Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Mpox Pain Management with Topical Agents: A Case Series.

With the recent spread in monkeypox cases, continuous efforts are made to manage the disease efficiently. Pain at the site of monkeypox lesions and in areas of skin breakdown can be severe. The origin of pain is likely neuropathic. The Centers for Disease Control and Prevention (CDC) has issued general guidelines to control pain with non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, gabapentin, and topical agents such as corticosteroids and lidocaine. Guidelines circulated by the World Health Organization (WHO) suggest acetaminophen, tramadol, opioids, and/or topical lidocaine for symptomatic pain management. No first line agent with proven beneficial effect has been recommended in these patients. We present two patients' painful experiences with Monkeypox and suggest lessons learned.

Lithium and Chlorine-Rich Preparation of Mechanochemically Activated Antiperovskite Composites for Solid-State Batteries.

Assembling all-solid-state batteries presents a unique challenge due to chemical and electrochemical complexities of interfaces between a solid electrolyte and electrodes. While the interface stability is dictated by thermodynamics, making use of passivation materials often delays interfacial degradation and extends the cycle life of all-solid cells. In this work, we investigated antiperovskite lithium oxychloride, Li3OCl, as a promising passivation material that can engineer the properties of solid electrolyte-Li metal interfaces. Our experiment to obtain stoichiometric Li3OCl focuses on how the starting ratios of lithium and chlorine and mechanochemical activation affect the phase stability. For substantial LiCl excess conditions, the antiperovskite phase was found to form by simple melt-quenching and subsequent high-energy ball-milling. Li3OCl prepared with 100% excess LiCl exhibits ionic conductivity of 3.2 × 10-5 S cm-1 at room temperature, as well as cathodic stability against Li metal upon the extended number of cycling. With a conductivity comparable to other passivation layers, and stable interface properties, our Li3OCl/LiCl composite has the potential to stably passivate the solid-solid interfaces in all-solid-state batteries.

Disaster Ethics: Shifting Priorities in an Unstable and Dangerous Environment.

Emergency and critical care medicine are fraught with ethically challenging decision making for clinicians, patients, and families. Time and resource constraints, decisional-impaired patients, and emotionally overwhelmed family members make obtaining informed consent, discussing withholding or withdrawing of life-sustaining treatments, and respecting patient values and preferences difficult. When illness or trauma is secondary to disaster, ethical considerations increase and change based on number of casualties, type of disaster, and anticipated life cycle of the crisis. This article considers the ethical issues that arise when health providers are confronted with the challenges of caring for victims of disaster.

Quality metrics for the evaluation of Rapid Response Systems: Proceedings from the third international consensus conference on Rapid Response Systems.

BACKGROUND: Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS. METHODS: We conducted an international consensus process. Participants included patients, carers, clinicians, research scientists, and members of the International Society for Rapid Response Systems with representatives from Europe, Australia, Africa, Asia and the US. Scoping reviews of the literature identified potential metrics. We used a modified Delphi methodology to arrive at a list of candidate indicators that were reviewed for feasibility and applicability across a broad range of healthcare systems including low and middle-income countries. The writing group refined recommendations and further characterized measurement tools. RESULTS: Consensus emerged that core outcomes for reporting for quality improvement should include ten metrics related to structure, process and outcome for RRS with outcomes following the domains of the quadruple aim. The conference recommended that hospitals should collect data on cardiac arrests and their potential predictability, timeliness of escalation, critical care interventions and presence of written treatment goals for patients remaining on general wards. Unit level reporting should include the presence of patient activated rapid response and metrics of organizational culture. We suggest two exploratory cost metrics to underpin urgently needed research in this area. CONCLUSION: A consensus process was used to develop ten metrics for better understanding the course and care of deteriorating ward patients. Others are proposed for further development.

Trigger Criteria: Big Data.

Electronic medical records can be used to mine clinical data (big data), providing automated analysis during patient care. This article describes the source and potential impact of big data analysis on risk stratification and early detection of deterioration. It compares use of big data analysis with existing methods of identifying at-risk patients who require rapid response. Aggregate weighted scoring systems combined with big data analysis offer an opportunity to detect clinical changes that precede rapid response team activation. Future studies must determine if this will decrease transfers to intensive care units and cardiac arrests on the floors.

Caring for Patients or Organs: New Therapies Raise New Dilemmas in the Emergency Department.

Two potentially lifesaving protocols, emergency preservation and resuscitation (EPR) and uncontrolled donation after circulatory determination of death (uDCDD), currently implemented in some U.S. emergency departments (EDs), have similar eligibility criteria and initial technical procedures, but critically different goals. Both follow unsuccessful cardiopulmonary resuscitation and induce hypothermia to "buy time": one in trauma patients suffering cardiac arrest, to enable surgical repair, and the other in patients who unexpectedly die in the ED, to enable organ donation. This article argues that to fulfill patient-focused fiduciary obligations and maintain community trust, institutions implementing both protocols should adopt and publicize policies to guide ED physicians to utilize either protocol for particular patients, in order to address the appearance of conflict of interest arising from the protocols' similarities. It concludes by analyzing ethical implications of incentives that may influence institutions to develop the expertise required for uDCDD but not EPR.

Hidden Obligatory Fluid Intake in Critical Care Patients.

INTRODUCTION: In addition to the fluid intake in the form of intravenous maintenance or boluses in intensive care unit (ICU) patients, there are sources of fluids that may remain unrecognized but contribute significantly to the overall fluid balance. We hypothesized that fluids not ordered as boluses or maintenance infusions-"hidden obligatory fluids"-may contribute more than a liter to the fluid intake of a patient during any random 24 hours of critical care admission. METHODS: Patients admitted to the Harlem Hospital ICU for at least 24 hours were included in this study (N = 98). Medical records and nursing charts were reviewed to determine the sources and volumes of various fluids for the study patients. RESULTS: The mean hidden obligatory volume for an ICU patient was calculated to be 978 mL (standard deviation [SD]: 904, median: 645) and 1571 mL (SD: 1023, median: 1505), with enteral feeds compared to the discretionary volume of 2821 mL (SD: 2367, median: 2595); this obligatory fluid volume was affected by a patient's need for pressor support and renal replacement therapy. CONCLUSION: Hidden obligatory fluids constitute a major source of the fluid intake among patients in a critical care unit. Up to 1.5 L should be taken into account during daily decision making to effectively regulate their volumes.

Experience With a New Process - Condition T - for Uncontrolled Donation After Circulatory Determination of Death in a University Emergency Department.

BACKGROUND: In the United States, organ donation after circulatory death (DCD) determination is increasing among those who are removed from life-sustaining therapy but is rare when death is unexpected. We created a program for uncontrolled DCD (uDCD). METHODS: A comprehensive program was created to train personnel to identify and respond quickly to potential donors after unexpected death. The process termed Condition T was implemented in the emergency department (ED) of 2 academic medical centers. All ED deaths were screened for uDCD potential. Eligible donors included patients with preexisting donor designation who received cardiopulmonary resuscitation, failed to respond, and were pronounced dead. RESULTS: Over 350 nurses, physicians, perfusionists, organ procurement personnel, and administrators were trained. From February 2009 to June 2010, a total of 18 patients were potential Condition T candidates. Six Condition T responses were triggered. Three donors underwent cannulation, and 4 organs were recovered (3 kidney and 1 liver) from 2 donors. Time from Condition T trigger to perfusion with organ preservation solution ranged from 14 to 22.3 minutes. Perfusion duration was 197 and 221 minutes. No recovered organs were transplanted because biopsies showed prolonged warm ischemia. CONCLUSIONS: It is feasible to create a process to rapidly intervene in the ED for uDCD. However, no organ transplants resulted. The utility and sustainability of an uDCD program in this particular setting are questionable.