Improved pre-hospital care efficiency due to the implementation of pre-hospital trauma life support (PHTLS®) algorithms.

PURPOSE: Pre-hospital trauma life support (PHTLS®) includes a standardized algorithm for pre-hospital care. Implementation of PHTLS® led to improved outcome in less developed medical trauma systems. We aimed to determine the impact of PHTLS® on quality of pre-hospital care in a European metropolitan area. We hypothesized that the introduction of PHTLS® was associated with improved efficiency of pre-hospital care for severely injured patients and less emergency physician deployment. METHODS: We included adult polytrauma (ISS > 15) patients that were admitted to our level one trauma center during a 7-year time period. Patients were grouped based on the presence or absence of a PHTLS®-trained paramedic in the pre-hospital trauma team. Group I (no-PHTLS group) included all casualties treated by no-PHTLS®-trained personnel. Group II (PHTLS group) was composed of casualties managed by a PHTLS® qualified team. We compared outcome between groups. RESULTS: During the study period, 187,839 rescue operations were executed and 280 patients were included. No differences were seen in patient characteristics, trauma severity or geographical distances between groups. Transfer times were significantly reduced in PHTLS® teams than non-qualified teams (9.3 vs. 10.5 min, P = 0.006). Furthermore, the in-field operation times were significantly reduced in PHTLS® qualified teams (36.2 vs. 42.6 min, P = 0.003). Emergency physician involvement did not differ between groups. CONCLUSION: This is the first study to show that the implementation of PHTLS® algorithms in a European metropolitan area is associated with improved efficiency of pre-hospital care for the severely injured. We therefore recommend considering the introduction of PHTLS® in metropolitan areas in the first world.

Atualização do atendimento do paciente em parada cardiorrespiratória: O que todo clínico deve saber? / Update of medical care in cardiorespiratory arrest: What should every clinician know?

O objetivo deste estudo foi apresentar uma revisão narrativa do atendimento à parada cardiorrespiratória, baseada nas diretrizes mais atuais e, também, uma análise crítica de informações de literatura recente, que vão além das recomendações gerais das diretrizes vigentes. A parada cardiorrespiratória, quando ocorre de forma inesperada, abrupta, em indivíduo que se encontrava estável horas antes do evento, é chamada de morte súbita. Essa condição é a principal causa de óbito extra-hospitalar não traumático e, dentre suas diversas causas, a síndrome coronariana aguda é a mais comum em adultos. Uma vez que a frequência de síndrome coronariana aguda tende a aumentar com o aumento da expectativa de vida e de prevalência de outros fatores de risco na população, a ocorrência de morte súbita também tende a aumentar nesse cenário. No intuito de orientar o atendimento de pacientes em parada cardiorrespiratória, há mais de quatro décadas foram criadas diretrizes internacionais, que evoluíram com o surgimento de novas evidências, especialmente nos últimos 20 anos. Todo médico deve estar preparado para atender uma situação de parada cardiorrespiratória, pois ele pode ser chamado para atender tais casos em diferentes cenários (emergência, unidade de internação ou em ambiente extra-hospitalar). Entretanto, apesar da importância da incorporação de novas evidências nessas diretrizes, mudanças frequentes nas recomendações representam grande desafio para os clínicos se manterem atualizados. Além da dificuldade na atualização permanente, há recomendações feitas pelas diretrizes de sociedades médicas que divergem entre si e são questionadas por especialistas, o que gera dúvida na tomada de decisão do clínico. Conforme pormenorizado neste artigo de atualização, as etapas do algoritmo de Suportes Básico e Avançado de Vida são apresentadas como uma sequência, para facilitar para o socorrista que atua sozinho a oferecer intervenções com impacto na sobrevivência do paciente, devendo priorizar a reanimação cardiopulmonar de qualidade e a desfibrilação precoce, se indicada.

The objective of this study was to present a narrative review of cardiac arrest care based on the most current guidelines, and also a critical analysis of recent literature information that goes beyond the general recommendations of the current guidelines. Cardiac arrest, when occurring unexpectedly, abruptly, in an individual who was stable hours before the event, is called sudden death. This condition is the leading cause of non-traumatic out-of-hospital death and, among its many causes, acute coronary syndrome is the most common in adults. Since the frequency of acute coronary syndrome tends to increase with increasing life expectancy and the prevalence of other risk factors in the population, sudden death also tends to increase in this scenario. In order to guide the care of patients with cardiopulmonary arrest, for over 4 decades, international guidelines have been created and have evolved with the emergence of new evidence, especially in the last 20 years. Every physician should be prepared to deal with a cardiac arrest situation as he or she may be called upon to treat such cases in different scenarios (emergency, inpatient unit or out-of-hospital setting). However, despite the importance of incorporating new evidence into these guidelines, frequent changes to the recommendations pose a major challenge for clinicians to update their knowledge. In addition to the difficulty of constantly updating, there are recommendations made by the guidelines of medical societies that differ from each other and are questioned by specialists, which creates doubt in the process of decision making among clinicians. As detailed in this update article, the stages of the algorithm of Basic and Advanced Life Support are presented in a sequence to help the rescuer who works alone to provide interventions that impact the patient's survival, and prioritize quality cardiopulmonary resuscitation and early defibrillation, if required.

Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan.

Background: Physician Orders for Life-Sustaining Treatment (POLST) is an advance care planning tool that is designed to document end-of-life (EoL) care wishes of those living with limited life expectancies. Although positive impacts of POLST program has been studied, variations in state-specific POLST programs across the nation remain unknown. Objective: Identify state variations in POLST forms and determine if variations are associated with program maturity status. Design: Environmental scan. Measurements: Using the national POLST website, state-specific POLST program characteristics were examined. With available sample POLST forms, EoL care options were abstracted. Results: Of all 51 states (50 United States states and Washington, D.C examined), the majority (n = 48, 98%) were actively participating in POLST; 3 states (5.9%) had Mature status, 19 states and District of Columbia (39.2%) were Endorsed, 24 states were in the developing phase (47.1%), and 4 states (7.8%) were nonconforming. Forty-five states (88.2%) had forms available for review. Antibiotic and intravenous fluid options were identified in 32 (71.1%), and 33 (73.3%) POLST forms, respectively. Hospital transfer and use of oxygen were mentioned in all forms. Use of respiratory devices (i.e., continuous positive airway pressure and bi-level positive airway pressure) were mentioned on 27 (60%) forms, whereas ventilator or intubation use were mentioned in 36 POLST forms (80%). No associations were found between POLST maturity status and provision of treatment options. Conclusions: Variations in integration of infection and symptom management options were identified. Further research is needed to determine if there are regional factors associated with provision of treatment options on POLST forms and if there are differences in actual rates of infection or symptoms reported.

Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study.

OBJECTIVE: To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. STUDY DESIGN: Prospective multicenter study. SETTING: Eleven ICUs. PATIENTS: All patients who died and/or had limitations on life support after ICU admission during a four-month period. VARIABLES: Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. RESULTS: 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). CONCLUSION: Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.

Cross-Cultural Adaptation of the Physician Orders for Life-Sustaining Treatment Form to Brazil.

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) paradigm is considered one of the most important strategies to respect patients' values at the end of life in the United States. The cross-cultural adaptation of POLST entailed several methodological considerations, which may be informative for international researchers who may also consider bringing POLST to their countries as a means to promote care at the end of life that is consistent with patients' preferences. OBJECTIVE: To report the methods and outcome of the cross-cultural adaptation of the POLST form to Brazil. DESIGN: Cross-cultural adaptation study. SETTING/SUBJECTS: Twenty physicians and 10 patients at a university hospital participated in the pilot tests. RESULTS: The cross-cultural adaptation process included choosing which existing POLST form(s) to use as a source, deciding the intended reading level, which healthcare professionals should be allowed to sign the form, and consultation with attorneys, bioethicists, and members of the National POLST Paradigm Task Force. Pilot tests occurred in two stages using different approaches. First, 20 physicians were trained about POLST and asked for any unclear aspects related to the form. Second, trained investigators completed POLST forms after engaging in advance care planning conversations with 10 hospitalized patients or patients' surrogates. CONCLUSIONS: This report provides a basis for future cross-cultural adaptations of POLST to other countries. The authors hope such new adaptations will broaden the possibilities of research using POLST and also may promote wider provision of care at the end of life that is consistent with patients' preferences.

Implementing and Assessing a Standardized Protocol for Weaning Children Successfully From Extracorporeal Life Support.

Extracorporeal life support (ECLS) weaning is a complex interdisciplinary process with no clear guidelines. To assess ventricular and pulmonary function as well as hemodynamics including end-organ recovery during ECLS weaning, we developed a standardized weaning protocol. We reviewed our experience 2 years later to assess its feasibility and efficacy. In 2015 we established an inter-professional, standardized, stepwise protocol for weaning from ECLS. If the patient did not require further surgery, weaning was conducted bedside in the intensive care unit (ICU). Most of the weaning procedures are guided via echocardiography. Data acquisition began at baseline level, followed by four-step course (each step lasting 10 min), entailing flow-reduction and ending 30 min after decannulation. Moreover, data from the preprotocol era are presented. Between May 2015 and 2017, 26 consecutive patients (18 male), median age 177 days (2 days-20 years) required ECLS with median support of 4 (2-11) days. Excluding eight not weanable patients, 21 standardized weaning procedures were protocolled in the remaining 18 children. Our generally successful protocol-guided weaning rate (with at least 24-h survival) was 89%, with a discharge home rate of 58%. Practical application of the novel standard protocol seems to facilitate ECLS weaning and to improve its success rate. The protocol can be administered as part of standard bedside ICU assessment.

Construction and validation of a distance Basic Life Support Course / Construcción y validación de Curso de Soporte Básico a la Vida a distancia / Construção e validação de Curso de Suporte Básico de Vida a distância

ABSTRACT Objective: to describe the content construction and validation process of the Distance Education Basic Life Support Course. Method: methodological study, developed through literature review, outlined in the light of the Bloom's Taxonomy and Ausubel's Meaningful Learning Theory. For validation, the analysis was performed with judges, using a structured tool. Results: the construction of the distance course was complex and challenging, since it was tried to develop it with logical-methodological coherence, considering the constructivist perspective, representing an advance in the process of dissemination of the Urgency and Emergency teaching culture. As for the content validation process, it was verified that of the 16 suggestions made by the judges, 14 were accepted and two rejected. Conclusion: the course had its contents validated by experts.

RESUMEN Objetivo: describir el proceso de construcción y validación de contenido de un curso de Soporte Básico a la Vida en la modalidad de educación a distancia. Método: estudio metodológico, desarrollado mediante revisión de la literatura, delineado a la luz de la Taxonomía de Bloom y la Teoría del Aprendizaje Significativo de Ausubel. Para validación, fue realizado un análisis con jueces mediante la utilización de instrumento estructurado. Resultados: la construcción de un curso a distancia se mostró compleja y desafiante una vez que se intentó desarrollarlo con coherencia lógico-metodológica, considerando la perspectiva constructivista, representando un avance en el proceso de diseminación de la cultura de la enseñanza de urgencia y emergencia. En cuanto al proceso de validación de contenido, se verificó que de las 16 sugerencias realizadas por los jueces, 14 fueron acatadas y 2, rechazadas. Conclusión: el curso obtuvo su contenido validado por expertos.

RESUMO Objetivo: descrever o processo de construção e validação de conteúdo do curso de Suporte Básico de Vida na modalidade Educação a Distância. Método: estudo metodológico, desenvolvido mediante revisão da literatura, delineado à luz da Taxonomia de Bloom e Teoria da Aprendizagem Significativa de Ausubel. Para validação, foi realizada a análise com juízes, mediante utilização de instrumento estruturado. Resultados: a construção do curso a distância se mostrou complexa e desafiadora, uma vez que se procurou desenvolvê-lo com coerência lógico-metodológica, considerando a perspectiva construtivista, representando um avanço no processo de disseminação da cultura do ensino de Urgência e Emergência. Quanto ao processo de validação de conteúdo, verificou-se que das 16 sugestões realizadas pelos juízes, 14 foram acatadas e duas rejeitadas. Conclusão: o curso obteve o seu conteúdo validado por especialistas.

Emergency Neurological Life Support: Intracerebral Hemorrhage.

Intracerebral hemorrhage (ICH) is a subset of stroke due to spontaneous bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, proper diagnosis, and early management of several specific issues such as blood pressure, coagulopathy reversal, and surgical hematoma evacuation for appropriate patients. ICH was chosen as an Emergency Neurological Life Support (ENLS) protocol because intervention within the first hours may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. / Recomendaciones para el tratamiento de los pacientes críticos de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

The Role of Advanced Practice Registered Nurses in the Completion of Physician Orders for Life-Sustaining Treatment.

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm records advance care planning for patients with advanced illness or frailty as actionable medical records. The National POLST Paradigm Task Force recommends that physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) be permitted to execute POLST forms. OBJECTIVE: To investigate the percentage of Oregon POLST forms signed by APRNs, and examine the obstacles faced by states attempting to allow APRNs to sign POLST forms. DESIGN: Cross-sectional. SETTING/SUBJECTS: 226,101 Oregon POLST Registry forms from 2010 to 2015. MEASUREMENTS: POLST forms in the Oregon Registry were matched with signer type (MD, DO, APRN, PA). RESULTS: 226,101 POLST forms have been added to the Oregon POLST Registry from 2010 to 2015: 85.3% of forms were signed by a physician, 10.9% of forms were signed by an APRN, and 3.8% of forms were signed by a PA. From 2010 to 2015, the overall percentage of POLST forms signed by an APRN has increased from 9.0% in 2010 to 11.9% in 2015. Physicians are authorized signers in all 19 states with endorsed POLST Paradigm programs; 16 of these states also authorize APRN signature, and 3 states (LA, NY, and GA) allow only physicians to sign. CONCLUSIONS: More than 10% of Oregon POLST forms are signed by APRNs. Given the need for timely POLST form completion, ideally by a member of the interdisciplinary team who knows the patient's preferences best, these data support authorizing APRNs to complete POLST forms.

Cuidados de enfermagem ao idoso no fim da vida / Cuidados de enfermería al anciano em el fin de la vida / Nursing care of the elderly in the end of life

RESUMO Esta reflexão emergiu como fruto da prática docente e assistencial aos idosos no fim da vida em um hospital universitário enquanto professoras da Disciplina de Fundamentos de Enfermagem e no atendimento ambulatorial em um Centro de Atenção à Saúde dos Idosos e Cuidadores. No desenvolvimento do artigo, buscou-se pontuar os parâmetros que norteiam o cuidado de enfermagem ao idoso que vivencia sua terminalidade com uma visão existencialista. Enfocou-se a finitude como parte do existir, em que o envelhecimento traz consigo um entendimento de proximidade da morte. A filosofia transpessoal do cuidado de Watson, referencial utilizado neste ensaio, permitiu delinear o cuidado singular ao idoso que vivencia o fim da vida através da descrição dos Elementos e o Processo Cáritas. Deste modo, a Enfermagem utiliza outras ciências para direcionar suas ações e assim possibilitar a escolha de referenciais filosóficos existencialistas como base de conhecimento, visto ser uma profissão que objetiva cuidar da vida da pessoa em sua totalidade. Sugeriu-se um modo de cuidar do idoso no fim da vida valorizando este contexto, onde cuidar é também lhe dar autonomia para ser o senhor da sua história e ter a oportunidade de com ele compartilhar seus últimos momentos.

RESUMEN Esta reflexión ha surgido como consecuencia de la práctica de la enseñanza y la atención a las personas mayores en el final de la vida en un hospital universitario, mientras que los maestros de Curso Fundamentos de enfermería y la atención ambulatoria en un centro de atención de la tercera edad Salud y cuidadores. El desarrollo del artículo buscó para puntuar los parámetros que guían la atención de enfermería al anciano que vive a través de su enfermedad terminal con una visión existencialista. Enfocado a la finitud como parte de la existencia, donde el envejecimiento trae una comprensión proximidad de la muerte. filosofía transpersonal marco de la atención Watson utilizada en este ensayo permitió delinear el cuidado exclusivo de los ancianos que han vivido el final de la vida mediante la descripción de los elementos y el proceso de Cáritas. Por lo tanto, la enfermería utiliza otras ciencias para dirigir sus acciones y por lo tanto hacer posible la elección de referencias filosóficas existencialistas como base de conocimientos, ya que es una profesión que tiene como objetivo cuidar de la propia vida en su totalidad. Se sugirió una forma de cuidar a los ancianos al final de la vida valorar este contexto, donde la atención también se dará autonomía a ser el dueño de su historia y tienen la oportunidad de compartir con él sus últimos momentos.

ABSTRACT This reflection has emerged as a result of the teaching and care practice for older people at the end of life in a university hospital, while teachers of Nursing Fundamentals Course and outpatient care in a care center Health Seniors and Caregivers. The development of the article sought to punctuate the parameters that guide the nursing care of the elderly who lives through his terminal illness with an existentialist vision. Focused to finitude as part of existence, where aging brings a proximity understanding of death. Transpersonal Philosophy Watson care framework used in this trial allowed delineating the unique care to the elderly who experience the end of life by describing the elements and the Caritas process. Thus, the Nursing uses other sciences to direct their actions and thus make possible the choice of existentialist philosophical references as a knowledge base, as it is a profession that aims to take care of one's life in its entirety. It was suggested a way of caring for the elderly at the end of life valuing this context, where care is also given autonomy to be the master of their history and have the opportunity to share with him his last moments.

Guidelines for the withdrawal of life-sustaining measures.

BACKGROUND: Withdrawal of life-sustaining measures is a common event in the intensive care unit yet it involves a complex balance of medical, legal and ethical considerations. Very few healthcare providers have been specifically trained to withdraw life-sustaining measures, and no comprehensive guidelines exist to help ensure clinicians deliver the highest quality of care to patients and families. Hence, we sought to develop guidelines for the process of withdrawing life-sustaining measures in the clinical setting. METHODS: We convened an interdisciplinary group of ICU care providers from the Canadian Critical Care Society and the Canadian Association of Critical Care Nurses, and used a modified Delphi process to answer key clinical and ethical questions identified in the literature. RESULTS: A total of 39 experienced clinicians completed the initial workshop, and 36 were involved in the subsequent Delphi rounds. The group developed a series of guidelines to address (1) preparing for withdrawal of life-sustaining measures; (2) assessment of distress; (3) pharmaceutical management of distress; and (4) discontinuation of life-sustaining measures and monitoring. The group achieved consensus on all aspects of the guidelines after the third Delphi round. CONCLUSION: We present these guidelines to help physicians provide high-quality end of life (EOL) care in the ICU. Future studies should address their effectiveness from both critical care team and family perspectives.

When birds can't fly: an analysis of interfacility ground transport using advanced life support when helicopter emergency medical service is unavailable.

BACKGROUND: Helicopter emergency medical service (HEMS) transport of trauma patients is costly and of unproven benefit. Recent retrospective studies fail to control for crew expertise and therefore compare highly trained advance life support with less-trained basic life support crews. The purpose of our study was to compare HEMS with ground, interfacility transport while controlling for crew training. We hypothesized that patients transported by HEMS would experience shorter interhospital transport time and reduced mortality. METHODS: Our National Trauma Registry of the American College of Surgeons database was retrospectively queried to identify consecutive interfacility, hospital transfers (January 1, 2008, to November 1, 2012) to our Level I trauma center. Transfers were stratified by transportation vehicle (i.e., HEMS vs. ground transport). Cohorts were compared across standard demographic and clinical variables using univariate analysis. Multivariate logistic regression was performed to determine the association of these variables with mortality. RESULTS: The HEMS (n = 2,190) and ground (n = 223) cohorts were well matched overall, with no significant differences for demographics, injury severity, physiology, hospital length of stay, or complications. Median (interquartile range) time to definitive care was significantly lower for HEMS (150 [114] minutes vs. 255 [157] minutes, p < 0.001), without change in mortality (9.0% vs. 8.1%, p = 0.71). Multivariate logistic regression did not identify an association between transport mode and mortality. CONCLUSION: Despite faster interfacility transport times, HEMS offered no mortality benefit compared with ground when crew expertise was controlled for, contradicting recent large, retrospective National Trauma Data Bank studies. Our study may represent the best approximation of a prospective study by focusing on patients deemed worthy of HEMS by referring providers. Although HEMS may seem intuitively beneficial for time-dependent injuries, larger studies with a similar methodology are warranted to justify the cost and risk of HEMS and identify subsets of patients who may benefit. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

[To maintain or to withdraw life support? Variations on the methods of ending life in a pediatric intensive care unit over a period of 6 years]. / Continuer, limiter ou arrêter? Évolution des modalités de décès sur une période de 6ans en réanimation pédiatrique.

Since 2005, forgoing live-support (FLS) is allowed by the French law (known as the Leonetti law) for end-of-life patients only. This study aims at describing the variations over time in the use of the following methods to end life: FLS, brain death and cardiopulmonary resuscitation failure (CPR failure). It is a single retrospective study from 2007 to 2012. The Cochran-Armitage trend test is used in the statistical analysis. Over six years, 263 of the 5100 children who were hospitalized in our intensive care unit died, which represents a 5.2% mortality rate. FLS increased yearly from 31% of the deaths in 2007, to 71% in 2012 (P=0.0008). The rate of CPR failure decreased over the same period (P=0.0015). The rate of brain death remained constant. Following to the Leonetti law, FLS increase, and palliative cares develop without any increase of mortality.

Hospice offers more palliative care but costs less than usual care for terminal geriatric hepatocellular carcinoma patients: a nationwide study.

BACKGROUND: Hospice care is important for patients with terminal hepatocellular carcinoma (HCC), especially in endemic areas of viral hepatitis. Differences between hospice care and usual care for geriatric HCC inpatients have not yet been explored in a nationwide survey. OBJECTIVE: The study's purpose was to analyze differences between hospice care and usual care for geriatric HCC inpatients in a nationwide survey. METHODS: This nationwide, population-based study used data obtained from the Taiwan National Health Insurance Database. Patients with terminal HCC who were ≥65 years old and received their end-of-life care in the hospital between January 2001 and December 2004 were recruited. The comparison group was selected by propensity score matching from patients receiving usual care in acute wards. RESULTS: We enrolled 729 terminal HCC patients receiving inpatient hospice care and 729 matched controls selected from 2482 HCC patients receiving usual care. Hospice care patients were treated mainly by family medicine doctors (36%) and oncologists (26%), while usual care patients were treated mainly by gastroenterologists (60.2%). The natural opium alkaloids were used more in the hospice care group than in the usual care group (72.7% versus 25.5%, P<0.001), whereas the length of stay (8±7.7 days versus 14.1±14.3 days, P<0.001), aggressive procedures (all P<0.005), and medical expenses (all P<0.001) were significantly less in the hospice care group. CONCLUSION: HCC patients in hospice wards received more narcotic palliative care, underwent fewer aggressive procedures, and incurred lower costs than those in acute wards. Hospice care should be promoted as a viable option for terminally ill, elderly HCC patients.

Evaluation of three paediatric weight estimation methods in Singapore.

AIM: Rapid paediatric weight estimation methods in the emergency setting have not been evaluated for South East Asian children. This study aims to assess the accuracy and precision of three such methods in Singapore children: Broselow-Luten (BL) tape, Advanced Paediatric Life Support (APLS) (estimated weight (kg) = 2 (age + 4)) and Luscombe (estimated weight (kg) = 3 (age) + 7) formulae. METHODS: We recruited 875 patients aged 1-10 years in a Paediatric Emergency Department in Singapore over a 2-month period. For each patient, true weight and height were determined. True height was cross-referenced to the BL tape markings and used to derive estimated weight (virtual BL tape method), while patient's round-down age (in years) was used to derive estimated weights using APLS and Luscombe formulae, respectively. The percentage difference between the true and estimated weights was calculated. For each method, the bias and extent of agreement were quantified using Bland-Altman method (mean percentage difference (MPD) and 95% limits of agreement (LOA)). The proportion of weight estimates within 10% of true weight (p10) was determined. RESULTS: The BL tape method marginally underestimated weights (MPD +0.6%; 95% LOA -26.8% to +28.1%; p10 58.9%). The APLS formula underestimated weights (MPD +7.6%; 95% LOA -26.5% to +41.7%; p10 45.7%). The Luscombe formula overestimated weights (MPD -7.4%; 95% LOA -51.0% to +36.2%; p10 37.7%). CONCLUSIONS: Of the three methods we evaluated, the BL tape method provided the most accurate and precise weight estimation for Singapore children. The APLS and Luscombe formulae underestimated and overestimated the children's weights, respectively, and were considerably less precise.