The Saudi Critical Care Society practice guidelines on the management of COVID-19 in the ICU: Therapy section.

BACKGROUND: The rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU). METHODS: The SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations. RESULTS: The SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations. CONCLUSION: The SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available.

Saudi Heart Association, National Heart Center and National Cardiopulmonary Resuscitation Committee taskforce statement on CPR and resuscitation during COVID-19 pandemic.

Corona virus disease 2019 is a global pandemic, which affects around 2million individuals with a high death rate that exceeds 90,000 death cases across the globe. The Saudi Heart Association and the national cardiopulmonary resuscitation committee developed a taskforce to discuss the magnitude of clinical situation and CPR management on COVID-19 patients in a prehospital and in-hospital settings. Meanwhile, the taskforce aims to develop a nation-wide clinical guidance to be used by health care workers and untrained laypersons to resuscitate COVID-19 suspected and diagnosed patients.

The Effect of Point-of-Care Testing at Triage: An Observational Study in a Teaching Hospital in Saudi Arabia.

INTRODUCTION: Prolonged waiting times during episodes of emergency department (ED) crowding are associated with poor outcomes. Point-of-care testing (POCT) at ED triage prior to physician evaluation may help identify critically ill patients. We studied the impact of ED POCT in a single ED with a high degree of crowding for patients with high-risk complaints who were triaged as non-critically ill. METHODS: We conducted the study from April-July 2017 at King Abdulaziz University (KAU) Hospital in Jeddah, Saudi Arabia. Patients with one of seven complaints received triage POCT. The primary outcome was whether POCT results at triage resulted in immediate transfer of the patient from the waiting room into the ED. Secondary outcomes were whether the triage nurse felt that the POCT results were useful, and whether triage POCT changed triage acuity. We used simple descriptive statistics to summarize the data. RESULTS: A total of 94 patients were enrolled and received i-STAT® POCT. The most common symptoms and triage protocols were for chest pain (42%), abdominal pain (31%), and shortness of breath (22%). In 11 cases (12%), care was changed as a result of triage POCT. In 12 cases (13%), triage level was changed. The triage nurse found POCT helpful in 93% of cases. CONCLUSION: In this ED, triage POCT was a helpful adjunct at ED triage and resulted in immediate care (transfer to an ED room) in one in eight cases. Therefore, POCT at triage may be a useful adjunct to improve patient safety, particularly in crowded EDs.

Simulation-based training in Ebola Personal Protective Equipment for healthcare workers: Experience from King Abdulaziz University Hospital in Saudi Arabia.

BACKGROUND: Millions of Muslims from across the world gather annually to perform pilgrimage. This can import unusual communicable diseases such as Ebola. Communicable diseases with a high risk of mortality necessitate special training to master the required competency to avert transmission of infections. The efficacy of simulation-based training (SBT) has been shown in such circumstances. OBJECTIVE: We sought to develop an SBT program in Ebola Personal Protective Equipment (PPE) for all healthcare workers (HCWs). METHODS: We conducted a quasi-experimental study at the clinical skills and simulation center at the King Abdulaziz University. An interdisciplinary committee was formed to develop this program in three stages. Pre-intervention: Needs assessment "Diagnostic drill"; we conducted in-situ simulation in the emergency department (ED). High-fidelity simulator (HFS) was used as a suspected Ebola case to assess HCWs' competency of PPE. We used a checklist that was developed in accordance with the national and international guidelines. We then conducted "Train the Trainer in Ebola PPE" course to develop potential instructors. INTERVENTION: PPE competency SBT courses. This involved focusing on trainees to be skilled in Ebola PPE and becoming trained observers using skill stations and Ebola scenario with HFS, followed by debriefing. All courses gathered participants' evaluations, pre, and post-tests. Post-intervention: In-situ simulation in the ED two months later that was similar to the diagnostic drill. RESULTS: Pre-intervention: 7 HCWs were involved in the drill, the average score was 37% of the checklist items. For train the trainer, 19 potential PPE instructors attended the program; of them, 65% were female and 35% male, and 6 were physicians and 13 nurses. Average pre and post-tests scores were 72% and 86%, respectively. INTERVENTION: 10 PPE courses that were attended by 179 HCWs; of them, 67% were female and 33% male, and 52 were physicians, 112 nurses, and 15 others. Pre and posttests were 67% (57-75%) and 85% (81-91%), respectively, with a p-value<0.01. Post-intervention: Post Program drill's average score was 86% of the checklist items (37% in diagnostic drill). CONCLUSIONS: Using SBT could be an effective method of developing competent HCWs in Ebola PPE.

Emergency department physician-level and hospital-level variation in admission rates.

STUDY OBJECTIVE: We explore the variation in physician- and hospital-level admission rates in a group of emergency physicians in a single health system. METHODS: This was a cross-sectional study that used retrospective data during various periods (2005 to 2010) to determine the variation in admission rates among emergency physicians from 3 emergency departments (EDs) within the same health system. Patients who left without being seen or left against medical advice, patients treated in fast-track departments, patients with primary psychiatric complaints, and those younger than 18 years were excluded, as were physicians with fewer than 500 ED encounters during the study period. Emergency physician-level and hospital-level admission rates were estimated with hierarchic logistic regression, which adjusted for patient age, sex, race, chief complaint, arrival mode, and arrival day and time. RESULTS: A total of 389,120 ED visits were included in the analysis, and patients were treated by 89 attending emergency physicians. After adjusting for patient and clinical characteristics, the hospital-level admission rate varied from 27% to 41%. At the physician level, admission rates varied from 21% to 49%. CONCLUSION: There was 2.3-fold variation in emergency physician adjusted admission rates and 1.7-fold variation at the hospital level. In the new era of cost containment, wide variation in this common, costly decision requires further exploration.

The prevalence of quality issues and adverse outcomes among 72-hour return admissions in the emergency department.

BACKGROUND: Records of patients discharged from the Emergency Department (ED) who return within 72 h and are admitted are often reviewed for potential quality issues. OBJECTIVES: We explored 72-h return admissions and determined the prevalence and predictors for substandard management on the initial visit or any adverse outcome. METHODS: Retrospective review of quality assurance data from 72-h return admissions in three hospitals from 2006-2010 was performed. Any substandard quality on the first visit or change in outcome on the return admission was considered "low quality." Multivariate logistic regression was used to assess the relationship between cases judged as low quality vs. not low quality. RESULTS: Of 741,132 ED visits across 5 years, 3682 (0.5%) were 72-h return admissions. Of those, 192 (5%) were low quality. In 158 (4%) and 8 (0.2%) there were moderate and severe deviations from care standards, respectively. Similarly, in 53 (1%) and 14 (0.4%) there were moderate and severe changes in outcome. In adjusted analysis, there were higher rates of low-quality 72-h return admissions in ambulance arrivals (odds ratio [OR] 1.5, 95% confidence interval (CI) 1.1-2.1); and lower rates in Medicaid patients (OR 0.3, 95% CI 0.2-0.7). There were higher rates in low-quality 72-h return admissions in hospital 1 (OR 3.6, 95% CI 2.2-6.1) and hospital 3 (OR 3.2, 95% CI 2.0-4.7) compared to hospital 2. CONCLUSIONS: Poor care on the initial visit or any poor outcome upon returning in 72-h return admissions is relatively rare in the ED. Reporting 72-h return admissions without chart review may not be a good way to measure clinical quality.

Practice patterns and management strategies for purulent skin and soft-tissue infections in an urban academic ED.

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is the most common cause of purulent skin and soft-tissue infections (SSTIs) in the Unites States. Little is known regarding health care provider management strategies for abscesses in the emergency department (ED). Understanding variability in practice patterns could be an important step in implementing evidence-based guidelines. OBJECTIVES: The objectives of this study are to describe practice patterns for purulent SSTI in a single, urban, academic ED, including antibiotic selection and incision and drainage (I & D) technique, and to compare these practices with current evidence. METHODS: Prospective data were collected on a convenience sample of adults presenting to our urban, academic ED (annual volume, 65 000 per year) between June 2009 and May 2010. Characteristics of patients and their providers were collected as well as specific management strategies including use of irrigation, packing, and antibiotics. RESULTS: One hundred forty-five patients were enrolled. Most SSTIs were single (80.4% abscesses), most commonly on the extremities (29.8%). Both I & D and antibiotics were used 79.9% of the time, with the largest predictor for the addition of antibiotics being erythema more than 2 cm (odds ratio, 4.52; 95% confidence interval, 1.39-14.7); I & D technique varied by provider-type and experience. Providers suspected MRSA in 75% of cases, despite only 48% demonstrating MRSA on culture. Many patients received antimicrobials after I & D, even in those with 2 cm or less abscesses (57.5%). CONCLUSIONS: Practice patterns vary significantly, especially antibiotic overuse, at least in this urban academic ED. Further study should be undertaken to evaluate factors that influence management strategies for SSTI.

Consensus-based recommendations for research priorities related to interventions to safeguard patient safety in the crowded emergency department.

This article describes the results of the Interventions to Safeguard Safety breakout session of the 2011 Academic Emergency Medicine (AEM) consensus conference entitled "Interventions to Assure Quality in the Crowded Emergency Department." Using a multistep nominal group technique, experts in emergency department (ED) crowding, patient safety, and systems engineering defined knowledge gaps and priority research questions related to the maintenance of safety in the crowded ED. Consensus was reached for seven research priorities related to interventions to maintain safety in the setting of a crowded ED. Included among these are: 1) How do routine corrective processes and compensating mechanism change during crowding? 2) What metrics should be used to determine ED safety? 3) How can checklists ensure safer care and what factors contribute to their success or failure? 4) What constitutes safe staffing levels/ratios? 5) How can we align emergency medicine (EM)-specific patient safety issues with national patient safety issues? 6) How can we develop metrics and skills to recognize when an ED is getting close to catastrophic overload conditions? and 7) What can EM learn from experts and modeling from fields outside of medicine to develop innovative solutions? These priorities have the potential to inform future clinical and human factors research and extramural funding decisions related to this important topic.