RESUMO
Introduction: COVID-19 outbreak has generated an unprecedented surge of deteriorating and critically ill patients with severe and sustained pressures on intensive care units (ICUs) and staff. This has resulted in major staff redeployment from other areas, including some critical care outreach into ICU leaving the wards uncovered. Critical care outreach has the potential to optimise acutely ill and deteriorating patients on the wards and avert critical care admission;but its benefit during a pandemic is unclear. Objectives: To determine the clinical need for critical care outreach during the Coronavirus disease 2019 pandemic. To evaluate patients' outcomes to guide decision-making and resource prioritisation. Methods: We evaluated all consecutive patients referred to critical care outreach during a twelve-month period from 1 March 2020 to 28 February 2021. We reported the cumulative number of activities and interventions, and baseline characteristics, acuity level and clinical outcomes. Results: Amongst 4849 patients referred, 3913 had a clinical review and of those 895 were COVID-19 positive. Non-invasive ventilation was mostly delivered to COVID-19 patients (COVID-19 +VE: 853/895, 95% vs COVID-19 -VE: 119/3018, 4%) alongside awake positioning (COVID-19 +VE: 232/895, 26% vs COVID-19 -VE: 0/3018, 0%). Compared to prepandemic, patients were sicker meeting Level 2 acuity (observed: 51% vs historical: 21%;P= 0.003), however ICU admissions did not increase significantly (observed: 12% vs historical: 9%;P= 0.065), but greater mortality (observed: 14% vs historical: 8%;P= 0.046) was observed. Conclusion: Critical care outreach support the delivery of non-invasive respiratory support bridging the gap between intensive care units and general wards. Critical care outreach act as a valuable resource in optimising and triaging acutely unwell patients and potentially averting critical care admissions.
RESUMO
Introduction: Focused Ultrasound in Intensive Care (FUSIC) refers to the use of ultrasound by a trained bedside clinician to guide patient management in real-time. Ultrasound is widely applied in practice and there is growing consensus that it is an essential tool for managing acutely ill patients in the intensive care unit (ICU). The Critical Care Outreach Team uses FUSIC as an additional assessment tool to guide management and decision-making plan for deteriorating patients on the wards. Objectives: To investigate whether how often information gained fromFUSICimaging had an impact on patient care and management decisions in a critical care outreach setting. Methods: A single-centre observational study at an academic tertiary referral institution. We included all patients reviewed by critical care outreach who were assessed by ultrasound during a 12-month period. Routine procedures for teaching purposes were not included. Results: Forty-six patients were assessed and supported by a combined focused lung and heart ultrasound performed at the patient bedside on the wards. In 46 patients FUSIC was instrumental in the differential diagnostic workup and in guiding the clinical management. In 32 (70%) patients FUSIC aided fluid therapy or diuresis (in case of pulmonary oedema) and helped targeting fluid balance. In three patients though to have consolidation on chest x-ray we were able to identify significant pleural effusions without needing an additional CT scan. In four patients with hypotension, an additional CT-PA was warranted due to dilated right ventricle (RV) with abnormal septal motion and decreased left ventricle (LV) size ratio (i.e. sign of right heart strain) as highly suspicious of pulmonary embolus. In two young patients with Coronavirus disease 2019 (COVID-19), using FUSIC we identified severe LV dysfunction which was subsequentially diagnosed as myocarditis and Angiotensin-converting enzyme (ACE) inhibitors therapy was commenced within 24 hours. Further diagnosis included cardiac tamponade (n = 2) requiring pericardiocentesis and pneumothorax (n =1). In all cases, the use of ultrasound helped in promptly referring patients to the specialist team (i.e. respiratory or cardiology) and to the ICU consultant. Conclusions: In our critical care outreach practice, FUSIC is considered an indispensable tool for safe and accurate management of acutely ill and deteriorating patients on the wards.