Achieving regionalization through rural interhospital transfer.

Regionalization of emergency medical care aims to provide consistent and efficient high-quality care leading to optimal clinical outcomes by matching patient needs with appropriate resources at a network of hospitals. Regionalized care has been shown to improve outcomes in trauma, myocardial infarction, stroke, cardiac arrest, and acute respiratory distress syndrome. In rural areas, effective regionalization often requires interhospital transfer. The decision to transfer is complex and includes such factors as capabilities of the presenting hospital; capacity at the receiving hospital; and financial, geographic, and patient-preference considerations. Although transfer to a comprehensive center has proven benefits for some conditions, the transfer process is not without risk. These risks include clinical deterioration, limited resource availability during transport, vehicular crashes, time delays for time-sensitive care, poor communication between providers, and neglect of patient preferences. This article reviews the transfer decision, financial implications, risks, and considerations for patients undergoing rural interhospital transfer. We identify several strategies that should be considered for development of the regionalized emergency health care system of the future and identify areas where further research is necessary.

Novel Use of Glidescope Indirect Laryngoscopy for Insertion of a Minnesota Tube for Variceal Bleeding.

BACKGROUND: With improvements in endoscopic and interventional radiologic therapies, insertion of gastroesophageal balloon tamponade catheters, commonly known as Sengstaken-Blakemore or Minnesota tubes, is a rarely performed procedure for esophageal or gastric variceal bleeding. In small hospitals or freestanding emergency departments, endoscopic or interventional radiology (IR) therapies might not be available, so patients with exsanguinating variceal bleeding must be stabilized or temporized for transport to larger hospitals. Occasionally, tamponade devices are necessary as a rescue therapy for failed endoscopic or IR therapies or can be used as definitive therapy in select cases. In addition to being rarely performed, there are multiple technical complications associated with blind insertion of tamponade catheters. DISCUSSION: We describe a novel use of indirect laryngoscopy using a Glidescope for assisting in placement of a Minnesota tube in 4 patients with exsanguinating esophageal bleeding. CONCLUSIONS: Insertion of a Minnesota tube for bleeding esophageal or gastric varices is an uncommon, technically challenging procedure that can be lifesaving, and is something emergency physicians, intensivists, and gastroenterologists should be capable of performing. Addition of indirect laryngoscopy may help to improve rapid, safe, and successful placement of these devices.

No Decrease in Early Ventilator-Associated Pneumonia After Early Use of Chlorhexidine.

BACKGROUND: Oral chlorhexidine prophylaxis can decrease occurrence of ventilator-associated pneumonia. However, the importance of timing has never been fully explored. OBJECTIVE: To see if early administration of oral chlorhexidine is associated with lower incidence of early ventilator-associated pneumonia (within 5 days of admission to intensive care unit) in intubated air ambulance patients. METHODS: A single-center, retrospective cohort study of intubated adults transported by a university-based air ambulance service and admitted to a surgical intensive care unit from July 2011 through April 2013. Primary exposure was time from helicopter retrieval to the first dose of oral chlorhexidine in the intensive care unit. Early chlorhexidine was defined as receipt of the drug within 6 hours of helicopter departure. The primary outcome was clinical diagnosis of early ventilator-associated pneumonia. Patients who were less than 18 years old, died within 72 hours of admission, or had pneumonia at admission were excluded. RESULTS: Among 134 patients, 49% were treated with chlorhexidine before 6 hours, 84% were treated before 12 hours, and 11% were treated for early pneumonia. Early chlorhexidine (before 6 hours; 15%) was not associated (P = .21) with early pneumonia (8%). Furthermore, median times to chlorhexidine did not differ significantly (P = .23) between patients in whom pneumonia developed (5.2 hours) and patients with no pneumonia (6.1 hours). CONCLUSIONS: Early administration of oral chlorhexidine in intubated patients was not associated with a reduction in the incidence of ventilator-associated pneumonia in a surgical intensive care unit with high rates of chlorhexidine administration before 12 hours.

Myocardial infarction and cardiac complications in emergency department patients admitted to the intensive care unit with gastrointestinal hemorrhage.

Patients admitted with significant gastrointestinal hemorrhage (GIH) often experience in-hospital cardiac complications. This retrospective study examined 68 patients admitted from the Emergency Department to the Intensive Care Unit (ICU) over a 1-year period. The patients were 75% Caucasian, 60% male, with a mean age of 57 +/- 19 years. Medical co-morbidity was noted in 70%, and 54% of patients had a history of significant alcohol use. A systolic blood pressure < 100 mm Hg was present in 26%, hemoglobin < 7 mg/dL in 32%, and three patients (4%) expired. Death, acute myocardial infarction or other cardiac complications were noted in 32% of patients. Patients older than 60 years were three times more likely to have a complicated course than were younger patients, and those with a co-morbidity were 14.8 times more likely. Patients with a history of significant alcohol use were 31% less likely to have an inpatient complication than those without such a history. Regression analysis supported the protective effect of a history of significant alcohol use and also demonstrated that a history of peptic ulcer disease was predictive of inpatient complications. Older GIH patients and those with co-morbidities may benefit from ICU disposition given their greater risk. Younger patients presenting with hematemesis and a history of significant alcohol use tended to have fewer complications such that it may be possible to manage these patients outside of the ICU if hemodynamically stable.