Impact of a national collaborative project to improve the care of mechanically ventilated patients.

This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).

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.

Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial.

BACKGROUND: To evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality. METHODS: The SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of "possible sepsis alert" to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days. DISCUSSION: The trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019.

Managing critical care during COVID-19 pandemic: The experience of an ICU of a tertiary care hospital.

BACKGROUND: The COVID-19 pandemic has strained ICUs worldwide. To learn from our experience, we described the critical care response to the outbreak. METHODS: This is a case study of the response of the Intensive Care Department (75-bed capacity) at a tertiary-care hospital to COVID-19 pandemic, which resulted in a high number of critically ill patients. RESULTS: Between March 1 and July 31, 2020, 822 patients were admitted to the adult non-cardiac ICUs with suspected (72%)/confirmed (38%) COVID-19. At the peak of the surge, 125 critically ill patients with COVID-19 were managed on single day. To accommodate these numbers, the bed capacity of 4 ICUs was increased internally from 58 to 71 beds (+40%) by cohorting 2 patients/room in selected rooms; forty additional ICUs beds were created in 2 general wards; one cardiac ICU was converted to managed non-COVID-19 general ICU patients and one ward was used as a stepdown for COVID-19 patients. To manage respiratory failure, 53 new ICU ventilators, 90 helmets for non-invasive ventilation and 47 high-flow nasal cannula machines were added to the existing capacity. Dedicated medical teams cared for the COVID-19 patients to prevent cross-contamination. The nurse-to-patient and RT-to-patient ratio remained mostly 1:1 and 1:6, respectively. One-hundred-ten ward nurses were up-skilled to care for COVID-19 and other ICU patients using tiered staffing model. Daily executive rounds were conducted to identify patients for transfer and at least 10 beds were made available for new COVID-19 admissions/day. The consumption of PPE increased multiple fold compared with the period preceding the pandemic. Regular family visits were not allowed and families were updated daily by videoconferencing and phone calls. CONCLUSIONS: Our ICU response to the COVID-19 pandemic required almost doubling ICU bed capacity and changing multiple aspects of ICU workflow to be able to care for high numbers of affected patients.

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

Developing an emergency medicine handoff tool: an electronic Delphi approach.

BACKGROUND: Handoffs at the end of clinical shifts occur with high frequencies in the emergency department setting and they pose an increased risk to patients. There is a need to standardize handoff practices. This study aimed to use an electronic Delphi method to identify the core elements essential for an emergency department physician to physician handoff and propose a framework for implementation. METHODS: An electronic Delphi-style study with a national panel of board-certified emergency physicians in Saudi Arabia. The panel was conducted over four rounds. The first to identify elements relevant to the end of shift handoff and categorize them into domains, while the remaining three to score and debate individual elements. RESULTS: Twenty-five board-certified emergency physicians from various cities and practice settings were enrolled. All panelists completed the entire Delphi process. Thirty-two elements were identified and classified into 4 domains. The top five rated handoff elements were patient identification, chief complaint history, clinical stability, working diagnosis, and consulting services involved. Panel scores showed convergence as rounds progressed and the final list of elements had a high-reliability score (Cronbach's alpha 0.93). CONCLUSIONS: This study yielded an itemized and ranked list of elements that are easy to implement and could be used to standardize patient handoffs by emergency physicians. While this study was conducted on an emergency medicine panel, the methods used may be adapted to develop standardized handoff frameworks that serve different disciplines or practice settings.

The association of duration of boarding in the emergency room and the outcome of patients admitted to the intensive care unit.

BACKGROUND: The demand for critical care beds is increasing out of proportion to bed availability. As a result, some critically ill patients are kept in the Emergency Department (ED boarding) awaiting bed availability. The aim of our study is to examine the impact of boarding in the ED on the outcome of patients admitted to the Intensive Care Unit(ICU). METHODS: This was a retrospective analysis of ICU data collected prospectively at King Abdulaziz Medical City, Riyadh from ED between January 2010 and December 2012 and all patients admitted during this time were evaluated for their duration of boarding. Patients were stratified into three groups according to the duration of boarding from ED. Those admitted less than 6 h were classified as Group I, between 6 and 24 h, Group II and more than 24 h as Group III. We carried out multivariate analysis to examine the independent association of boarding time with the outcome adjusting for variables like age, sex, APACHE, Mechanical ventilation, Creatinine, Platelets, INR. RESULTS: During the study period, 940 patients were admitted from the ED to ICU, amongst whom 227 (25%) were admitted to ICU within 6 h, 358 (39%) within 6-24 h and 355 (38%) after 24 h. Patients admitted to ICU within 6 h were younger [48.7 ± 22.2(group I) years, 50.6 ± 22.6 (group II), 58.2 ± 20.9 (group III) (P = 0.04)]with less mechanical ventilation duration[5.9 ± 8.9 days (Group I), 6.5 ± 8.1 (Group II) and 10.6 ± 10.5 (Group III), P = 0.04]. There was a significant increase in hospital mortality [51(22.5), 104(29.1), 132(37.2), P = 0.0006) and the ICU length of stay(LOS) [9.55 days (Group I), 9.8 (Group II) and 10.6 (Group III), (P = 0.002)] with increase in boarding duration. In addition, the delay in admission was an independent risk factor for ICU mortality(OR for group III vs group I is 1.90, P = 0.04) and hospital mortality(OR for group III vs Group I is 2.09, P = 0.007). CONCLUSION: Boarding in the ED is associated with higher mortality. This data highlights the importance of this phenomenon and suggests the need for urgent measures to reduce boarding and to improve patient flow.

Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: a systematic review of the literature.

BACKGROUND: In patients presenting with skin and soft tissue infections (SSTI), the use of ultrasound may lead to a more accurate distinction between cellulitis and abscess compared with clinical assessment alone. OBJECTIVES: This systematic review aims to determine the diagnostic accuracy of ultrasound for detecting skin abscesses. In addition, it aims to assess the impact of using ultrasound on management decisions in patients with SSTI. METHODS: We searched relevant electronic databases for primary studies including MEDLINE, EMBASE, and CINAHL. We searched conference proceedings, checked references of retrieved articles, and contacted field experts. Two reviewers assessed the quality of each full-text publication using a modified QUADAS-2 tool. RESULTS: Five studies (n=710) fulfilled our inclusion criteria. Four studies compared the diagnostic accuracy of ultrasound with clinical examination alone (n=584). Most studies reported an improvement in diagnostic accuracy. The sensitivity of ultrasound ranged from 89 to 98% and the specificity ranged from 64 to 88%. However, the sensitivity of clinical assessment ranged from 75 to 90% and the specificity ranged from 55 to 83%; most of these results did not reach statistical significance. Sensitivity was further improved in cases of indeterminate clinical assessment. Two studies (n=176) examined the impact of ultrasound on management decisions. Use of ultrasound has led to significant and appropriate changes in management decisions in 16 to 39% of patients. CONCLUSION: The use of ultrasound could potentially improve diagnostic accuracy and lead to improved management decisions in patients with SSTI, especially in cases of indeterminate clinical assessment. Most of our findings did not achieve statistical significance. Further research is required to confirm these findings.

Ultrasound credentialing in North American emergency department systems with ultrasound fellowships: a cross-sectional survey.

OBJECTIVE: To describe the credentialing systems of North American emergency department systems (EDS) with emergency ultrasound (EUS) fellowship programmes. METHODS: This is a prospective, cross-sectional, survey-based study of North American EUS fellowships using a 62-item, pilot-tested, web-based survey instrument assessing credentialing and training systems. The American College of Emergency Physicians (ACEP) distributed the surveys using SNAP survey (Snap Surveys Ltd, Portsmouth, New Hampshire, USA). RESULTS: Over 6 months, 75 eligible programmes were surveyed, 55 responded (73% response rate); 1 declined to participate leaving 54 participating programmes. Less than 20% of EDS credential nurses, physician assistants, nurse practitioners and students in EUS. Respondent EDS reported having an average of 4.2 ± 3.3 ultrasound faculty members (faculty identifying their career focus as EUS). The median number of annual point-of-care ultrasounds reported was 5000 (IQR 3000-8000). 30 EDS (56%) credential each examination individually and 48 EDS (89%) use ACEP credentialing criteria. 61% of fellowship leadership believe their credentialing system is either satisfactory or very satisfactory (Cronbach's coefficient α=0.84). CONCLUSIONS: The data show heterogeneity among North American EDS with EUS fellowship programmes with regard to credentialing systems despite published guidelines from the ACEP and Canadian Emergency Ultrasound Society.

Ultrasound-guided peripheral venous access: a systematic review of randomized-controlled trials.

OBJECTIVE: To systematically review the current literature on the effect of using ultrasound (US) guidance for the placement of peripheral intravenous (PIV) catheters in patients with difficult access. MATERIALS AND METHODS: A systematic search was performed for the keywords ultrasonography, catheterization, and peripheral vein. A systematic review was performed on randomized-controlled studies comparing the use of dynamic US guidance with the conventional landmark technique. The primary outcome was the success rate of PIV placement and the secondary outcomes included the number of attempts and time to successful PIV placement. RESULTS: A total of 1778 titles were identified from the search and the review identified 50 potentially relevant studies that were reviewed comprehensively; six articles were included in the final review. The six studies enrolled a total of 316 patients, 153 in the control group and 163 in the US group. Two of the studies reported a significantly higher success rate for US on the basis of initial success or the overall success rate. The two pediatric studies found that time to successful cannulation was shorter and fewer attempts were required to achieve success for patients randomized to US compared with the traditional method. The six studies included were found to vary significantly in the definition of difficult venous access, recording of procedure time, definition of success rate, and other important factors, making a meta-analysis inappropriate. CONCLUSION: On the basis of this review, routine use of US guidance for PIV placement is not strongly supported by the literature.