Intensive Care Team Research Articles

Determining the Requirements for the Development and Implementation of Follow-up Software for Patients Discharged from intensive Care: A Qualitative Study

Background: Intensive care unit stays are associated with numerous complications. These complications can be reduced with timely and appropriate medical services. Mobile applications can provide these services without geographical limitations. Accordingly, the present study aimed to evaluate the statements by the intensive care staff and care team of intensive care survivors on the necessary functionality for designing a mobile-based system for monitoring and following up on patients discharged from intensive care. Methods: This prospective study involved interviews with specialists that provided care to patients after discharge (including nurses, physicians, physiotherapists, speech therapists, psychologists, and nutritionists). The first interviewees were selected from the specialists in Kerman, Iran and then, the selection of the participants proceeded with the snowball sampling method. Interviews were transcribed and analyzed based on content analysis. Codes were extracted and categorized into three levels of abstraction using MAXQDA software. Results: Four general categories emerged from the interview analysis: 1) Training, 2) Consultation, 3) Electronic health records (EHRs), and 4) Care team. The interviewees mentioned items such as nursing and physiotherapy training (training category), physician and psychological consultation (consultation category), nurses (care team category), and side reports (EHRs category). Conclusion: This study presented healthcare professionals’ opinions and statements regarding the requirements for developing a mobile-based intensive care follow-up system. User input is essential to design a scalable and efficient system. Provider input can create a system with all the necessary features. The results can be used to adjust insurance regulations, provide the necessary infrastructure, and train care teams.

Management of tetralogy of Fallot in the pediatric intensive care unit.

Tetralogy of Fallot (ToF) is one of the most common congenital cyanotic heart lesions and can present to a variety of health care professionals, including teams working in pediatric intensive care. Pediatric intensive care teams may care for a child with ToF pre-operatively, peri-operatively, and post-operatively. Each stage of management presents its own unique challenges. In this paper we discuss the role of pediatric intensive care in each stage of management.

A Survey of Pediatric Neurocritical Care Fellowship Training in North America

BackgroundPediatric neurocritical care (PNCC) has emerged as a field to care for children at the intersection of critical illness and neurological dysfunction. PNCC fellowship programs evolved over the past decade to train physicians to fill this clinical need. We aimed to characterize PNCC fellowship training infrastructure and curriculum in the United States and Canada. MethodsWeb-based survey of PNCC fellowship program leaders during November 2019 to January 2020. ResultsThere were 14 self-identified PNCC fellowship programs. The programs were supported by Child Neurology and/or Pediatric Critical Care Medicine divisions at tertiary/quaternary care institutions. Most programs accepted trainees who were board-eligible or board-certified in child neurology or pediatric critical care medicine. Clinical training consisted mostly of rotations providing PNCC consultation (n = 13) or as a provider on the pediatric intensive care unit-based neurointensive care team (n = 2). PNCC-specific didactics were delivered at most institutions (n = 13). All institutions provided training in electroencephalography use in the intensive care unit and declaration of death by neurological criteria (n = 14). Scholarly activity was supported by most programs, including protected time for research (n = 10). ConclusionsWe characterized PNCC fellowship training in the United States and Canada, which in this continuously evolving field, lays the foundation for exploring standardization of training going forward.

Safety, efficacy, and timing of transplantation(s) in propionic and methylmalonic aciduria.

Propionic (PA) and methylmalonic aciduria (MMA) share many clinical similarities, which include the risk of acute metabolic encephalopathies, and some long-term complications, such as optic neuropathy, pancreatic involvement, developmental disability, and similar management approaches, but they also represent distinct clinical and biochemical entities. In the severe forms of PA and MMA, most long-term complications cannot be prevented with conventional clinical management. Organ transplantation represents a form of partial enzyme replacement to improve the long-term outlook for these disorders. There is evidence that early liver transplant in both disorders greatly improves metabolic stability and reduces the risk of long-term complications. For MMA, early liver transplant reduces methylmalonic acid levels which in turns reduces its effects on kidneys, and therefore slows progression of chronic kidney disease. However, established organ damage cannot be reversed. For patients with MMA who present with chronic kidney disease, consideration should be given for combined liver and kidney transplants. Transplantation in PA and MMA carries a high risk of complications and requires highly specialised pre-operative and peri-operative management. Involvement of a multidisciplinary team is essential and should include metabolic team, nephrologist, hepatologist, hepatobiliary and renal transplant surgeons, anaesthesiologists, cardiologists, intensive care team, dieticians and specialist nurses. These patients require life-long multidisciplinary follow-up. There is increasing evidence in the literature on excellent short to medium-term patient and allograft survival following transplantation when patients are managed by a multidisciplinary team in a specialist centre. Improved early diagnosis and reductions in transplant-related mortality and morbidity have allowed early transplantation to be used electively to further improve the outcome.

Sepsis mortality and ICU length of stay after the implementation of an intensive care team in the emergency department.

Emergency department patient boarding is associated with hospital mortality and increased hospital length of stay. The objective of thepresent study is to describe the impact of deploying an Intensive Care team in the ED and its association with sepsis mortality and ICU length of stay. Patients admitted to ICU through theED with an ICD-10 CM diagnosis of sepsis were included. Preintervention and postintervention phases included 4 and 15months, respectively. Sepsis time zero, SEP-1 compliance, and lag time from time zero to antibiotic administration were compared. Outcomes of interest were mortality and ICU LOS. 1021 septic patients were included. Sixty-six percent fulfilled compliance with 3h SEP-1 bundle. Lag time from time zero to antibiotic administration was 75min. Multivariate analysis showed no association between ICU team in the ED and hospital mortality (Log OR 0.94, CI 0.67-1.34; p = 0.73). The ICU team in the ED was associated with prolonged ICU LOS (Log OR 1.21, CI 1.13-1.30; p < 0.01). Septic shock and ED boarding time were associated with prolonged ICU LOS. Compliance with SEP-1 bundle was associated with its reduction. Implementation of an ICU team in the ED for the treatment of septic patients during high volume hospitalizations is not associated with a reduction of mortality or ICU LOS.

V03-09 MANAGEMENT OF INTRAOPERATIVE VASCULAR INJURIES IN UROLOGIC SINGLE-PORT OR MULTI-PORT ROBOTIC SURGERY

You have accessJournal of UrologyCME1 Apr 2023V03-09 MANAGEMENT OF INTRAOPERATIVE VASCULAR INJURIES IN UROLOGIC SINGLE-PORT OR MULTI-PORT ROBOTIC SURGERY Anh Nguyen, David Ali, Benjamin Rudnick, Rogerio Huang, Mubashir Shabil Billah, and Mutahar Ahmed Anh NguyenAnh Nguyen More articles by this author , David AliDavid Ali More articles by this author , Benjamin RudnickBenjamin Rudnick More articles by this author , Rogerio HuangRogerio Huang More articles by this author , Mubashir Shabil BillahMubashir Shabil Billah More articles by this author , and Mutahar AhmedMutahar Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There are many challenges to managing vascular injuries during robotic urologic surgeries. These include limited exposure due to the small field, inability to quickly expand the surgical field with retractors and additional personnel, inability manually palpate or apply manual pressure over a broad area, and reliance on a limited array of robotic instruments. Other challenges include the limited field of vision of the robotic camera, as well as reliance on insufflation to maintain adequate visualization. Consultant surgeons may not have significant experience with using the robot. These all can translate into longer operative times for repair of vascular injuries with resultant blood loss. We sought to share insights on how a robotic surgeon may handle repairing a vascular injury. METHODS: Three robotic multi- and single-port operative cases with vascular injuries were examined. Operative strategy was analyzed and discussed. RESULTS: A single-port robotic nephroureterctomy was done on a 68 year-old female with past history of endometrial cancer, hysterectomy with lymph node dissection, and radiation to the pelvis. A common iliac vein injury was incurred during dissection of the distal ureter and was repaired using robotic 4th arm to clamp the injured vessel, strategic use of ROSI suction, and non-absorbable 4-0 suture. A multi-port robotic radical prostatectomy was done on a 63 year-old male with history of Gleason 4+3 prostate cancer with inadvertent injury of the external iliac artery. A combination of robotic bulldog clamps, assistant suction and non-absorbable 4-0 suture was used to successfully repair the injury. Lastly, a multi-port robotic adrenalectomy was done for a 48 year-old female with a 6.5 cm adrenal mass with invasion into the IVC. Repair of the IVC was done with a combination of 4th arm and bulldog clamps, vessel loop traction, and non-absorbable 4-0 suture. CONCLUSIONS: Strategies to robotically repair inadvertent vascular injuries during urologic surgery require strategic use of the 4th robotic arm, assistant- or robotically-applied clamps, and assistant instruments to free up working arms. Non-absorbable suture should be readily available. Closure of large blood vessels require releasing clamps momentarily before closure to avoid air embolus. Maximal visualization can be achieved using the zoom features of the robotic camera and its ability to discriminate fine detail. Maintaining composure with frequent and adequate communication with anesthesia and intensive care teams is vital in safely managing vascular injuries. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e248 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anh Nguyen More articles by this author David Ali More articles by this author Benjamin Rudnick More articles by this author Rogerio Huang More articles by this author Mubashir Shabil Billah More articles by this author Mutahar Ahmed More articles by this author Expand All Advertisement PDF downloadLoading ...

Successful Autologous Bone Marrow Transplantation in Active COVID-19 Patients: Case Report

BackgroundPatients with hematologic malignancies are considered at high risk for COVID-19 infection either from the disease or the treatment. Hematopoietic stem cell transplantation, one of the approved therapies for hematologic malignancies, was performed worldwide during the COVID-19 era with some regulations, such as COVID-19 testing, before proceeding with transplantation or cellular therapy. To the authors’ knowledge, none have reported the result of autologous hematopoietic stem cell transplantation in an active COVID-19 patient. Case PresentationWe describe a successful clinical course of autologous bone marrow transplantation for 2 lymphoma patients who tested positive for COVID-19. A thorough discussion was conducted between multidisciplinary hemato-oncology, intensive care, and infectious diseases teams. The decision was to proceed toward bone marrow transplantation with some modifications in the transplantation protocol and close patient monitoring. ConclusionOur cases lend credence that successful autologous bone marrow transplantation is possible among active COVID-19 patients. The obstacles we faced could be overcome with collaboration between a highly qualified multidisciplinary team. Despite the potential complications, the benefits of bone marrow transplantation among patients with a high risk of relapse and who are still COVID-19-positive outweigh the risks. However, further studies are still recommended to support our inference.

Warm versus cold-blood cardioplegia in paediatric congenital heart surgery: a randomized trial.

Intermittent cold blood cardioplegia is commonly used in children whereas intermittent warm blood cardioplegia is widely used in adults. We aimed to compare clinical and biochemical outcomes with these two methods. A single centre, randomized controlled trial was conducted to compare the effectiveness of warm (≥34°C) versus cold (4-6°C) antegrade cardioplegia in children. The primary outcome was cardiac troponin T over the first 48 postoperative hours. Intensive care teams were blinded to group allocation. Outcomes were compared by intention-to-treat using linear mixed-effects, logistic, or Cox regression. 97 participants with median age of 1.2 years were randomized (49 to warm, 48 to cold cardioplegia); 59 participants (61%) had a risk-adjusted congenital heart surgery score of 3 or above. There were no deaths and 92 participants were followed to 3-months. Troponin release was similar in both groups (geometric mean ratio 1.07; 95% confidence interval [CI], 0.79-1.44; P = 0.66), as were other cardiac function measures (echocardiography, arterial and venous blood gases, vasoactive-inotrope score, arrhythmias). Intensive care stay was on average 14.6 hours longer in the warm group (hazard ratio 0.52; 95% CI, 0.34-0.79; P = 0.003), with a trend towards longer overall hospital stays (hazard ratio 0.66; 95% CI, 0.43-1.02; P = 0.060) compared with the cold group. This could be related to more unplanned reoperations on bypass in the warm group compared to cold group (3 vs 1). Warm blood cardioplegia is a safe and reproducible technique but does not provide superior myocardial protection in paediatric heart surgery. ISRCTN13467772.

Neuromonitoring in Critically Ill Patients.

Critically ill patients are at high risk of acute brain injury. Bedside multimodality neuromonitoring techniques can provide a direct assessment of physiologic interactions between systemic derangements and intracranial processes and offer the potential for early detection of neurologic deterioration before clinically manifest signs occur. Neuromonitoring provides measurable parameters of new or evolving brain injury that can be used as a target for investigating various therapeutic interventions, monitoring treatment responses, and testing clinical paradigms that could reduce secondary brain injury and improve clinical outcomes. Further investigations may also reveal neuromonitoring markers that can assist in neuroprognostication. We provide an up-to-date summary of clinical applications, risks, benefits, and challenges of various invasive and noninvasive neuromonitoring modalities. English articles were retrieved using pertinent search terms related to invasive and noninvasive neuromonitoring techniques in PubMed and CINAHL. Original research, review articles, commentaries, and guidelines. Syntheses of data retrieved from relevant publications are summarized into a narrative review. A cascade of cerebral and systemic pathophysiological processes can compound neuronal damage in critically ill patients. Numerous neuromonitoring modalities and their clinical applications have been investigated in critically ill patients that monitor a range of neurologic physiologic processes, including clinical neurologic assessments, electrophysiology tests, cerebral blood flow, substrate delivery, substrate utilization, and cellular metabolism. Most studies in neuromonitoring have focused on traumatic brain injury, with a paucity of data on other clinical types of acute brain injury. We provide a concise summary of the most commonly used invasive and noninvasive neuromonitoring techniques, their associated risks, their bedside clinical application, and the implications of common findings to guide evaluation and management of critically ill patients. Neuromonitoring techniques provide an essential tool to facilitate early detection and treatment of acute brain injury in critical care. Awareness of the nuances of their use and clinical applications can empower the intensive care team with tools to potentially reduce the burden of neurologic morbidity in critically ill patients.

Improvement in Multidisciplinary Provider Rounding (Surgical Rounds) in the Pediatric Cardiac ICU: An Application of Lean Methodology.

Provider-only, combined surgical, and medical multidisciplinary rounds ("surgical rounds") are essential to achieve optimal outcomes in large pediatric cardiac ICUs. Lean methodology was applied with the aims of identifying areas of waste and nonvalue-added work within the surgical rounds process. Thereby, the goals were to improve rounding efficiency and reduce rounding duration while not sacrificing critical patient care discussion nor delaying bedside rounds or surgical start times. Single-center improvement science study with observational and interventional phases from February 2, 2021, to July 31, 2021. Tertiary pediatric cardiac ICU. Cardiothoracic surgery and cardiac intensive care team members participating in daily "surgical" rounds. Implementation of technology automation, creation of work instructions, standardization of patient presentation content and order, provider training, and novel role assignment. Sixty-one multidisciplinary rounds were observed (30 pre, 31 postintervention). During the preintervention period, identified inefficiencies included prolonged preparation time, redundant work, presentation variability and extraneous information, and frequent provider transitions. Application of targeted interventions resulted in a 26% decrease in indexed rounds duration (2.42 vs 1.8 min; p = 0.0003), 50% decrease in indexed rounds preparation time (0.53 vs 0.27 min; p < 0.0001), and 66% decrease in transition time between patients (0.09 vs 0.03 min; p < 0.0001). The number of presenting provider changes also decreased (9 vs 4; p < 0.0001). Indexed discussion duration did not change (1 vs 0.98 min; p = 0.08) nor did balancing measures (bedside rounds and surgical start times) change (8.5 vs 9 min; p = 0.89 and 38 vs 22 min; p = 0.09). Lean methodology can be effectively applied to multidisciplinary rounds in a joint cardiothoracic surgery/cardiac intensive care setting to decrease waste and inefficiency. Interventions resulted in decreased preparation time, transition time, presenting provider changes, total rounds duration indexed to patient census, and anecdotal improvements in provider satisfaction.

When pediatric resuscitation and anesthesia teams simulate together

At the Grenoble-Alpes University Hospital Center, a high-fidelity simulation training project was born from the collaboration of the intensive care and pediatric anesthesia teams. The objective of these sessions was to improve practices by developing the technical and non-technical skills of the teams. Fifteen days were organized from 2018 to 2022, training 170 healthcare professionals. The results highlighted excellent satisfaction and helped improve professional practices.

Evaluation of pediatric renal transplant recipients admitted to the intensive care unit: A retrospective cohort study

Background/Aim: The best course of treatment for children with end-stage kidney disease (ESKD) is renal transplantation (RT), but some pediatric RT recipients are admitted to an intensive care unit (ICU) post-transplant. In the early and late post-operative phases, clinical data about pediatric RT recipients who are admitted to ICU are available. In this study, we aimed to evaluate demographic features, main reasons, and outcomes of pediatric RT patients admitted to the ICU during the early and late post-operative phases. Methods: This study was a cohort study. We analyzed the medical records of pediatric RT recipients (&lt;18 years of age) who were admitted to the ICU between May 30, 2011, and October 16, 2021, at our center, retrospectively. Patients ≥18 years of age and those without available data were excluded. We obtained the following data from ICU follow-up records and hospital medical records. The median (minimum-maximum) for continuous variables, frequencies, and percentages for categorical variables were used. The Chi-square test was used to compare categorical variables. We created graphs using percentages and frequencies to summarize the results. Results: Nineteen (16.5%) of the 115 pediatric patients who underwent RT were admitted to the ICU during the study period. Thirteen patients (68.4%) were male, and the mean age was 10.2 (4.9) years. Hypertension (21.2%) was the most common comorbidity. Eighteen (94.7%) received transplants from living donors. Cystic-hereditary-congenital disorders (42.1%, n=8) and congenital anomalies of the kidney and urinary tract (26.3%, n=5) were among the etiologies of ESKD. Ten patients (52.6%) were admitted to the ICU &gt;6 months after transplantation. Epileptic seizure (n=6, 31.6%), respiratory failure (n=4, 21.1%), and cardiac diseases (n=2, 10.5%) were among the main reasons for ICU admission. During ICU follow-up, invasive mechanical ventilation was needed for five patients (26.3%), and renal replacement treatment was needed for four patients (21.1%). The mean length of ICU was 12.4 (28.5), and the mean hospital stay was 25.8 (29.4) days. The ICU and hospital survival rates were 78.9% and 97%, respectively, while 3.5% was the hospital mortality rate. Hemorrhagic cerebrovascular disease, acute hepatic failure, and cardiogenic shock secondary to pericardiocentesis were the causes of death in the ICU. Conclusion: Patients mostly had ICU admissions because of epileptic seizures and acute respiratory failure. A multidisciplinary approach involving pediatric nephrologists, transplant surgeons, and an intensive care team successfully manages pediatric RT recipients admitted to the intensive care unit.

Airway and Respiratory Devices in the Prevention of Ventilator-Associated Pneumonia.

Ventilator-associated pneumonia (VAP) is the most common ICU-acquired infection among patients under mechanical ventilation (MV). It may occur in up to 50% of mechanically ventilated patients and is associated with an increased duration of MV, antibiotic consumption, increased morbidity, and mortality. VAP prevention is a multifaceted priority of the intensive care team. The use of specialized artificial airways and other devices can have an impact on the prevention of VAP. However, these devices can also have adverse effects, and aspects of their efficacy in the prevention of VAP are still a matter of debate. This article provides a narrative review of how different airway and respiratory devices may help to reduce the incidence of VAP.

Finding New Meaning in the Practice of Medicine: A Quality Improvement Project Evaluating the Remote Communication Liaison Program During the Initial COVID Pandemic Surge.

Background: In spring 2020, the COVID-19 pandemic overwhelmed intensive care teams with severely ill patients. Even at the end of life, families were barred from hospitals, relying solely on remote communication. A Remote Communication Liaison Program (RCLP) was established to ensure daily communication for families, while supporting overstretched intensivists. Objectives: To evaluate the effectiveness and impact of the RCLP on participating liaisons and intensivists. Design: Two quality improvement surveys were developed and administered electronically. Setting/Subjects: Based in the United States, all liaisons and intensivists who participated in this program were invited to take the surveys. Measurements: Descriptive statistics were used to analyze the quantitative Likert-scale data, and qualitative analysis was used to assess themes. Results: Among respondents, all (100%) liaisons and more than 90% of intensivists agreed or strongly agreed that the RCLP provided a valuable service to families. More than 70% of intensivists agreed or strongly agreed that the program lessened their workload. More than 90% of liaisons agreed or strongly agreed that participation in the program improved their confidence and skills in end-of-life decision making, difficult conversations, and comprehension of critical care charts. Themes elicited from the liaisons revealed that participation fostered a renewed sense of purpose as physicians, meaningful connection, and opportunities for growth. Conclusions: RCLP successfully trained and deployed liaisons to rapidly develop skills in communication with beleaguered families during COVID-19 surge. Participation in the program had a profound effect on liaisons, who experienced a renewed sense of meaning and connection to the practice of medicine.

Intensivist-led ultrasound-guided percutaneous tracheostomy: a phase IV cohort study.

To describe, with a larger number of patients in a real-world scenario following routine implementation, intensivist-led ultrasound-guided percutaneous dilational tracheostomy and the possible risks and complications of the procedure not identified in clinical trials. This was a phase IV cohort study of patients admitted to three intensive care units of a quaternary academic hospital who underwent intensivist-led ultrasound-guided percutaneous tracheostomy in Brazil from September 2017 to December 2021. There were 4,810 intensive care unit admissions during the study period; 2,084 patients received mechanical ventilation, and 287 underwent tracheostomy, 227 of which were performed at bedside by the intensive care team. The main reason for intensive care unit admission was trauma, and for perform a tracheostomy it was a neurological impairment or an inability to protect the airways. The median time from intubation to tracheostomy was 14 days. Intensive care residents performed 76% of the procedures. At least one complication occurred in 29.5% of the procedures, the most common being hemodynamic instability and extubation during the procedure, with only 3 serious complications. The intensive care unit mortality was 29.1%, and the hospital mortality was 43.6%. Intensivist-led ultrasound-guided percutaneous tracheostomy is feasible out of a clinical trial context with outcomes and complications comparable to those in the literature. Intensivists can acquire this competence during their training but should be aware of potential complications to enhance procedural safety.

Digital technology for the prevention of healthcare-related infections in critical care.

To develop digital technology for patient and family integration into the Intensive Care Unit care team, aiming to subsidize decision-making for the prevention of infections related to healthcare. Methodological research of technological production in three phases: pre-production, production, and post-production in a teaching hospital in southern Brazil. Sixteen intensive care unit nurses participated. The research produced six videos: general guidelines on the Intensive Care Unit, Preventing infections: hand hygiene; Pneumonia associated with mechanical ventilation; Catheter-associated primary bloodstream infection; Catheter-related urinary tract infection. The proposed technology was developed and aims to assist nurses in bringing patients and families closer to the routines of the intensive care environment to provide safety in the contact of the patient of intensive care units with family members and in the active participation for the prevention of infections related to healthcare.

Evaluation of "Care Plus," A Multidisciplinary Program to Improve Population Health for Patients With High Utilization.

With rising health care costs, health systems have adopted alternative care models targeting high-need, high-cost patients to improve chronic disease management and population health. Intensive primary care teams may reduce health care utilization by tackling medical and psychosocial needs specific to this patient population. This study presents health care utilization trends from a high-intensity primary care program that employs a multidisciplinary team (including clinicians, psychologists, pharmacists, chaplaincy, and community health workers) and community partnerships. Using descriptive statistics and Poisson rates of differences, this study evaluates patient and utilization characteristics of those enrolled (n = 341) versus declined (n = 54) program participation from 2013 to 2020. Both enrolled and declined patients experienced significant reduction in emergency department and inpatient utilization, but differences between enrolled and declined patients were not statistically significant. Programs aimed at decreasing health care utilization for high-need, high-cost, medically complex patients may be best supported by interventions that simultaneously address social and behavioral health needs.

Just-in-time in-situ simulation for high stakes success in viral haemorrhagic fever (VHF)

Success of just-in-time in-situ simulation to find new ways of working, test processes, and uncover latent error to promote patient and staff safety is well documented from the COVID-19 pandemic [1,2]. We used just-in-time simulation in a unique situation where imminent transfer of a critically unwell patient with VHF was required to our high-level isolation unit (HLIU). The Trexler isolator tent is custom made for treating high consequence infectious diseases (HCID), requires specific training. Staff provide care by ‘stepping’ into ‘suits’ in the plastic walls. Transfers into the tent are time-critical to reduce potential exposure risk to staff. This was the first time ever an intubated, ventilated patient was to be transferred into the tent. Simulation, Infectious Diseases, and Intensive Care teams collaborated within a few hours’ notice to simulate in-situ the mechanism of transferring a patient (using a Laerdal SimMan 3G) intubated and ventilated with multiple drug infusions running, headfirst from a transport trolley into the foot end of the isolator tent. This was repeated subsequently in several Plan-Do-Study-Act (PDSA) cycles to refine the process and reduce transfer time taken. There were multiple pauses as problems, latent threats, and potential failure points were identified, and time outs to discuss solutions. Transfer teams informally reported increased confidence being able to troubleshoot and rehearse the transfer process before patient arrival. Key learning related to leadership, communication, highlighting safety steps, and sharing mental models between teams such as airway management, significance during transfer and ergonomics of airway-trained personnel positioning in the tent. This was written up as a visual aid for the transfer team. Environmental latent threats found included safe ventilator mounting, IV pump management, emergency drug preparation, and allowed for enhanced consideration of the practicalities of caring for an intensive care patient in the HLIU tent. The actual transfer of the patient went smoothly and without incident. Further simulations were run during the patient care episode to rehearse and potential anticipate airway and ventilation management issues. Just-in-time in-situ simulation provided a valuable opportunity to rehearse a high-stakes, never done before activity, and facilitated identification of environmental latent threats before patient arrival. It created a shared mental model between different specialities of patient needs contributing towards an increased situational awareness and ability to forward plan and project, ultimately increasing patient and staff safety. 1. Guris RJ, Doshi A, Boyer DL, Good G, Gurnaney HG, Rosenblatt S, McGowan N, Widmeier K, Kishida M, Nadkarni V, Nishisaki A. Just-in-time simulation to guide workflow design for coronavirus disease 2019 difficult airway management. Pediatric Critical Care Medicine. 2020;21(8):e485. 2. Zucco L, Chen MJ, Levy N, Obeidat SS, Needham MJ, Hyatt A, Keane JR, Pollard RJ, Mitchell JD, Ramachandran SK. Just-in-Time In Situ Simulation Training as a Preparedness Measure for the Perioperative Care of COVID-19 Patients. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare. 2022 Feb 10; Published Ahead of Print. doi: 10.1097/SIH.0000000000000635 We acknowledge the hard work and expertise of the Infectious diseases and Intensive care medical and nursing leads and team who supported the delivery of this simulation, and the clinical and support staff who maintain and run the HLIU, and the NHS England Contact High Consequence Infectious Diseases Network.

Emergent Bedside Resternotomy: An Innovative Simulation Model for Training Pediatric Cardiac Intensive Care Teams

AbstractCardiac tamponade after cardiac surgery is a life-threatening event that requires simultaneous resuscitation and emergent resternotomy by the intensive care team. A simulated scenario using an innovative mannequin with sternotomy wound has the capability of reproducing cardiac arrest associated with postoperative tamponade. We evaluated the validity of this mannequin to investigate the confidence level and crisis resource management skills of the team during bedside resternotomy to manage postoperative cardiac tamponade. The simulation scenario was developed using the sternotomy mannequin for a pediatric cardiac intensive care unit (CICU) team. The case involved a 3-year-old male, intubated, and mechanically ventilated after surgical repair of congenital heart disease, progressing to cardiac arrest due to cardiac tamponade. We conducted a formative learner assessment before and after each scenario as well as a structured, video debriefing following each encounter. The simulation was repeated in a 6-month interval to assess knowledge retention and improvement in clinical workflow. The data were analyzed using student t-test and chi-square test, when appropriate. Of the 72 CICU providers, a significant proportion of providers (p &lt; 0.0001) showed improved confidence in assessing and managing cardiac arrest associated with postoperative cardiac tamponade. All providers scored ≥3 for the impact of the scenario on practice, teamwork, communication, assessment skills, improvement in cardiopulmonary resuscitation, and opening the chest and their confidence in attending similar clinical situations in future. Most (96–100%) scored ≥3 for the perception on the realism of mannequin, the scenario, reopening the sternotomy, and level of stress. Time to diagnosis of cardiac tamponade (p = 0.004), time to the first dose of epinephrine (p = 0.045), and median number of interruptions to chest compressions (p = 0.006) all significantly decreased between the two sessions. Time to completion of resternotomy improved by 81.4 seconds; however, this decrease was not statistically significant. Implementation of a high-fidelity mannequin for postoperative cardiac tamponade simulation can achieve a realistic and reproducible training model with positive impacts on multidisciplinary team education.

Implementation of a medical intensive care team in the emergency department of a tertiary medical center in the USA

ABSTRACT Objective Critically ill patients boarding in the ED have higher mortality rates. Several strategies have been implemented to deliver care to boarding patients. Our institution opted for a strategy consisting on deploying an Intensive Care team in the ED. This article reports outcomes before-and-after implementation of that team. Methods On November 2020, a Medical Intensive Care Team was deployed in the ED. The team performed consultations for ICU patients boarding in the ED. A retrospective analysis of critically ill patients arriving to the ED before-and-after team implementation was performed. Outcome data were reviewed. Direct hospitalization costs per patient, and direct costs per department were assessed. Wilcoxon rank sum and Chisq-test were utilized to compare differences pre- and post-implementation. Multivariate analyses to model outcomes toward pre- and post-implementation and other variables were performed. Results 1,828 and 3,272 patients were included in the pre- and post-intervention groups. ICU LOS (days) pre- and post-intervention were 3 (1,6) and 3 (1,6), respectively (p = 0.41). ICU readmission rates were 6.7% pre-intervention and 7.4% post-intervention (p = 0.37). Total direct costs were US$ 19,928 (11,006, 37,815) and US$ 15,795 (9016, 28,993), respectively (p < 0.01). Multivariate analysis showed no association between team deployment and ICU LOS or readmission. However, there was association between its implementation and hospitalization cost reduction per patient of US$ 7,171. Conclusion The implementation of a Medical Intensive Care team in the ED is not associated with a reduction of ICU LOS or ICU readmission. Nevertheless, its implementation is associated with a reduction of hospitalization costs.