Global resuscitation alliance utstein recommendations for developing emergency care systems to improve cardiac arrest survival.

INTRODUCTION: The Global Resuscitation Alliance (GRA) was established in 2015 to improve survival for Out- of-Hospital Cardiac Arrest (OHCA) using the best practices developed by the Seattle Resuscitation Academy. However, these 10 programs were recommended in the context of developed Emergency Care Systems (ECS). Implementing these programs can be challenging for ECS at earlier stages of development. We aimed to explore barriers faced by developing ECS and to establish pre-requisites needed. We also developed a framework by which developing ECS may use to build their emergency response capability. METHOD: A consensus meeting was held in Singapore on 1st-2nd August 2017. The 74 participants were key stakeholders from 26 countries, including Emergency Medical Services (EMS) directors, physicians and academics, and two Physicians who sit on the World Health Organisation (WHO) panel for development of Emergency Care Systems. Five discussion groups examined the chain of survival: community, dispatch, ambulance and hospital; a separate group considered perinatal resuscitation. Discussion points were voted upon to reach a consensus. RESULTS: The answers and discussion points from each groupwere classified into a table adapted from WHO's framework of development for Emergency Services. After which, it was used to construct the modified survival framework with the chain of survival as the backbone. Eleven key statements were then derived to describe the pre-requisites for achieving the GRA 10 programs. The participants eventually voted on the importance and feasibility of these 11 statements as well as the GRA 10 programs using a matrix that is used by organisations to prioritise their action steps. CONCLUSION: In this paper, we propose a modified framework of survival for developing ECS systems. There are barriers for developing ECS systems to improve OHCA survival rates. These barriers may be overcome by systematic prioritisation and cost-effective innovative solutions.

Predicting methicillin resistance among community-onset Staphylococcus aureus bacteremia patients with prior healthcare-associated exposure.

To develop and validate prediction rules to identify the risk of methicillin-resistant Staphylococcus aureus (MRSA) infection among community patients who have healthcare-associated (HA) exposure and S. aureus bacteremia. A total of 1,166 adults with community-onset S. aureus bacteremia were retrospectively enrolled. The background prevalence of community MRSA infection was extrapolated from 392 community-associated S. aureus bacteremia (CA-SAB) patients without HA exposure. Complete and clinical risk scores were derived and tested using data from 774 healthcare-associated S. aureus bacteremia (HA-SAB) patients. The risk scores were modeled with and without incorporating previous microbiological data as a model predictor and stratified patients to low-, intermediate-, and high-risk groups for MRSA infection. The clinical risk score included five independent predictors and the complete risk score included six independent predictors. The clinical and complete risk scores stratified 32.7 % and 42.0 % of HA-SAB patients to the low-risk group for MRSA infection respectively. The prevalence of MRSA infection in score-stratified low-risk groups ranged from 16.3 % to 23.3 %, comparable to that of CA-SAB patients (13.8 %). Simple decision rules allow physicians to stratify the risk of MRSA infection when treating community patients with prior HA exposure and possible S. aureus infection.

Should bleeding tendency deter abdominal paracentesis?

BACKGROUND AND AIMS: This study was conducted to evaluate the complications and bleeding associated with either thrombocytopoenia or prolongation of prothrombin time for ultrasound-guided abdominal paracentesis in the emergency department. STUDY DESIGN AND PATIENTS: In an emergency department of a tertiary centre, patients receiving ultrasound-guided abdominal paracentesis by the emergency physicians were prospectively enrolled. Patient characteristics, the preprocedure international normalised ratio for prothrombin time and the platelet count, and the procedure-related complications were collected and analysed. RESULTS: For a 2-year study period, a total of 410 abdominal paracenteses in 163 patients were investigated. The preprocedure international normalised ratio for prothrombin time was more than 1.5 in 142 paracenteses; the preprocedure platelet count was less than 50 x 10(3) microL(-1) in 55 paracenteses. Only two out of 410 procedures (0.5%, 95% confidence interval=0.1-1.8%) were associated with minor complications of cutaneous bleeding in the same patient (0.6%, 95% confidence interval=0.1-3.4%) at different visits. There was no significant procedure-related bleeding or complications even in patients with marked thrombocytopoenia or prolongation in international normalised ratio. CONCLUSIONS: Bleeding complication of ultrasound-guided abdominal paracentesis is uncommon and appears to be very mild, regardless of preprocedure international normalised ratio or platelet count. Routine correction of prolonged international normalised ratio or thrombocytopoenia before abdominal paracentesis may not be necessary.