Emergency Medicine Experts Research Articles

Bringing PERT to Pediatrics: Initial Experience and Outcomes of a Pediatric Multidisciplinary Pulmonary Embolism Response Team (PERT)

IntroductionMultidisciplinary Pulmonary Embolism Response Teams (PERTs) streamline care of adults with life-threatening pulmonary embolism (PE). Given rarity of pediatric PE, developing a clinical, educational, and research PERT paradigm is a novel and underutilized concept in pediatrics. Research QuestionIs PERT feasible in pediatrics, and does it improve PE care? Study Design and MethodsA strategy-to-execution proposal to launch a pediatric PERT was developed for institutional buy-in. Key stakeholders collectively implemented PERT. Data were collected for the two-year pre- and post-PERT eras, and outcomes were compared. ResultsPERT implementation took 12 months. Our PERT, led by hematology, comprises of pediatric experts in emergency medicine, critical care, interventional cardiology, anesthesiology, and interventional radiology. Data on 30 patients pre-PERT and 31 post-PERT were analyzed. Pre-PERT, 10%(3/30), 13%(4/30), 20%(6/30), and 57%(17/30), and post-PERT, 3%(1/31), 10%(3/31), 16%(5/31), and 71%(22/31) were categorized as high-risk, intermediate-LOW risk, intermediate-HIGH risk, and low-risk PE, respectively. Post-PERT, there were 13 unique PERT activations. PERT was activated on all eligible PE patients and, additionally, on four low-risk PEs. Time-to-echocardiogram was shorter post-PERT (4.7 hrs vs 2 hrs, P=0.0147). Anticoagulation was ordered (90 min vs 54 min, P=0.003) and given sooner (154 min vs 113 min, P=0.049) post-PERT. There were no differences in time-to-reperfusion therapies (12 hrs pre-PERT vs 8.7 hrs post-PERT, P=0.1). Five (83.3%) of six eligible (intermediate-HIGH and high-risk) patients received reperfusion therapies in the post-PERT era compared to three (37.5%) of eight eligible patients in the pre-PERT era (P=0.0001). There were no differences in major bleeding, mortality, or length of stay in either era. InterpretationThe pediatric PERT paradigm was successfully created and adopted locally. Our PERT enhanced access to experts, facilitated timely advanced therapies, and held value for low-risk PE. The University of Texas Southwestern Medical Center (UTSW) and Children’s Health System of Texas pediatric PERT may serve as a best-practice model for streamlining care for pediatric PE.

Development of an Emergency Department Safety Checklist through a global consensus process.

Emergency departments (EDs) are at high risk for medical errors. Checklist implementation programs have been associated with improved patient outcomes in other high-risk clinical settings and when used to address specific aspects of ED care. The aim of this study was to develop an ED Safety Checklist with broad applicability across different international ED settings. Athree-round modified Delphi consensus processwasconductedwith a multidisciplinary and multinational panel of experts in emergency medicine and patient safety. Initial checklist items were identified through a systematic review of the literature. Each item was evaluated for inclusion in the final checklist during two rounds of web-based surveys and an online consensus meeting. Agreement for inclusion was defined a priori with a threshold of 80% combined agreement. Eighty panel members from 34 countries across all seven world regions participated in the study, with comparable representation from low- and middle-income and high-income countries. The final checklist contains 86 items divided into: (1) a general ED Safety Checklist focused on diagnostic evaluation, patient reassessment, and disposition and (2) five domain-specific ED Safety Checklists focused on handoff, invasive procedures, triage, treatment prescription, and treatment administration. The checklist includes key clinical tasks to prevent medical errors, as well as items to improve communication among ED team members and with patients and their families. This novel ED Safety Checklist defines the essential elements of high-quality ED care and has the potential to ensure their consistent implementation worldwide.

Expert management consensus for the application of point-of-care testing in emergency and critical care (2024)

Point-of-care testing (POCT) is a testing approach that can be completed promptly, and for patients with acute and severe diseases, it can help clinicians identify changes in patients' conditions early and save patients' lives. Currently, the application of POCT in critical and emergency situations lacks a comprehensive clinical management consensus, leading to a lack of standardized guidance for its practical application. In order to standardize the application of POCT in critical and emergency situations, Emergency Medicine Association of Wuhan Medical Association organized multiple experts in the field of emergency and critical care to discuss and identify the current clinical issues that require standardized consensus in the application of POCT in emergency and critical care. Furthermore, a comprehensive literature search of domestic and international literature was conducted, and discussions and modifications were organized among emergency and critical care medicine experts. Ultimately, the Expert management consensus for the application of point-of-care testing in emergency and critical care (2024), which involves personnel management, equipment management and data management was formed. This consensus aims to provide more comprehensive standards and guidance for the application of POCT in critical care, thereby improving the quality of patient care and medical efficiency.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement.

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

International Consensus Criteria for Pediatric Sepsis and Septic Shock

Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. To update and evaluate criteria for sepsis and septic shock in children. The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.

Integration of Geriatric Education Within the American Board of Emergency Medicine Model.

Emergency medicine (EM) resident training is guided by the American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (EM Model) and the EM Milestones as developed based on the knowledge, skills, and abilities (KSA) list. These are consensus documents developed by a collaborative working group of seven national EM organizations. External experts in geriatric EM also developed competency recommendations for EM residency education in geriatrics, but these are not being taught in many residency programs. Our objective was to evaluate how the geriatric EM competencies integrate/overlap with the EM Model and KSAs to help residency programs include them in their educational curricula. Trained emergency physicians independently mapped the geriatric resident competencies onto the 2019 EM Model items and the 2021 KSAs using Excel spreadsheets. Discrepancies were resolved by an independent reviewer with experience with the EM Model development and resident education, and the final mapping was reviewed by all team members. The EM Model included 77% (20/26) of the geriatric competencies. The KSAs included most of the geriatric competencies (81%, 21/26). All but one of the geriatric competencies mapped onto either the EM Model or the KSAs. Within the KSAs, most of the geriatric competencies mapped onto necessary level skills (ranked B, C, D, or E) with only five (8%) also mapping onto advanced skills (ranked A). All but one of the geriatric EM competencies mapped to the current EM Model and KSAs. The geriatric competencies correspond to knowledge at all levels of training within the KSAs, from beginner to expert in EM. Educators in EM can use this mapping to integrate the geriatric competencies within their curriculums.

Chinese experts consensus on aldehyde metabolism disorder guided the early management of emergency and critical care medicine (2023)

Emergency and critical diseases is characterized by suddenness, complexity and unpredictability, which can lead to severe adverse prognosis such as shock or multiple organ failure. It has been confirmed that the common mechanism of aldehyde metabolism disorder leading to the accumulation of a large number of aldehydes, injury of cells and tissues caused by toxic aldehydes, and organ dysfunction existed in various emergency and critical diseases. However, the definition of the theory of aldehyde metabolism disorder, the detection methods of aldehydes, and the application of the theory of aldehyde metabolism disorder in guiding the early treatment of emergency and critical diseases have not been systematized and standardized. Therefore, Chinese Society of Emergency Medicine, Chest Pain Branch of China International Exchange and Promotive Association for Medical and Health Care, and Multidisciplinary Joint Committee on Cardiopulmonary Resuscitation and Extracorporeal Life Support of Shandong Medical Association organized multidisciplinary experts in emergency and critical care medicine, pharmacy, and molecular chemistry, etc., to comprehensively review the basic and clinical research on the effect of aldehyde metabolism disorder in the early stage of emergency and critical diseases at home and abroad, and jointly formulated the Chinese experts consensus on aldehyde metabolism disorder guided the early management of emergency and critical care medicine (2023). The novel and common consensus on the aldehyde metabolism disorder aims to further improve the treatment level of the emergency and critical diseases, so as to put forward a new, safe and reliable treatment strategy for the critical patients, and improve the overall survival rate of the critical patients.

Factors causing emergency medical care overload during heatwaves: A Delphi study.

Heatwaves pose an important risk for population health and are associated with an increased demand for emergency care. To find factors causing such overload, an online Delphi study included 15 experts in emergency medicine, disaster medicine, or public health. One open-ended question was delivered in the first round. After content analysis, the obtained statements were sent to the experts in two rounds to be rated on a 7-point linear scale. Consensus was defined as a standard deviation ≤ 1.0. Thirty-one statements were obtained after content analysis. The experts agreed on 18 statements, mostly focusing on the input section of patient processing and identifying stakeholders, the population, and primary care as targets of potential interventions. Additional dedicated resources and bed capacity were deemed important as per throughput and output sections, respectively. These findings could be used in the future to implement and test solutions to increase emergency healthcare resilience during heatwaves and reduce disaster risk due to climatic change.

Delphi Process for Validation of Fluid Treatment Algorithm for Critically Ill Pediatric Trauma Patients

IntroductionWhile intravenous fluid therapy is essential to re-establishing volume status in children who have experienced trauma, aggressive resuscitation can lead to various complications. There remains a lack of consensus on whether pediatric trauma patients will benefit from a liberal or restrictive crystalloid resuscitation approach and how to optimally identify and transition between fluid phases. MethodsA panel was comprised of physicians with expertise in pediatric trauma, critical care, and emergency medicine. A three-round Delphi process was conducted via an online survey, with each round being followed by a live video conference. Experts agreed or disagreed with each aspect of the proposed fluid management algorithm on a five-level Likert scale. The group opinion level defined an algorithm parameter's acceptance or rejection with greater than 75% agreement resulting in acceptance and greater than 50% disagreement resulting in rejection. The remaining were discussed and re-presented in the next round. ResultsFourteen experts from five Level 1 pediatric trauma centers representing three subspecialties were included. Responses were received from 13/14 participants (93%). In round 1, 64% of the parameters were accepted, while the remaining 36% were discussed and re-presented. In round 2, 90% of the parameters were accepted. Following round 3, there was 100% acceptance by all the experts on the revised and final version of the algorithm. ConclusionsWe present a validated algorithm for intavenous fluid management in pediatric trauma patients that focuses on the de-escalation of fluids. Focusing on this time point of fluid therapy will help minimize iatrogenic complications of crystalloid fluids within this patient population.

Implementation of a Multipronged Intervention to Improvement Inpatient Sickle Cell Disease Care

Introduction: Over the decades, many interventions have been used to improve care for patients with Sickle Cell Disease (SCD). There are 19 whole lifespan SCD centers, 30 pediatric SCD centers, and 28 adult SCD centers compared to 6,129 hospitals and over 220 children's hospitals in the US. The number of providers is insufficient to meet the needs of patients with SCD. Caring for patients without a dedicated Comprehensive SCD Center, such as our institution, can be challenging. Therefore, we developed a framework to leverage expertise in hematology, internal medicine, and emergency medicine to improve SCD patient care processes. In these settings, filling the gap in SCD care requires a multipronged creative approach that is implemented over time in a stepwise fashion. This allows time to adapt the intervention to the local medical system for more enduring change. This project looks at the longitudinal interventions that have occurred at the University of Chicago (UC) to address SCD care and discusses procedures to achieve successful implementation. Methods: In the first step, we identified the key stakeholders to determine the system's needs and goals (Table 1). This involved clinicians and staff who were interested in improving care for patients with SCD. The second step involved stakeholders creating a plan after analyzing the current care. Multipronged interventions were developed and implemented (see Figure 1 for a timeline and list of interventions). The final steps involved provider training. Furthermore, we tracked the progress of our interventions using the Electronic Medical Record (EMR). An EMR review was performed from 7/17/22 to 6/13/23 to evaluate our utilization. Descriptive statistics and Chi-Square were used to evaluate the data. This project was formally determined to be quality improvement and was therefore not overseen by the Institutional Review Board. Results: Regarding the first step, our task force comprises a large multidisciplinary group (see Table 1 for a full list). Next, it was important that we implement sustainable and useful systems (see Figure 1). In the review period, 154 patients were admitted 488 times. The SPP was used or viewed 134 times. Seventy-nine percent (122/154) of admitted patients had an IPP that was used, viewed, or created during their admission. Since the opening of the SCD Day clinic, there have been a total of 1045 SCD-related encounters, with an average of 36 patients a month or 1.7 patients a day. When comparing the review period to the same time in the prior year, the inpatient hydroxyurea protocol did not significantly improve the use of the medication. Hydroxyurea use changed from 64% to 65% of admissions and 65% to 68% of admitted patients. The inpatient SCD consult service received new consult requests in 44% of SCD admissions (214 total times). Lastly, over 100 hospitalists, resident physicians, inpatient teaching team physicians, and hematology physicians were educated along the way regarding changes in our system. Discussion: With time and a multipronged approach, achieving change in a large medical system is possible. The largest hurdle to overcome is funding. This is why our initial interventions focused on the implementation of EMR tools such as SPP, IPP, and educating providers. Though there was an up-front time cost, once completed, these interventions could be iterated on easily. It was not until 2022, that dedicated funding for a consult service could be secured. Having a large multidisciplinary team allows for creative ideas, dividing of tasks, accountability, and expertise in implementation. This does come with a limitation as it is harder to implement changes the larger the group becomes. Thus, a balance of members is vital. Frequent provider education is paramount in disseminating and improving the changes that are in the system. The plan, do, study, act model is a staple in quality improvement. It is important that there is foresight in developing a model to track the quality of care. The EMR's tools should be maximized to aid clinicians as efficiently as possible. Conclusion: Making large changes without funding or an institutional push can be challenging. Small incremental grassroots changes may be necessary until additional funding has been negotiated and secured. Meeting and exchanging ideas as a team and establishing pathways for improvement is a viable initial step.

Prehospital management of earthquake crush injuries: A collective review.

Earthquakes are natural disasters which can destroy the rural and urban infrastructure causing a high toll of injuries and death without advanced notice. We aim to review the prehospital medical management of earthquake crush injuries in the field. PubMed was searched using general terms including rhabdomyolysis, crush injury, and earthquake in English language without time restriction. Selected articles were critically evaluated by three experts in disaster medicine, emergency medicine, and critical care. The medical response to earthquakes includes: (1) search and rescue; (2) triage and initial stabilization; (3) definitive care; and (4) evacuation. Long-term, continuous pressure on muscles causes crush injury. Ischemia-reperfusion injury following the relieving of muscle compression may cause metabolic changes and rhabdomyolysis depending on the time of extrication. Sodium and water enter the cell causing cell swelling and hypovolemia, while potassium and myoglobin are released into the circulation. This may cause sudden cardiac arrest, acute extremity compartment syndrome, and acute kidney injury. Recognizing these conditions and treating them timely and properly in the field will save many patients. Majority of emergency physicians who have worked in the field of the recent Kahramanmaraş 2023, Turkey, earthquakes, have acknowledged their lack of knowledge and experience in managing earthquake crush injuries. We hope that this collective review will cover the essential knowledge needed for properly managing seriously crushed injured patients in the earthquake field.

Proposal for participation in intensive care and emergency medicine studies for patients unable to give informed consent (Cologne Model)

When conducting clinical trials in intensive care and emergency medicine, physicians, ethics committees, and legal experts have differing views regarding the inclusion of patients who are incapable of giving consent. These different views on the participation of patients who are not capable of giving consent also complicate how clinical trials are prepared and conducted. Based on the results of a literature search, aconsensus model (Cologne Model) was developed by physicians performing clinical research, ethics committees, and lawyers in order to provide patients, those scientifically responsible for the study, ethics committees, and probate (guardianship) judges with amaximum of patient safety and legal certainty, while simultaneously enabling scientific research.

Management of regional citrate anticoagulation for continuous renal replacement therapy: guideline recommendations from Chinese emergency medical doctor consensus

Continuous renal replacement therapy (CRRT) is widely used for treating critically-ill patients in the emergency department in China. Anticoagulant therapy is needed to prevent clotting in the extracorporeal circulation during CRRT. Regional citrate anticoagulation (RCA) has been shown to potentially be safer and more effective and is now recommended as the preferred anticoagulant method for CRRT. However, there is still a lack of unified standards for RCA management in the world, and there are many problems in using this method in clinical practice. The Emergency Medical Doctor Branch of the Chinese Medical Doctor Association (CMDA) organized a panel of domestic emergency medicine experts and international experts of CRRT to discuss RCA-related issues, including the advantages and disadvantages of RCA in CRRT anticoagulation, the principle of RCA, parameter settings for RCA, monitoring of RCA (mainly metabolic acid–base disorders), and special issues during RCA. Based on the latest available research evidence as well as the paneled experts’ clinical experience, considering the generalizability, suitability, and potential resource utilization, while also balancing clinical advantages and disadvantages, a total of 16 guideline recommendations were formed from the experts’ consensus.

The Priorities of End Users of Emergency Department Electronic Health Records: Modified Delphi Study

The needs of the emergency department (ED) pose unique challenges to modern electronic health record (EHR) systems. A diverse case load of high-acuity, high-complexity presentations, and ambulatory patients, all requiring multiple transitions of care, creates a rich environment through which to critically examine EHRs. This investigation aims to capture and analyze the perspective of end users of EHR about the strengths, limitations, and future priorities for EHR in the setting of the ED. In the first phase of this investigation, a literature search was conducted to identify 5 key usage categories of ED EHRs. Using key usage categories in the first phase, a modified Delphi study was conducted with a group of 12 panelists with expertise in both emergency medicine and health informatics. Across 3 rounds of surveys, panelists generated and refined a list of strengths, limitations, and key priorities. The findings from this investigation highlighted the preference of panelists for features maximizing functionality of basic clinical features relative to features of disruptive innovation. By capturing the perspectives of end users in the ED, this investigation highlights areas for the improvement or development of future EHRs in acute care settings.

Rethinking the Current "Stage-and-Wait" Paradigm.

The experience of terrorist incidents involving a secondary explosive device that targeted rescue forces led to changes in the safety protocols of these forces in most countries of the world. These protocols are the foundation of the current "Stage-and-Wait" paradigm that prohibits the entry of Emergency Medical Services (EMS) from entering the scene and treating casualties until it is deemed safe. These guidelines were established absent of an evidence-base detailing the risk to responders and the potential consequences to the injured on-scene. The lack of clarity is compounded by the fact that different situations, as well as operational considerations, such as the length of time until bomb squad arrival at the scene versus time of massive bleeding injuries, for example, impact outcomes must be taken into account. This study sought to shed light on this matter while employing an evidence-based approach exploring the investigations of the frequency of secondary explosion threats in terrorist attacks over the last 20 years and discussing some of the ethical challenges and ramifications ensuing. While this study does not propose an outright change to current guidelines, in light of the evidence gathered, an open review and discussion based on the findings may be beneficial. The Global Terrorism Database (GTD) was used as the data source of bombing incidents world-wide. The results revealed that approximately 70 per-1,000 bombing incidents involved secondary explosions across regions and countries within the study period. This study emphasizes the need to rethink the current "Stage-and-Wait" paradigm by recommending brainstorming conferences comprised of multi-sectoral experts aimed at deliberating the matter. World-wide experts in emergency medicine, bioethics, and disaster management should cautiously consider all aspects of bomb-related incidents. These brainstorming deliberations should consider the calculated risk of secondary explosions that account for approximately 70 per-1,000 bombing incidents. This study highlights the need to re-examine the current versus new paradigm to achieve a better balance between the need to ensure EMS safety while also providing the necessary and immediate care to improve casualty survival. This ethical dilemma of postponing urgent care needs to be confronted.

Rural trauma telementoring: a pilot project.

Background:Given Canada’s geographically dispersed population, initial trauma care may occur at rural sites that may not manage patients with trauma frequently; thus, telementoring can play a life-saving role. In this article, we describe a rural trauma telementoring pilot program in British Columbia and report the results of an evaluation of its strengths and weaknesses.Methods:Trauma surgeons from a quaternary trauma centre in Vancouver helped facilitate 3 in situ trauma simulation sessions at a rural BC hospital between fall 2019 and summer 2020. The sessions involved 4 physician participants (a trauma surgeon telementor, a family physician with additional expertise in emergency medicine acting as trauma team leader, a family physician with additional expertise in anesthesia and a family physician with Enhanced Surgical Skills), an emergency department nurse, 2 operating room/trauma team nurses, and laboratory and radiology technicians. The sessions involved simulated damage-control procedures and lasted about 2 hours. The participants completed surveys assessing comfort and confidence regarding aspects of trauma care and use of the telehealth unit before and after each session, and the facilitators assessed team dynamics using the Modified Non-Technical Skills for Trauma (T-NOTECHS) tool. Focus groups were held to gather qualitative data, and costs were tracked.Results:The average presimulation confidence survey score was 19.6/30, and the average postsimulation score was 24.0/30. The mean score improved significantly after both the first and second sessions (p = 0.01 and p = 0.004, respectively). Across the 3 sessions, the average T-NOTECHS score improved significantly, from 18.5/25 to 21.5/25 (p = 0.02). Qualitative analysis identified 3 dominant themes: telementoring increased provider confidence, telementoring increased order to the resuscitation procedure and the technical aspects of telementorship. The telementoring program was well received by all participants.Conclusion:A significant improvement was seen across simulations in physician confidence and trauma team dynamics with telementorship support. Telementoring in trauma may provide a way to lessen the difference between rural and urban patient outcomes within Canada’s geographically dispersed population, although further work investigating the impact of its use in real-life patients, as well as barriers to its implementation, is required.

Diagnosis and Acute Treatment of Ischemic Stroke.

Stroke is defined as an acute cerebrovascular accident characterized by an interruption of vascular supply lasting more than 24 hours. Therapeutic goal, reassumed at the well-known "time is brain", is strictly focused on achieving timely restoration of cerebral blood flow at risk of infarction to reduce neurological complications. Consequently, time to treatment is the most important determinant of the efficacy of reperfusion. Current guidelines strongly recommend the use of intravenous thrombolysis with tissue plasminogen activator and endovascular thrombectomy to reach that goal. These therapies allow to obtain 1.9 million neurons saved per each minute of onset-to-reperfusion time and 4.2 days of extra healthy life and are crucial in the reduction of mortality and morbidity of ischemic stroke. Multidisciplinary collaboration involving a coordinated prehospital management and stroke team composed of physicians with expertise in emergency medicine, neurologists, radiologists, nurses, technicians, and laboratory personnel are essential for rapid triage and should guide clinical decisions to deliver the appropriate reperfusion therapy for each patient.

Expert consensus for a national essential antidote list: E-Delphi method

Antidote stocking represents a major challenge to hospitals all over the world, including Kuwait. In order to assist hospitals to reduce costs and improve patient care, an essential antidote list can be used as an initial foundation for securing sufficient antidote availability at healthcare institutions. The aim of our study is to generate a nationally relevant essential antidote list for emergency care hospitals in Kuwait using the e-Delphi method by establishing consensus through a multidisciplinary expert group of healthcare providers. An electronic survey with 47 essential antidotes was developed. The e-Delphi method was used, with three rounds of voting, to determine expert consensus on an essential antidote list for hospitals in Kuwait. A purposive sample of healthcare professionals from governmental and private hospitals were selected for this study (n = 30). Consensus was gained if ≥75% of the expert panel agreed on the inclusion of the antidote, without any strong disagreements. Round 1 of the e-Delphi resulted in 41 antidotes reaching consensus and seven new antidotes suggested by the expert panel. Round 2 had two antidotes (out of seven newly suggested ones) reaching consensus. Round 3 was a confirmatory round, where the expert group agreed on their previous rounds’ opinions. This resulted in the development of an essential antidote list with 43 antidotes. The optimal approach for ensuring adequate availability of antidotes is continuous monitoring of local poisoning incidence and antidote requirements through collaborations between academic researchers and emergency care clinicians. The development of an essential antidote list, with expert consensus, is one of the initial steps in securing a foundation for appropriate provision of antidotes at all healthcare institutions. This is the first study that the authors are aware of that demonstrates that the e-Delphi technique can consolidate recommendations of experts in emergency medicine to provide a list of essential antidotes.

Consensus Development of a Core Content for a Standardized Medical Toxicology Curriculum for Medical Students.

BackgroundCurrently, no standardized core content in medical toxicology exists for medical students. The goals of this study were to (1) assess the current state and needs of medical toxicology clerkships and (2) develop a consensus-derived list of core topics that should be covered during a medical toxicology clerkship.MethodsWe assembled a task force established by the American College of Medical Toxicology (ACMT) of nine experts in medical toxicology or emergency medicine. We developed a needs assessment survey that was sent to all medical student clerkship directors in medical toxicology. Based on their responses, we used a modified Delphi process to develop a consensus of core topics that should be covered during a medical student clerkship.ResultsNineteen out of 42 (45%) clerkship directors completed the survey; 18 met inclusion criteria. The majority of clerkships were 4 weeks in duration with an average of 15 students/year. The three most common teaching methods used were bedside teaching (n = 17/18), classroom teaching (n = 17/18), and journal club (n = 14/18). All the clerkship directors (n = 18/18) reported they would use a standardized curriculum as well as educational content developed by ACMT. There was overwhelming consensus on the core topics which included, but were not limited to, pharmacology/toxicology; drugs; drugs of abuse; natural products; pharmacological basis of antidote use; toxicologic syndromes; vital sign abnormalities; initial management; supportive and other care; withdrawal syndrome management; industrial, household, and environmental toxins; differential diagnosis by clinical findings; and ABCs-resuscitation.ConclusionThe ACMT task force developed a medical toxicology clerkship core content. The task force also identified a need for shared resources among clerkships.