Emergency Department Resuscitation Room Research Articles

Reducing the length of stay for patients stranded in the emergency department: A single-center prospective study of 18,631 patients in China.

The purpose of this study was to reduce the length of stay (LOS) for patients stranded in the emergency department (ED) of a Grade III A hospital in China, and to improve patient flow and increase bed capacity. We utilized a pre-/postintervention design and employed the Six Sigma methodology, which is based on the DMAIC cycle (define, measure, analyze, improve, and control), to evaluate and improve the existing process. Data from 18,631 patients who were stranded in the ED were collected and analyzed. The median LOS for stranded patients decreased from 17.21 (6.22, 27.36) hours to 13.45 (5.56, 25.85) hours (P < .05). Similarly, the median LOS for admitted patients decreased from 19.64 (7.77, 27.68) hours to 15.92 (6.19, 26.24) hours (P < .05). The median LOS for patients with an ED triage Level IV decreased from 16.15 (5.80, 26.62) hours to 12.59 (5.20, 24.97) hours (P < .05). In addition, the average hospitalization days of hospitalized patients decreased from 0.92 days to 0.82 days (P < .05). Furthermore, the bed utilization rate increased from 66.79% to 72.29% (P < .05). The number of bed turnovers in the ED resuscitation room increased from 20.30 to 21.96 (P < .05). We had effectively met our goal of minimizing ED patient LOS. Six Sigma method can effectively shorten patient LOS by measuring and analyzing the key factors affecting patient LOS, and by implementing measures such as strict implementation of emergency classification and triage system, establishment of multidisciplinary cooperative team, reasonable allocation of human resources, information management of bed resources, and improvement of performance appraisal scheme to improve and control the effectiveness of patient LOS.

A Study on the Ethical Aspects of Witnessed Resuscitation from the Perspective of Prehospital Emergency Caregivers

Aim: Patients' relatives are routinely removed from the emergency department resuscitation room. One can attribute this practice primarily to reasons such as safeguarding patient welfare, protecting medical personnel and patient's relatives from potential risks. In prehospital emergency medicine, it is often not possible to prevent witnessed resuscitation efforts. Prehospital emergency caregivers responding to cardiopulmonary arrest must focus only on the patient. It is aimed to investigate the ethical perspectives of prehospital emergency caregivers on witnessed resuscitation and to make policy recommendations according to the results of the research.Methods: The study was designed as a prospective, descriptive survey. Between February 18, 2022 and March 18, 2022, the survey prepared for EMTs, paramedics, health officers, nurses, and physicians working in the ambulance service of Kırşehir Provincial Health Directorate was applied face-to-face.Results: The majority of the participants were women, associate degree graduates, EMT, and paramedics, and their career duration was between 6-10 years. When comparing paramedic and EMT responses to the questions, a statistically significant difference was only found in the response to question “Does witnessing the resuscitation you perform in the prehospital area cause a situation that may harm the patient?”. Additionally, the ethical aspects of witnessed resuscitation in the prehospital setting were examined under the headings such as the witness of the family and nonfamily individuals, professionalism, patient privacy and confidentiality, the grieving process, medical staff safety, and nonmaleficence.Conclusions: Witnessed resuscitation in the prehospital setting has many controversial ethical aspects and needs regulations and training in this regard.

Association between hypotension and myocardial injury in patients with severe trauma

PurposeDuring resuscitation of patients with severe trauma, guidelines recommend permissive hypotension prior to surgical bleeding control. However, hypotension may be associated with reduced organ perfusion and multiple organ dysfunction, e.g. myocardial injury. The association between hypotension and myocardial injury in trauma patients is underexplored. We hypothesized that hypotension is associated with myocardial injury in this population.Materials and methodsThis retrospective study included patients ≥ 18 years suffering from severe trauma [defined as Injury Severity Score (ISS) ≥ 16] that were treated in the emergency department resuscitation room between 2016 and 2019. Primary endpoint was the incidence of myocardial injury defined as high-sensitive troponin T > 14 ng/l. Main exposure was the duration of arterial hypotension during resuscitation period defined as mean arterial pressure < 65 mmHg.ResultsOut of 368 patients screened, 343 were analyzed (73% male, age: 55 ± 21, ISS: 28 ± 12). Myocardial injury was detected in 143 (42%) patients. Overall in-hospital mortality was 26%. Multivariate binary logistic regression with forced entry of nine predefined covariables revealed an odds ratio of 1.29 [95% confidence interval 1.16–1.44]; p = 0.012) for the association between the duration of hypotension and myocardial injury.ConclusionThe duration of hypotension during resuscitation period is independently associated with the incidence of myocardial injury in patients with severe trauma.

Predictive value of qSOFA score for death in emergency department resuscitation room among adult trauma patients:a retrospective study

BackgroundTo explore the predictive value of the quick Sequential Organ Failure Assessment (qSOFA) score for death in the emergency department (ED) resuscitation room among adult trauma patients.MethodsDuring the period November 1, 2016 to November 30, 2019, data was retrospectively collected of adult trauma patients triaged to the ED resuscitation room in the First Affiliated Hospital of Soochow University. Death occurring in the ED resuscitation room was the study endpoint. Univariate and multivariate analyses were performed to explore the association between qSOFA score and death. Receiver operating characteristic (ROC) curve analysis was also performed for death.ResultsA total of 1739 trauma victims were admitted, including 1695 survivors and 44 non-survivors. The death proportion raised with qSOFA score: 0.60% for qSOFA = 0, 3.28% for qSOFA = 1, 12.06% for qSOFA = 2, and 15.38% for qSOFA = 3, p < 0.001. Subgroup of qSOFA = 0 was used as a reference. In univariate analysis, crude OR for death with qSOFA = 1 was 5.65 [95% CI 2.25 to 14.24, p < 0.001], qSOFA = 2 was 22.85 [95% CI 8.84 to 59.04, p < 0.001], and qSOFA = 3 was 30.30 [95% CI 5.50 to 167.05, p < 0.001]. In multivariate analysis, with an adjusted OR (aOR) of 2.87 (95% CI 0.84 to 9.87, p = 0.094) for qSOFA = 1, aOR 6.80 (95% CI 1.79 to 25.90, p = 0.005) for qSOFA = 2, and aOR 24.42 (95% CI 3.67 to 162.27, p = 0.001) for qSOFA = 3. The Area Under the Curve (AUC) for predicting death in the ED resuscitation room among trauma patients was 0.78 [95% CI, 0.72–0.85].ConclusionsThe qSOFA score can assess the severity of emergency trauma patients and has good predictive value for death in the ED resuscitation room.

A Cognitive Aid Improves Adherence to Guidelines for Critical Endotracheal Intubation in the Resuscitation Room: A Randomized Controlled Trial With Manikin-Based In Situ Simulation.

Emergency endotracheal intubation (ETI) is a high-risk procedure. Some of its adverse events are life-threatening, and guidelines emphasize the need to anticipate complications by thorough preparation. The emergency department (ED) can be an unpredictable environment, and we tested the hypothesis that a cognitive aid would help the emergency practitioners better follow guidelines. The main objective of this study was to determine whether the use of a cognitive aid focusing on both preintubation and postintubation items could improve ETI preparation and implementation in the ED resuscitation room regarding adherence to guidelines. The secondary objective was to measure and describe procedure times. We conducted a single-blind randomized controlled trial with manikin-based in situ simulation. The participants were not aware of the purpose of the study. The cognitive aid was developed using national guidelines and current scientific literature. The most relevant items were the preparation and implementation of a rapid sequence induction for ETI followed by mechanical ventilation. Emergency department physician-nurse pairs were randomized into a "cognitive aid" group and a "control" group. All pairs completed the same scenario that led to ETI in their own resuscitation room. An adherence to guidelines score of 30, derived from the 30 items of the cognitive aid (1 point per item), and preparation and intubation times were collected. Seventeen pairs were included in each group. Adherence to guidelines scores were significantly higher in the cognitive aid group than in the control group (median = 28 of 30, interquartile range = 25-28, vs. median = 24 of 30, interquartile range = 21-26, respectively, P < 0.01). Preparation, intubation, and total procedure times were slightly longer in the cognitive aid group, but these results were not significant. In an in situ simulation, a cognitive aid for the preparation and implementation of an emergency intubation procedure in the ED resuscitation room significantly improved adherence to guidelines without increasing procedure times. Further work is needed in a larger sample and in different settings to evaluate the optimal use of cognitive aids in critical situations.

Early in-hospital course of critically ill nontrauma patients in aresuscitation room of aGerman emergency department (OBSERvE2 study).

BackgroundManagement of critically ill nontrauma (CINT) patients in the resuscitation room of the emergency department (ED) is very challenging. Detailed data describing the patient characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the resuscitation room.MethodsThis prospective, single center observational study included all adult patients who were consecutively admitted to the ED resuscitation room during 2 periods of 1 year (September 2014–August 2015 vs. September 2017– August 2018). Patient characteristics, out-of-hospital/in-hospital treatment, admission-related conditions, time intervals for diagnostics and interventions and outcome were recorded using a self-developed questionnaire.ResultsA total of 34,303 patients in the first and 35,039 patients in the second study period were admitted to the ED, of whom 532 and 457 patients, respectively, were admitted to the nontrauma resuscitation room due to acute life-threatening conditions. The patient characteristics did not differ significantly between the study periods (male: 58% vs. 59%, age: 68 ± 17 years vs. 65 ± 17 years). Time intervals for diagnostic and therapeutic interventions were similar. The CINT patients during the second study period were treated faster compared to the first study period (end of ED management: 53 ± 33 min vs. 41 ± 24 min, p < 0.0001). The 30-day all-cause mortality was comparable (34.0% vs. 36.3%).ConclusionObservation of critically ill patient management in the ED resuscitation room showed reliable results between both study periods. Structured ED management guidelines for CINT patients may provide comparable results at one institution.Supplementary InformationThe online version of this article (10.1007/s00101-021-00962-3) contains an additional table and the evaluation chart. The article and the supplementary material are available at www.springermedizin.de.Please enter the article title in the search box; the supplementary material is available with the article under “Supplementary Information”.

Elevated admission lactate levels in the emergency department are associated with increased 30-day mortality in non-trauma critically ill patients

BackgroundElevated blood lactate levels were reported as useful predictors of clinical outcome and mortality in critically ill patients. To identify higher-risk patients, this investigation evaluated the relationship between patient mortality and admission lactate levels during the management of non-trauma critically ill patients in the emergency department (ED).MethodsIn this prospective, single centre observational study in a German university ED, all adult patients who were admitted to the ED resuscitation room were evaluated between September 1, 2014 and August 31, 2015. Blood samples for blood gas analysis, including lactate levels, were obtained immediately at admission. Study endpoint was 30-day mortality.ResultsDuring the study period, 532 patients were admitted to the resuscitation room of the ED. The data of 523 patients (98.3%) were available. The overall 30-day mortality was 34.2%. Patients presenting to the resuscitation room with admission lactate levels < 2.0 mmol/l had a 30-day mortality of 22.7%, while admission lactate levels above 8.0 mmol/l were associated with higher mortality (8.0–9.9 mmol/l: OR: 2.83, 95%CI: 1.13–7.11, p = 0.03, and ≥ 10 mmol/l: OR: 7.56, 95%CI: 4.18–13.77, p < 0.001).ConclusionHigh lactate levels at admission are associated with an increased 24-h and 30-day mortality. These measurements may be used not only to predict mortality, but to help identify patients at risk for becoming critically ill. The breakpoint for mortality may be an ALL ≥8.0 mmol/l.

Reversible Toxic Myocarditis with Intraventricular Thrombus Associated with Aluminium Phosphide Poisoning Treated with Trimetazidine: A Case Report

Objectives: To report atypical aspects of cardiovascular manifestations related to phostoxin poisoning and to propose a therapeutic approach in the case of myocarditis induced by intoxication. Patient and method: We report the medical observation of an atypical case of a patient admitted to the medical intensive care unit then to cardiology department in university hospital Ibn Rochd of Casablanca for aluminum phosphide poisoning. Case report: A 30 -year-old man initially admitted to the emergency department resuscitation room and then to the cardiology department, presenting with ventricular dysfunction at 30% ejection fraction following myocarditis due to aluminum phosphide voluntary poisoning with left ventricular apical thrombus. Under treatment of heart failure, associated with the administration of trimetazidine and anticoagulation, the patient recovered to 50% of LVEF after fifteen days of treatment with thrombus dissolution. From a case reported in the literature on the impact of trimetazidine in the evolution of myocarditis in phostoxin intoxication, we discussed the particular effect of trimetazidine in the favorable evolution in our patient. Conclusion: No specific drug has been established as an antidote for the phostoxin poisoning, Hence treatment strategy is mainly supportive until the myocardial injury induced by the active metabolite (phosphine) subsides. Our use of Trimetazidine for this patient with encouraging results needs further validation by others, as it may be a useful adjunct to aggressive supportive care when needed alongside with other conventional treatments for heart failure.

Prospective observational study to assess the circulatory status of the patients presenting to resuscitation room in emergency department

Background: Circulation forms an integral part of a patient presenting to the emergency department (ED). Appropriate management of critically ill patients being brought to the ED is of paramount importance, and inappropriate resuscitation during prehospital transfer could be fatal. Methodology: This prospective study included all priority 1 and trauma patients arriving to the resuscitation room of our ED between August 2018 and October 2018. Details of prehospital management of the circulatory status in the different types of prehospital transport and methods used were noted. A comparison was done between ambulances and private vehicles and receiving prehospital care with the help of univariate analysis. Results: During the study, we recruited 209 patients which comprised trauma (64.1%) and 67 nontrauma (35.9%) priority 1 patients. There was a male predominance (76.7%). Patients were transported by 108 ambulances (9.6%), private ambulances (26.9%), and private vehicles (car, auto, and other vehicles) (60.3%). Of the 142 trauma patients, 66.1% received hemorrhage control as a part of prehospital management. Of the 39.4% trauma patients transported through an ambulance, hypotension was observed in 3.6%, upon their arrival to the ED. Dead and left against medical advice was seen in 0.5% and 1.9%, respectively, whereas 48.8% were discharged stable from the ED. Conclusion: Ambulances bought in patients with adequate hemorrhage control than other vehicles. With an unstable prehospital management in place, a significant sample of patients arrived at ED with a compromised circulatory status. Our study clearly highlights the glaring deficiency in circulatory status at arrival to ED.

Clinical Survey and Predictors of Outcomes of Pediatric Out-of-Hospital Cardiac Arrest Admitted to the Emergency Department

Pediatric out-of-hospital cardiac arrest (OHCA) is a rare event with severe sequelae. Although the survival to hospital-discharge (STHD) rate has improved from 2–6% to 17.6–40.2%, only 1–4% of OHCA survivors have a good neurological outcome. This study investigated the characteristics of case management before and after admittance to the emergency department (ED) associated with outcomes of pediatric OHCA in an ED. This was a retrospective study of data collected from our ED resuscitation room logbooks dating from 2005 to 2016. All records of children under 18 years old with OHCA were reviewed. Outcomes of interest included sustained return of spontaneous circulation (SROSC), STHD, and neurological outcomes. From the 12-year study period, 152 patients were included. Pediatric OHCA commonly affects males (55.3%, n = 84) and infants younger than 1 year of age (47.4%, n = 72) at home (76.3%, n = 116). Most triggers of pediatric OHCA were respiratory in nature (53.2%, n = 81). Sudden infant death syndrome (SIDS) (29.6%, n = 45), unknown medical causes (25%, n = 38), and trauma (10.5%, n = 16) were the main causes of pediatric OHCA. Sixty-two initial cardiac rhythms at the scene were obtained, most of which were asystole and pulseless electrical activity (PEA) (93.5%, n/all: 58/62). Upon ED arrival, cardiopulmonary resuscitation (CPR) was continued for 32.66 ± 20.71 min in the ED and 34.9% (n = 53) gained SROSC. Among them, 13.8% (n = 21) achieved STHD and 4.6% (n = 7) had a favorable neurological outcome. In multivariate analyses, fewer ED epinephrine doses (p < 0.05), witness of OHCA (p = 0.001), and shorter ED CPR duration (p = 0.007) were factors that increased the rate of SROSC at the ED. A longer emergency medical service (EMS) scene interval (p = 0.047) and shorter ED CPR interval (p = 0.047) improved STHD.

Resuscitation room management of critically ill nontraumatic patients in a German emergency department (OBSERvE-study).

Management of critically ill nontrauma (CINT) patients in the resuscitation room (RR) of the emergency department (ED) is very challenging. Detailed data describing the characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the RR. From September 2014 to August 2015, data were collected prospectively on adult CINT patients admitted to the RR of a single German University ED. Patient characteristics, out-of-hospital/in-hospital treatment, admission-related diseases, time intervals for diagnostics and interventions plus outcome were recorded using a self-developed questionnaire. A total of 34 303 patients were admitted to the ED; of these 21 074 patients were admitted for nontrauma emergencies and because of acute life-threatening problems. Five hundred and thirty-two CINT patients were admitted to the RR (median age: 71 years, 58.3% men). The main problems on admission were obstructed airway (3.8%, A), respiratory insufficiency (26.5%, B), shock (35.5%, C), unconsciousness (33.3%, D) or other (0.9%, E). Out-of-hospital and in-hospital management included intravenous access (96.8 vs. 76.9%), 12-lead ECG (50.0 vs. 86.5%), invasive airway management (30.1 vs. 27.1%), noninvasive and invasive ventilation (7.0 vs. 16.4% and 30.1 vs. 57.2%), catecholamines (16.2 vs. 24.1%), arterial line (0.2 vs. 58.1%) and cardiopulmonary resuscitation (18.4 vs. 12.2%). The mean length of stay was 34±24 min. At day 30, all-cause mortality was 34.2% (patients with and without cardiopulmonary resuscitation: 72.7 vs. 24.0%, P<0.001). Observation of critically ill patients in the resuscitation room of the Emergency Department shows the challenge of care for CINT patients in the ED. With high levels of mortality, there is an urgent need for structured ED management guidelines.

Pediatric Emergency Medicine Simulation Curriculum: Electrical Injury.

Electrical injuries are rare but potentially life-threatening medical emergencies that require providers to manage a critically ill patient while recognizing and treating the unique sequelae associated with the diagnosis. This simulation case is designed to give pediatric and emergency medicine residents, fellows, attendings, and nurses the opportunity to practice these skills in a realistic setting. This simulation-based curriculum was designed for a high-fidelity mannequin in an emergency department resuscitation room but can be adapted to fit a variety of learning environments. The case featured a 16-year-old boy presenting to the emergency department after arresting in the field after sustaining an electrical injury. He developed ventricular tachycardia during the simulation and had significant hyperkalemia, requiring emergent management. The included debriefing tools assisted instructors in providing formative feedback to learners. A total of 40 residents, medical students, and fellows participated in this scenario and provided overwhelmingly positive feedback about the learning experience. Mean Likert scores for participant confidence related to learning objectives after the simulation were 4 or greater on a 5-point scale. This case was developed to help learners at various levels of training recognize and manage a low-frequency, high-acuity scenario in a standardized environment. Participants specifically had the opportunity to perform airway management, cardiopulmonary resuscitation, defibrillation, and management of hyperkalemia, which may present in real life from a multitude of etiologies. The included materials helped prepare and assist facilitators with debriefing, supplemental education, and bidirectional feedback.

The association between the patient and the physician genders and the likelihood of intensive care unit admission in hospital with restricted ICU bed capacity.

Despite the evidence that the patient gender is an important component in the intensive care unit (ICU) admission decision, the role of physician gender and the interaction between the two remain unclear. To investigate the association of both the patient and the physician gender with ICU admission rate of critically ill emergency department (ED) medical patients in a hospital with restricted ICU bed capacity operates with 'closed door' policy. A retrospective population-based cohort analysis. We included patients above 18 admitted to an ED resuscitation room (RR) of a tertiary hospital during 2011-12. Data on medical, laboratory and clinical characteristics were obtained. We used an adjusted multivariable logistic regression to analyze the association between both the patient and the physician gender to the ICU admission decision. We included 831 RR admissions, 388 (46.7%) were female patients and 188 (22.6%) were treated by a female physicians. In adjusted multivariable analysis (adjusted for age, diabetes, mode of hospital transportation, first pH and patients who were treated with definitive airway and vasso-pressors in the RR), female-female combination (patient-physician, respectively) showed the lowest likelihood to be admitted to ICU (adjusted OR: 0.21; 95% CI: 0.09-0.51) compared to male-male combination, in addition to a smaller decrease among female-male (adjusted OR: 0.53; 95% CI: 0.32-0.86) and male-female (adjusted OR: 0.43; 95% CI: 0.21-0.89) combinations. We demonstrated the existence of the possible gender bias where female gender of the patient and treating physician diminish the likelihood of the restricted health resource use.

Injury Patterns and Emergency Department Mortality After Unsuccessful Suicide. A Descriptive Study of a Consecutive Case Series

We hypothesized that trauma bay management and 24-hour emergency department (ED) mortality of patients that survived unsuccessful suicide attempts differ from other patients. Severely injured patients after an unsuccessful suicide attempt can be admitted to resuscitation rooms of any ED. To our knowledge, 24-hour mortality has not been investigated yet. We studied such patients admitted to the resuscitation room of a large ED. This consecutive case series included 64 patients who were evaluated in the resuscitation room because of an unsuccessful suicide attempt. Patient variables were recorded including method of suicide attempt, injuries, hemodynamic status, and treatment. Most patients were male [57 patients (89%)], and the most frequent methods were ingestion of harmful devices or substances [15 patients (23%)]; hanging [9 patients (14%)]; and strangulation [9 patients (14%)]. There were 2 patients who died in the ED: 1 from a self-inflicted gunshot to the head and the other from self-inflicted herbal poisoning. The frequency of emergency airway intervention was greater in patients after unsuccessful attempted suicide [18 patients, 28% (95% confidence interval [CI], 17.2%, 39%; endotracheal intubation, 17 patients; emergency tracheotomy, 1 patient] than all ED patients [1458 patients (16%); (95% CI, 14.9%, 16.4%; P = 0.005)]. Following attempted survived suicide, 24-hour ED mortality was 3% and 4% within the control group; the difference is insignificant (P = 0.9596). However, ED mortality showed a trend toward earlier death within the suicidal group. Resuscitation room mortality of patients that survived unsuccessful suicide does not differ from the general population of an ED resuscitation room.

Prognostic value of National Early Warning Scores combined with arterial lactate level in critical elderly ill patients

Objective To investigate the prognostic value of National Early Warning Scores (NEWS) combined with arterial lactate level in elderly patients with critical illness in emergency department. Methods A total of 413 elderly patients with critical illness randomly (random number) selected from resuscitation room in emergency department from September 2013 to July 2015 were enrolled in this study. NEWS system was employed to determine the patients’ condition. Arterial lactate level was detected. The patients were followed for the 30-day death by telephone calls and patients were divided into survival group and death group. Multivariate logistic regression analysis and receiver operating characteristic curve (ROC) were used to evaluate the prognostic values of NEWS score, arterial lactate level, and NEWS score combined with arterial lactate level in patients without survival. Results There were significant differences in NEWS score and arterial lactate level between the death group and the survival group. The results of multiple factor regression showed that NEWS score, arterial lactate level, and NEWS score combined with arterial lactate level were all independent predictors of 30-day death (P 1). The AUCs of the three evaluation modalities were 0.721, 0.746 and 0.762, respectively. There was a significant difference in the area under the ROC curve between NEWS score and NEWS score combined with arterial lactate level. The optimal cut-off point of NEWS score was 7, and arterial lactate level was 2.7 mmol/L. Conclusions NEWS score, arterial lactate level, and NEWS score combined with arterial lactate level were independent predictors of 30-day death in elderly patients with critical illness in emergency department. They all had some predictive value, and NEWS score combined with arterial lactate level had higher capability to predict 30-day death in elderly patients with critical illness in emergency department than NEWS score alone. Key words: National early warning score; Arterial lactate level; Death risk; Prognosis; Aged; Emergency; Critical illness

Pediatric Emergency Medicine Simulation Curriculum: Hyponatremic Seizures.

Seizures are a common complaint in the pediatric emergency department. Effective care of this potentially life-threatening medical emergency requires the ability to stabilize the patient while simultaneously identifying and treating the underlying cause. This simulation-based curriculum involves the identification and management of a generalized seizure in a 4-month-old infant secondary to hyponatremia. The target audience is pediatric and emergency medicine residents, fellows, faculty, and nurses. There is no prerequisite preparation for the trainees prior to the case. The simulation scenario, simulation environment preparation, teamwork and communication glossary, and PowerPoint presentation are provided for the instructor in preparation for the simulation case. The setting is the emergency department (ED) resuscitation room. The simulation can be conducted in the ED resuscitation room or in the simulation lab. We used a high-fidelity infant mannequin. The debriefing tools have been tailored specifically for this scenario with advice on how the instructor can edit them for different learners. We have used this curriculum with a group of six pediatric emergency medicine fellows at various stages of their training at our institution. The curriculum received overwhelmingly positive feedback through the evaluation form. This resource will help support standardization of the teaching process, assisting simulation instructors to maximize their impact. In our experience, we have found that instructors who teach intermittently can successfully foster simulation-based education using similar resources. The inclusion of a learner feedback form supports the instructor's ongoing growth while helping faculty to document their teaching efforts.

Effectiveness of double lumen CVC with extra port in preventing multiple CVC insertions in critically ill patients

Critically ill shock patients presenting to the Emergency Department (ED) in Hamad General Hospital (HGH), Doha Qatar often needs central line when fluid resuscitation fails to improve their blood pressure (BP). Triple lumen central lines are used when vasopressor or inotropic support becomes necessary. In some of these patients, a double lumen dialysis line is later inserted (often in the femoral vein), when it becomes clearer that the patient will need urgent dialysis for worsening renal function or acid-base physiology. Another clinical scenario we often encounter is when patient admitted to the ED for emergency dialysis session. Some of these patients have borderline to low BP that become obvious during the dialysis, eventually needing some vasopressor support to enable the dialysis session to be continued. More than 2 years ago we introduced the use of dialysis line with extra port (Trilyse Expert by Vygon) in the Intensive Care Unit and now its use has spread to front line ED resuscitation room. Indications for Trilyse Expert insertion are: 1. Patients who needed vasopressor or inotropic support who may need dialysis, 2. Patients who needed dialysis with borderline to low BP who may need vasopressor support during dialysis, 3. Patients who needed both dialysis and vasopressor/inotropic support on presentation to ED. In this retrospective cohort we looked into the effectiveness of Trilyse Expert inserted in our ED resuscitation room in preventing the need of a second central line insertion. We also reviewed all relevant complications related to the device and its insertion. We also conducted a systematic literature review in the use of dialysis line with extra port in critically ill patients to support our findings. Results is shown in charts and tables. Concluding better outcome when using double lumen CVC with extra port.

Airway trolley in the Emergency Department – A service development project case report

Background: Hamad General Hospital (HGH) houses the main Emergency Department (ED) in Qatar. This busy ED has a 27 bedded resuscitation area. Within a 24 hour period there could be any number between 1 to 10 cases that needed emergency or urgent intubation. Over the years, there has been multiple addition of new life saving devices to the resuscitation areas. All these devices add to the clutter of the already crowded resuscitation area, and may indirectly add to the chaos and occupational risk typically seen in a busy environment. Methods: We aim to develop an airway trolley (by re-cycling available parts in the hospital) which can accommodate all standard airway equipment and all of our current difficult airway devices – Glidoscope, Stortz CMAC video laryngoscope and Stortz Flexible Intubating Video Endoscope. Results: We created a robust and easy to clean trolley, with ample of work platform and storage spaces within easy reach. At the same time it is also small and mobile enough to tolerate our narrow resuscitation room floor space. It has multiple power sockets to charge all of the video intubating devices, and its main power cord is long enough to reach any wall socket without significantly obstructing medical staff movements. Conclusion: With the help of the Engineering Department, we managed to create an airway trolley that fulfills our exact requirement more than what we can find in the current medical equipment market. At the same time we also declutter our busy ED resuscitation room.

Tracheal Intubation during Pediatric Cardiopulmonary Resuscitation: A Videography-Based Assessment in an Emergency Department Resuscitation Room: Donoghue A, Hsieh T, Nishisaki A, Myers S. Resuscitation 2016;99:38–43

Tracheal Intubation during Pediatric Cardiopulmonary Resuscitation: A Videography-Based Assessment in an Emergency Department Resuscitation Room: Donoghue A, Hsieh T, Nishisaki A, Myers S. Resuscitation 2016;99:38–43

Tracheal intubation during pediatric cardiopulmonary resuscitation: A videography-based assessment in an emergency department resuscitation room

ObjectivesTo describe procedural characteristics of tracheal intubation (TI) during cardiopulmonary resuscitation (CPR) in a pediatric emergency department, and to characterize interruptions in CPR associated with TI performance. MethodsRetrospective single center case series. Resuscitations in a pediatric ED are videorecorded for quality improvement. Children who underwent TI while receiving chest compressions were eligible for inclusion. Intubations done by methods other than direct laryngoscopy were excluded. Background data included patient age and training background of intubator. Data on intubation attempts (success, laryngoscopy time) and chest compressions (interruptions, duration of pauses) were collected. ResultsBetween December 2012 and February 2014, 32 patients had 59 TI attempts performed during CPR. Overall first attempt success at TI was 15/32 (47%); a median of 2 attempts were made per patient (range 1 to 4). Median laryngoscopy time was 47s (range 8–115s). 32/59 (54%) TI attempts had an associated interruption in CPR; the median interruption duration was 25s (range 3–64s). TI attempts without interruption in CPR were successful in 20/32 (63%) compared to 11/27 (41%) when CPR was paused (p=0.09). Laryngoscopy time was not significantly different between TI attempts with (47±21s) and without (47±26s; p=0.2) interruptions in compressions. 25/32 (78%) of pauses exceeded 10s in duration. ConclusionsTI during pediatric CPR results in significant interruptions in chest compressions. Procedural outcomes were not significantly different between attempts with and without compressions paused. In children receiving CPR, TI should be performed without pausing chest compressions.