Critical Services Research Articles

Managing End of Life Care for the Critically Ill: A Novel Program to Deliver Bedside Critical Care Without Transfer to the Intensive Care Unit

Background: Navigating medical care at the end of life can be a challenging experience for patients. There are also significant resource burdens, including intensive care unit (ICU) admissions, accompanying terminal illness. For actively dying patients, developing a care plan based on patient goals and delivering care at the bedside can enhance patient well-being, avoid inappropriate transfers or interventions, and improve resource management. Methods: The Rapid Response Team (RRT) is an around the clock intensivist service that responds to all acutely decompensating patients in our hospital. Through the Appropriate Care Escalation (ACE) program, the RRT intensivist identifies amongst decompensating patients, terminally ill individuals for whom prognosis is extremely poor irrespective of available interventions. These patients receive discussions about goals of care, code status, and management options. They receive care on a dedicated stepdown unit without escalation to the ICU. If aligned with patient goals, care plans incorporate critical care interventions including ventilator and vasopressor therapy. Results: Over 5 years, RRT identified 413 terminally ill patients under the ACE program to continue end of life care on the stepdown unit. Following discussions of goals, 60.8% of patients requested DNR/DNI, 30.9% were full code, and 8.5% requested DNR/OK-TO-INTUBATE status. At discharge, 82.1% of ACE patients expired compared to 23% of all RRT consultations. Patients received 233 critical care procedures at bedside including intubations, central access catheters and bronchoscopy. Conclusion: The ACE program helped identify, in real time, actively dying, terminally ill patients, establish patient goals, and expand critical care services outside the ICU.

Disease Patterns among Patients Seeking Emergency and Intensive Care: A single-hospital study in north central Vietnam in 2020

Objective: This retrospective study aims to describe the disease patterns among patients admitted to intensive care units (ICUs) in a public provincial hospital in North Central Vietnam in 2020. Design: We conducted a retrospective descriptive study. Setting: The study was conducted in the Thanh Hoa General Hospital, Thanh Hoa Province, Vietnam. The study included all emergency and critical care admissions hospitalized from January 1, 2020 to December 31, 2020. Main outcome measures: Data on age, gender, hospital admission, and discharge dates, length of hospital stays, illness chapters (based on ICD-10 codes), and treatment results determined at the hospital discharge of 27,152 episodes of ICU admission were collected. Results: The three illness chapters of ICD-10 with the most patients were Chapter IX-Diseases of the Circulatory System, Chapter XI-Diseases of the Digestive System, and Chapter XIX-Injury, Poisoning, and Some Other Consequences of External Causes, with 21.6%, 21%, and 20.3% of patients, respectively. Most episodes (n = 21,999, 81.0%) showed improved health at the time of hospital discharge, with up to 87% of patients finding a cure. Conclusions: The insights gained from this study can inform healthcare strategies, resource planning, and policy decisions to enhance the delivery of critical care services in the region. Further research and ongoing surveillance will be essential to adapt healthcare systems to the evolving landscape of diseases and to ensure the continued improvement of patient outcomes in intensive care settings.

2023 Reviewers With Distinction Award

Abstract The Editor and Editorial Board of the Journal of Mechanical Design would like to thank all of the reviewers for volunteering their expertise and time reviewing manuscripts in 2023. Serving as reviewers for the journal is a critical service necessary to maintain the quality of our publication and to provide the authors with a valuable peer review of their work. Below is a complete list of reviewers for 2023. We would also like to acknowledge four outstanding Reviewers of the Year and seven Reviewers with Distinction.

Optimizing the location and configuration of disaster resilience hubs under transportation and electric power network failures

Natural disasters often result in failures of transportation network components and blackouts that imperil the wellbeing of vulnerable populations. In response to these events, resilience hubs have been proposed as a pre-disaster planning strategy to improve access to critical services. This paper introduces an optimization-based approach to locate and configure electric power-generating resilience hubs considering the possibility of failures in transportation and electric power systems. The model’s objective is to identify hub locations and configurations that maximize transportation accessibility to the hubs and maximize the satisfaction of basic energy needs through hub-generated electric power. Besides a budget constraint, the model accounts for limits on the levels of hub energy generation vis-à-vis community energy demands, and on the transportation network distance of communities to hubs. Three heuristics are presented for the proposed planning problem. The first heuristic is a genetic algorithm (GA) with problem-specific solution generation procedures. The other two heuristics implement greedy search techniques. Numerical experiments were conducted, using data from rural Puerto Rico, to illustrate the application of the proposed model and heuristics, and examine their performance. In the numerical experiments, the GA heuristic found better solutions than the greedy heuristics. Additionally, design solutions consisting of spatially dispersed hubs with low energy generation capacity were better than solutions with spatially concentrated high-capacity hubs. Lastly, across a wide range of hub demand scenarios, only a small number of candidate hub locations consistently ranked among the best locations for establishing a hub.

Critical Care Service Transformation at the ALERT Comprehensive Specialized Hospital, A Case Study.

BackgroundThe intensive care unit (ICU) is a specialized department within a hospital that provides care for critically ill patients requiring close monitoring, multidisciplinary intervention, and advanced life support. It is a resource-intensive healthcare service, with the patient outcome determined by the adequate utilization of human resources, supplies, technologies, and infrastructure. ALERT Hospital is one of the largest referral hospitals that provides critical care services for both adult and pediatric patients. This case study narrates the establishment and transformation of critical care services at ALERT Hospital over the last five years.ObjectiveTo describe the transformation of critical care services at ALERT Comprehensive Specialized Hospital from the beginning of the service to the current stateMethodsA descriptive case study design was applied to narrate critical care service transformation at ALERT Comprehensive Specialized Hospital. Data was gathered from desk reviews of the emergency department, ICU, quality directorate, hospital data management unit, and the annual audit report.ResultALERT Hospital provides services for about 4.2 million people, encompassing 22 health centers, 8 hospitals, and other private health facilities within its catchment area. The ALERT Trauma Center, established in 2015, had only 3 ICU beds with two functional mechanical ventilators and a few trained nurses, with an annual hospital and emergency patient flow of 328,242 and 13,642, respectively. The critical care service expansion at ALERT Hospital encountered various obstacles concerning infrastructure, personnel, and supplies. Therefore, the hospital administration and clinicians designed and implemented different strategies to transform the service into the current picture. Accordingly, after intensive facilitation of all requiredinputs a general ICU with seven beds and five mechanical ventilators was initially established in 2018. During the second phase of the service expansion in 2022, the hospital has established a large ICU with twelve beds, providing more specialized services for over 349 critical patients annually.

Developing Emergency, Critical and Operative Care (ECO) Services in Ethiopia—A Public Health Priority

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Threats, Attacks, and Cryptography Frameworks of Cybersecurity in Critical Infrastructures

Critical Infrastructures (CIs), such as healthcare facilities, power grids, transportation systems, and financial institutions, are vital components of a functioning society, with the economy and safety being dependent on them. Nevertheless, they have become increasingly vulnerable to cyber threats and attacks in recent years. The main reason is their inability to quickly adapt to technological changes, employ updated cryptographic frameworks, and implement a thoroughly secure architecture based on their characteristics. In this study, the unique complexities of these systems are highlighted. Various verified cyberattacks that were executed against CIs in recent years are analyzed. Moreover, the general framework of CIs is demonstrated together with the employed technologies and cryptographic primitives. A thorough architecture of said technologies is developed to better understand the targeted components and easily identify potentially hidden threats. Afterwards, threat, adversary, and attack models that target critical systems and services are designed. The purpose is a better comprehension of the systems’ vulnerabilities, attack structures, motives, and targets for assisting CIs’ designers in creating secure frameworks and mechanisms, with the ability to mitigate such threats. Lastly, security controls and cryptography frameworks are demonstrated together with efficient mitigation architectures and implementations from the research community.

Innovative Approaches in Tax Enforcement and Tax Compliance for Sustainable Economic Development in Nigeria; A Conceptual Review

This paper delves into a conceptual review of the vital role of innovative approaches in tax enforcement and compliance for achieving sustainable economic development in Nigeria. Amidst evolving global economic landscapes, the integration of cutting-edge technologies such as blockchain, data analytics, digital platforms, and real-time reporting has emerged as a powerful catalyst for transforming the nation's tax system. These innovations have significantly streamlined tax processes, facilitating easier tax compliance for individuals and businesses. They have also fostered transparency and trust within the tax system by ensuring secure and tamper-proof tax records and enhancing voluntary compliance. The implementation of these innovative strategies presents a unique opportunity to bolster Nigeria's revenue collection, thereby contributing to sustainable economic development by funding critical public services, infrastructure projects, and socio-economic development initiatives. The paper concludes that the adoption of innovative approaches in tax enforcement is pivotal for sustainable economic development in Nigeria. By promoting compliance and transparency, these technologies contribute to a robust and reliable revenue base essential for funding public services and infrastructure projects. This paper, therefore, recommends investment in digital Infrastructure, implementation of real-time reporting and data analytics, utilisation of data analytics and artificial intelligence and leverage on mobile payment systems.

A Survey Study on IoT Application and its Attacks

The Internet of Things (IoT) has witnessed exponential growth in recent years, with billions of interconnected devices seamlessly communicating and exchanging data. While IoT offers unprecedented opportunities for innovation and convenience, it also introduces a plethora of security challenges. This abstract provides an overview of the key security concerns in IoT and explores emerging solutions to address them. Security in IoT is paramount due to the potential consequences of breaches. IoT devices are often resource-constrained and lack robust security features. Malicious actors can exploit this vulnerability to gain unauthorized access, compromise privacy, launch cyberattacks, and disrupt critical services. Therefore, securing IoT ecosystems is imperative for the continued growth and adoption of IoT technologies.

Consensus statement on the interhospital transfer of patients with acute aortic syndrome: TRAVERSING Delphi study

BackgroundStandardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim...

2023 Reviewers With Distinction Award

Abstract The Editor and Editorial Board of the Journal of Mechanisms and Robotics would like to thank all of the reviewers for volunteering their expertise and time reviewing manuscripts in 2023. Serving as reviewers for the journal is a critical service necessary to maintain the quality of our publication and to provide the authors with a valuable peer review of their work. Below is a complete list of reviewers for 2023. We would also like to acknowledge three outstanding Reviewers of the Year and nine Reviewers With Distinction.

Total ammonia aeration control (TAAC) theory – An innovative ammonia-based aeration controller

Abstract Water resource recovery facilities (WRRFs) need optimized and robust solutions to ensure efficient and reliable operation for this critical environmental service. Secondary treatment aeration control is a prime example as the activated sludge treatment process consumes the largest amount of energy for WRRFs, which require oxygen to biologically remove the ammonia content through nitrification. The selected control strategy will directly impact system efficiency and ability to maintain discharge permit compliance levels. The use of an ammonia-based aeration controller has two major benefits for these systems: (1) cost savings, through minimization of energy usage, and (2) enhanced performance from a steady effluent ammonia concentration. These benefits come from an increase in the system biological kinetics. The process control improvements result in a higher rate of total nitrogen removal, via simultaneous nitrification/denitrification, through delivery of the minimum instantaneous oxygen necessary over time. The thesis contained herein is a novel controller algorithm, which leverages the relationship between primary input and output variables of this complex treatment process. The approach provides continuous output stability and a substantial reduction of the overall system costs, through decreased wear of large-budget equipment and by requiring fewer algorithm input data sources than any other possible solution.

Attitudes Towards Turtle Conservation: An Island Wide Study in Sri Lanka


 
 
 Sri Lanka is visited by the five of the seven living sea turtle species recorded in the world. Sea turtle populations are declining, as is their ability to perform critical services in ocean ecosystems. Some of the obvious risks faced by marine turtles in Sri Lanka include incidental bycatch, illegal egg poaching, habitat change, destruction, and natural causes such as predation and erosion. Attitudes towards conservation of turtles and underlying motives for such attitudes is a lesser researched subject in the country. The present study therefore aims at assessing the attitudes of Sri Lankans towards conservation of sea turtles. A household survey was conducted using a pre-tested questionnaire adopting simple random sampling among 1084 households across the twenty-five districts of Sri Lanka through telephone and in-person interview from December 2021 to May 2022. The socioeconomic data of respondents, membership in a wild life or environmental organizations, recreational experience of turtles were also collected. A set of statements on sea turtles were presented for which the respondents indicated their preferences. Their willingness to contribute towards conservation was also recorded. The results of the study indicate that individuals from twenty-five districts had already been exposed to a wealth of knowledge regarding marine turtles and were well-informed. There were 603 individuals from coastal districts while 481 were from non-coastal districts. The average age was 45 years while number of respondents who had a membership of any environmental related wildlife organization was 164. Seventy four percent of the sample had seen live marine turtles; 37.6% of them had seen marine turtles in zoological gardens. Majority of respondents strongly agreed that (84% on average) sea turtles are worth protecting. Forty one percent of respondents agreed that it is everyone‘s duty to ensure the existence of plants and animals for future generations, showing that respondents had bequest motive for marine turtle conservation. Majority (63.3%) of respondents strongly agreed that sea turtles have the right to exist in the environment, showing that there is a strong existence motive for the conservation of sea turtles. The study emphasize the need to better utilize the strong motives of people for sea turtle conservation efforts in Sri Lanka that requires attention of legislators and decision-makers.
 Keywords: Sea turtle, Attitudes, Conservation, Motives
 
 

Heatwaves increase larval mortality and delay development of a solitary bee

Abstract Heatwaves are expected to increase in frequency, intensity and duration due to climate change. For organisms like insects with discrete development, sensitivity may differ among life stages. Thermal sensitivity is of particular concern for species like bees that provide critical ecosystem services. Although social bees moderate nest temperatures through worker behaviour, solitary bees do not thermoregulate their nests, making immobile developing offspring especially vulnerable to such extreme events. We studied the effects of heatwaves on larval development in the solitary bee, Osmia lignaria, an important orchard pollinator and model species for solitary bee biology. We used a factorial design to assess the impacts of heatwave temperature and duration on larval mortality and development rate. Larvae were exposed to heatwaves under realistic diel temperature regimes, with daytime maxima of 31 or 37°C for 4 or 7 days at the beginning of development. Heatwave temperature strongly affected larval mortality. Exposure to 37°C heatwaves increased larval mortality by 130%, but the cooler 31°C heatwaves did not significantly impact mortality. Heatwave duration did not impact larval mortality. Larval development time also was affected by heatwave exposure. Compared with the no‐heatwave‐control, bees in the 31°C heatwave developed faster, and bees in the 37°C heatwave developed slower. Our study reveals the importance of stage‐specific effects of extreme events and suggests that the timing and maximum temperature of projected heatwaves may be more detrimental to populations than heatwave duration.

Local Wisdom-Based Policy Innovation in Indonesia During 2018-2021

Several studies on the innovation of Indonesian public services only provide general and less specific descriptions of inclusive public services based on local wisdom. This study aims to find innovative models of local wisdom-based public services in Indonesia. This study is a descriptive-exploratory study, and the research method is an archival one emphasizing secondary data use. The findings revealed that (1) Local government dominated policy innovation proposals based on local wisdom compared to the central government because of the proximity aspect of service distance to objects, so the type of service is specific. 2) Product-oriented service types dominated service innovation due to specific, urgent, and critical service needs that must be resolved immediately. 3) Innovation with the outcome of problem-solving was very dominant because it is related to critical service issues that require solving problems by minimizing existing local cultural clashes. 4) The sectors of education, community empowerment, food security, environmental preservation, and the health sector almost evenly influenced service policy innovations based on local wisdom, because it is a wedge between direct contact with basic community services and the culture adopted by local communities. 5) Innovator originating from Java and Outside Java had competed quite dynamically over the last four years, because Outside Java excelled in the quantity of both organizations and local communities, while Java excelled in its human resources and infrastructure's quality.

Nurses' views on the presence of family members during invasive procedures in hospitalised children: A questionnaire survey.

(I) To identify the opinion and practices of nursing professionals regarding the presence of family members during invasive procedures in hospitalised children; (II) to determine the knowledge of nursing professionals about the patient-and family-centred care model. Family presence in invasive procedures benefits the patient and their relatives, but varied attitudes exist among healthcare personnel, with some being favourable and others unfavourable toward family presence. Observational, descriptive, cross-sectional study. Study population: Nurses from paediatric critical care services, emergency services, hospital wards, day hospitals and outpatient clinics at a Catalan tertiary hospital who participated voluntarily between September 2021 and July 2022. Data collection instrument: A questionnaire prepared by the researchers, based on the literature and reviewed by experts. REDCap link with access to the questionnaire was sent out to potential respondents through the institutional email. Bivariate analysis was performed with the R 4.2 program. The study was approved by the hospital's Clinical Research Committee and participants gave informed consent before responding to the questionnaire. A total of 172 nurses participated, and 155 valid responses were obtained. All respondents consider the family as a key element in paediatric care and report inviting family members to participate in the care given to their child. However, 12.0% of nurses do not invite the family to be present in invasive procedures. Almost all respondents note the need for training to acquire communication skills and improve the management of emotions. The results show a favourable opinion towards the presence of family members and highlight the need to train nurses to develop communication skills. The data provided can favour the design of measures to improve and promote the presence of parents during invasive procedures, reinforcing the patient-and family-centred care model and improving the quality of care provided. One example is the creation of family care protocols where the inclusion of parents and the roles of each individual involved in the care process appears.

Global pediatric anesthesia-Anglophone West Africa perspective.

This article gives the pediatric anesthesia perspective from Cameroon, Nigeria, Ghana, Liberia, and Gambia, five out of six countries in Anglophone West Africa. Over 40% of the population of most of these countries are younger than 14 years and there is an increasing need for paediatric anesthesia services. Workforce density ranges from 0.08 to 0.58 physician anesthesia providers per 100,000 population. There are only 13 trained pediatric anesthetists; ratios range from 0 to 0.4 per 100,000 children, thus pediatric anesthesia services are provided by various cadres of physician and non-physician anesthesia providers. Physician anesthesia training is mostly carried out by the West African College of Surgeons as well as national postgraduate colleges. Pediatric anesthesia services are provided in tertiary (teaching), secondary (general), district, faith-based, military, private hospitals and through surgical missions. Challenges include lack of trained personnel, high morbidity from late presentation to health facilities and financial constraints, lack of health insurance for pediatric anesthesia services, unavailability of appropriate equipment and consumables, a narrow range of medications, very few pediatric-specific operating theaters, and inadequate critical care services. The lack of opportunities for sub-specialty training in pediatric anesthesia in West Africa is currently being addressed in Nigeria and Ghana. Non-governmental agencies fund programs and courses related to pediatric anesthesia and have also provided fully equipped operating theaters. Advocacy for pediatric anesthesia can be achieved through the National Surgical Obstetric Anesthesia and Nursing Plans Implementation Committee of the various countries. There is an urgent need for prioritization of health in the budgets of Anglophone West African countries and governments must deliberately provide support for anesthesia and surgical services. More international collaborations towards workforce training and creation of children's hospitals are needed.

(070) Androgen Status in Men and Risk Of COVID-19 Complications: An Analysis of United States Claims Data

Abstract Introduction Biological males have had worse COVID-19 outcomes compared to females. Yet, the impact of hypogonadism (HG) on COVID complications remains unclear. Objective We sought to compare COVID complications in males with various androgen status (eugonadal, treated HG, untreated HG) to females to evaluate the effect of testosterone levels on COVID outcomes. Methods We used the IBM MarketScan database of commercial claims encounters to identify patients ages 18+ with a COVID diagnosis (n=756,855). We compared eugonadal males (no HG diagnosis), untreated HG males (HG diagnosis without therapy), treated HG males (HG diagnosis and testosterone prescription within 180 days before COVID diagnosis) to females. Rates of intensive care unit (ICU) admission co-occurring with initial COVID diagnosis were modeled using logistic regression. Acute respiratory distress syndrome (ARDS), acute respiratory failure (ARF), and use of critical care services (CCS) were modeled using Cox proportional hazards models. Outcomes were regressed against group, age, rurality, and Charlson Comorbidity Index. Results Eugonadal males (n=315,050) were at higher odds of ICU admission (OR: 1.611, 95% CI: 1.549-1.676), having ARDS (HR 1.766, CI: 1.670-1.868), having ARF (HR 1.609, CI: 1.575-1.644), and needing CCS (HR 1.696, CI: 1.652-1.742) compared to females. Treated HG males (n=2,343) and untreated HG males (n=22,614) were also more likely to experience all adverse outcomes compared to females. For untreated HG males the effect was less pronounced compared to eugonadal males and treated HG males for all outcomes (Figure 1). There were no differences in odds of all outcomes for castrate males (n=89) compared to females due to small sample size. Conclusions Eugonadal males, treated HG males, and untreated HG males were more likely to have adverse COVID outcomes compared to females. This effect was most pronounced for eugonadal and treated HG males compared to untreated HG males, suggesting normal androgen status is detrimental to COVID-19 outcomes. This is one of the largest studies to show a complex relationship between testosterone and COVID outcomes. Disclosure No.

Impact of the COVID-19 Pandemic on the Diagnostic Frequency and Medical Therapies Applied to Subjects With Functional Seizures.

The coronavirus 2019 (COVID-19) pandemic was associated with catastrophic consequences and increased psychological distress. However, it is unknown if the pandemic impacted the frequency of functional seizures (FS), a well known manifestation of psychiatric disease. The study objectives are to evaluate FS diagnostic code frequency before and during the COVID-19 pandemic and the therapies applied. We hypothesized that FS frequency would be higher during the pandemic, but that the therapies applied would be similar between the two time periods. This was a retrospective observational cohort study utilizing the TriNetX ® electronic health record (EHR) database. We included subjects aged 8 to 65years with a diagnostic code of "conversion disorder with seizures or convulsions." After the query, the study population was divided into 2 groups [pre-COVID-19 (3/1/2018 to 2/29/2020) and COVID-19 (3/1/2020 to 2/28/2022). We analyzed subject demographics, diagnostic, procedure, and medication codes. We included 8680 subjects [5029 (57.9%) pre-COVID-19 and 3651 (42.1%) COVID-19] in this study. There was a higher odds of mental health conditions, anxiolytic prescription, emergency department services, and hospital services, but a lower odds of critical care services during COVID-19. There was no difference in antiepileptic use between the time periods. During the COVID-19 pandemic, a higher odds of anxiolytic use, need for emergency department services, and hospital services was reported. In addition, there was a decreased odds of critical care services. This may reflect a change in how patients with FS were managed during the pandemic.

Assessment of the predictive value of plasma calprotectin in the evolution of SARS-Cov-2 primo-infection

BackgroundThe COVID-19 epidemic still calls for anticipation aimed at preventing the overloading of critical care services. With this in mind, the predictive value of easily accessible biomarkers is to be assessed. ObjectiveSecretion of calprotectin is stimulated during an inflammatory process, especially in the cytokine storm. We tried to determine whether early plasma concentration of calprotectin in patients with primary SARS-CoV-2 infection could predict an adverse outcome in cases of COVID-19. MethodsWe included 308 patients with a primary diagnosis of SARS-CoV-2 confirmed by PCR. Heparinized tube samples, collected within the first 24 h of hospitalization, were used for biomarker assays, in which plasma calprotectin was included. Data from the patients' medical records and severity groups established subsequent to diagnosis at the end of hospitalization were collected. ResultsEarly plasma calprotectin concentration is significantly associated with progression to a severe form of COVID-19 in patients with primary infection (Relative Risk: 2.2 [1.6–2.7]). In multivariate analysis, however, it does not appear to provide additional information compared to other parameters (age, GFR, CRP…). ConclusionOur study shows that while an early single blood test for calprotectin could help to predict the progression of a primary SARS-CoV-2 infection, it is not superior to the other parameters currently used in emergency medicine. However, it paves the way for future considerations, such as the interest of this biomarker for high-risk infected patients (immunocompromised individuals…). Finally, the usefulness of early serial measurements of plasma calprotectin to assess progression towards severity of COVID-19 requires further assessment.