Factors Associated With Quality of Death in Korean ICUs As Perceived by Medical Staff: A Multicenter Cross-Sectional Survey.

OBJECTIVES: Facilitating a high quality of death is an important aspect of comfort care for patients in ICUs. The quality of death in ICUs has been rarely reported in Asian countries. Although Korea is currently in the early stage after the implementation of the "well-dying" law, this seems to have a considerable effect on practice. In this study, we aimed to understand the status of quality of death in Korean ICUs as perceived by medical staff, and to elucidate factors affecting patient quality of death. DESIGN: A multicenter cross-sectional survey study. SETTING: Medical ICUs of two tertiary-care teaching hospitals and two secondary-care hospitals. PATIENTS: Deceased patients from June 2016 to May 2017. INTERVENTIONS: Relevant medical staff were asked to complete a translated Quality of Dying and Death questionnaire within 48 hours after a patient's death. A higher Quality of Dying and Death score (ranged from 0 to 100) corresponded to a better quality of death. MEASUREMENTS AND MAIN RESULTS: A total of 416 completed questionnaires were obtained from 177 medical staff (66 doctors and 111 nurses) of 255 patients. All 20 items of the Quality of Dying and Death received low scores. Quality of death perceived by nurses was better than that perceived by doctors (33.1 ± 18.4 vs 29.7 ± 15.3; p = 0.042). Performing cardiopulmonary resuscitation and using inotropes within 24 hours before death were associated with poorer quality of death, whereas using analgesics was associated with better quality of death. CONCLUSIONS: The quality of death of patients in Korean ICUs was considerably poorer than reported in other countries. Provision of appropriate comfort care, avoidance of unnecessary life-sustaining care, and permission for more frequent visits from patients' families may correspond to better quality of death in Korean medical ICUs. It is also expected that the new legislation would positively affect the quality of death in Korean ICUs.

Rubrum Coelis: The Contribution of Real-Time Telementoring in Acute Trauma Scenarios-A Randomized Controlled Trial.

Background: Most deaths in military trauma occur soon after wounding, and demand immediate on scene interventions. Although hemorrhage predominates as the cause of potentially preventable death, airway obstruction and tension pneumothorax are also frequent. First responders caring for casualties in operational settings often have limited clinical experience.Introduction: We hypothesized that communications technologies allowing for real-time communications with a senior medically experienced provider might assist in the efficacy of first responding to catastrophic trauma.Methods: Thirty-three basic life saving (BLS) medics were randomized into two groups: either receiving telementoring support (TMS, n = 17) or no telementoring support (NTMS, n = 16) during the diagnosis and resuscitation of a simulated critical battlefield casualty. In addition to basic life support, all medics were required to perform a procedure needle thoracentesis (not performed by BLS medics in Israel) for the first time. TMS was performed by physicians through an internet link. Performance was assessed during the simulation and later on review of videos.Results: The TMS group was significantly more successful in diagnosing (82.35% vs. 56.25%, p = 0.003) and treating pneumothorax (52.94% vs. 37.5%, p = 0.035). However, needle thoracentesis time was slightly longer for the TMS group versus the NTMS group (1:24 ± 1:00 vs. 0:49 ± 0:21 minu, respectively (p = 0.016). Complete treatment time was 12:56 ± 2:58 min for the TMS group, versus 9:33 ± 3:17 min for the NTMS group (p = 0.003).Conclusions: Remote telementoring of basic life support performed by military medics significantly improved the medics' ability to perform an unfamiliar lifesaving procedure at the cost of prolonging time needed to provide care. Future studies must refine the indications and contraindications for using telemedical support.

Mothers' Voices Related to Caregiving: The Transition of a Technology-Dependent Infant from the NICU to Home.

PURPOSE: The transition from the NICU to home is a complicated, challenging process for mothers of infants dependent on lifesaving medical technology, such as feeding tubes, supplemental oxygen, tracheostomies, and mechanical ventilation. The study purpose was to explore how these mothers perceive their transition experiences just prior to and during the first three months after initial NICU discharge. DESIGN: A qualitative, descriptive, longitudinal design was employed. SAMPLE: Nineteen mothers of infants dependent on lifesaving technology were recruited from a large Midwest NICU. MAIN OUTCOME VARIABLE: Description of mothers' transition experience. RESULTS: Three themes were identified pretransition: negative emotions, positive cognitive-behavioral efforts, and preparation for life at home. Two posttransition themes were negative and positive transition experiences. Throughout the transition, the mothers expressed heightened anxiety, fear, and stress about life-threatening situations that did not abate over time despite the discharge education received.

Intermediate life support for the adult.

Stuart Barker, Graduate Tutor in Adult Nursing, Northumbria University (stuart.j.barker@northumbria.ac.uk), discusses more advanced skills to complement basic life support, including early recognition of deterioration, different types of airway support for an unconscious patient and automated defibrillation.

The Role of Health Care Provider Goals, Plans, and Physician Orders for Life-Sustaining Treatment (POLST) in Preparing for Conversations About End-of-Life Care.

The Physician Orders for Life-Sustaining Treatment (POLST) is a planning tool representative of an emerging paradigm aimed at facilitating elicitation of patient end-of-life care preferences. This study assessed the impact of the POLST document on provider goals and plans for conversations about end-of-life care treatment options. A 2 (POLST: experimental, control) × 3 (topic of possible patient misunderstanding: cardiopulmonary resuscitation, medical intervention, artificially administered nutrition) experimental design was used to assess goals, plan complexity, and strategies for plan alterations by medical professionals. Findings suggested that the POLST had little impact on plan complexity or reaction time with initial plans. However, preliminary evidence suggested that the utility of the POLST surfaced with provider responses to patient misunderstanding, in which differences in conditions were identified. Significant differences in goals reported as most important in driving conversational engagement emerged. Implications for findings are discussed.

The development and implementation of an inter-professional simulation based pediatric acute care curriculum for ward health care providers.

An interprofessional, simulation based, acute care course for ward health care providers was developed and implemented with the objectives of teaching identification of deteriorating patients, practicing crisis resource management and basic life support skills, and using the SBAR (Situation Background Assessment Recommendation) communication tool. Thirty-eight physicians and 51 nurses attended the four separate courses. Nine questions on a 5-point Likert scale and two open-ended questions revealed that over 95% of respondents strongly agreed/agreed that facilitators encouraged active participation, lectures were presented in an interesting manner, and that simulations were useful for practical skills and for practicing communication. Open-ended questions revealed that participants felt more confident, understood the importance of communication, roles, teamwork and valued the day. Based on this evaluation, the program was regarded as feasible and acceptable to all health care providers.

Nurses' knowledge and comfort levels using the Physician Orders for Life-sustaining Treatment (POLST) form in the progressive care unit.

Many patients are admitted to the hospital with an active Physician Orders for Life-sustaining Treatment (POLST) Form; however, not all registered nurses (RNs) are familiar with the form or comfortable with initiating a discussion about end-of-life care. Evidence indicates that an education program increases RNs' knowledge and utilization of the POLST form. The purpose of this evidence-based practice project was to answer the question: among the RNs in a progressive care unit (PCU), does implementing a formal evidence-based practice POLST program compared to current practice increase RNs' knowledge and comfort level using the POLST form? A pre-post education survey was used. Results indicated a POLST education program increased PCU RNs' knowledge and comfort level in using the POLST form. It is recommended to include POLST form education for PCU RNs in workplace education programs.

A scenario-based, randomized trial of patient values and functional prognosis on intensivist intent to discuss withdrawing life support.

OBJECTIVES: To evaluate the effect of 1) patient values as expressed by family members and 2) a requirement to document patients' functional prognosis on intensivists' intention to discuss withdrawal of life support in a hypothetical family meeting. DESIGN: A three-armed, randomized trial. SETTING: One hundred seventy-nine U.S. hospitals with training programs in critical care accredited by the Accreditation Council for Graduate Medical Education. SUBJECTS: Six hundred thirty intensivists recruited via e-mail invitation from a database of 1,850 eligible academic intensivists. INTERVENTIONS: Each intensivist was randomized to review 10, online, clinical scenarios with a range of illness severities involving a hypothetical patient (Mrs. X). In control-group scenarios, the patient did not want continued life support without a reasonable chance of independent living. In the first experimental arm, the patient wanted life support regardless of functional outcome. In the second experimental arm, patient values were identical to the control group, but intensivists were required to record the patient's estimated 3-month functional prognosis. MEASUREMENTS AND MAIN RESULTS: Response to the question: "Would you bring up the possibility of withdrawing life support with Mrs. X's family?" answered using a five-point Likert scale. There was no effect of patient values on whether intensivists intended to discuss withdrawal of life support (p = 0.81), but intensivists randomized to record functional prognosis were 49% more likely (95% CI, 20-85%) to discuss withdrawal. CONCLUSIONS: In this national, scenario-based, randomized trial, patient values had no effect on intensivists' decisions to discuss withdrawal of life support with family. However, requiring intensivists to record patients' estimated 3-month functional outcome substantially increased their intention to discuss withdrawal.

Basic life support skill improvement with newly designed renewal programme: cluster randomised study of small-group-discussion method versus practice-while-watching method.

BACKGROUND: For the basic life support (BLS) renewal course, we have devised a new educational programme entitled a small-group-discussion (SGD) programme using personalised video-based debriefing. OBJECTIVE: We compared the efficacy in BLS skill improvement of the SGD programme with the currently used practice-while-watching (PWW) programme, which uses a standardised education video. METHOD: This was a prospective, cluster randomised study, conducted in a single centre, over 6 months from May 2009 to October 2009. Training was performed in two groups of participants, each group with a different renewal education programme. The efficacy of the programmes was compared using the modified Cardiff test and skill-reporting manikins. RESULTS: Results from 2169 participants were analysed: 1061 in the SGD programme group and 1108 in the PWW programme group. There were no differences between groups on the pretest, either in compression or non-compression skills. However, on the post-test, the SGD programme gave better results for both compression skills and non-compression skills. CONCLUSIONS: The new SGD renewal programme is more effective than the PWW programme for improving skills in BLS renewal training.

Remote symptom support training programs for oncology nurses in Canada: an environmental scan.

The overall aim of this study was to explore current remote symptom support training programs provided to nurses in ambulatory oncology programs across Canada, using a survey-methods environmental scan. Of 36 delivered invitations, 28 programs responded (77.8%) representing 10 provinces. Of 25 programs that offer telephone symptom support, 17 provide symptom support training, seven do not, and one did not say. Seven programs shared training materials with the investigators and elements of training included: symptom management guidelines (n = 6), telephone triage process/principles (n = 5), competent telephone practices (n = 4), documentation (n = 4), professional standards (n = 3), role-play (n = 3), communication skills/etiquette (n = 3), and monitoring quality (n = 1). Formats included: presentations (n = 3), paper-based resources (n = 3), or e-learning modules (n = 1). No training programs were rigorously evaluated. Training in telephone nursing symptom support across oncology programs is variable. Opportunities exist to identify core competencies and evaluate if training programs enhance delivery of remote cancer symptom support.

Setup and maintenance of extracorporeal life support programs.

Setting up an extracorporeal life support program requires motivated experts, institutional commitment, and an interprofessional team of healthcare providers with dedicated time, space, and resources. This article provides guidance on the key steps involved in the process of developing a sustainable extracorporeal membrane oxygenation program, based on guidelines from the Extracorporeal Life Support Organization and from an international perspective.

The implementation of PEARS training: supporting nurses in non-critical care settings to improve patient outcomes.

Children's Hospital Boston's Life Support Program began offering the newly developed American Heart Association Pediatric Emergency Assessment, Recognition and Stabilization (PEARS) course for nurses working in non-critical care settings in December of 2007. The goal was to provide an appropriate alternative to pediatric advanced life support (PALS) training for clinical staff caring for the general pediatric population. To date, more than 900 nurses have completed the course with feedback from the participants being extremely positive. Even more impressive is a more appropriate use of the hospital's emergency medical response system promoting early intervention and the significant reduction in cardiac arrests on inpatient units. During a 12-month period, nurses involved in activations of the response system were asked to rate their ability to assess, categorize, decide and act after each event. The overwhelming majority agreed they were able to apply the PEARS systematic approach of assessment and early intervention to the situation. This article describes the planning and implementation of PEARS training for non-critical care nursing staff and provides data that demonstrates improved patient outcomes. Supporting activities and strategies promoting early recognition and interventions contributing to the successful reduction of cardiac arrests on inpatient units are also discussed.

Integrated model for providing tactical emergency medicine support (TEMS): analysis of 120 tactical situations.

BACKGROUND: Various models for organising tactical emergency medicine support (TEMS) in law enforcement operations exist. In Helsinki, TEMS is organised as an integral part of emergency medical service (EMS) and applied in hostage, siege, bomb threat and crowd control situations and in other tactical situations after police request. Our aim was to analyse TEMS operations, patient profile, and the level of on-site care provided. METHODS: We conducted a retrospective cohort study of TEMS operations in Helsinki from 2004 to 2009. Data were retrieved from EMS, hospital and dispatching centre files and from TEMS reports. RESULTS: One hundred twenty TEMS operations were analysed. Median time from dispatching to arrival on scene was 10 min [Interquartile Range (IQR) 7-14]. Median duration of operations was 41 min (IQR 19-63). Standby was the only activity in 72 operations, four patients were dead on arrival, 16 requests were called off en route and patient examination or care was needed in 28 operations. Twenty-eight patients (records retrieved) were alive on arrival and were classified as trauma (n = 12) or medical (n = 16). Of traumas, two sustained a gunshot wound, one sustained a penetrating abdominal wound, three sustained medium severity injuries and nine sustained minor injuries. There was neither on-scene nor in-hospital mortality among patients who were alive on arrival. The level of on-site care performed was basic life support in all cases. CONCLUSIONS: The results showed that TEMS integrated to daily EMS services including safe zone working only was a feasible, rapid and efficient way to provide medical support to law enforcement operations.

The Effectiveness of a New Dispatcher-Assisted Basic Life Support Training Program on Quality in Cardiopulmonary Resuscitation Performance During Training and Willingness to Perform Bystander Cardiopulmonary Resuscitation: A Cluster Randomized Controlled Study.

INTRODUCTION: A new dispatcher-assisted basic life support training program, called "Home Education and Resuscitation Outcome Study (HEROS)" was developed with a goal to provide high-quality dispatcher-assisted cardiopulmonary resuscitation (CPR) training, with a focus on untrained home bystanders. This study aimed to determine whether the HEROS program is associated with improved quality in CPR performance during training and willingness to provide bystander CPR compared with other basic life support programs without dispatcher-assisted CPR (non-HEROS). METHODS: This clustered randomized trial was conducted in 3 district health centers in Seoul. Intervention group was trained with the HEROS program and control group was trained with non-HEROS program. The primary outcome was overall CPR quality, measured as total CPR score. Secondary outcomes were other CPR quality parameters including average compression depth and rate, percentages of adequate depth, and acceptable release. Tertiary outcomes were posttraining survey results. Difference in difference analysis was performed to analyze the outcomes. RESULTS: Among total 1929 trainees, 907 (47.0%) were trained with HEROS program. Compared with the non-HEROS group, the HEROS group showed higher-quality CPR performances and better maintenance of their CPR quality throughout the course (total scores of 84% vs. 80% for first session and 72% vs. 67% for last session; difference in difference of 12.2 vs. 13.2). Other individual CPR parameters also showed significantly higher quality in the HEROS group. The posttraining survey showed that both groups were highly willing to perform bystander CPR (91.4% in the HEROS vs. 92.3% in the non-HEROS) with only 3.4% of respondents in the HEROS group were not willing to volunteer compared with 6.2% in the non-HEROS group (P < 0.01). CONCLUSIONS: The HEROS training program helped trainees perform high-quality CPR throughout the course and enhanced their willingness to provide bystander CPR.

Improving Advanced Care Planning through Physician Orders for Life-Sustaining Treatment (POLST) Expansion across the United States: Lessons Learned from State-Based Developments.

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is an effective advance care planning tool. However, barriers to implementation persist. In the United States, POLST program development occurs at the state-level. Substantial differences between states has left POLST implementation largely unstandardized. No peer-reviewed studies to date have evaluated state-based POLST program development over time. OBJECTIVE: To assess and learn from the successes and barriers in state-based POLST program development over time to improve the reach of POLST or similar programs across the United States. DESIGN: An exploratory, prospective cohort study that utilized semistructured telephone interviews was conducted over a 3-year period (2012-2015). Stakeholder representatives from state POLST coalitions (n = 14) were repeatedly queried on time-relevant successes, barriers, and innovations during POLST program development with levels of legislative and medical barriers rated 1 to 10. Interviews were transcribed and analyzed using techniques grounded in qualitative theory. RESULTS: All coalition representatives reported continuous POLST expansion with improved outreach and community partnerships. Significant barriers to expansion included difficulty in securing funding for training and infrastructure, lack of statewide metric systems to adequately assess expansion, lack of provider support, and legislative concerns. Medical barriers (mean [standard deviation]: 5.0 [0.2]) were rated higher than legislative (3.0 [0.6]; P < .001). CONCLUSION: POLST programs continue to grow, but not without barriers. Based on the experiences of developing coalitions, we were able to identify strategies to expand POLST programs and overcome barriers. Ultimately the "lessons learned" in this study can serve as a guide to improve the reach of POLST or similar programs.

Do all pediatric patients who have a febrile seizure require transport by advanced life support?

OBJECTIVE: In the state of New Jersey, all pediatric patients who are transported to the hospital by emergency medical services for seizures are evaluated by both advanced life support (ALS) and basic life support (BLS) units. The state triage protocol mandates that a paramedic unit be dispatched. The purpose of this study is establish that the subset of those patients who experience simple febrile seizures could be safely transported by BLS, subsequently freeing much needed ALS resources. METHODS: This study was performed using a retrospective chart review. Seventy-one consecutive patients who experienced febrile seizures and were transported to the Bristol-Meyers-Squib Children's Hospital/Robert Wood Johnson University Hospital via ALS were included. These patients were risk stratified into groups which were analyzed for interventions, including inpatient admission, medication delivery, intubation, or respiratory support. RESULTS: From this analysis, we are identified factors in the history and physical examination of patients in the field that would help to classify the patient as having a "simple febrile seizure" and thus significantly lowering the risk of any potential negative outcome. CONCLUSIONS: Simple febrile seizure patients are suitable for transport via BLS. Further studies should be done to confirm this conclusion.

Selecting and evaluating decision-making strategies in the intensive care unit: A systematic review.

PURPOSE: Many patients in the Intensive Care Unit (ICU) die after a decision to withhold or withdraw treatment. To ensure that for each patient the appropriate decision is taken, a careful decision-making process is required. This review identifies strategies that can be used to optimize the decision-making process for continuing versus limiting life sustaining treatment of ICU patients. METHODS: We conducted a systematic review of the literature by searching PUBMED and EMBASE. RESULTS: Thirty-two studies were included, with five categories of decision-making strategies (1) integrated communication, (2) consultative communication, (3) ethics consultation, (4) palliative care consultation and (5) decision aids. Many different outcome measures were used and none of them covered all aspects of decisions on continuing versus limiting life sustaining treatment. Integrated communication strategies had a positive effect on multiple outcome measures. Frequent, predefined family-meetings as well as triggered and integrated ethical or palliative consultation were able to reduce length of stay of patients who eventually died, without increasing overall mortality. CONCLUSIONS: The decision-making process in the ICU can be enhanced by frequent family-meetings with predefined topics. Ethical and palliative support is useful in specific situations. These interventions can reduce non-beneficial ICU treatment days.