Understanding Team Dynamics and Culture of Safety using Video Reflexive Ethnography during Real-Time Emergent Intubation.

RATIONALE: Endotracheal intubation is the third most common bedside procedure in U.S. hospitals. In over 40% of intubations preventable complications attributable to human factors occur. A better understanding of team dynamics during intubation may improve patient safety. OBJECTIVE: To explore team dynamics and safety-related actions during emergent endotracheal intubations in the emergency department (ED) and intensive care unit (ICU), and to engage members of the care team in reflection for process improvement through a novel video-based team debriefing technique. METHODS: Video-reflexive ethnography involves in-situ video-recording and reflexive discussions with practitioners to scrutinize behaviors and to identify opportunities for improvement. In this study, real-time intubations were recorded in the ED and ICU at Mayo Clinic Rochester and facilitated video-reflexive sessions were conducted with the multidisciplinary procedural teams. Themes about team dynamics and safety-related action were identified inductively from transcriptions of recorded sessions. RESULTS: Between December 2022 and January 2023, eight video-reflexive sessions were conducted with a total of 78 participants. Multidisciplinary members included nurses (n=23), respiratory therapists (n=16), pharmacists (n=7), advanced practitioners (n=5), and physicians (n=26). Video-reflexive discussions identified major safety gaps and proposed several solutions related to the use of a multidisciplinary intubation checklist, standardized communication and team positioning, developing a culture of safety, and routinely debriefing after the procedure. CONCLUSION: The findings of this study may inform the development of a team supervision model for emergent endotracheal intubations. This approach could integrate key components such as a multidisciplinary intubation checklist, standardized communication and team positioning, a culture of safety, and debriefing as part of the procedure itself.

Cumulative epinephrine dose during cardiac arrest and neurologic outcome after extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Epinephrine is recommended without an apparent ceiling dosage during cardiac arrest. However, excessive alpha- and beta-adrenergic stimulation may contribute to unnecessarily high aortic afterload, promote post-arrest myocardial dysfunction, and result in cerebral microvascular insufficiency in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). METHODS: This was a retrospective cohort study of adults (≥ 18 years) who received ECPR at large academic ECMO center from 2018 to 2022. Patients were grouped based on the amount of epinephrine given during cardiac arrest into low (≤ 3 mg) and high (> 3 mg) groups. The primary endpoint was neurologic outcome at hospital discharge, defined by cerebral performance category (CPC). Multivariable logistic regression was used to assess the relationship between cumulative epinephrine dosage during arrest and neurologic outcome. RESULTS: Among 51 included ECPR cases, the median age of patients was 60 years, and 55% were male. The mean cumulative epinephrine dose administered during arrest was 6.2 mg but ranged from 0 to 24 mg. There were 18 patients in the low-dose (≤ 3 mg) and 25 patients in the high-dose (> 3 mg) epinephrine groups. Favorable neurologic outcome at discharge was significantly greater in the low-dose (55%) compared to the high-dose (24%) group (p = 0.025). After adjusting for age, those who received higher doses of epinephrine during the arrest were more likely to have unfavorable neurologic outcomes at hospital discharge (odds ratio 4.6, 95% CI 1.3, 18.0, p = 0.017). CONCLUSION: After adjusting for age, cumulative epinephrine doses above 3 mg during cardiac arrest may be associated with unfavorable neurologic outcomes after ECPR and require further investigation.

Stercoral Colitis in the Emergency Department: A Retrospective Review of Presentation, Management, and Outcomes.

STUDY OBJECTIVE: Stercoral colitis is inflammation of the bowel wall caused by fecal impaction. Despite reported high morbidity and risk of perforation, little research assessing outcomes is available. This study characterizes the presentation, management, and outcomes of emergency department patients with stercoral colitis. METHODS: We performed a retrospective chart review of ED patients with stercoral colitis identified on computed tomography (CT) scan. Of 814, 522 visits to multiple EDs across the US, 269 met the inclusion criteria. Variables regarding patient presentation, management, and outcomes were extracted from electronic medical records. Results were analyzed with percentages and 95% confidence intervals (CIs). RESULTS: Of 269 patients, the median age was 76 years. The most common chief concern was abdominal pain/distension (33.8%). However, abdominal pain was documented as absent in 62.1% of cases. The most common CT findings included fecal impaction (96.7%), bowel wall inflammation (72.9%), and fat stranding (48.3%). Eighty-four (31.2%) patients were discharged home from the ED, and over half of these (45/84, 53.6%) received no enema, laxatives, or disimpaction. Overall, 9 patients (3.3%, 95% CI 1.6% to 6.5%) required surgical management of a related complication within 3 months, 27 (10.0%, 95% CI 6.8% to 14.4%) returned to the ED within 72 hours, and 9 (3.3%, 95% CI 1.6% to 6.5%) died from a cause related to stercoral colitis within 3 months. CONCLUSION: Patients with stercoral colitis often present in a nonspecific manner, and short-term mortality is substantial. In this study, most discharged patients did not receive recommended treatment. This represents the largest ED study of stercoral colitis and provides further evidence linking this diagnosis with adverse outcomes.

Characteristics and Outcomes of Patients in the Emergency Department with Left Ventricular Assist Devices.

Introduction: Left ventricular assist devices (LVAD) are increasingly common among patients with heart failure. The unique physiologic characteristics of patients with LVADs present a challenge to emergency clinicians making treatment and disposition decisions. Despite the increasing prevalence of LVADs, literature describing emergency department (ED) visits among this population is sparse. We aimed to describe clinical characteristics and outcomes among patients with LVADs seen in two quaternary-care EDs in a five-year period. Secondarily, we sought to evaluate mortality rates and ED return rates for bridge to transplant (BTT) and destination therapy (DT) patients. Methods: We conducted a retrospective cohort study of adult patients known to have an LVAD who were evaluated in two quaternary-care EDs from 2013-2017. Data were collected from the electronic health record and summarized with descriptive statistics. We assessed patient outcomes with mixed-effects logistic regression models including a random intercept to account for patients with multiple ED visits. Results: During the five-year study period, 290 ED visits among 107 patients met inclusion criteria. The median patient age was 61 years. The reason for LVAD implantation was BTT in 150 encounters (51.7%) and DT in 140 (48.3%). The most common presenting concerns were dyspnea (21.7%), bleeding (18.6%), and chest pain (11.4%). Visits directly related to the LVAD were infrequent (7.9%). Implantable cardioverter-defibrillator discharge was reported in 3.4% of visits. A majority of patients were dismissed home from the ED (53.8%), and 4.5% required intensive care unit admission. Among all patients, 37.9% returned to the ED within 30 days, with similar rates between DT and BTT patients (32.1 vs 43.3%; P = 0.055). The LVAD was replaced in three cases (1.0%) during hospitalization. No deaths occurred in the ED, and the mortality rate within 30 days was 2.1% among all patients. Conclusion: In this multicenter cohort study of ED visits among patients with an LVAD, dyspnea, bleeding, and chest pain were the most common presenting concerns. Visits directly related to the LVAD were uncommon. Approximately half of patients were dismissed home, although return ED visits were common.

International Virtual Simulation Education in Critical Care During COVID-19 Pandemic: Preliminary Description of the Virtual Checklist for Early Recognition and Treatment of Acute Illness and iNjury Program.

SUMMARY STATEMENT: The Checklist for Early Recognition and Treatment of Acute Illness and iNjury program is a well-established, interactive, and simulation-based program designed to improve the quality of care delivered in intensive care units. The COVID-19 pandemic created an overwhelming surge of critically ill patients worldwide, and infection control concerns limited healthcare providers' access to in-person and hands-on simulation training when they needed it the most. Virtual simulation offers an alternative to in-person training but is often complex and expensive. We describe our successful development and initial implementation of an inexpensive, simulation-based virtual Checklist for Early Recognition and Treatment of Acute Illness and iNjury program to address the pressing need for effective critical care training in various resource-limited settings both within and outside of the United States. The overall satisfaction rate ("excellent" or "very good" responses) was 94.4% after the virtual simulation workshop. Our initial experience suggests that virtual interactions can be engaging and build strong relationships, like in-person continuing professional education, even using relatively simple technology. This knowledge-to-practice improvement platform can be readily adapted to other disciplines beyond critical care medicine.

Clinical Presentations and Outcomes of Patients Receiving Immune Checkpoint Inhibitors Presenting to the Emergency Department.

Immune checkpoint inhibitors (ICIs) are increasingly used in the treatment of cancer. Immune checkpoint inhibitors may cause a wide-range of autoimmune toxicities referred to as immune-related adverse events (irAEs). There is a paucity of data regarding the presentations and outcomes of patients receiving ICIs who seek care in an emergency department (ED). We performed a retrospective review of patients receiving an ICI who presented to a tertiary care ED between May 1, 2017, and April 30, 2018. Data including ED chief complaint, diagnosis, treatment, and disposition were collected along with baseline characteristics and diagnosis at the time of outpatient oncology follow-up. We report descriptive statistics summarizing the characteristics of the cohort. There were 98 ED visits identified among 67 unique patients. Immune-related adverse events were diagnosed in 16 (16.3%) cases. The most common chief complaints within the irAE group were gastrointestinal symptoms 10 (62.5%). Among the 16 confirmed irAE cases, the most common irAE diagnosed was colitis 9 (56.3%). Two (12.5%) patients with irAEs received corticosteroids during their stay in the ED, and 10 (62.5%) patients with irAEs required hospital admission. Emergency medicine providers documented consideration of an irAE in the differential diagnosis in 14.3% of all ED visits and in 43.8% of visits in which an irAE was ultimately diagnosed. Emergency providers should be familiar with ICIs given their expanding use and potential adverse effects to improve early recognition and patient outcomes in ED settings.

Three Cases of Emergency Department Medical Malpractice Involving "Consultations": How Is Liability Legally Determined?

This article presents three successfully litigated medical malpractice cases involving emergency physicians and consultants. We discuss the respective case medical diagnoses, as well as established legal principles that determine in a court proceeding which provider will be liable. Specifically, we explain the legal principles of "patient physician relationship" and "affirmative act."

Teaching procedural skills to medical students: A pilot procedural skills lab.

BACKGROUND: Medical students have limited confidence in performing procedural skills. A pilot study was conducted to evaluate the effect of a multifaceted Procedural Skills Lab (PSL) on the confidence of medical students to perform procedural skills. METHODS: Twelve 2nd year medical students were randomly selected to participate in a pilot PSL. The PSL students met with an instructor for 2 h once a week for 4 weeks. Students participated in a flipped classroom and spaced education program before laboratory sessions that included a cadaver laboratory. Procedural skills included a focused assessment with sonography in trauma (FAST) scan, cardiac echocardiogram, lumbar puncture, arthrocentesis, and insertion of intraosseous and intravenous catheters. Students in the PSL were asked to rank their confidence in performing procedural skills before and after completion of the laboratory sessions (Wilcoxon ranked-sum test). A web-based questionnaire was also emailed to all 2nd year medical students to establish a baseline frequency for observing, performing, and confidence performing procedural skills (Mann-Whitney U-test). RESULTS: Fifty-nine percent (n = 106) of 180 2nd year medical students (n = 12 PSL students [treatment group], n = 94 [control group]) completed the survey. Frequency of observation, performance, and confidence in performing procedural skills was similar between the control and treatment groups at baseline. There was an increased confidence level (p < 0.001) for performing all procedural skills for the treatment group after completion of the PSL. DISCUSSION: An innovative PSL may increase students' confidence to perform procedural skills. Future studies will examine competency after a PSL.