Challenges to the provision of emergency services and critical care in resource-constrained settings.

The practice of intensive care unit (ICU) care in Sub-Saharan Africa is challenging and can have a significant impact on the lives of people in the region. Sub-Saharan Africa bears a disproportionate global burden of disease compared with the rest of the world. Inadequate emergency care services and transportation infrastructure; long lead times to hospital admission, evaluation, treatment and transfer to ICU; inadequate ICU and hospital infrastructure and, unreliable consumable and medical equipment supply chains all present significant challenges to the provision of ICU care in Sub-Saharan Africa. These challenges, coupled with an inadequate supply of trained healthcare workers and biomedical technicians and a lack of formal ICU-related research in Sub-Saharan Africa, would seem to be insurmountable. However, ICU care is being provided in district and regional hospitals throughout the region. We describe some of the challenges to the provision of emergency services and critical care in Tanzania.

To drain or not to drain: an evidence-based approach to palliative procedures for the management of malignant pleural effusions.

Malignant pleural effusions are often symptomatic and diagnosed late in the course of cancer. The optimal management strategy is controversial and includes both invasive and non-invasive strategies. Practitioners have the option of invasive procedures such as intermittent drainage or more permanent catheter drainage to confirm malignancy and to palliate symptoms. Because these effusions are often detected late in the course of disease in patients who may have limited life expectancy, procedural management may be associated with harms that outweigh benefits. We performed a literature review to examine the available evidence for catheter drainage of malignant pleural effusions in advanced cancer and reviewed alternative management strategies for the management of dyspnea. We provide a clinical case within the context of the research evidence for invasive and non-invasive management strategies. Our intent is to help inform decision making of patients and families in collaboration with their health care practitioners and interventionists by weighing the risks and benefits of catheter drainage versus alternative medical management strategies for malignant pleural effusions.

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

BACKGROUND: An evidence-based teamwork system, Team-STEPPS, was implemented in an academic medical center's pediatric and surgical ICUs. METHODS: A multidisciplinary change team of unit- and department-based leaders was formed to champion the initiative; develop a customized action plan for implementation; train frontline staff; and identify process, team outcome, and clinical outcome objectives for the intervention. The evaluation consisted of interviews with key staff, teamwork observations, staff surveys, and clinical outcome data. RESULTS: All PICU, SICU, and respiratory therapy staff received TeamSTEPPS training. Staff reported improved experience of teamwork posttraining and evaluated the implementation as effective. Observed team performance significantly improved for all core areas of competency at 1 month postimplementation and remained significantly improved for most of the core areas of competency at 6 and 12 months postimplementation. Survey data indicated improvements in staff perceptions of teamwork and communication openness in both units. From pre- to posttraining, the average time for placing patients on extracorporeal membrane oxygenation (ECMO) decreased significantly. The average duration of adult surgery rapid response team events was 33% longer at postimplementation versus pre-implementation. The rate of nosocomial infections at postimplementation was below the upper control limit for seven out of eight months in both the PICU and the SICU. CONCLUSIONS: The implementation of a customized 2.5-hour version of the TeamSTEPPS training program in two areas--the PICU and SICU--that had demonstrated successful ability to innovate suggests that the training was successful.

Free and local continuing medical education does not guarantee surgeon participation in maintenance of certification learning activities.

The American Board of Surgery has adopted the Maintenance of Certification requirement for surgeons. It requires continuous professional development (CPD) using active and passive learning modalities in contrast to traditional continuing medical education (CME). The Rural Trauma Team Development Course developed by the American College of Surgeons Committee on Trauma is a CPD learning activity. We provided 22 free courses between May 2007 and June 2009 to trauma care providers at 11 affiliated community and critical access hospitals. The course was taught on-site by an interdisciplinary group and at least one trauma surgeon was faculty. Free Category I CME credits and continuing education units were provided. Two hundred thirty-four providers attended and the majority were RNs (60%) and emergency medical technicians (21.8%). Only 18 were physicians (7.7%) and none were surgeons. The majority felt that they would change their practice as a result of the course but cited the lack of attendance at the course by emergency physicians and surgeons as a deficit. It may be that surgeons have barriers such as time away from a practice to attending these newer types of educational opportunities. Those who develop and offer these courses may need to develop different strategies to reach this target audience.

Treatment of complicated skin and soft tissue infections.

BACKGROUND: Skin and soft tissue infections (SSTIs) may produce substantial morbidity and mortality rates, particularly those classified as complicated or necrotizing. OBJECTIVE: To weigh the strength of recommendations using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology and to provide evidence-based recommendations for diagnosis and management for SSTIs. DATA SOURCES: Computerized identification of published research and review of relevant articles. STUDY SELECTION: All published reports on the management of complicated and necrotizing SSTIs were evaluated by an expert panel of members of the Surgical Infection Society according to published guidelines for evidence-based medicine. The quality of the evidence was judged by the GRADE methodology and criteria. Practice surveys, pharmacokinetic studies, and reviews or duplicative publications presenting primary data already considered were excluded from analysis. DATA EXTRACTION: Information on demographics, study dates, microbiology findings, antibiotic type, surgical interventions, infection-related outcomes, and the methodologic quality of the studies was extracted. Results were submitted to the Therapeutic Agents Committee of the Surgical Infection Society for review prior to creation of the final consensus document. DATA SYNTHESIS: Current surgical and antibiotic management of complicated SSTIs is based on a small number of studies that often have insufficient power to draw well-supported conclusions, with the exception of antimicrobial therapy for non-necrotizing soft tissue infections, for which ample data are available.

Effects on health of volunteers deployed during a disaster.

Little is known about the risks, hazards, and health outcomes for health care personnel and volunteers working in disaster relief. We sought to characterize risks and outcomes in volunteers deployed to provide relief for victims of Hurricane Katrina. We performed a longitudinal e-mail survey that assessed preventive measures taken before and during deployment, exposures to hazards while deployed, and health outcomes at 1, 3, and 6 months postdeployment. Overall response rate was 36.1 per cent and one-third of those who responded did so for all three surveys. Exposures to different types of hazards changed over time with exposures to contaminated water being common. Despite predeployment and on-site education, use of preventive measures such as vaccination, appropriate clothing, hydration, sunscreen, and insect repellant was variable. Few injuries were sustained. Insect bites were common despite the use of insect repellants. Skin lesions, diarrhea, and other gastrointestinal complaints occurred most commonly early on during or after deployment. Psychological complaints were common at 3 and 6 months. In conclusion, identification of at risk volunteer cohorts with longitudinal surveillance is critical for future disaster planning to provide training for volunteers and workers and to allow for deployment of appropriate resources pre, during, and postdeployment.

American College of Surgeons Guidelines Program: a process for using existing guidelines to generate best practice recommendations for central venous access.

BACKGROUND: Many professional organizations help their members identify and use quality guidelines. Some of these efforts involve developing new guidelines, and others assess existing guidelines for their clinical usefulness. The American College of Surgeons Guidelines Program attempts to recognize useful surgical guidelines and develop research questions to help clarify existing clinical guidelines. We used existing guidelines about central venous access to develop a set of summary recommendations that could be used by practitioners to establish local best practices. STUDY DESIGN: A comprehensive literature search identified existing clinical guidelines for short-term central venous access. Two reviewers independently rated the guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Highly scored guidelines were analyzed for content, and their recommendations were compiled into a summary table. The summary table was reviewed by an independent panel of experts for clinical utility. RESULTS: Thirty-two guidelines were identified, and 23 met inclusion criteria. The AGREE rating resulted in four guidelines that were strongly recommended and five that were recommended with alterations. Three comprehensive tables of recommendations were produced: procedural, maintenance, and infectious assessment. A panel of experts came to consensus agreement on the final format of the best practice recommendations, which included 30 summary recommendations. CONCLUSIONS: Our process combined assessing existing guidelines methodology with expert opinion to produce a best practice list of guidelines that could be fashioned into local care routines by practicing physicians. The American College of Surgeons guidelines program believes this process will help validate the clinical utility of existing guidelines and identify areas needing further investigation to determine practical validity.

Incidence and management of occult hemothoraces.

BACKGROUND: Little is known about the incidence of and associated management outcomes of occult hemothorax in blunt trauma patients. The increased use of computed thoracic tomography for the evaluation of the multiply injured blunt trauma patient has led to an increase in the identification of these hemothoraces and management dilemmas. METHODS: A retrospective review of blunt trauma patients with occult hemothoraces was performed. Patients were divided into 2 groups: chest tube versus no chest tube. Outcomes and complications for the 2 groups were defined. Data included demographics, Injury Severity Score, length of stay, need for mechanical ventilation and thoracic consult, pneumonia, and empyema. The size of the occult hemothorax was measured on the computed thoracic tomography. RESULTS: Eighty-eight patients (21.4%) had a total of 107 occult hemothoraces. Patients in the chest tube group were more likely to have a higher Injury Severity Score and an associated occult pneumothorax and to have smaller hemothoraces. CONCLUSIONS: Occult pneumothoraces occur in a significant proportion of the multiply injured blunt trauma population. Small, isolated, occult hemothoraces can be managed safely in the stable patient.

Effective retention of primary survey skills by medical students after participation in an expanded Trauma Evaluation and Management course.

BACKGROUND: The Trauma Evaluation and Management (TEAM) module orients medical students to the initial assessment of an injured patient. At the Medical College of Wisconsin, a course based on expanded TEAM (eTEAM) was developed for junior medical students. This study determined whether eTEAM improved the ability to perform and retain primary survey skills. METHODS: Objective Structured Clinical Examination methodology was used to compare 2 groups of senior medical students 1 year after receiving either a 2-hour lecture or eTEAM. RESULTS: Students receiving eTEAM performed the primary survey much better than those receiving lecture alone. The overall Objective Structured Clinical Examination scores did not differ between groups. CONCLUSIONS: Medical students participating in eTEAM retained the ability to perform a primary survey in proper sequence 1 year later better than students receiving the information in lecture format only.

Surgical infections in the critically ill.

Surgical infections in the critically ill patient population are a significant cause of morbidity and mortality. Intra-abdominal and surgical soft-tissue infections are responsible for a significant proportion of the disease burden. Multiple risk factors have been identified that are associated with the development of surgical infections and subsequent morbidity and mortality. The microbiologic spectrum associated with these infections is broad and is determined by the site from which the infection arises and whether the infection is community acquired or nosocomial in origin. The diagnosis and management of these infections require a high index of suspicion, prompt surgical intervention, and adequate antibiotic therapy and resuscitation. Therefore, these infections present a challenge to the intensivist caring for a critically ill patient.