile were associated with significantly lower adherence to Steps 3 and 10. The presence of another external reassessment within 5 years was associated with a significantly higher adherence rate to Step 3, and a significantly higher full implementation rate for the clinical practices. Hospitals that fully implemented management procedures had a significantly higher fulfilment percentage for all clinical practices. The western region had higher adherence rates for all the clinical practices than other regions. Reassessments seem useful for sustainability. Full compliance with Steps 1 and 2 is important for higher adherence to the clinical steps. Regional variations should be taken into account in the implementation of the programme.

Use of Robots in Critical Care: Systematic Review.

BackgroundThe recent focus on the critical setting, especially with the COVID-19 pandemic, has highlighted the need for minimizing contact-based care and increasing robotic use. Robotics is a rising field in the context of health care, and we sought to evaluate the use of robots in critical care settings.ObjectiveAlthough robotic presence is prevalent in the surgical setting, its role in critical care has not been well established. We aimed to examine the uses and limitations of robots for patients who are critically ill.MethodsThis systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MEDLINE, Embase, IEEE Xplore, and ACM Library were searched from their inception to December 23, 2021. Included studies involved patients requiring critical care, both in intensive care units or high-dependency units, or settings that required critical care procedures (eg, intubation and cardiopulmonary resuscitation). Randomized trials and observational studies were included.ResultsA total of 33 studies were included. The greatest application of robots in the intensive care unit was in the field of telepresence, whereby robots proved advantageous in providing a reduced response time, earlier intervention, and lower mortality rates. Challenges of telepresence included regulatory and financial barriers. In therapy and stroke rehabilitation, robots achieved superior clinical outcomes safely. Robotic use in patient evaluation and assessment was mainly through ultrasound evaluation, obtaining satisfactory to superior results with the added benefits of remote assessment, time savings, and increased efficiency. Robots in drug dispensing and delivery increased efficiency and generated cost savings. All the robots had technological limitations and hidden costs.ConclusionsOverall, our results show that robotic use in critical care settings is a beneficial, effective, and well-received intervention that delivers significant benefits to patients, staff, and hospitals. Looking ahead, it is necessary to form strong ethical and legislative frameworks and overcome various regulatory and financial barriers.Trial RegistrationPROSPERO International Prospective Register of Systematic Reviews CRD42021234162; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=234162

Empirical investigation in analysing the key determinants of employee engagement in influencing the employee performance using multiple regression analysis approach

In the current business context, a highly engaged employees support in realising the organisational goals in an effective manner. An employee who is not engaged will lead the group to realised lower level of income, reduce the profitability and impact the business growth negatively. Hence, the top management need to focus in devising critical policies and procedures which will support in enhancing the employee engagement in the organisation. The competitive environment has compelled the management to implement various procedures and policies which support in retaining the best talent in the organisation and ensure that they perform their tasks effectively in order to enhance performance of the employees and organisation. The highly engaged employees provide better results to the company through enhancing their performance, these employees offer suggestions and methods which will lead to reducing the operational cost, create new process and methods in generating new services and products, identify ways in increasing revenues and also work collaboratively for realising sustainable growth and advantage. This study involves in using empirical investigation to understand the critical determinants of employee engagement practices in enhancing the performance of the individuals in the organisation.

A facial ulcer secondary to a non-invasive ventilation mask in COVID-19 pneumonia

Sir, An 83-year-old patient hospitalized in the intensive care unit (ICU) of the pulmonary department for chronic respiratory failure complicated by severe COVID-19 pneumonia with respiratory involvement of 50% of the lungs. The comorbidities included diabetes, uncontrolled hypertension, ischemic heart disease, Parkinson’s disease, and bronchial asthma. The patient was unable to maintain adequate arterial oxygen saturation with a face mask and nasal prongs. The attending physician ordered non-invasive ventilation (NIV) and a continuous positive airway pressure (CPAP) mask was applied. On day ten of the patient’s ICU stay, his attending physician noticed a grade II cheekbone ulcer. The patient was put on a paraffin dressing. The evolution was marked five days later by a worsening in the stage of the pressure ulcer, which had become a stage III ulcer and, therefore, our opinion was requested. An examination of the patient revealed a well-adjusted, full-face mask with pressure against the zygomatic bone aggravated by the application of compresses, which further increased the aggression against the bone. A dermatological examination found two necrotic patches on both cheekbones without a peripheral detachment or inflammatory border (Fig. 1). There were no signs of bacterial infection. Upon investigation, the caregivers revealed that the CPAP mask had been left in place for nearly eighteen hours daily without formal monitoring or the inspection of the pressure areas. Fortunately, the patient’s condition began to improve as did her arterial oxygen saturation. The pulmonologist was gradually attempting to remove the patient from NIV. Strict monitoring of the pressure points was recommended and the patient was put on a hydrogel dressing for five days until the necrosis was eliminated, then on a hydrocolloid dressing after the mechanical removal of the remnants of the necrosis and fibrin with good improvement of the ulcer. The COVID-19 epidemic represents a new challenge for critical care physicians (ICU). In the context of this epidemic, the management of arterial oxygenation during critical care procedures is one of the main challenges for ICU physicians. As an effective means of ensuring satisfactory arterial oxygenation during COVID-19 pneumonia, more than 50% of patients treated in China required non-invasive ventilation (NIV) [1]. During NIV with headgear, ICU nurses should focus on interventions that help to improve the patient’s comfort to maximize the acceptability of the device and minimize mask-induced skin irritability [1]. Skin pressure sores secondary to helmet application may be prevented by applying hydrocolloid dressings associated with close monitoring of the patient’s tolerance to the pressure exerted by the mask [2]. The development of NIV-related pressure sores is due to a combination of pressure effects and shear forces exerted by the presence of a mask, pressure changes during the different phases of ventilation, and the tension of the mask’s strap [3]. The use of oronasal masks and increased time on NIV increases the risk of pressure ulcer formation, as do patient factors such as age, sensory impairment, chronic skin conditions, and hypotension [4]. Oronasal masks remain the most popular interface, with a European survey revealing that they are the first choice in 70% of cases. The reasons given by respondents for their choice were the reduction of air leakage, patient comfort, and cost [5].

589 Burn Center Trainees: Not Just for Surgery or Plastic Surgery Residents

IntroductionThe Burn unit offers a unique training environment for residents. The Accreditation Council for Graduate Medical Education (ACGME) requires all General Surgery trainees to have knowledge of burn physiology and experience with initial burn management. However, there are no burn requirements for other ACGME-sponsored training programs except for Plastic Surgery. Since care of the burned patient spans multiple settings – the intensive care unit, operating room, wards, outpatient clinic, and the emergency department – having residents from varied specialties might benefit not only the trainee, but also the Burn Center.MethodsA retrospective review of all residents rotated to the burn center of an American Burn Association verified unit was performed. Data from the 7/2018-6/2018 academic year were collected by analyzing resident rotational and call schedules of both intra institutional and inter-institutional residents. The specific time period was chosen to account for COVID affecting the number of residents more recently.ResultsA total of 48 residents rotated at the burn center during the studied academic year. Within the institution, there were 34 residents (71%): 12 general surgery interns (8 categorical, 4 preliminary), 2 plastic surgery interns, 10 emergency medicine (EM) residents, and 10 anesthesia residents. There were 14 residents (29%) from 3 outside institutions: 3 plastic surgery residents, 8 surgery interns from one program, and 3 surgery interns from another program. All surgical specialty trainees were interns, whereas other specialties, EM and anesthesia, were PGY2 trainees.ConclusionsWhile most residents were from general surgery and plastic surgery programs (58%) due to ACGME requirement, a significant portion of the resident complement (42%) was from non-surgical specialties. EM residents gain competency in wound reading as well as burn critical care. Anesthesia residents learn surgical management of the burn patient and critical care procedures. Since the burn center is a tertiary referral center, having outside residents rotating in the burn unit might facilitate transfers and increase knowledge of proper resuscitation.