Complications during intrahospital transport of critically ill patients: Focus on risk identification and prevention

Simulated impact of lift car sizes on transport of critical care patients: Informing the design of the New Dunedin Hospital

The New Dunedin Hospital (NDH) is New Zealand's largest health infrastructure build. Here we describe the use of a simple simulation-based hospital design exercise to inform the appropriate lift car size for critical care intrahospital transfers in the NDH. The intensive care unit (ICU) user group tested a series of entries and exits of simulated complex patient transfers in mocked-up lift cars of three different dimensions. Time taken to enter and exit the lift were recorded, reflecting the relative difficulty of transfer. Qualitative assessments were made of ease and perceived safety of transfer. These simulations demonstrated that recommended standard patient lift cars, often proposed for critical care transfers, could not physically accommodate all complex ICU transfers. A size of 1800 mm wide (W) × 3000 mm deep (D) had the physical capacity to permit all simulated ICU transfers, but with staff and patient risk. As lift car size increased to 2200 mm W × 3300 mm D, the simulation demonstrated reduced transfer times, smoother entry and exit, improved access to the head end of the bed, and reduced risk of disconnection or dislodgement of lines and airway support. The resultant clinical recommendations for the dimensions of a critical care lift car surpass current international health architecture guidelines and may help to inform future updates. The NDH project benefited from an objective assessment of risk, in language familiar to clinicians and healthcare architects. The outcome was an upsizing of the two ICU-capable lifts.

Clinical Value and Operational Risks of MRI in ICU patients - A Retrospective Analysis Performed at a University Medical Center

PURPOSE

 Intensive care unit (ICU) patients have a high risk of developing complications when leaving the ICU for diagnostic procedures or therapeutic interventions. Our study examined the frequency of adverse events associated with magnetic resonance imaging (MRI) of intensive care patients and the extent of changes in therapy due to the MRI scan to weigh the risks associated with the scan against the potential benefits of an MR scan, using a change in therapy as an indicator of benefit.

MATERIALS AND METHODS

 4434 ICU patients (January to December 2015) were identified by Hospital Information System (SAP-R/3 IS-H, Walldorf, Germany), ICU patient data management system Metavision (iMDsoft, Israel), and Radiology Information System (Nexus.medRIS, Version 8.42, Nexus, Germany). All intensive care and medical records (HIS) and MRI reports (RIS) were matched and further evaluated in a retrospective case-to-case analysis for biometric data, mechanical ventilation, ICU requirements, planned postoperative vs. emergency diagnostic requirements, complications and impact on further diagnosis or therapy.

RESULTS

 Out of 4434 ICU patients, 322 ICU patients (7.3 %) underwent a total of 385 MRI examinations. 167 patients needed a total of 215 emergency scans, while 155 patients underwent 170 planned postoperative MRI exams. 158 (94.6 %) out of 167 emergency scan patients were ventilated under continuous intravenous medication and monitoring. In the planned postoperative group, only 6 (3.9 %) out of 155 were ventilated, but a total of 38 (24.5 %) were under continuous medication. 111 patients were accompanied by nurses only during MRI. Only one severe adverse event (0.3 %) was noted and was attributed to study preparation (n = 385). In 8 MRI examinations (2.1 %), the examination was interrupted or cancelled due to the patients' condition. While all MRI examinations in the planned group were completed (n = 170, 100 %) (e. g., postoperative controls), only 207 out of 215 (96.3 %) could be performed for emergency diagnostic reasons. MRI influenced the clinical course with a change in diagnosis or therapy in 74 (19.2 %) of all 385 MRI examinations performed, and in the emergency diagnostic group it was 31.2 % (n = 67/215).

CONCLUSION

 Nearly 20 % of MRI examinations of ICU patients resulted in a change of therapy. With only one potentially life-threatening adverse event (0.3 %) during transport and the MRI examination, the risk seems to be outweighed by the diagnostic benefit.

KEY POINTS

· The risk of adverse events associated with MRI scans in ICU patients is low.. · The rate of premature termination of ICU patients' MRI scans is low.. · Almost 20 % of ICU patients' MRI scans lead to a change of therapy..

The Association Between Inter-Hospital Transfers and the Prognosis of Pediatric Injury in the Emergency Department

BACKGROUND

Inter-hospital transfers of severely injured patients are inevitable due to limited resources. We investigated the association between inter-hospital transfer and the prognosis of pediatric injury using the Korean multi-institutional injury registry.

METHODS

This retrospective observational study was conducted from January 2013 to December 2017; data for hospitalized subjects aged < 18 years were extracted from the Emergency Department-based Injury in Depth Surveillance database, in which 22 hospitals are participating as of 2022. The survival rates of the direct transfer group and the inter-hospital transfer group were compared, and risk factors affecting 30-day mortality and 72- hour mortality were analyzed.

RESULTS

The total number of study subjects was 18,518, and the transfer rate between hospitals was 14.5%. The overall mortality rate was 2.3% (n = 422), the 72-hour mortality was 1.7% (n = 315) and the 30-day mortality rate was 2.2% (n = 407). The Kaplan-Meier survival curve revealed a lower survival rate in the inter-hospital transfer group than in the direct visit group (log-rank, P < 0.001). Cox proportional hazards regression analysis showed that inter-hospital transfer group had a higher 30-day mortality rate and 72-hour mortality (hazard ratio [HR], 1.681; 95% confidence interval [CI], 1.232-2.294 and HR, 1.951; 95% CI, 1.299-2.930) than direct visit group when adjusting for age, sex, injury severity, and head injury.

CONCLUSION

Among the pediatric injured patients requiring hospitalization, inter-hospital transfer in the emergency department was associated with the 30-day mortality rate and 72-hour mortality rate in Korea.

Pro-Con Debate: Should Critically Ill Patients Undergo Procedures at Bedside or in the Operating Room?

Nonoperating room anesthesia (NORA) is a fast-growing field in anesthesiology, wherein anesthesia care is provided for surgical procedures performed outside the main operating room (OR) pavilion. Advances in medical science and technology have led to an increasing number of procedures being moved out of the operating room to procedural suites. One such NORA location is the intensive care unit (ICU), where a growing number of urgent and emergent procedures are being performed on medically unstable patients. ICU-NORA allows medical care to be provided to patients who are too sick to tolerate transport between the ICU and the OR. However, offering the same, high-quality, and safe care in this setting may be challenging. It requires special planning and a thorough consideration of the presence of life-threatening comorbidities and location-specific and ergonomic barriers. In this Pro-Con commentary article, we discuss these special considerations and argue in favor of and against routinely performing procedures at the bedside in the ICU versus in the OR.

Entangled Circuit during Transport of Patient

How to cite this article: Sriramka B, Mallik D, Nanda S. Entangled Circuit during Transport of Patient. Indian J Crit Care Med 2023;27(10):774-775.

Current role of portable MRI in diagnosis of acute neurological conditions

Neuroimaging is an inevitable component of the assessment of neurological emergencies. Magnetic resonance imaging (MRI) is the preferred imaging modality for detecting neurological pathologies and provides higher sensitivity than other modalities. However, difficulties such as intra-hospital transport, long exam times, and availability in strict access-controlled suites limit its utility in emergency departments and intensive care units (ICUs). The evolution of novel imaging technologies over the past decades has led to the development of portable MRI (pMRI) machines that can be deployed at point-of-care. This article reviews pMRI technologies and their clinical implications in acute neurological conditions. Benefits of pMRI include timely and accurate detection of major acute neurological pathologies such as stroke and intracranial hemorrhage. Additionally, pMRI can be potentially used to monitor the progression of neurological complications by facilitating serial measurements at the bedside.

Thoracic ultrasonographic and clinical findings at 12-month follow-up of patients admitted with COVID-19

Introduction

Thoracic ultrasound (TUS) has proven useful in the diagnosis, risk stratification and monitoring of disease progression in patients with coronavirus disease 2019 (COVID-19). However, utility in follow-up is poorly described. To elucidate this area, we performed TUS as part of a 12-month clinical follow-up in patients previously admitted with COVID-19 and correlated findings with clinical assessment and pulmonary function tests.

Methods

Adult patients discharged from our hospital following admission with COVID-19 during March to May 2020 were invited to a 12-month follow-up. Enrolled patients were interviewed regarding persisting or newly developed symptoms in addition to TUS, spirometry and a 6-min walk test. Patients were referred to high-resolution computed tomography (HRCT) of the lungs if suspicion of pulmonary fibrosis was raised.

Results

Forty patients were enrolled in the study of whom had 13 developed acute respiratory distress syndrome (ARDS) during admission. Patients with ARDS were more prone to experience neurological symptoms at follow-up (p = 0.03) and showed more B-lines on TUS (p = 0.008) but did not otherwise differ significantly in terms of pulmonary function tests. Four patients had pathological findings on TUS where subsequent diagnostics revealed that two had interstitial lung abnormalities and two had heart failure. These four patients presented with a significantly lower diffusing capacity of lung for carbon monoxide (p=0.03) and 6-min walking distance (p=0.006) compared to the remaining 36 patients without ultrasound pathology. No significant difference was observed in spirometry values of % of predicted FEV1 (p=0.49) or FVC (p=0.07). No persisting cardiovascular pathology was observed in patients without ultrasonographic pathology.

Conclusion

At 12-month after admission with COVID-19, a follow-up combining TUS, clinical assessment, and pulmonary function tests may improve the selection of patients requiring further diagnostic investigations such as HRCT or echocardiography.

Brain imaging with portable low-field MRI

The advent of portable, low-field MRI (LF-MRI) heralds new opportunities in neuroimaging. Low power requirements and transportability have enabled scanning outside the controlled environment of a conventional MRI suite, enhancing access to neuroimaging for indications that are not well suited to existing technologies. Maximizing the information extracted from the reduced signal-to-noise ratio of LF-MRI is crucial to developing clinically useful diagnostic images. Progress in electromagnetic noise cancellation and machine learning reconstruction algorithms from sparse k-space data as well as new approaches to image enhancement have now enabled these advancements. Coupling technological innovation with bedside imaging creates new prospects in visualizing the healthy brain and detecting acute and chronic pathological changes. Ongoing development of hardware, improvements in pulse sequences and image reconstruction, and validation of clinical utility will continue to accelerate this field. As further innovation occurs, portable LF-MRI will facilitate the democratization of MRI and create new applications not previously feasible with conventional systems.

Adverse Events during Intrahospital Transport of Critically Ill Patients: A Multicenter, Prospective, Observational Study (I-TOUCH Study)

Background

Critically ill patients are frequently transported to various locations within the hospital for diagnostic and therapeutic purposes, which increases the risk of adverse events (AEs). This multicenter prospective observational study was undertaken to determine the incidence of AEs related to intrahospital transport, their severity, and their effects on patient outcomes.

Patients and methods

We included consecutive unstable critically ill patients requiring intrahospital transport, across 15 Indian tertiary care centers over 5 months (October 11, 2022-February 20, 2023). Apart from the demographics and severity of illness, data related to transport itself, such as indications and destination, incidence of AEs, their category and treatment required, and patient outcomes, were recorded in a standard form.

Results

Eight hundred and ninety-three patients were transported on 1065 occasions out of the intensive care unit (ICU). The mean (SD) acute physiology and chronic health evaluation II score of the patients was 15.38 (±7.35). One hundred and two AEs occurred, wherein cardiovascular instability was the most common occurrence (31, 30.4%). Two patients had cardiac arrest immediately after transport. Acute physiology and chronic health evaluation II [odds ratio (OR): 1.02, 95% confidence interval (CI) - 1.00-1.05, p = 0.04], emergent transport (OR: 5.11, 95% CI - 3.32-7.88, p = 0.00), and team composition (OR: 5.34, 95% CI - 1.63-17.5, p = 0.00) during transport were found to be independent predictors of AEs.

Conclusion

We found a high incidence of AEs during intrahospital transport of critically ill patients. These events were more common during emergent transports and when the patients were transported by doctors. Transport by itself was not related to ICU mortality. We feel that stabilization of the patients before transport and adherence to a standardized protocol may help in minimizing the AEs, thereby enhancing patient safety.

How to cite this article

Zirpe KG, Tiwari AM, Kulkarni AP, Govil D, Dixit SB, Munjal M, et al. Adverse Events during Intrahospital Transport of Critically Ill Patients: A Multicenter, Prospective, Observational Study (I-TOUCH Study). Indian J Crit Care Med 2023;27(9):635-641.

MRI and the Critical Care Patient: Clinical, Operational, and Financial Challenges

Neuroimaging in conjunction with a neurologic examination has become a valuable resource for today's intensive care unit (ICU) physicians. Imaging provides critical information during the assessment and ongoing neuromonitoring of patients for toxic-metabolic or structural injury of the brain. A patient's condition can change rapidly, and interventions may require imaging. When making this determination, the benefit must be weighed against possible risks associated with intrahospital transport. The patient's condition is assessed to decide if they are stable enough to leave the ICU for an extended period. Intrahospital transport risks include adverse events related to the physical nature of the transport, the change in the environment, or relocating equipment used to monitor the patient. Adverse events can be categorized as minor (e.g., clinical decompensation) or major (e.g., requiring immediate intervention) and may occur in preparation or during transport. Regardless of the type of event experienced, any intervention during transport impacts the patient and may lead to delayed treatment and disruption of critical care. This review summarizes the commentary on the current literature on the associated risks and provides insight into the costs as well as provider experiences. Approximately, one-third of patients who are transported from the ICU to an imaging suite may experience an adverse event. This creates an additional risk for extending a patient's stay in the ICU. The delay in obtaining imaging can negatively impact the patient's treatment plan and affect long-term outcomes as increased disability or mortality. Disruption of ICU therapy can decrease respiratory function after the patient returns from transport. Because of the complex care team needed for patient transport, the staff time alone can cost $200 or more. New technologies and advancements are needed to reduce patient risk and improve safety.

Benchmarking Hospital Practices and Policies on Intrahospital Neurocritical Care Transport: The Safe-Neuro-Transport Study

An electronic survey was administered to multidisciplinary neurocritical care providers at 365 hospitals in 32 countries to describe intrahospital transport (IHT) practices of neurocritically ill patients at their institutions. The reported IHT practices were stratified by World Bank country income level. Variability between high-income (HIC) and low/middle-income (LMIC) groups, as well as variability between hospitals within countries, were expressed as counts/percentages and intracluster correlation coefficients (ICCs) with a 95% confidence interval (CI). A total of 246 hospitals (67% response rate; n = 103, 42% HIC and n = 143, 58% LMIC) participated. LMIC hospitals were less likely to report a portable CT scanner (RR 0.39, 95% CI [0.23; 0.67]), more likely to report a pre-IHT checklist (RR 2.18, 95% CI [1.53; 3.11]), and more likely to report that intensive care unit (ICU) physicians routinely participated in IHTs (RR 1.33, 95% CI [1.02; 1.72]). Between- and across-country variation were highest for pre-IHT external ventricular drain clamp tolerance (reported by 40% of the hospitals, ICC 0.22, 95% CI 0.00-0.46) and end-tidal carbon dioxide monitoring during IHT (reported by 29% of the hospitals, ICC 0.46, 95% CI 0.07-0.71). Brain tissue oxygenation monitoring during IHT was reported by only 9% of the participating hospitals. An IHT standard operating procedure (SOP)/hospital policy (HP) was reported by 37% (n = 90); HIC: 43% (n= 44) vs. LMIC: 32% (n = 46), p = 0.56. Amongst the IHT SOP/HPs reviewed (n = 13), 90% did not address the continuation of hemodynamic and neurophysiological monitoring during IHT. In conclusion, the development of a neurocritical-care-specific IHT SOP/HP as well as the alignment of practices related to the IHT of neurocritically ill patients are urgent unmet needs. Inconsistent standards related to neurophysiological monitoring during IHT warrant in-depth scrutiny across hospitals and suggest a need for international guidelines for neurocritical care IHT.

Complications during transport of adult patients on extracorporeal membrane oxygenation

INTRODUCTION

Transport on extracorporeal membrane oxygenation (ECMO) is a risky and complex procedure. Although most published data support the feasibility of interhospital transport on ECMO, data concerning intra-facility transportation and frequency and severity of complications during ECMO transport of adult patients are still scarce. The aim of this study was to assess transport arrangements and complications during intra and interhospital ECMO-supported patients transport at a high-volume ECMO center.

METHODS

Retrospective single-center descriptive study evaluating the prevalence and severity of complications associated with the transportation of adult patients on ECMO support between 2014 and 2022 in our ECMO center.

RESULTS

We performed 393 transfers of patients on ECMO support. Those comprised 206 intra-facility, 147 primary, 39 secondary and one tertiary transports. For primary and tertiary transportations, the average transfer length was 118.6 km (range 2.5-1446) and the mean total transport time was 5 h 40 min. The majority of transportations were made by ambulance (93.2%). Complications occurred in 12.7% of all transports and were more frequent in intra-facility and primary/tertiary transfers. Most complications were patient (46%) and staff related (26%). Risk category two was the most frequent (50%), and only five complications were classified as risk category 1 (10%). No deaths occurred during all patient transport.

CONCLUSIONS

Most transports carry minor problems that entail a negligible risk to the patient. When ECMO-supported transport is performed by an experienced team, the severe complications are not related with an increased morbimortality.

Network Analysis Examining Intrahospital Traffic of Patients With Traumatic Hip Fracture

INTRODUCTION

Increased intrahospital traffic (IHT) is associated with adverse events and infections in hospitalized patients. Network science has been used to study patient flow in hospitals but not specifically for patients with traumatic injuries.

METHODS

This retrospective analysis included 103 patients with traumatic hip fractures admitted to a level I trauma center between April 2021 and September 2021. Associations with IHTs (moves within the hospital) were analyzed using R (4.1.2) as a weighted directed graph.

RESULTS

The median (interquartile range) number of moves was 8 (7-9). The network consisted of 16 distinct units and showed mild disassortativity (-0.35), similar to other IHT networks. The floor and intensive care unit (ICU) were central units in the flow of patients, with the highest degree and betweenness. Patients spent a median of 20-28 hours in the ICU, intermediate care unit, or floor. The number of moves per patient was mildly correlated with hospital length of stay (ρ = 0.26, p = .008). Intrahospital traffic volume was higher on weekdays and during daytime hours. Intrahospital traffic volume was highest in patients aged <65 years ( p = .04), but there was no difference in IHT volume by dependent status, complications, or readmissions.

CONCLUSIONS

Network science is a useful tool for trauma patients to plan IHT, flow, and staffing.

Development of Traumatic Brain Injury Associated Intracranial Hypertension Prediction Algorithms: A Narrative Review

Traumatic intracranial hypertension (tIH) is a common and potentially lethal complication of moderate to severe traumatic brain injury (m-sTBI). It often develops with little warning and is managed reactively with the tiered application of intracranial pressure (ICP)-lowering interventions administered in response to an ICP rising above a set threshold. For over 45 years, a variety of research groups have worked toward the development of technology to allow for the preemptive management of tIH in the hope of improving patient outcomes. In 2022, the first operationalizable tIH prediction system became a reality. With such a system, ICP lowering interventions could be administered prior to the rise in ICP, thus protecting the patient from potentially damaging tIH episodes and limiting the overall ICP burden experienced. In this review, we discuss related approaches to ICP forecasting and IH prediction algorithms, which collectively provide the foundation for the successful development of an operational tIH prediction system. We also discuss operationalization and the statistical assessment of tIH algorithms. This review will be of relevance to clinicians and researchers interested in development of this technology as well as those with a general interest in the bedside application of machine learning (ML) technology.

S100B predicts neurological injury and 30-day mortality following surgery for acute type A aortic dissection: an observational cohort study

BACKGROUND

Neurological injuries are frequent following Acute Type A Aortic Dissection (ATAAD) repair occurring in 4-30% of all patients. Our objective was to study whether S100B can predict neurological injury following ATAAD repair.

METHODS

This was a single-center, retrospective, observational study. The study included all patients that underwent ATAAD repair at our institution between Jan 1998 and Dec 2021 and had recorded S100B-values. The primary outcome measure was neurological injury, defined as focal neurological deficit or coma diagnosed by clinical assessment with or without radiological confirmation and with a symptom duration of more than 24 h. Secondary outcome measure was 30-day mortality.

RESULTS

538 patients underwent surgery during the study period and 393 patients, had recorded S100B-values. The patients had a mean age of 64.4 ± 11.1 years and 34% were female. Receiver operating characteristic curve for S100B 24 h postoperatively yielded area under the curve 0.687 (95% CI 0.615-0.759) and best Youden's index corresponded to S100B 0.225 which gave a sensitivity of 60% and specificity of 75%. Multivariable logistic regression identified S100B ≥ 0.23 μg/l at 24 h as an independent predictor for neurological injury (OR 4.71, 95% CI 2.59-8.57; p < 0.01) along with preoperative cerebral malperfusion (OR 4.23, 95% CI 2.03-8.84; p < 0.01) as well as an independent predictor for 30-day mortality (OR 4.57, 95% CI 1.18-11.70; p < 0.01).

CONCLUSIONS

We demonstrated that S100B, 24 h after surgery is a strong independent predictor for neurological injury and 30-day mortality after ATAAD repair.

TRIAL REGISTRATION

As this was a retrospective observational study it was not registered.

Open Bedside Tracheostomy: Safe and Cost Saving but Underutilized Nationally

OBJECTIVE

To evaluate open bedside tracheostomy (OBT) and compare it with open operating room (OR) tracheostomy and bedside percutaneous dilatational tracheostomy (PDT) in complications and cost. To determine the tracheostomy practice patterns of academic otolaryngology programs.

STUDY DESIGN

Retrospective cohort study and cross-sectional study.

SETTING

Public hospital and tertiary care hospital.

METHODS

Otolaryngology program directors were surveyed to determine their institutions' tracheostomy practice patterns and the factors preventing the implementation of open bedside tracheostomies. A retrospective chart review was done of tracheostomies performed at our institutions from 2009 to 2019 for prolonged mechanical ventilation. Complications, length of intubation, comorbidities, body mass index, demographics, mortality rates, and decannulation rates were recorded. A cost analysis between OBT and PDT was conducted.

RESULTS

Data from 802 patients were analyzed for 449 OBTs, 206 PDTs, and 147 open OR tracheostomies. Complication rates were low. PDTs were more likely to have perioperative tracheal bleeding (P = .028) and mucus plugging (P = .006). OBTs were performed on sicker patients with a higher Charlson Comorbidity Index than PDT and OR tracheostomies. The cost of OBT was less than that of PDT. The survey response rate of tracheostomy practice patterns was 46%. The otolaryngologists at the responding programs all conducted OR tracheostomies, while 52.7% did OBTs and 30.9% PDTs.

CONCLUSION

OBT can be done safely in patients with multiple comorbidities and has a cost that can be less than PDT. Despite these benefits, only 50% of academic institutions routinely performed OBT.

LEVEL OF EVIDENCE: 3

First Experience With Postoperative Transcranial Ultrasound Through Sonolucent Burr Hole Covers in Adult Hydrocephalus Patients

BACKGROUND

Managing patients with hydrocephalus and cerebrospinal fluid (CSF) disorders requires repeated head imaging. In adults, it is typically computed tomography (CT) or less commonly magnetic resonance imaging (MRI). However, CT poses cumulative radiation risks and MRI is costly. Ultrasound is a radiation-free, relatively inexpensive, and optionally point-of-care alternative, but is prohibited by very limited windows through an intact skull.

OBJECTIVE

To describe our initial experience with transcutaneous transcranial ultrasound through sonolucent burr hole covers in postoperative hydrocephalus and CSF disorder patients.

METHODS

Using cohort study design, infection and revision rates were compared between patients who underwent sonolucent burr hole cover placement during new ventriculoperitoneal shunt placement and endoscopic third ventriculostomy over the 1-year study time period and controls from the period 1 year before. Postoperatively, trans-burr hole ultrasound was performed in the clinic, at bedside inpatient, and in the radiology suite to assess ventricular anatomy.

RESULTS

Thirty-seven patients with sonolucent burr hole cover were compared with 57 historical control patients. There was no statistically significant difference in infection rates between the sonolucent burr hole cover group (1/37, 2.7%) and the control group (0/57, P = .394). Revision rates were 13.5% vs 15.8% (P = 1.000), but no revisions were related to the burr hole or cranial hardware.

CONCLUSION

Trans-burr hole ultrasound is feasible for gross evaluation of ventricular caliber postoperatively in patients with sonolucent burr hole covers. There was no increase in infection rate or revision rate. This imaging technique may serve as an alternative to CT and MRI in the management of select patients with hydrocephalus and CSF disorders.

Effectiveness of the graded transport mode for the intrahospital transport of critically ill patients: A retrospective study

Aim

The purpose of this study was to evaluate the effectiveness of the graded transport mode in the intrahospital transport (IHT) of critically ill patients.

Methods

This is a retrospective study, including 800 patients and categorized them into control and observation groups. The control group included 420 critically ill patients who were transported via conventional methods from our emergency resuscitation unit from June 2017 to December 2017. The observation group included 380 critically ill patients who were transported through a graded transport mode from January 2018 to June 2018. We performed intergroup comparisons of the incidence rates and causes of adverse events (AEs), transport time, length of stay, and mortality rate.

Results

The observation group had significantly lower transport time and AE incidence rates than the control group. However, no significant differences were observed in terms of the length of stay and mortality rate between the two groups.

Conclusion

The most notable merits of the graded transport mode in the IHT of critical care patients include the fact that it significantly reduces the incidence of AEs during IHT, shortens the transport time, and improves transport efficiency, thereby ensuring the safety of critically ill patients.

Methodology for designing intrahospital transportation of patients with suspected infectious disease that limits infection spread risk in China

Aims

The transport of patients suspected of having COVID-19 requires careful consideration. Using paths selected at random and not accounting for person flow along the path are risk factors for infection spread. Intrahospital transportation (IHT) protocols and guidelines should be used to help reduce the risk of secondary virus transmission during transport. This study aimed to propose optimal IHT for patients with an infectious disease presenting in an out-patient area.

Design

The map of a West China Hospital was used. We also used field investigation findings and simulated person flow to establish pathway length and transportation time. We identified three optimum pathways and estimated safety boundary marks, including a patient transportation border (PTB) and safety transportation border (STB). Finally, IHT, PTB, and STP formed a virtual transport pipeline (VTP) and a traceable IHT management system, which can generate a virtual isolation space.

Results

The three pathways met efficiency, accessibility, and by-stander flow criteria. No facility characteristic modification was required.

Conclusions

Using virtual models to identify pathways through out-patient hospital areas may help reduce the risk of infection spread.

Relevance of Routine Postoperative CT Scans Following Aneurysm Clipping-A Retrospective Multicenter Analysis of 423 Cases

AIM

Postoperative head computed tomography (POCT) is routinely performed in numerous medical institutions, mainly to identify possible postsurgical complications. This study sought to assess the clinical appropriateness of POCT in asymptomatic and symptomatic patients after ruptured or unruptured aneurysm clipping.

METHODS

This is a retrospective multicenter study involving microsurgical procedures of ruptured (RA) and unruptured intracranial aneurysm (UA) surgeries performed in the Centers associated with the Pomeranian Department of the Polish Society of Neurosurgeons. A database of surgical procedures of intracranial aneurysms from 2017 to 2020 was created. Only patients after a CT scan within 24 h were included.

RESULTS

A total of 423 cases met the inclusion criteria for the analysis. Age was the only significant factor associated with postoperative blood occurrence on POCT. A total of 37 (8.75%) cases of deterioration within 24 h with urgent POCT were noted, 3 (8.1%) required recraniotomy. The highest number necessary to predict (NNP) one recraniotomy based on patient deterioration was 50 in the RA group.

CONCLUSION

We do not recommend POCTs in asymptomatic patients after planned clipping. New symptom onset requires radiological evaluation. Simultaneous practice of POCT after ruptured aneurysm treatment within 24 h is recommended.

Bedside monitoring of hypoxic ischemic brain injury using low-field, portable brain magnetic resonance imaging after cardiac arrest

BACKGROUND

Assessment of brain injury severity is critically important after survival from cardiac arrest (CA). Recent advances in low-field MRI technology have permitted the acquisition of clinically useful bedside brain imaging. Our objective was to deploy a novel approach for evaluating brain injury after CA in critically ill patients at high risk for adverse neurological outcome.

METHODS

This retrospective, single center study involved review of all consecutive portable MRIs performed as part of clinical care for CA patients between September 2020 and January 2022. Portable MR images were retrospectively reviewed by a blinded board-certified neuroradiologist (S.P.). Fluid-inversion recovery (FLAIR) signal intensities were measured in select regions of interest.

RESULTS

We performed 22 low-field MRI examinations in 19 patients resuscitated from CA (68.4% male, mean [standard deviation] age, 51.8 [13.1] years). Twelve patients (63.2%) had findings consistent with HIBI on conventional neuroimaging radiology report. Low-field MRI detected findings consistent with HIBI in all of these patients. Low-field MRI was acquired at a median (interquartile range) of 78 (40-136) hours post-arrest. Quantitatively, we measured FLAIR signal intensity in three regions of interest, which were higher amongst patients with confirmed HIBI. Low-field MRI was completed in all patients without disruption of intensive care unit equipment monitoring and no safety events occurred.

CONCLUSION

In a critically ill CA population in whom MR imaging is often not feasible, low-field MRI can be deployed at the bedside to identify HIBI. Low-field MRI provides an opportunity to evaluate the time-dependent nature of MRI findings in CA survivors.

Intrahospital transport of critically ill patients: A cross-sectional survey of Nurses' attitudes and experiences in adult intensive care units

AIMS

To describe adult intensive care nurses' experiences and attitudes towards intrahospital transport (IHT) of critically ill patients and to assess the relationship between nurses' characteristics, attitudes and experiences.

DESIGN

Cross-sectional survey.

METHODS

Factor analysis identified factors within the attitudinal and experience domains. Univariate analysis was performed to demonstrate the relationship between attitudinal and experience factors and demographic and professional characteristics of the participants. Multiple regression equations were applied to determine associations between nurses' experiences and attitudes. The study took place from July to August 2019.

RESULTS

A total of 480 nurses from 12 adult intensive care units in China participated, with a response rate of 65%. Most respondents had a baccalaureate nursing degree (75%). The majority (80%) had participated in IHT of critically ill more than five times in the previous 12 months and 90% agreed that checklists led to an improvement in patient safety during transport. However, 75% of respondents expressed that transport increased the workload of the nurses who accompany patients off unit and those who remained in the intensive care unit (66%). Variables that were associated with a favourable perception of transport competency and checklists/tool use were nurses' prior transport experiences and knowledge/training.

CONCLUSION

Nurses perceived IHT was a sourse of stress and increased workload. Checklists and training were beneficial for patient safety during IHT.

IMPACT

The findings point out a clear need for ICU nurse training, standardised policy/procedure and customisation of existing intrahospital transfer checklists according to hospital procedures and local circumstances. New research is needed to evaluate the impact of novel IHT interventions on patient safety and nurses' stress.

Methodology for Low-Field, Portable Magnetic Resonance Neuroimaging at the Bedside

Neuroimaging is a critical component of triage and treatment for patients who present with neuropathology. Magnetic resonance imaging and non-contrast computed tomography are the gold standard for diagnosis and prognostication of patients with acute brain injuries. However, these modalities require intra-hospital transport to strict, access-controlled environments, which puts critically ill patients at risk for complications and secondary injuries. A novel, portable MRI (pMRI) device that can be deployed at the patient's bedside provides a needed solution. In a dual-center investigation, Yale New Haven Hospital has obtained regular neuroimaging on patients using the pMRI as part of routine clinical care in the Emergency Department and Intensive Care Unit (ICU) since August of 2020. Massachusetts General Hospital has begun using pMRI in the Neuroscience Intensive Care Unit since January 2021. This technology has expanded the population of patients who can receive MRI imaging by increasing accessibility and timeliness for scan completion by eliminating the need for transport and increasing the potential for serial monitoring. Here we describe our methods for screening, coordinating, and executing pMRI exams and provide further detail on how to scan specific patient populations.

Management of complex pleural disease in the critically ill patient

Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.

MRI at the Bedside: A Case Report Comparing Fixed and Portable Magnetic Resonance Imaging for Suspected Stroke

Magnetic resonance imaging (MRI) provides high-contrast resolution and is the preferred diagnostic tool for neurological disease. However, long exam times discourage MRI in emergency settings, and high-field MRI scanners (1.5-3T) require dedicated imaging suites. New, portable low-field-strength MRI machines (0.064T) have lower resolution than fixed MRI, but do not require restrictive environments or intrahospital transport. We present a case of a 78-year-old male with altered mental status who underwent 0.064T portable MRI and fixed 3T MRI exams in the emergency department. Imaging showed no evidence of acute infarction or intracranial lesions. The 0.064T images were of poor quality relative to 3T sequences, but the results of the portable MRI agreed with the conventional 3T MRI and a computed tomography scan from the same day. The compatible imaging results suggest that portable, low-field MRI can aid in neurological diagnosis without transporting patients to the MRI suite. Further studies should expand this comparison between high- and low-field MRI to better characterize the role and clinical applications of point-of-care MRI.

Application of the improved simple bedside method for emergency temporary pacemaker implantation suitable for primary hospitals

The purpose of the research was to evaluate the safety and effectiveness of the X-ray-free improved simple bedside method for emergency temporary pacemaker implantation as well as the practicability of the method in primary hospitals. Patients [including those suffering from sick sinus syndrome and third-degree and advanced atrioventricular blockage (AVB)] who needed emergency temporary pacemaker implantation from July 2017 to August 2020 in Hunan Provincial People’s Hospital were selected. They were stochastically divided into a research group (95 cases) treated with the improved simple bedside method and a control group (95 cases) with X-ray guidance. The ordinary bipolar electrodes were used in both groups. On this condition, the operation duration, the first-attempt success rate of electrodes, pacing threshold, success rate of the operation, the rate of electrode displacement, and complications in the two groups were separately calculated. The comparison results of the research group with the control group are shown as follows: operation time [(18 ± 5.91) min vs. (43 ± 2.99) min, P < 0.05], the first-attempt success rate of the electrode (97% vs. 98%, P > 0.05), pacing threshold [(0.97 ± 0.35) vs. (0.97 ± 0.32) V, P > 0.05], success rate of the operation (98.9% vs. 100%, P > 0.05), the rate of electrode displacement (8.4% vs. 7.3%, P > 0.05) and complications (3.2% vs. 2.1%, P > 0.05). The emergency temporary pacemaker implantation based on the improved simple bedside method is as safe and effective as the surgical method under X-ray guidance, and the operation is simpler and easier to learn and requires a shorter operating time, therefore, it is more suitable for use in emergency and primary hospitals.

Application of comprehensive u nit-based safety program model in the inter-hospital transfer of patients with critical diseases: a retrospective controlled study

Background

To explore the effect of applying a comprehensive unit-based safety program (CUSP) in the intrahospital transfer of patients with critical diseases.

Methods

A total of 426 critically ill patients in the first affiliated Hospital of Anhui Medical University from August 2018 to February 2019 were divided into two groups according to the time of admission. Overall, 202 patients in the control group were treated with the routine transfer method, and 224 patients in the observational group were treated with the transfer method based on the CUSP model. The safety culture assessment data of medical staff, the occurrence rate of adverse events and related causes, the time of transfer, and the satisfaction of patients’ relatives to the transfer process were compared before and after implementation of the transfer model between the two groups.

Results

Before and after the implementation of the CUSP mode transfer program, there were significant differences in the scores of all dimensions of the safety culture assessment of medical staff (P < 0.05), and the occurrence rate of adverse events and the causes in the observational group were significantly lower than those in the control group (disease-related, staff-related, equipment-related, environment-related) (P < 0.05). The transfer time for Computed Tomography (CT), Magnetic Resonance Imaging (MRI), operating room, and the interventional room was significantly shorter in the observational group than that in the control group (P < 0.05), while the satisfaction of relatives to the transfer process was significantly higher than those in the control group (P < 0.05).

Conclusion

The implementation of CUSP model for the intrahospital transfer of critically ill patients can significantly shorten the in-hospital transfer time, improve the attitude of medical staff towards safety, reduce the occurrence rate of adverse events, and improve the satisfaction of patients’ relatives to the transfer process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06650-7.

Evidence-Based Guideline on Critical Patient Transport and Handover to ICU

The perioperative period is a time in which significant physiological change occurs. Improper transfer of information at this point can lead to medical errors. Planning and preparation for critical patient transport to ICU is vital to prevent adverse events. Critical patient transport to ICU must be as safe as possible and should not cause additional risks. It needs good communication, planning, and appropriate staffing with standard monitoring. Evidence shows inconsistency and variability on the use of standardized protocols during critical patient transfer and handover to the ICU. There is a variety of controversial approaches about the need of sedation, use of end-tidal CO₂ monitoring, and manual versus mechanical ventilation based on different evidence. The objective of this review was to recommend safer options of critical patient transfer to the ICU that help reduce patient morbidity and mortality. Methods. Google Scholars, PubMed through HINARI, and other search engines were used to search high-quality evidence that help reach appropriate conclusions. Discussion. Critical patient transfer and handover to ICU is a complex procedure that needs experienced hands, availability of appropriate team members, standard monitoring, and necessary emergency and patient-specific medications. Appropriate and adequate transfer of patient information to the receiving team decreases patient morbidity and mortality when the transfer team uses standardized checklist. Conclusion. Involvement of senior physicians, use of standard monitoring, and appropriate transfer of information have been shown to decrease critical patient morbidity and mortality.

Low dose radiation therapy for severe COVID-19 pneumonia: a randomized double-blind study

PURPOSE

The morbidity and mortality of patients requiring mechanical ventilation for coronavirus disease 2019 (COVID-19) pneumonia is considerable. We studied the use of whole-lung low dose radiation therapy (LDRT) in this patient cohort.

METHODS AND MATERIALS

Patients admitted to the intensive care unit (ICU) and requiring mechanical ventilation for COVID-19 pneumonia were included in this randomized double-blind study. Patients were randomized to 1 Gy whole-lung LDRT or sham irradiation (sham-RT). Treatment group allocation was concealed from patients and ICU clinicians, who treated patients according to the current standard of care. Patients were followed for the primary endpoint of ventilator-free days (VFDs) at day 15 post-intervention. Secondary endpoints included overall survival, as well as changes in oxygenation and inflammatory markers.

RESULTS

Twenty-two patients were randomized to either whole-lung LDRT or sham-RT between November and December 2020. Patients were generally elderly and comorbid, with a median age of 75 years in both arms. No difference in 15-day VFDs was observed between groups (p = 1.00), with a median of 0 days (range, 0-9) in the LDRT arm, and 0 days (range, 0-13) in the sham-RT arm. Overall survival at 28 days was identical at 63.6% (95%CI, 40.7-99.5%) in both arms (p = 0.69). Apart from a more pronounced reduction in lymphocyte counts following LDRT (p < 0.01), analyses of secondary endpoints revealed no significant differences between the groups.

CONCLUSIONS

Whole-lung LDRT failed to improve clinical outcomes in critically ill patients requiring mechanical ventilation for COVID-19 pneumonia.

Lung ultrasound may be a valuable aid in decision making for patients admitted with COVID-19 disease

INTRODUCTION: COVID-19 is associated with a risk of severe pneumonia and acute respiratory distress syndrome (ARDS), requiring treatment at an intensive care unit (ICU). Since clinical deterioration may occur rapidly, a simple, fast, bedside, non-invasive method for assessment of lung changes is warranted. The primary aim of this study was to investigate whether lung ultrasound (LUS) findings within 72 hours of admission were predictive of clinical deterioration in hospitalized patients with confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

METHODS: Patients admitted to a dedicated COVID-19 unit were subject to daily LUS examinations. Number of present consolidations and pleural effusions were registered and a Mongodi score was calculated. These findings were correlated with initial chest x-ray and clinical deterioration, defined as ICU-admission, ARDS diagnosis, death.

RESULTS: In total, 29 of 83 patients had LUS performed during admission, 18 within 72 h of admission. Of these, four patients died during admission, six were transferred to the ICU and 13 were diagnosed with ARDS.

Initial Mongodi-score did not differ significantly between patients with and without clinical deterioration (p = 0.95). Agreement between initial LUS and chest x-ray findings were fair with Cohen’s Kappa at 0.21.

CONCLUSION: LUS performed within 72 h in patients admitted to a dedicated COVID-19 unit could not predict ARDS, ICU admission or death. However, consecutive investigations may be of value, as sudden substantial changes may herald disease progression, enabling earlier supplementary diagnostics and treatment initiation.

A New Tool to Assess Clinician Experience With Patient Care Transitions

BACKGROUND AND OBJECTIVES

Clinician experience of intrahospital patient care transfers can drive transfer success and safe patient care. Measuring clinician experience can provide insights into opportunities to improve transfer processes that impact patient care. As part of a quality improvement project, we developed a brief survey to gauge clinician experience with patient care transfers that occur within a hospital.

METHODS

The survey framework was built upon a previously identified taxonomy of intrahospital transfers that includes categories of transfer activities: disposition, notification, preparation, communication, and coordination. The survey tool was administered twice to physicians, nurses, and other health professionals across a single hospital. Data were analyzed comparing providers sending patients, and those receiving patients.

RESULTS

The survey response rate was 33% to 34% across both years. While helpful in demonstrating improving trends in provider experience and engagement with transfer processes, the survey also allowed for differences between the experiences of sending and receiving providers to be revealed. Nurses reported improved preparedness to receive patients and receivers overall reported improved teamwork. Senders' perceptions showed improved trends in all transfer categories. Preliminary data also suggest acceptable reliability across respondent type, item category, and time. Specifically, reliability across sending and receiving clinicians was demonstrated in the categories of timeliness (α = 0.85) and culture (α = 0.72). Responses of sending clinicians were internally consistent within culture (α = 0.82), while responses of receiving clinicians were internally consistent within culture (α = 0.86), timeliness (α = 0.76), notification (α = 0.77), communication (α = 0.73), and teamwork (α = 0.73).

CONCLUSIONS

Overall, the survey was feasible to implement and built to optimize content, construct, and response process validity. Survey results drove practical improvement work, such as informing a verbal transfer protocol to improve nursing preparedness to receive patients on general medicine units. As a practical tool, the survey and its results can help hospital administrators to focus on categories of transfer activities that are most problematic for clinicians and to track trends for quality improvement.

Evaluation, Treatment, and Impact of Neurologic Injury in Adult Patients on Extracorporeal Membrane Oxygenation: a Review

Purpose

Extracorporeal membrane oxygen (ECMO) is increasingly used as an advanced form of life support for cardiac and respiratory failure. Unfortunately, in infrequent instances, circulatory and/or respiratory recovery is overshadowed by neurologic injury that can occur in patients who require ECMO. As such, knowledge of ECMO and its implications on diagnosis and treatment of neurologic injuries is indispensable for intensivists and neurospecialists.

Recent findings

The most common neurologic injuries include intracerebral hemorrhage, ischemic stroke, seizure, cerebral edema, intracranial hypertension, global cerebral hypoxia/anoxia, and brain death. These result from events prior to initiation of ECMO, failure of ECMO to provide adequate oxygen delivery, and/or complications that occur during ECMO. ECMO survivors also experience neurological and psychological sequelae similar to other survivors of critical illness.

Summary

Since many of the risk factors for neurologic injury cannot be easily mitigated, early diagnosis and intervention are crucial to limit morbidity and mortality from neurologic injury during ECMO.

Nosocomial Pneumonia in the Era of Multidrug-Resistance: Updates in Diagnosis and Management

Nosocomial pneumonia (NP), including hospital-acquired pneumonia in non-intubated patients and ventilator-associated pneumonia, is one of the most frequent hospital-acquired infections, especially in the intensive care unit. NP has a significant impact on morbidity, mortality and health care costs, especially when the implicated pathogens are multidrug-resistant ones. This narrative review aims to critically review what is new in the field of NP, specifically, diagnosis and antibiotic treatment. Regarding novel imaging modalities, the current role of lung ultrasound and low radiation computed tomography are discussed, while regarding etiological diagnosis, recent developments in rapid microbiological confirmation, such as syndromic rapid multiplex Polymerase Chain Reaction panels are presented and compared with conventional cultures. Additionally, the volatile compounds/electronic nose, a promising diagnostic tool for the future is briefly presented. With respect to NP management, antibiotics approved for the indication of NP during the last decade are discussed, namely, ceftobiprole medocaril, telavancin, ceftolozane/tazobactam, ceftazidime/avibactam, and meropenem/vaborbactam.

Caring for critically ill patients during interhospital transfers: A qualitative study

BACKGROUND

The coronavirus pandemic has resulted in an increased number of interhospital transfers of patients with artificial airways. The transfer of these patients is associated with risks and has been experienced as highly challenging, which needs to be further explored.

AIMS AND OBJECTIVES

To describe critical care nurses' experiences of caring for critically ill patients with artificial airways during interhospital transfers.

DESIGN

A cross-sectional study using a qualitative approach was conducted during spring 2020. Participants were critical care nurses (n = 7) from different hospitals (n = 2).

METHODS

The data were collected through semi-structured interviews based on an interview guide. A qualitative content analysis using an inductive approach was performed.

RESULTS

The analysis resulted in one main theme, "Preserving the safety in an unknown environment," and three sub-themes, "Being adequately prepared is essential to feel secure," "Feeling abandoned and overwhelmingly responsible," and "Being challenged in an unfamiliar and risky environment."

CONCLUSIONS

Critical care nurses experienced interhospital transfers of critically ill patients with artificial airways as complex and risky. It is essential to have an overall plan in order to prevent any unpredictable and acute events. Adequate communication and good teamwork are key to the safe transfer of a critically ill patient in that potential complications and dangers to the patient can be prevented.

RELEVANCE TO CLINICAL PRACTICE

Standardized checklists need to be created to guide the transfers of critically ill patients with different conditions. This would prevent failures based on human or system factors, such as lack of experience and lack of good teamwork.

Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness

Aim

Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation.

Design and implementation

We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including ‘VITAL’ (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, ‘STOP’ (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and ‘STOP’ (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme.

Results

The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001).

Conclusion

The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

Does preoperative magnetic resonance imaging alter the surgical plan in patients with acute traumatic cervical spinal cord injury?

BACKGROUND

Whether magnetic resonance imaging (MRI) adds value to surgical planning for patients with acute traumatic cervical spinal cord injury (ATCSCI) remains controversial. In this study, we compared surgeons' operative planning decisions with and without preoperative MRI. We had two hypotheses: (1) the surgical plan for ATCSCI would not change substantially after the MRI and (2) intersurgeon agreement on the surgical plan would also not change substantially after the MRI.

METHODS

We performed a vignette-based survey study that included a retrospective review of all adult trauma patients who presented to our American College of Surgeons-verified level 1 trauma center from 2010 to 2019 with signs of acute quadriplegia and underwent computed tomography (CT), MRI, and subsequent cervical spine surgery within 48 hours of admission. We abstracted patient demographics, admission physiology, and injury details. Patient clinical scenarios were presented to three spine surgeons, first with only the CT and then, a minimum of 2 weeks later, with both the CT and MRI. At each presentation, the surgeons identified their surgical plan, which included timing (none, <8, <24, >24 hours), approach (anterior, posterior, circumferential), and targeted vertebral levels. The outcomes were change in surgical plan and intersurgeon agreement. We used Fleiss' kappa (κ) to measure intersurgeon agreement.

RESULTS

Twenty-nine patients met the criteria and were included. Ninety-three percent of the surgical plans were changed after the MRI. Intersurgeon agreement was "slight" to "fair" both before the MRI (timing, κ = 0.22; approach, κ = 0.35; levels, κ = 0.13) and after the MRI (timing, κ = 0.06; approach, κ = 0.27; levels, κ = 0.10).

CONCLUSION

Surgical plans for ATCSCI changed substantially when the MRI was presented in addition to the CT; however, intersurgeon agreement regarding the surgical plan was low and not improved by the addition of the MRI.

LEVEL OF EVIDENCE

Diagnostic, level II.

Real-time three-dimensional transesophageal echocardiographic guidance versus fluoroscopic guidance for transvenous temporary cardiac pacemaker implantation during transcatheter aortic valve implantation surgeries

Background

Fluoroscopic guidance is the traditional method for the implantation of transvenous temporary cardiac pacemakers (TVTPs). This study aimed to compare the time, effectiveness, and safety of real-time three-dimensional transesophageal echocardiography (3D TEE) with those of fluoroscopy in guiding TVTP implantation.

Methods

The records of patients who underwent transcatheter aortic valve implantation (TAVI) guided by real-time 3D TEE or fluoroscopy between July 1, 2016, and June 30, 2020, were retrospectively analyzed. TVTPs were implanted by anesthesiologists via the right internal jugular vein (IJV) in the real-time 3D TEE-guided group (3D TEE group), and by interventional cardiologists via the femoral vein in the fluoroscopy-guided group (fluoro group).

Results

A total of 143 patients (3D TEE-group n=79, and fluoro group n=64) were included. No statistical differences were observed in the baseline characteristics of the two groups. TVTPs were successfully implanted in all of the patients. The needle-to-pace time was significantly shorter in 3D TEE group than in fluoro group (5.2±2.9 vs. 8.5±4.6 min, P<0.001). Further, the incidence of access complications was significantly lower in 3D TEE group than in fluoro group (3.8% vs. 12.5%, P<0.05). One patient in fluoro group who suffered cardiac perforation underwent drainage via pericardiocentesis. No patients in either group died because of TVTP placement. The total complication rates were significantly lower in 3D TEE group than in fluoro group (19.0% vs. 39.1%, P<0.05). No statistically significant differences existed between groups in terms of pacing threshold, the incidence of permanent pacemaker insertion after surgery, the length of postoperative intensive care unit (ICU) stay, or the duration of postoperative hospitalization.

Conclusions

Real-time 3D TEE-guided can be used to effectively, quickly, and safely guide TVTP implantation. The procedure can be performed by properly trained anesthesiologists. Therefore, real-time 3D TEE is a suitable option for guiding perioperative TVTP implantation in patients undergoing cardiac surgery.

Endotracheal Tube Placement Confirmation with Bedside Ultrasonography in the Pediatric Intensive Care Unit: A Validation Study

Critically ill patients who are intubated undergo multiple chest X-rays (CXRs) to determine endotracheal tube position; however, other modalities can save time, medical expenses, and radiation exposure. In this article, we evaluated the validity and interrater reliability of ultrasound to confirm endotracheal tube (ETT) position in patients. A prospective study was performed on intubated patients with cuffed ETTs. The accuracy of ultrasound to confirm correct ETT placement in 92 patients was 97.8%. Sensitivity, positive predictive value, and agreement of 97.7, 93.3, and 91.3% were found on comparing ultrasound to CXR findings. Ultrasound is feasible, reliable, and has good interrater reliability in assessing correct ETT position in children.

Dealing with the Sick Rural Surgery Patient in Need of Transfer

Care for rural and urban surgical patients is increasingly more complex due to advancing knowledge and technology. Interhospital transfers occur in approximately 10% of index encounters at rural hospitals secondary to mismatch of patient needs and local resources. Due to the recent expansion of air transport to rural areas, distance and geography are less of a barrier. The interhospital transfer process is understudied and far from standardized. Interhospital transfer status is associated with increase in mortality, complications, length of stay, and costs. The cost, price to patients, and safety of air ambulance transports cannot be ignored.

Novel approaches to metabolic assessment and structured exercise to promote recovery in ICU survivors

PURPOSE OF REVIEW

Survivorship or addressing impaired quality of life (QoL) in ICU survivors has been named 'the defining challenge of critical care' for this century to address this challenge; in addition to optimal nutrition, we must learn to employ targeted metabolic/muscle assessment techniques and utilize structured, progressive ICU rehabilitative strategies.

RECENT FINDINGS

Objective measurement tools such as ccardiopulmonary exercise testing (CPET) and muscle-specific ultrasound show great promise to assess/treat post-ICU physical dysfunction. CPET is showing that systemic mitochondrial dysfunction may underlie development and persistence of poor post-ICU functional recovery. Finally, recent data indicate that we are poor at delivering effective, early ICU rehabilitation and that there is limited benefit of currently employed later ICU rehabilitation on ICU-acquired weakness and QoL outcomes.

SUMMARY

The combination of nutrition with effective, early rehabilitation is highly likely to be essential to optimize muscle mass/strength and physical function in ICU survivors. Currently, technologies such as muscle-specific ultrasound and CPET testing show great promise to guide ICU muscle/functional recovery. Further, we must evolve improved ICU-rehabilitation strategies, as current methods are not consistently improving outcomes. In conclusion, we must continue to look to other areas of medicine and to athletes if we hope to ultimately improve 'ICU Survivorship'.

Improving the safety and quality of the intra-hospital transport of critically ill patients

BACKGROUND

Adverse events during patient transport are common and may threaten critically ill patients' lives.

AIM

This study aimed to determine the incidence of adverse events during intra-hospital transport and to obtain suggestions from critical care nurses for improving the transportation process.

DESIGN

This was a cross-sectional study.

METHODS

This study was carried out with 160 critical care nurses between September 2018 and January 2019. Data were collected through a semi-structured interview using a 53-item questionnaire developed by Brunsveld-Reinders et al. It assesses nurses' experiences of adverse events during the three phases of intra-hospital transport related to equipment, patient physiology, monitoring, medications, and fluid management. The data were analysed using descriptive statistics in SPSS software, and the responses of open-ended questions were analysed using a conventional qualitative content analysis.

RESULTS

On scales from 0 to 10, the mean (and SD) values of fear, confidence, and skill to carry out a safe intra-hospital transport were 2.66 (2.73), 6.45 (3.16), and 7.75 (1.55), respectively. The most important causes of feeling afraid or unconfident about the transport among the nurses were unstable patient condition, cardiac arrest, extubation, and oxygen desaturation. In all three phases, oxygen desaturation, haemodynamic instability, and agitation were reported as the most frequent events. The most important suggestions by nurses for improving the transport process were related to paying attention to the patient's clinical condition and connections before, during, and after the transfer.

CONCLUSIONS

Along with the acquisition and improvement of technical and tactical skills, adequate human resources and appropriate equipment can improve the quality of intra-hospital transport.

RELEVANCE TO CLINICAL PRACTICE

Nurses are key members of the transport team and lead the team. They are responsible for keeping patients safe during transport. By identifying adverse events and trying to modify risk factors, nurses can improve patients' safety.

Organisational factors underpinning intra-hospital transfers: a guide for evaluating context in quality improvement

During intra-hospital transfers, multiple clinicians perform coordinated tasks that leave patients vulnerable to undesirable outcomes. Communication has been established as a challenge to care transitions, but less is known about the organisational complexities within which transfers take place. We performed a qualitative assessment that included various professions to capture a multi-faceted understanding of intra-hospital transfers. Ethnographic observations and semi-structured interviews were conducted with clinicians and staff from the Medical Intensive Care Unit, Emergency Department, and general medicine units at a large, urban, academic, tertiary medical centre. Results highlight the organisational factors that stakeholders view as important for successful transfers: the development, dissemination, and application of protocols; robustness of technology; degree of teamwork; hospital capacity; and the ways in which competing hospital priorities are managed. These factors broaden our understanding of the organisational context of intra-hospital transfers and informed the development of a practical guide that can be used prior to embarking on quality improvement efforts around transitions of care.

The value of immediate postoperative radiographs following fluoroscopically-guided orthopaedic surgery in a polytrauma ICU setting in KwaZulu-Natal, South Africa

BACKGROUND

Radiographic imaging remains a cornerstone of orthopaedic practice. Traditional control X-Rays are routinely requested after procedures. These X-rays may add little value in post-op evaluation of trauma ICU patients, in light of intra-operative screening already performed and reviewed, but has high potential morbidity risk.

AIM

The aim is to determine if patients undergoing extra-articular fracture fixation, with fluoroscopic image guidance, require any management change due to immediate check x-rays findings.

METHOD

Electronic patient and imaging records from January 2015 to November 2019 at a Trauma-specific ICU at a Trauma Society of South Africa accredited, Level 1 Trauma Unit were reviewed retrospectively. All patients matching the inclusion criteria were evaluated to determine if there were any complications and changes in management after the check X-Rays.

RESULTS

There were 103 ICU patients identified with a mean age of 32 years (3 to 94). Fifty-seven percent had fluoroscopy images as well as post-operative check x-rays and 51.5% had only check X-rays. Only two cases needed revision surgery based on the control x-ray findings. The post-operative x-ray did not alter the management of 98.1% of our patients.

CONCLUSION

In this study, routine post-op check x-rays did not add significant additional information to warrant early additional surgical intervention especially in ICU patients with adequate intra-operative fluoroscopy images. This investigation should be ordered for individual patients based on clinical grounds. This will help minimize patient exposure to avoidable radiation, labour intensive transfers to the radiology department, and decrease investigations that have financial implications but with limited benefits.

Trauma Response Nurse: Bringing Critical Care Experience and Continuity to Early Trauma Care

Multitrauma patients can benefit significantly from specialized care. Prior to mid-2016, this hospital's trauma team did not include a surgical intensive care unit (SICU) nurse. As the value of bringing this expertise to the patient upon arrival was realized, the role of the trauma response nurse (TRN) was developed. The TRN role was designed to provide a dedicated SICU nurse to care for trauma patients from emergency department (ED) arrival through disposition. The integration of the TRN role into the trauma team sought to improve quality and safety, as well as communication and collaboration, and enhance continuity of care. The primary responsibilities of the TRN were to assist with clinical interventions, transport patients fromthe ED to tests and procedures, and assume care through disposition. Additional TRN duties included education, community outreach, and performance improvement. TRNs now respond to all trauma activations that occur on weekday day shift. This role has improved collaboration between nursing disciplines, improved the overall function of the trauma team, and enhanced the safety of trauma patients during transport. TRNs make valuable contributions to the education and outreach missions of the trauma program and ensure that patients are receiving the highest level of trauma care.