Occurrence Of Critical Events Research Articles

Association between mortality and critical events within 48 hours of transfer to the pediatric intensive care unit.

Critical deterioration in hospitalized children, defined as ward to pediatric intensive care unit (PICU) transfer followed by mechanical ventilation (MV) or vasoactive infusion (VI) within 12 h, has been used as a primary metric to evaluate the effectiveness of clinical interventions or quality improvement initiatives. We explore the association between critical events (CEs), i.e., MV or VI events, within the first 48 h of PICU transfer from the ward or emergency department (ED) and in-hospital mortality. We conducted a retrospective study of a cohort of PICU transfers from the ward or the ED at two tertiary-care academic hospitals. We determined the association between mortality and occurrence of CEs within 48 h of PICU transfer after adjusting for age, gender, hospital, and prior comorbidities. Experiencing a CE within 48 h of PICU transfer was associated with an increased risk of mortality [OR 12.40 (95% CI: 8.12-19.23, P < 0.05)]. The increased risk of mortality was highest in the first 12 h [OR 11.32 (95% CI: 7.51-17.15, P < 0.05)] but persisted in the 12-48 h time interval [OR 2.84 (95% CI: 1.40-5.22, P < 0.05)]. Varying levels of risk were observed when considering ED or ward transfers only, when considering different age groups, and when considering individual 12-h time intervals. We demonstrate that occurrence of a CE within 48 h of PICU transfer was associated with mortality after adjusting for confounders. Studies focusing on the impact of quality improvement efforts may benefit from using CEs within 48 h of PICU transfer as an additional evaluation metric, provided these events could have been influenced by the initiative.

Поддержка МИС IPSG.2. Повышение эффективности коммуникаций.

Ensuring high quality of medical care and patient safety is one of the most important tasks of modern medicine. Medical information systems (MIS) can make a significant contribution to achieving this result. MIS are important for the creation of clinical safety system due to their capabilities of access to information, unification of medical technological processes, organization of communication between participants of the therapeutic and diagnostic process, including the transmission of signals and warnings about the occurrence of critical events. When critical events are detected, MIS with different degree of automation is able to send a notification about them to the addressee – the attending physician or other responsible person, which allows to quickly take measures and prevent possible complications, contributing to improving the level of clinical safety and improving the quality of medical care. The article discusses the implementation of one of the ways to improve the efficiency of communications, namely, the transmission of messages when critical results of tests or other critical conditions of the patient are detected using the tools included in the MIS.

Integrating remote sensing and machine learning to detect turbidity anomalies in hydroelectric reservoirs

Monitoring water quality in reservoirs is essential for the maintenance of aquatic ecosystems and socioeconomic services. In this scenario, the observation of abrupt elevations of physicochemical parameters, such as turbidity and other indicators, can signal anomalies associated with the occurrence of critical events, requiring operational actions and planning to mitigate negative environmental impacts on water resources. This work aims to integrate Machine Learning methods specialized in anomaly detection with data obtained from remote sensing images to identify with high turbidity events in the surface water of the Três Marias Hydroelectric Reservoir. Four distinct threshold-based scenarios were evaluated, in which the overall performance, based on F1-score, showed decreasing trends as the thresholds became more restrictive. In general, the anomaly identification maps generated through the models ratified the applicability of the methods in the diagnosis of surface water in reservoirs in distinct hydrological contexts (dry and wet), effectively identifying locations with anomalous turbidity values.

The Association between the L3 Skeletal Muscle Index Derived from Computed Tomography and Clinical Outcomes in Patients with Urinary Tract Infection in the Emergency Department.

The occurrence of a critical event during a urinary tract infection (UTI) can have a significant impact on mortality. This study aimed to investigate the association between the skeletal muscle index (SMI) and critical events in patients with a UTI. From April 2019 to March 2022, a total of 478 patients who met the diagnostic criteria of a UTI and underwent an abdominal CT were included in this study. Multivariate binary logistic regression analysis was used to assess independent predictors of critical events. The primary outcome was any critical event, defined as the initiation of dialysis, invasive ventilation, initiation of vasoactive medications, cardiac arrest, or death. The UTI patients were divided into two groups: those with a low SMI (n = 93) and those with a high SMI (n = 385). In multivariate analysis, a low SMI, diabetes mellitus, altered mentality, lactate levels, and creatinine levels were identified as significant predictors of critical events. A low SMI is an independent factor associated with the occurrence of critical events in UTI patients during hospitalization. Patients with a low SMI, indicating muscle wasting, may have less resilience to infections and a higher risk of experiencing severe complications. Considering the SMI along with other clinical factors can help health care providers assess and manage UTI patients.

Practice of debriefing of critical events: a survey-based cross-sectional study of Portuguese anesthesiologists.

We performed a national cross-sectional online survey exploring the practice of anesthesiologists' debriefing practice after critical events in Portuguese hospitals. The questionnaire was distributed using a snowball sampling technique from July to September 2021. Data were descriptively and comparatively analyzed. We had replies from 186 anesthesiologists (11.3% of the Portuguese pool). Acute respiratory event was the most reported type of critical event (96%). Debriefing occurred rarely or never in 53% of cases, 59% of respondents needed more training in debriefing, and only 4% reported having specific tools in their institutions to carry it out. There was no statistical association between having a debriefing protocol and the occurrence of critical events (P=.474) or having trained personnel (P=.95). The existence of protocols was associated with lower frequencies of debriefing (P=.017). Portuguese anesthesiologists know that debriefing is an essential process that increases patient safety, but among those surveyed, there is a need for an adequate debriefing culture or practice. Research registry 7741 (https://www.researchregistry.com/browse-the-registry#home).

Quantification of electrosurgery-related critical events during laparoscopic cholecystectomy – a prospective experimental study among surgical novices

Uncontrolled movement of instruments in laparoscopic surgery can lead to inadvertent tissue damage, particularly when the dissecting or electrosurgical instrument is located outside the field of view of the laparoscopic camera. The incidence and relevance of such events are currently unknown. The present work aims to identify and quantify potentially dangerous situations using the example of laparoscopic cholecystectomy (LC). Twenty-four final year medical students were prompted to each perform four consecutive LC attempts on a well-established box trainer in a surgical training environment following a standardized protocol in a porcine model. The following situation was defined as a critical event (CE): the dissecting instrument was inadvertently located outside the laparoscopic camera’s field of view. Simultaneous activation of the electrosurgical unit was defined as a highly critical event (hCE). Primary endpoint was the incidence of CEs. While performing 96 LCs, 2895 CEs were observed. Of these, 1059 (36.6%) were hCEs. The median number of CEs per LC was 20.5 (range: 1–125; IQR: 33) and the median number of hCEs per LC was 8.0 (range: 0–54, IQR: 10). Mean total operation time was 34.7 min (range: 15.6–62.5 min, IQR: 14.3 min). Our study demonstrates the significance of CEs as a potential risk factor for collateral damage during LC. Further studies are needed to investigate the occurrence of CE in clinical practice, not just for laparoscopic cholecystectomy but also for other procedures. Systematic training of future surgeons as well as technical solutions address this safety issue.

1 Paediatric Transport Safety Collaborative (PTSIC): Critical Events with Family Presence During Paediatric Critical Care Transport

Abstract Background Health care of children in Canada is regionalized; thus, critically ill paediatric patients require transfer to a tertiary care centre for definitive medical and surgical management. There are risks inherent to transporting critically ill patients, and there is a body of literature looking to mitigate risk, which includes tracking and benchmarking quality metrics. One accepted metric is family accompaniment of a child during transport, with some studies suggesting that family accompaniment could compromise care. Currently, there has been no research that examines patient safety and outcomes during paediatric critical care transport with family presence. Objectives The primary objective of this study was to compare the rate of critical events (CEs) during the transport of paediatric patients by a specialized paediatric critical care transport team on transports with parental/caregiver accompaniment (P/CA) to those without P/CA. Secondary objectives included whether peak heart rate (HR), systolic blood pressure (SBP), and clinically relevant patient outcomes varied between groups. Design/Methods We conducted a retrospective cohort study of all patients (&amp;lt;18 years old) who were admitted to a Paediatric Critical Care Unit and transported by the local neonatal paediatric transport team between April 1st, 2018 and June 1st, 2019, inclusive. The primary outcome was CE occurrence using the composite definition of CE that was previously identified and defined by a national consensus process, which included patient-, transport provider-, laboratory- and system/vehicle- related safety factors. Secondary outcomes included peak and trough HR/SBP, and clinically relevant outcomes (including length of stay, mechanical ventilation free days, and severity of illness and organ dysfunction scores). Results There were a total of 178 transports eligible for analysis, and of those, 55 were with P/CA and 123 were without P/CA. The occurrence of CE was not significantly different between transports with and without P/CA (66% vs. 65%, respectively). Similarly, patient HR, SBP, and all measured clinical patient outcomes did not vary significantly between groups. Conclusion This study is the first to objectively measure CEs and relate them to patient clinical outcomes with regard to presence of P/CA during paediatric critical care transport. There was no identified increased risk to the patient or crew if parents/caregivers accompanied their child during transport. Areas of future study include whether parental/caregiver presence during transport affects patient anxiety and well-being.

A Distributed Multi-Tier Emergency Alerting System Exploiting Sensors-Based Event Detection to Support Smart City Applications.

The development of efficient sensing technologies and the maturation of the Internet of Things (IoT) paradigm and related protocols have considerably fostered the expansion of sensor-based monitoring applications. A great number of those applications has been developed to monitor a set of information for better perception of the environment, with some of them being dedicated to identifying emergency situations. Current IoT-based emergency systems have limitations when considering the broader scope of smart cities, exploiting one or just a few monitoring variables or even allocating high computational burden to regular sensor nodes. In this context, we propose a distributed multi-tier emergency alerting system built around a number of sensor-based event detection units, providing real-time georeferenced information about the occurrence of critical events, while taking as input a configurable number of different scalar sensors and GPS data. The proposed system could then be used to detect and to deliver emergency alarms, which are computed based on the detected events, the previously known risk level of the affected areas and temporal information. Doing so, modularized and flexible perceptions of critical events are provided, according to the particularities of each considered smart city scenario. Besides implementing the proposed system in open-source electronic platforms, we also created a real-time visualization application to dynamically display emergency alarms on a map, demonstrating a feasible and useful application of the system as a supporting service. Therefore, this innovative approach and its corresponding physical implementation can bring valuable results for smart cities, potentially supporting the development of adaptive IoT-based emergency-aware applications.

Higher ventricular rate during atrial fibrillation relates to increased cerebral hypoperfusions and hypertensive events

Atrial fibrillation (AF) is associated with cognitive impairment/dementia, independently of clinical cerebrovascular events (stroke/TIA). One of the plausible mechanisms is the occurrence of AF-induced transient critical hemodynamic events; however, it is presently unknown, if ventricular response rate during AF may impact on cerebral hemodynamics. AF was simulated at different ventricular rates (50, 70, 90, 110, 130 bpm) by two coupled lumped parameter validated models (systemic and cerebral circulation), and compared to corresponding control normal sinus rhythm simulations (NSR). Hemodynamic outcomes and occurrence of critical events (hypoperfusions and hypertensive events) were assessed along the internal carotid artery-middle cerebral artery pathway up to the capillary-venous bed. At the distal cerebral circle level (downstream middle cerebral artery), increasing ventricular rates lead to a reduced heart rate-related dampening of hemodynamic signals compared to NSR (p = 0.003 and 0.002 for flow rate and pressure, respectively). This response causes a significant progressive increase in critical events in the distal cerebral circle (p < 0.001) as ventricular rate increases during AF. On the other side, at the lowest ventricular response rates (HR 50 bpm), at the systemic-proximal cerebral circle level (up to middle cerebral artery) hypoperfusions (p < 0.001) occur more commonly, compared to faster AF simulations. This computational study suggests that higher ventricular rates relate to a progressive increase in critical cerebral hemodynamic events (hypoperfusions and hypertensive events) at the distal cerebral circle. Thus, a rate control strategy aiming to around 60 bpm could be beneficial in terms on cognitive outcomes in patients with permanent AF.

On the use of the critical event concept for quantifying soil moisture dynamics

Soil moisture is a key state variable in terrestrial water cycles, which links various land surface and hydrological processes. Owing to the significant spatiotemporal variability in soil moisture, collecting sufficient soil moisture data for relevant studies can be an astonishingly difficult task. Here, a statistical method based on the concept of depth functions was used to define Critical Events (CE) of soil moisture, which was hypothesized to contain disproportionally more system information on soil moisture dynamics. To test the feasibility of applying the CE concept for quantifying soil moisture dynamics, a long-term soil moisture dataset was retrieved from the Automated Weather Data Network (AWDN) located in the continental United States. The method of Temporal Stability Analysis (TSA) was adopted to examine the information embedded in soil moisture data that were collected under different conditions. The results showed that similar information on the relative as well as absolute wetness conditions at the AWDN sites was extracted from the entire time series and CEs of soil moisture, the latter of which contained much less soil moisture observations. Finally, the field data revealed that the occurrence of CEs of soil moisture in the study area was mainly affected by soil depth and interannual variability in precipitation. The number of CEs of soil moisture tended to be larger at deeper soil depths as well as in either dry or wet years than in normal years, suggesting that more soil moisture measurements under those conditions were needed to provide adequate information on soil moisture systems.

Quality of inter-hospital transportation in 431 transport survivor patients suffering from acute respiratory distress syndrome referred to specialist centers

BackgroundThe acute respiratory distress syndrome (ARDS) is a life-threatening condition. In special situations, these critically ill patients must be transferred to specialized centers for escalating treatment. The aim of this study was to evaluate the quality of inter-hospital transport (IHT) of ARDS patients.MethodsWe evaluated medical and organizational aspects of structural and procedural quality relating to IHT of patients with ARDS in a prospective nationwide ARDS study. The qualification of emergency staff, the organizational aspects and the occurrence of critical events during transport were analyzed.ResultsOut of 1234 ARDS patients, 431 (34.9%) were transported, and 52 of these (12.1%) treated with extracorporeal membrane oxygenation. 63.1% of transferred patients were male, median age was 54 years, and 26.8% of patients were obese. All patients were mechanically ventilated during IHT. Pressure-controlled ventilation was the preferred mode (92.1%). Median duration to organize the IHT was 165 min. Median distance for IHT was 58 km, and median duration of IHT 60 min. Forty-two patient-related and 8 technology-related critical events (11.6%, 50 of 431 patients) were observed. When a critical event occurred, the PaO2/FiO2 ratio before transport was significant lower (68 vs. 80 mmHg, p = 0.017). 69.8% of physicians and 86.7% of paramedics confirmed all transfer qualifications according to requirements of the German faculty guidelines (DIVI).ConclusionsThe transport of critically ill patients is associated with potential risks. In our study the rate of patient- and technology-related critical events was relatively low. A severe ARDS with a PaO2/FiO2 ratio < 70 mmHg seems to be a risk factor for the appearance of critical events during IHT. The majority of transport staff was well qualified. Time span for organization of IHT was relatively short. ECMO is an option to transport patients with a severe ARDS safely to specialized centers.Trial registration NCT02637011 (ClinicalTrials.gov, Registered 15 December 2015, retrospectively registered)

ORGANIZATION OF DECISION SUPPORT SYSTEMS FOR PROPERTY ACCOUNTING

The structure of a typical property accounting system and its main elements are listed and described in the paper.The basic objectives of modern property accounting systems are given. System structure and description consisting of a property items database, a property accounting regulatory documents knowledge base, a data input and updating module, an information retrieval module, a module of report preparation and making are provided. The description of each of the system components is given. The restriction of opportunities to plan activities of property maintenance, and the lack of possibilities to forecast the occurrence of critical events during the operation are decribed as some disadvantages of the accounting system. To solve the problem of property accounting and its scheduled maintenance or discarding it is proposed to supplement the system of property accounting with a module of activities planning support and a forecasting module, i.e. with a passive system of decision support for property accounting and, consequently, the provision of intelligent data and knowledge processing. It is shown that this modification of the accounting system, in addition to general problems solution, provides support for planning activities related to property items, analysis of the existing data and events forecasting. A distinctive feature of the proposed system structure of decision support for property accounting is in the fact that it provides support for planning and forecasting of events and minimizes labor costs by eliminating re-entering of dara, optimization of future costs for property acquisition, optimization of property discarding and acquisition events, minimization of a possible negative effect in case of unfavorable events.

Assessing and modelling transport delays risk in supply chains

We propose in this paper, an approach for monitoring the dynamic evolution of risk associated to delays affecting the transportation operations. We use a new deployment of the failure mode, effects and criticality analysis (FMECA) organised around the dreaded scenarios and allowing a better representation of undesired cause-effect chains associated to the occurrence of critical events. This is a quantification technique to evaluate, at discrete points, the probability of the dreaded scenarios and their effect on the cost. The exploitation of this method is combined with a monitoring mechanism able to supervise the evolution of risk states during the course of operations in a logistic process. The operating states, involving threats, are represented in a model based on Petri nets. The obtained model is used to reproduce the behaviour of the logistic process, and then simulate the progress of their operations both in nominal mode and in degraded mode.

Patients with anxiety disorders: Pathways of care and their outcomes in Germany – A secondary data analysis

IntroductionAnxiety disorders are among the most common mental disorders in Germany. Different sectors and disciplines participate in mental healthcare of these patients, but there is a lack of empirical evidence of the treatment outcomes in different settings.ObjectivesThe study focuses on analyzing the care pathways of patients with anxiety disorders and the effects of such pathways on critical events like sick leave, early retirement and mortality.AimsThe analysis aims at developing recommendations for optimizing treatment with a view to minimize the rate of occurrence of critical events during the care pathway.MethodsSecondary data of three statutory health insurance companies and of the German Pension Funds of the years 2005–2007. The analyses are based on 744,742 persons with at least one diagnosis of an anxiety disorder.ResultsThe analyses reveal a low rate of changes between primary and specialized care. There was a high number of care pathways (n = 2.608).The most common type was care by primary care physicians/somatic specialists only (60.5% of patients), followed by a treatment by a psychiatrist only (9.5%). Patients, who were only treated by general practitioners/somatic specialists, had significantly lower rates of sick leave and early retirement. This may indicate that cases with more favourable prognoses are found with this care pathway.ConclusionsAnalyses of care pathways using secondary data can contribute to identify potential for optimizing mental health care services and provide information about intersectoral interface problems, which should be considered in the quality management of mental healthcare.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The Role of Circadian Rhythms in Fatal Arrhythmias and the Potential Impact of Intervention for Sleep-Disordered Breathing.

There exist circadian patterns in the occurrence of sudden cardiac death. The suprachiasmatic nuclei is the 'master clock' in mammalian bodies. Furthermore, several circadian genes have been successfully isolated in basic studies and a huge variety of key players form the human circadian rhythm. Obvious circadian patterns are present in the occurrence of critical events, but those characteristics differ greatly according to each disease. In this review we summarized the current understanding of the basic mechanism and association with specific cardiovascular diseases that demonstrate a circadian onset of fatal events. We also summarized the recent deep understanding of sleep-disordered breathing. The close relationship between sleep-disordered breathing and cardiovascular diseases may provide us with the possibility of a novel intervention against sudden cardiac death.

Prospective memory impairment and executive dysfunction in prefrontal lobe damaged patients: is there a causal relationship?

Background. The prospective memory (PM) construct is aimed at capturing cognitive operations involved in the successful accomplishment of delayed intentions. It is generally agreed that PM impairment occurs in patients with prefrontal lobes damage. Objective. To evaluate if there is a causal role of a deficit of executive abilities (failures of planning, set-shifting, selective attention, or working memory) over the PM impairment. Methods. We report a detailed investigation of PM and executive abilities in two patients with posttraumatic damage to prefrontal lobes who complained from a reduced compliance with appointments and daily routines. Results. Laboratory tests confirmed a difficulty in fulfilling delayed intentions in response to the occurrence of critical events and elapsed time. In one patient, PM impairment was associated with poor performance on tests investigating planning, working memory, and mental shifting. The other patient performed in the normal range on all executive tests. Conclusions. Despite the frequent claim of a dependence of PM deficits from executive dysfunction, the reported cases demonstrate that this is not necessarily the case. The results are discussed in the light of current hypotheses relating PM impairment to other deficits that commonly occur as a result of damage to the prefrontal lobes.

Forecasting Chaotic Series in Manufacturing Systems by Vector Support Machine Regression and Neural Networks

Currently, it is recognized that manufacturing systems are complex in their structure and dynamics. Management, control and forecasting of such systems are very difficult tasks due to complexity. Numerous variables and signals vary in time with different patterns so that decision makers must be able to predict the behavior of the system.This is a necessary capability in order to keep the system under a safe operation. This also helps to prevent  emergencies and the occurrence of critical events that may put in danger human beings and capital resources, such as expensive equipment and valuable production. When dealing with chaotic systems, the management, control, and forecasting are very difficult tasks. In this article an application of neural networks and vector support machines for the forecasting of the time varying average number of parts in a waiting line of a manufacturing system having a chaotic behavior, is presented. The best results were obtained with least square support vector machines and for the neural networks case, the best forecasts, are those with models employing the invariants characterizing the system’s dynamics.

Adaptive Multi-Path Routing with Guaranteed Target-Delivery Ratio of Critical Events in Wireless Sensor Networks

Wireless sensor networks are subject to node and link failures for a variety of reasons. This paper proposes a k-disjoint-path routing algorithm that varies the number of disjoint paths (k) in order to meet a target-delivery ratio of critical events and to reduce energy consumption. The proposed algorithm sends packets to the base station through a single path without the occurrence of critical events, however, it sends packets to the base station through k disjoint paths (k > 1) under the occurrence of critical events, where k is computed from a well-defined fault model. The proposed algorithm detects the occurrence of critical events by monitoring collected data patterns. The simulation results reveal that the proposed algorithm is more resilient to random node failure and patterned failure than other routing algorithms, and it also decreases energy consumption much more than the multi-path and path-repair algorithms.

Mammalian oocyte development: checkpoints for competence

During the lifespan of the female, biochemical changes occur in the ovarian environment. These changes are brought about by numerous endogenous and exogenous factors, including husbandry practices, production demands and disease, and can have a profound effect on ovarian oocyte quality and subsequent embryo development. Despite many investigations, there is no consensus regarding the time or period of follicular oocyte development that is particularly sensitive to insult. Here, the key molecular and morphological events that occur during oocyte and follicle growth are reviewed, with a specific focus on identifying critical checkpoints in oocyte development. The secondary follicle stage appears to be a key phase in follicular oocyte development because major events such as activation of the oocyte transcriptome, sequestration of the zona pellucida, establishment of bidirectional communication between the granulosa cells and the oocyte and cortical granule synthesis occur during this period of development. Several months later, the periovulatory period is also characterised by the occurrence of critical events, including appropriate degradation or polyadenylation of mRNA transcripts, resumption of meiosis, spindle formation, chromosome alignment and segregation, and so should also be considered as a potential checkpoint of oocyte development.

The effect of variability in temporal information on the control of a dynamic task

The present study is about the effect of temporal uncertainty on the control of a dynamic task. Two types of temporal uncertainty are defined: Data Uncertainty (DU), the variability in temporal information, and Knowledge Uncertainty (KU), the complexity in the temporal structure of a situation. The effect of temporal data uncertainty on the control of a dynamic task with high knowledge temporal uncertainty is tested experimentally. Fifty-seven participants practiced the computerized game ‘Save the Whale’, with three levels of data uncertainty about the moment of occurrence of critical events, DU0, DU1 and DU2. Results show that performance is better in the DU0 than in the other two conditions, which do not differ from each other. The performance improves with practice at the same rate, regardless of the level of uncertainty. It is also shown that the control strategies reported by the participants become more variable with an increase in uncertainty. It is concluded that temporal data uncertainty does not limit temporal pattern learning.