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OBJECTIVES: In the TRIAGE trial, a cluster randomised trial about diverting emergency department (ED) patients to a general practice cooperative (GPC) using a new extension to the Manchester Triage System, the difference in the proportion of patients assigned to the GPC was striking: 13.3% in the intervention group (patients were encouraged to comply to an ED or GPC assignment, real-world setting) and 24.7% in the control group (the assignment was not communicated, all remained at the ED, simulated setting). In this secondary analysis, we assess the differences in the use of the triage tool between intervention and control group and differences in costs and hospitalisations for patients assigned to the GPC. SETTING: ED of a general hospital and the adjacent GPC. PARTICIPANTS: 8038 patients (6294 intervention and 1744 control).Primary and secondary outcome measures proportion of patients with triage parameters (reason for encounter, discriminator and urgency category) leading to an assignment to the ED, proportion of patients for which the computer-generated GPC assignment was overruled, motivations for choosing certain parameters, costs (invoices) and hospitalisations. RESULTS: An additional 3.1% (p<0.01) of the patients in the intervention group were classified as urgent. Discriminators leading to the ED were registered for an additional 16.2% (p<0.01), mainly because of a perceived need for imaging. Nurses equally chose flow charts leading to the ED (p=0.41) and equally overruled the protocol (p=0.91). In the intervention group, the mean cost for patients assigned to the GPC was 23 (p<0.01) lower and less patients with an assignment to the GPC were hospitalised (1.0% vs 1.6%, p<0.01). CONCLUSION: Nurses used a triage tool more risk averse when it was used to divert patients to primary care as compared with a theoretical assignment to primary care. Outcomes from a simulated setting should not be extrapolated to real patients. TRIAL REGISTRATION NUMBER: NCT03793972.
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Medicina General , Triaje , Medicina Familiar y Comunitaria , Humanos , Triaje/métodosRESUMEN
AIM: To conduct a systematic review evaluating improvement in team and leadership performance and resuscitation outcomes after such a training of healthcare providers during advanced life support (ALS) courses. METHODS: This systematic review asked the question of whether students taking structured and standardised ALS courses in an educational setting which include specific leadership or team training, compared to no such specific training in these courses, improves patient survival, skill performance in actual resuscitations, skill performance at 3-15 months (patient tasks, teamwork, leadership), skill performance at course conclusion (patient tasks, teamwork, leadership), or cognitive knowledge PubMed, Embase and the Cochrane database were searched until April 2020. Screening of articles, analysis of risk of bias, outcomes and quality assessment were performed according to the Grading of Recommendations Assessment, Development and Evaluation methodology. Only studies with abstracts in English were included. RESULTS: 14 non-randomised studies and 17 randomised controlled trials, both in adults and children, and seven studies involving patients were included in this systematic review. No randomised controlled trials but three observational studies of team and leadership training showed improvement in the critical outcome of "patient survival". However, they suffered from risk of bias (indirectness and imprecision). The included studies reported many different methods to teach leadership skills and team behaviour. CONCLUSION: This systematic review found very low certainty evidence that team and leadership training as part of ALS courses improved patient outcome. This supports the inclusion of team and leadership training in ALS courses for healthcare providers.
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Liderazgo , Resucitación , Adulto , Niño , Competencia Clínica , Personal de Salud/educación , Humanos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
AIM OF THE SCOPING REVIEW: Scientific recommendations on resuscitation are typically formulated from the perspective of an ideal resource environment, with little consideration of applicability in lower-income countries. We aimed to determine clinical outcomes from out-of-hospital cardiac arrest (OHCA) in low-resource countries, to identify shortcomings related to resuscitation in these areas and possible solutions, and to suggest future research priorities. DATA SOURCES: This scoping review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR), and was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We identified low-resource countries as countries with a low- or middle gross national income per capita (World Bank data). We performed a literature search on outcomes after OHCA in these countries, and we extracted data on the outcome. We applied descriptive statistics and conducted a post-hoc correlation analysis of cohort size and ROSC rates. RESULTS: We defined 24 eligible studies originating from middle-income countries, but none from low-income regions, suggesting a reporting bias. The number of reported patients in these studies ranged from 54 to 3214. Utstein-style reporting was rarely used. Return of spontaneous circulation varied from 0% to 62%. Fifteen studies reported on survival to hospital discharge (between 1.0 and 16.7%) or favourable neurological outcome (between 1.0 and 9.3%). An inverse correlation was found for study cohort size and the rate of return of spontaneous circulation (ρâ¯=â¯-0.48, pâ¯=â¯0.034). CONCLUSION: Studies of OHCA outcomes in low-resource countries are heterogeneous and may be compromised by reporting bias. Minimum cardiopulmonary resuscitation standards for low-resource settings should be developed collaboratively involving local experts, respecting culture and context while balancing competing health priorities.
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Reanimación Cardiopulmonar , Servicios Médicos de Urgencia , Paro Cardíaco Extrahospitalario , Humanos , Paro Cardíaco Extrahospitalario/terapia , Alta del PacienteRESUMEN
Coronavirus disease 2019 (COVID-19) has had a substantial impact on the incidence of cardiac arrest and survival. The challenge is to find the correct balance between the risk to the rescuer when undertaking cardiopulmonary resuscitation (CPR) on a person with possible COVID-19 and the risk to that person if CPR is delayed. These guidelines focus specifically on patients with suspected or confirmed COVID-19. The guidelines include the delivery of basic and advanced life support in adults and children and recommendations for delivering training during the pandemic. Where uncertainty exists treatment should be informed by a dynamic risk assessment which may consider current COVID-19 prevalence, the person's presentation (e.g. history of COVID-19 contact, COVID-19 symptoms), likelihood that treatment will be effective, availability of personal protective equipment (PPE) and personal risks for those providing treatment. These guidelines will be subject to evolving knowledge and experience of COVID-19. As countries are at different stages of the pandemic, there may some international variation in practice.
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Infecciones por Coronavirus/complicaciones , Paro Cardíaco/etiología , Paro Cardíaco/terapia , Neumonía Viral/complicaciones , Betacoronavirus , COVID-19 , Reanimación Cardiopulmonar/normas , Europa (Continente) , Humanos , Pandemias , Equipo de Protección Personal/provisión & distribución , Medición de Riesgo , SARS-CoV-2 , Sociedades MédicasRESUMEN
AIM: To investigate whether a ventilation rate ≤10 breaths min-1 in adult cardiac arrest patients treated with tracheal intubation and chest compressions in a prehospital setting is associated with improved Return of Spontaneous Circulation (ROSC), survival to hospital discharge and one-year survival with favourable neurological outcome, compared to a ventilation rate >10 breaths min-1. METHODS: In this retrospective study, prospectively acquired data were analysed. Ventilation rates were measured with end-tidal CO2 and ventilation pressures. Analyses were corrected for age, sex, compression rate, compression depth, initial heart rhythm and cause of cardiac arrest. RESULTS: 337 of 652 patients met the inclusion criteria. Hyperventilation was common, with 85% of the patients ventilated >10 breaths min-1. The mean ventilation rate was 15.3 breaths min-1. The corrected odds ratio (OR) of ventilating >10 breaths min-1 for achieving ROSC was 0.91 (95% CI: 0.49 - 1.71, p = 0.78), the uncorrected OR of ventilating >10 breaths min-1 for survival to hospital discharge was 0.91 (95% CI: 0.30 - 2.77, p = 0.78), and the uncorrected OR of ventilating >10 breaths min1 for one-year survival with a favourable neurological outcome was 0.59 (95% CI: 0.19 - 1.87, p = 0.32). A logistic regression with continuous ventilation rate showed no significant relation with ROSC, and a ROC curve for ROSC showed a poor predictive performance (AUC: 0.52, 95% CI: 0.46 - 0.58), suggesting no other adequate cut-off value for ventilation rate. CONCLUSION: A ventilation rate ≤10 breaths min-1 was not associated with significantly improved outcomes compared to a ventilation rate >10 breaths min-1. No other adequate cut-off value could be proposed.
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Reanimación Cardiopulmonar/métodos , Paro Cardíaco/terapia , Frecuencia Respiratoria/fisiología , Tráquea/fisiopatología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Bélgica/epidemiología , Femenino , Paro Cardíaco/mortalidad , Paro Cardíaco/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Presión , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Adulto JovenRESUMEN
Penetrating and blunt trauma to the neck: clinical presentation, assessment ana emergency management. In Belgium, and even in Western Europe, penetrating and blunt injury to the neck is relatively uncommon in both the civilian and military populations. Pre-hospital and emergency assessment and management will therefore always prove challenging, as individual exposure to this specific type of injury remains low. Historically, the neck has been divided into three anatomical zones with specific landmarks to guide the diagnostic and therapeutic approach to penetrating neck injuries. Most penetrating injuries need to be explored surgically, although with the advent of multi-detector computed tomographic angiography (MDCTA), which yields high diagnostic sensitivity, this inflexible approach has recently changed to a more targeted management, based on clinical, radiographic and, if deemed necessary, endoscopic findings. However, some authors have addressed their concern about this novel, 'no-zone' approach, since the risk of missing less apparent aerodigestive tract injuries may increase. It is recommended, therefore, that all patients with penetrating neck injuries be closely observed, irrespective of the initial findings. The incidence of blunt neck injury is much lower, and this makes risk assessment and management even more difficult in comparison with penetrating injuries. Again, MDCTA is most often the first diagnostic tool if a blunt neck injury is suspected, due to its good sensitivity for blunt cerebrovascular injuries (BCVI) as well as for aerodigestive tract injuries. Specific patterns of injury and unexpected neurological and neuro-radiological findings in trauma patients should always warrant further investigation. Despite ongoing debate, systemic anticoagulation is recommended for most BCVI, sometimes combined with endovascular treatment. Aerodigestive tract injuries may present dramatically, but are often more subtle, making the diagnosis more difficult than other types of neck injuries. Treatment may be conservative if damage is minimal, but surgery is warranted in all other cases.
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Traumatismos del Cuello/diagnóstico , Traumatismos del Cuello/terapia , Manejo de la Vía Aérea , Anticoagulantes/uso terapéutico , Servicios Médicos de Urgencia , Procedimientos Endovasculares , Hemorragia/etiología , Hemorragia/terapia , Humanos , Hipotermia/diagnóstico , Cuello/anatomía & histología , Examen Físico , Neumotórax/diagnóstico , Neumotórax/etiología , Traumatismos de la Médula Espinal/diagnóstico , Heridas no Penetrantes/diagnóstico , Heridas Penetrantes/diagnósticoRESUMEN
Sudden cardiac arrest remains an important health care problem. If survival rates of all regions would equal those of the best performers, literally thousands of lives would be saved. Similar to injury, there is a need for an epidemiology-based approach for planning and execution of countermeasures. In this policy paper, we present the Haddon Matrix as an all-inclusive conceptual framework to assist in this. We advocate for a more community-centred 'public health' approach, with a crucial role for policy-level executives. There is a large potential gain in outcome by implementing 'passive' - not requiring individual action - measures. As happened for injury, 'Cardiac Arrest Academies' should be created to facilitate and coordinate this process.
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Paro Cardíaco/prevención & control , Modelos Estadísticos , Política Pública , Reanimación Cardiopulmonar , Paro Cardíaco/epidemiología , Humanos , Formulación de PolíticasRESUMEN
BACKGROUND: The Joint Commission International Patient Safety Goal 2 states that effective communication between health care workers needs to improve. The aim of this study was to determine the effect of SBAR (situation, background, assessment, recommendation) on the incidence of serious adverse events (SAE's) in hospital wards. METHOD: In 16 hospital wards nurses were trained to use SBAR to communicate with physicians in cases of deteriorating patients. A pre (July 2010 and April 2011) and post (June 2011 and March 2012) intervention study was performed. Patient records were checked for SBAR items up to 48 h before a SAE. A questionnaire was used to measure nurse-physician communication and collaboration. RESULTS: During 37,239 admissions 207 SAE's occurred and were checked for SBAR items, 425 nurses were questioned. Post intervention all four SBAR elements were notated more frequently in patient records in case of a SAE (from 4% to 35%; p<0.001), total score on the questionnaire increased in nurses (from 58 (range 31-97) to 64 (range 25-97); p<0.001), the number of unplanned intensive care unit (ICU) admissions increased (from 13.1/1000 to 14.8/1000 admissions; relative risk ratio (RRR)=50%; 95% CI 30-64; p=0.001) and unexpected deaths decreased (from 0.99/1000 to 0.34/1000 admissions; RRR=-227%; 95% CI -793 to -20; NNT 1656; p<0.001). There was no difference in the number of cardiac arrest team calls. CONCLUSION: After introducing SBAR we found increased perception of effective communication and collaboration in nurses, an increase in unplanned ICU admissions and a decrease in unexpected deaths.
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Muerte Súbita/prevención & control , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/prevención & control , Mortalidad Hospitalaria , Equipo Hospitalario de Respuesta Rápida , Comunicación Interdisciplinaria , Relaciones Médico-Enfermero , Encuestas y Cuestionarios , Adulto , Distribución de Chi-Cuadrado , Cuidados Críticos/normas , Progresión de la Enfermedad , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/normas , Seguridad del Paciente , Estadísticas no Paramétricas , Análisis de SupervivenciaRESUMEN
Automated external defibrillators (AEDs) have shown to improve survival after cardiopulmonary arrest (CPA) in many, but not all clinical settings. A recent study reported that the use of AEDs in-hospital did not improve survival. The current retrospective study reports the results of an in-hospital AED programme in a university hospital, and focuses on the quality of AED use. At Ghent University Hospital 30 AEDs were placed in non-monitored hospital wards and outpatient clinics treating patients with non-cardiac problems. Nurses were trained to use these devices. From November 2006 until March 2011, the AEDs were used in 23 of 39 CPA cases, in only one patient the presenting heart rhythm was ventricular fibrillation and this patient survived. Pulseless electrical activity was present in 14 patients (four survived) and asystole in eight patients (one survived). AEDs were attached to eight patients without CPA, and in 16 patients with CPA AED was not used. The quality of AED use was often suboptimal as illustrated by external artifacts during the first rhythm analysis by the AED in 30% (7/23) and more than 20 seconds delay before restart of chest compressions after the AED rhythm analysis in 50% (9/18). The literature data, supported by our results, indicate that in-hospital AED programmes are unlikely to improve survival after CPA. Moreover, their use is often suboptimal. Therefore, if AEDs are introduced in a hospital, initial training, frequent retraining and close follow-up are essential.
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Desfibriladores , Paro Cardíaco/mortalidad , Unidades Hospitalarias , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Paro Cardíaco/terapia , Humanos , Masculino , Persona de Mediana Edad , Servicio Ambulatorio en Hospital , Adulto JovenRESUMEN
INTRODUCTION: Studies show that students, trained to perform compressions between 40 and 50mm deep, often do not achieve sufficient depth at retention testing. We hypothesized that training to achieve depths >50mm would decrease the proportion of students with depth <40mm after 6 months, compared to students trained to a depth interval of 40-50mm. METHODS: A basic life support (BLS) self-learning station was attended by 190 third year medicine students. They were first offered the possibility to refresh their skills, following the instructions of a 15min abbreviated Mini Anne™ video (Laerdal, Norway) using a full size torso and a face shield. This was followed by further training using Resusci Anne Skills Station™ software (Laerdal, Norway). Voice feedback was provided according to randomisation to a standard group (SG) 40-50mm and a deeper group (DG) >50mm. Quality of compressions was tested after 6 months. RESULTS: The SG and DG groups consisted of 90 (67% female) and 100 (58% female) participants respectively. At the end of training, all students reached the target depth without overlap between groups. After 6 months, the proportion of students achieving a depth <40mm was 26/89 (29%) in the SG vs. 12/89 (14%) in the DG (P=0.01). The proportion of students with a depth >50mm was 5/89 (6%) for the SG and 44/89 (49%) in the DG (P<0.001). CONCLUSIONS: The educational strategy to train students to a deeper depth, reduced shallow compressions 6 months after training.