Airborne Isolation Cardiac Arrest: A Simulation Program for Interdisciplinary Code Blue Team Training.

Introduction: In-hospital cardiac arrest in patients with COVID-19 presents significant challenges to health care teams. Airborne precautions can delay patient care, place providers at high risk of virus exposure, and exacerbate an already stressful environment. Within the constraints of an ongoing pandemic, an efficient educational program is required to prepare health care teams for airborne isolation code blue. Methods: This simulation was conducted in a room on the target unit using a CPR manikin to represent the patient. A "talk-through walk-through" scripted simulation directed learners (internal medicine residents, unit nurses, and other code blue responders) through a resuscitation using an airborne isolation code blue protocol. Key scripted events prompted role identification, communication, and item transfer. Learners self-assessed their airborne isolation code blue knowledge and skills and their confidence in providing quality care while maintaining safety using a pre-/posttraining 5-point Likert-scale survey. Results: We trained 100 participants over a 5-month period, with 65 participants surveyed (43 respondents; 16 residents, 22 nurses). Following training, participants had a statistically significant (p < .001) increase in percentage selecting agree/strongly agree for all statements related to knowledge and skills specific to airborne isolation code blue protocol, as well as confidence in providing care while keeping themselves and their colleagues safe. Discussion: Our simulation program allowed a small number of educators to feasibly train a large number of learners, let learners practice required skills, and improved learners' self-assessed knowledge, skills, and confidence regarding quality and safety of care.

Bradycardia at the onset of pulseless electrical activity arrests in hospitalized patients is associated with improved survival to discharge.

BACKGROUND: Recent studies have suggested that the incidence of in-hospital pulseless electrical activity (PEA) arrests is increasing. Bradycardia in patients with in-hospital PEA is common but it is unknown if it is associated with respiratory arrest or patient outcomes. OBJECTIVE: To determine risk factors and outcomes associated with bradycardic-PEA arrests, and relationship between bradycardia and respiratory arrest. METHODS: This was a retrospective cohort study of all inpatient cardiac arrests at an academic medical center over a four-year period. Patient demographics, comorbidities, vital signs, arrest event data, and outcomes were abstracted from the medical record. PEA arrest was defined as a non-shockable rhythm with loss of pulse requiring cardiopulmonary resuscitation and having organized electrocardiographic activity. Bradycardia was classified as a HR < 60 bpm at the time of pulse loss. The primary outcomes were survival of arrest and survival to hospital discharge. RESULTS: Between July 2013 and August 2017, there were 176 in-hospital patients with PEA arrests. While 105 (59.7%) survived the arrest, only 38 (21.6%) survived to discharge. A total of 66 (37.5%) were bradycardic-PEA arrests. Patients with bradycardic PEA arrests were no more likely to have their arrest precipitated by respiratory failure than non-bradycardic PEA patients (36.4% vs 27.3%, P = 0.24), but patients with non-bradycardic PEA arrests were more likely to have a CIED than non-bradycardic PEA patients (14.5% vs 3.0%, P = 0.02). On multivariate analysis, bradycardic PEA was associated with improved survival to hospital discharge (OR = 3.31, 95% CI: 1.41-7.79, p = 0.006), but not survival of arrest (OR 1.45, 95% CI: 0.68-3.09, p = 0.34). Respiratory arrest was an independent predictor of survival of code (OR 2.62, 95% CI: 1.36-5.47, P = 0.01) and to hospital discharge (OR 3.47, 95% CI: 1.35-8.91, P = 0.01). Other predictors of survival to discharge include history of coronary artery disease, and non-use of epinephrine, atropine, and sodium bicarbonate. CONCLUSION: In a retrospective study of hospitalized patients in the intensive care unit and non-intensive care, bradycardia at the time of PEA cardiac arrest was associated with improved survival to hospital discharge but not survival of arrest. Respiratory arrest was an independent predictor of survival, but there was no association between respiratory arrest and bradycardic PEA arrest.

Family Support During Resuscitation: A Quality Improvement Initiative.

BACKGROUND: Despite increasing support for family presence during cardiopulmonary resuscitation, a review of the literature revealed no published protocols or training curricula to guide hospitals in implementing a family support provider role. OBJECTIVES: To develop a curriculum and train dedicated resuscitation team members whose role is to provide family support during in-hospital resuscitation events. METHODS: An interdisciplinary team developed a 4-hour training session for the family support staff. The session included an introduction to the evidence for family presence during resuscitation and local data on resuscitations. The training was composed of 4 sections: (1) clinical aspects of resuscitation, (2) integration into the resuscitation team and steps for providing family support during resuscitation, (3) responding to families in distress, and (4) self-care practices. Before and after the training session, the participants completed surveys of self-rated knowledge and attitudes toward family presence during resuscitation. RESULTS: Fifty-nine social workers and 8 spiritual care providers were trained in 2015. There was a significant increase in all rated aspects of knowledge of the family support role and self-care strategies. CONCLUSION: Through the creation of an interdisciplinary curriculum, an institution can effectively train health care providers in a new resuscitation team role: the family support provider.

A quality improvement project to improve early sepsis care in the emergency department.

BACKGROUND: Sepsis causes substantial morbidity and mortality in hospitalised patients. Although many studies describe the use of protocols in the management of patients with severe sepsis and septic shock, few have addressed emergency department (ED) screening and management for patients initially presenting with uncomplicated sepsis (ie, patients without organ failure or hypotension). OBJECTIVE: A quality improvement task force at a large, quaternary care referral hospital sought to develop a protocol focusing on early identification of patients with uncomplicated sepsis, in addition to severe sepsis and septic shock. INTERVENTION: The three-tiered intervention consisted of (1) a nurse-driven screening tool and management protocol to identify and initiate early treatment of patients with sepsis, (2) a computer-assisted screening algorithm that generated a 'Sepsis Alert' pop-up screen in the electronic medical record for treating clinical healthcare providers and (3) automated suggested sepsis-specific order sets for initial workup and resuscitation, antibiotic selection and goal-directed therapy. DESIGN: A before and after retrospective cohort study was undertaken to determine the intervention's impact on compliance with recommended sepsis management, including serum lactate measured in the ED, 2 L of intravenous fluid administered within 2 h of triage, antibiotics administered within 3 h of triage and blood cultures drawn before antibiotic administration. Mortality rates for patients in the ED with a sepsis-designated ICD-9 code present on admission were also analysed. RESULTS: Overall bundle compliance increased by 154%, from 28% at baseline to 71% in the last quarter of the study (p<0.001). Bundle, antibiotic and intravenous fluid compliance all increased significantly after launch of the sepsis initiative (eg, bundle and intravenous fluid compliance increased by 74% and 54%, respectively; p<0.001). Bundle and antibiotic compliance both showed further significant increases after implementation of suggested order sets (31% and 25% increases, respectively; p<0.001). The mortality rate for patients in the ED admitted with sepsis was 13.3% before implementation and fell to 11.1% after (p=0.230); mortality in the last two quarters of the study was 9.3% (p=0.107). CONCLUSIONS: The new protocol demonstrates that early screening interventions can lead to expedited delivery of care to patients with sepsis in the ED and could serve as a model for other facilities. Mortality was not significantly improved by our intervention, which included patients with uncomplicated sepsis.

Accuracy of stop-cursor method for determining systolic and pulse pressure variation.

BACKGROUND: Functional hemodynamic indicators (systolic pressure variation [SPV and SPV%] and pulse pressure variation [PPV%]) are sensitive and specific indicators of fluid responsiveness. It was unknown if these indicators could be accurately measured directly from the bedside monitor. OBJECTIVE: Determine the accuracy of SPV, SPV%, and PPV% measurements by using a stop-cursor method compared with a digitized analog strip (gold standard). METHODS: A prospective observational study using a convenience sample of 30 adult patients in a medical-surgical intensive care unit who were receiving mechanical ventilation and had no spontaneous breaths during 3 sequential ventilator breaths and had an optimized arterial catheter. The peak and nadir arterial pressure values for a ventilator cycle were simultaneously obtained by using the stop-cursor method on the bedside monitor and a hardcopy strip. The indicators were averaged over 3 breaths, and the difference between methods was calculated. RESULTS: Data were analyzed from 29 patients (1 patient excluded) on assist control ventilation (mean [SD] for tidal volume, 7.5 [2] mL/kg; positive end-expiratory pressure, 7 [4] cm H2O). For SPV, the mean bias was 0.4 (SD, 0.9) mm Hg (95% limits of agreement [LOA], -1.4 to 2.2 mm Hg); for SPV%, 0.3 (SD, 0.9; 95% LOA, -1.5% to 2.1%); for PPV%, 1.0 (SD, 3.3; 95% LOA, -5.5% to 7.5%). In only 1 case (PPV%) was there disagreement on fluid response characterization. CONCLUSIONS: Statistically significant small differences in SPV and SPV% were detected. The differences in SPV, SPV%, and PPV% were not clinically significant, suggesting that functional hemodynamic indicators can be obtained accurately with the stop-cursor method.

Accuracy and precision of noninvasive temperature measurement in adult intensive care patients.

BACKGROUND: Research on the accuracy and precision of noninvasive methods of measuring body temperature is equivocal. OBJECTIVES: To determine accuracy and precision of oral, ear-based, temporal artery, and axillary temperature measurements compared with pulmonary artery temperature. METHODS: Repeated-measures design conducted for 6 months. Sequential temperature measurements on the same side of the body were obtained within 1 minute, with measurements repeated 3 times at 20-minute intervals. Accuracy, precision, and confidence limits were analyzed. RESULTS: In 60 adults with cardiopulmonary disease and a pulmonary artery catheter, mean pulmonary artery temperature was 37.1 degrees C (SD 0.6 degrees C, range 35.3 degrees C-39.4 degrees C). Mean (SD) offset from pulmonary artery temperature (with the mean reflecting accuracy and SD reflecting precision) and confidence limits were 0.09 degrees C (0.43 degrees C) and -0.75 degrees C to 0.93 degrees C for oral measurements, -0.36 degrees C (0.56 degrees C) and -1.46 degrees C to 0.74 degrees C for ear measurements, -0.02 degrees C (0.47 degrees C) and -0.92 degrees C to 0.88 degrees C for temporal artery measurements, and 0.23 degrees C (0.44 degrees C) and -0.64 degrees C to 1.12 degrees C for axillary measurements. Percentage of pairs with differences greater than +/-0.5 degrees C was 19% for oral, 49% for ear, 20% for temporal artery, and 27% for axillary measurements. Intubation increased oral measurements compared with pulmonary artery temperatures (mean difference 0.3 degrees C, SD 0.3 degrees C, P = .001). CONCLUSIONS: Oral and temporal artery measurements were most accurate and precise. Axillary measurements underestimated pulmonary artery temperature. Ear measurements were least accurate and precise. Intubation affected the accuracy of oral measurements; diaphoresis and airflow across the face may affect temporal artery measurements.