Search Results (14)

Introduction: In-hospital cardiac arrest (IHCA) is still associated with high mortality. Introduction of multi-parameter early warning systems (EWS) could reduce the incidence of IHCA. However, data regarding prevention of IHCA remains conflicting. Moreover, an aging population and a shortage of healthcare workers strain Austrian acute care hospitals. Sicker patients and fewer staff could hinder the implementation of multi-parameter EWS in Austria. Therefore, we sought to identify such barriers by assessing local and national data. Furthermore, we investigated the incidence of in-hospital cardiac arrests at Medical University Innsbruck. Methods: In this perspective study, we retrospectively analyzed all patients experiencing an in-hospital cardiac arrest between 2017 and 2024. In the qualitative part, ten experts in in-hospital emergency medicine were interviewed using guided interviews. The main results from the interviews were identified using a structured content analysis according to Mayring. Quantitative and qualitative data were integrated through narrative. Using the Consolidated Framework for Implementation Research, we stratified our data into five domains. Finally, we applied the “eight steps for leading change” to develop a practice guideline. Results: In six years, 1356 patients were treated by an emergency medical team; 1317 emergencies were included, with 365 of them being resuscitated. Overall, 114 survived for 24 h. The incidence rate of in-hospital cardiac arrests was 0.86 cases/1000 admissions per year. The guided interviews demonstrated a nearly complete absence of EWS using multiple parameters in Austria. Strained human resources after the pandemic, the fear of an increased workload and the lack of robust data regarding the benefit of survival were mentioned as main reasons. The best practice tutorial considers the challenges identified and provides guidance for structured implementation in hospitals. Conclusions: Implementing NEWS2 can facilitate detection of critically ill patients despite decreased staffing. Identifying common barriers and facilitators in five domains described and applying this to the “eight steps for leading change” enabled us to provide a tutorial for implementation of an EWS. This could help master future challenges in in-hospital emergency medicine. Full article

Background: Stroke-related deaths often follow rapid deterioration, making end-of-life (EOL) care decisions particularly challenging in acute settings. Although national guidelines support structured approaches to end-of-life care, there is limited evidence of how these pathways are applied in routine stroke practice. Objective: To evaluate the use of structured end-of-life care pathways, including the AMBER Care Bundle and Dying Adults in the Last Days of Life (DALDL), in stroke patients who died during admission at a general hospital stroke center. Methods: This retrospective, single-center cohort study included 123 patients with confirmed stroke (73.2% ischemic, 26.8% hemorrhagic) who died in hospital during 2023. Clinical characteristics, the timing of care pathway decisions, palliative care involvement, withdrawing of medical procedures, and outcomes were analyzed. Descriptive statistics, Mann–Whitney U tests, Spearman correlations, chi-square tests, and a multivariate regression model were performed. Results: Of 123 patients, 101 (82.1%) entered the DALDL pathway a median of 14.8 days after admission, with a subsequent median survival of 2.9 days. Anticipatory medications were prescribed in 100% of DALDL patients versus 0% of non-DALDL. Do Not Attempt Cardiopulmonary Resuscitation orders were documented in 99%, and 67.3% received specialist palliative care input. Nasogastric tube insertion correlated with a higher National Institutes of Health Stroke Scale (NIHSS) and higher rate of infections. Conclusions: Most patients had access to structured EOL care, but variability in timing and interventions highlights the need for earlier palliative engagement and consistent implementation of pathways to improve the quality of EOL care in stroke patients. We detected areas that could be improved, such as access to a palliative care team and the anticipatory medication use in dying stroke patients. Full article

Severe burns are among the most traumatic injuries, characterized by tissue damage, systemic inflammation, significant fluid shifts, and a high risk of complications such as infections, organ failure, anemia, malnutrition, and psychological trauma. This article reviews recent literature from the PubMed and Google Scholar databases to outline critical components of burn care, from initial resuscitation and stabilization through rehabilitation. Key topics include early airway management to prevent respiratory compromise, meticulous fluid resuscitation to maintain tissue perfusion while avoiding complications like fluid overload, and optimal pain management. It also discusses nutritional support tailored to the burn patient’s hypermetabolic state and surgical techniques like early debridement and skin grafting. Beyond physical recovery, the review emphasizes the importance of addressing the psychological impact of burn injuries, including depression, anxiety, and post-traumatic stress, which can significantly affect long-term outcomes. By integrating the expertise of a multidisciplinary team with a personalized approach and practical recommendations, this review aims to provide clinicians with a comprehensive framework for managing severe burns, from the initial emergency response to the challenges of inpatient care and, finally, rehabilitation. Full article

Penetrating orbit injury is a rare but complex and life-threatening occurrence that may easily be overlooked. Management in the emergency department requires an early multidisciplinary approach but still lacks standard guidelines. This narrative review aims to provide a systematic approach to the management of penetrating orbital injuries for emergency clinicians. Mortality and morbidity are significant due to the orbit’s proximity to numerous anatomical structures. Complications may be infectious, ocular, or cerebro-vascular. Their incidence depends on the mechanism of injury, entry point, and object’s characteristics such as its shape, composition, and velocity. Non-occult cases are often associated with medial orbital rim or medial eyelid penetration, whereas occult cases mainly present with trivial lateral eyelid injury and could be overlooked. Radiological workup consists of computed tomography or magnetic resonance according to the object’s composition. Treatment in the emergency department focuses on initial resuscitation, broad-spectrum antibiotics, and tetanus immunization. Subsequently, early removal of the foreign object in a controlled environment and other specific treatments must be discussed with a multidisciplinary team. Penetrating orbital injury is an uncommon but complex type of head trauma that may be challenging to diagnose. Systematic and multidisciplinary management in the emergency department is crucial to improve overall prognosis. Full article

Extracorporeal cardiopulmonary resuscitation (ECPR) is a complex, life-saving procedure that uses mechanical support for patients with refractory cardiac arrest, representing the pinnacle of extracorporeal membrane oxygenation (ECMO) applications. Effective ECPR requires precise patient selection, rapid mobilization of a multidisciplinary team, and skilled cannulation techniques. Establishing a program necessitates a cohesive ECMO system that promotes interdisciplinary collaboration, which is essential for managing acute cardiogenic shock and severe pulmonary failure. ECPR is suited for selected patients, emphasizing the need to optimize every step of cardiac arrest management—from public education to advanced post-resuscitation care. The flexibility of ECMO teams allows them to manage various emergencies such as cardiogenic shock, massive pulmonary embolism, and severe asthma, showcasing the program’s adaptability. Launching an ECPR program involves addressing logistical, financial, and organizational challenges. This includes gaining administrative approval, assembling a diverse team, and crafting detailed protocols and training regimens. The development process entails organizing teams, refining protocols, and training extensively to ensure operational readiness. A systematic approach to building an ECPR program involves establishing a team, defining patient selection criteria, and evaluating caseloads. Critical elements like patient transport protocols and anticoagulation management are vital for the program’s success. In conclusion, initiating an ECPR program demands thorough planning, collaborative effort across specialties, and ongoing evaluation to improve outcomes in critical cardiac emergencies. This guide offers practical insights to support institutions in navigating the complexities of ECPR program development and maintenance. Full article

Out-of-hospital cardiac arrest (OHCA) represents a significant global public health burden, characterized by low survival and few established diagnostic tools to guide intervention. OHCA presents with a wide variety of etiologies in a heterogeneous population, posing a clinical challenge to care teams. In this review, we describe evolving research focused on diagnostic approaches to OHCA following resuscitation, including electrocardiography, coronary angiography, computed tomography, ultrasonography, and serologic biomarker assessment. These diagnostic tools have been employed in post-resuscitative efforts for diagnosing ischemic and non-ischemic cardiac, respiratory, neurologic, vascular, traumatic, and metabolic causes of arrest. Full article

According to the latest international resuscitation guidelines, extracorporeal cardiopulmonary resuscitation (ECPR) involves the utilization of extracorporeal membrane oxygenation (ECMO) in specific patients experiencing cardiac arrest, and it can be considered in situations where standard cardiopulmonary resuscitation efforts fail if they have a potentially reversible underlying cause, among which we can also find hypothermia. In cases of cardiac arrest, both witnessed and unwitnessed, hypothermic patients have higher chances of survival and favorable neurological outcomes compared to normothermic patients. ECPR is a multifaceted procedure that requires a proficient team, specialized equipment, and comprehensive multidisciplinary support within a healthcare system. However, it also carries the risk of severe, life-threatening complications. With the increasing use of ECPR in recent years and the growing number of centers implementing this technique outside the intensive care units, significant uncertainties persist in both prehospital and emergency department (ED) settings. Proper organization is crucial for an ECPR program in emergency settings, especially given the challenges and complexities of these treatments, which were previously not commonly used in ED. Therefore, within a narrative review, we have incorporated the initial case of ECPR in an ED in Romania, featuring a successful resuscitation in the context of severe hypothermia (20 °C) and a favorable neurological outcome (CPC score of 1). Full article

Aim: To describe the challenges for optimum resuscitation processes in Emergency Departments in Limpopo Province, South Africa. Design: A qualitative explorative research approach was adopted to explore the resuscitation team’s experiences in Emergency Departments. Method: Five medical doctors and twelve professional nurses were purposively sampled to participate in the study. The depth of the information obtained from the participants determined the sample size. Data collected from semi-structured individual interviews were analyzed using thematic analysis. Data quality was ensured by applying four elements: credibility, transferability, dependability, and confirmability. Results: The study findings indicated diverse challenges for optimum resuscitation processes that include: A general shortage of emergency personnel, the lack of material resources and the unavailability of funds for payment of national and international trauma symposiums, the poor maintenance of emergency equipment, the lack of a continuous training program and the resuscitation team receiving different instructions from various team leaders about the standardized procedures and policies of the resuscitation process. The team leaders and managers often blamed, depreciated and disregarded the resuscitation team for failed resuscitation efforts. Public contribution: The study findings are a point of reference for the emergency resuscitation team and the department of health policymakers. Trained and well-equipped emergency resuscitation teams can improve the quality of life for patients with cardiac arrest. Full article

Introduction. Sepsis is an overwhelming reaction to infection with significant morbidity, requiring urgent interventions in order to improve outcomes. The 2016 Sepsis-3 guidelines modified the previous definitions of sepsis and septic shock, and proposed some specific diagnostic and therapeutic measures to define the use of fluid resuscitation and antibiotics. However, some open issues still exist. Methods. A literature research was performed on PubMed and Cochrane using the terms “sepsis” AND “intra-abdominal infections” AND (“antibiotic therapy” OR “antibiotic treatment”). The inclusion criteria were management of intra-abdominal infection (IAI) and effects of antibiotic stewardships programs (ASP) on the outcome of the patients. Discussion. Sepsis-3 definitions represent an added value in the understanding of sepsis mechanisms and in the management of the disease. However, some questions are still open, such as the need for an early identification of sepsis. Sepsis management in the context of IAI is particularly challenging and a prompt diagnosis is essential in order to perform a quick treatment (source control and antibiotic treatment). Antibiotic empirical therapy should be based on the kind of infection (community or hospital acquired), local resistances, and patient’s characteristic and comorbidities, and should be adjusted or de-escalated as soon as microbiological information is available. Antibiotic Stewardship Programs (ASP) have demonstrated to improve antimicrobial utilization with reduction of infections, emergence of multi-drug resistant bacteria, and costs. Surgeons should not be alone in the management of IAI but ideally inserted in a sepsis team together with anaesthesiologists, medical physicians, pharmacists, and infectious diseases specialists, meeting periodically to reassess the response to the treatment. Conclusion. The cornerstones of sepsis management are accurate diagnosis, early resuscitation, effective source control, and timely initiation of appropriate antimicrobial therapy. Current evidence shows that optimizing antibiotic use across surgical specialities is imperative to improve outcomes. Ideally every hospital and every emergency surgery department should aim to provide a sepsis team in order to manage IAI. Full article

Patients with COVID-19 who require aerosol-generating medical procedures (such as endotracheal intubation) are challenging for paramedic services. Although potentially lifesaving for patients, aerosolizing procedures carry an increased risk of infection for paramedics, owing to the resource limitations and complexities of the pre-hospital setting. In this paper, we describe the development, implementation, and evaluation of a novel pre-hospital COVID-19 High-Risk Response Team (HRRT) in Peel Region in Ontario, Canada. The mandate of the HRRT was to attend calls for patients likely to require aerosolizing procedures, with the twofold goal of mitigating against COVID-19 infections in the service while continuing to provide skilled resuscitative care to patients. Modelled after in-hospital ‘protected code blue’ teams, operationalizing the HRRT required several significant changes to standard paramedic practice, including the use of a three-person crew configuration, dedicated safety officer, call–response checklists, multiple redundant safety procedures, and enhanced personal protective equipment. Less than three weeks after the mandate was given, the HRRT was operational for a 12-week period during the first wave of COVID-19 in Ontario. HRRT members attended ~70% of calls requiring high risk procedures and were associated with improved quality of care indicators. No paramedics in the service contracted COVID-19 during the program. Full article

Healthcare staff are required to undertake mandatory training programs to ensure they maintain key clinical competencies. This study was conducted in a private hospital in Ireland, where the processes for accessing mandatory training were found to be highly complex and non-user friendly, resulting in missed training opportunities, specific training license expiration, and underutilized training slots which resulted in lost time for both the trainers and trainees. A pilot study was undertaken to review the process for accessing mandatory training with a focus on the mandatory training program of Basic Life Support (BLS). This was chosen due to its importance in patient resuscitation and its requirement in the hospital achieving Joint Commission International (JCI) accreditation. A pre- and post-team-based intervention design was used with Lean Six Sigma (LSS) methodology employed to redesign the process of booking, scheduling, and delivery of BLS training leading to staff individual BLS certification for a period of two years. The redesign of the BLS training program resulted in a new blended delivery method, and the initiation of a pilot project led to a 50% increase in the volume of BLS classes and a time saving of 154 h 30 min for staff and 48 h 14 min for BLS instructors. The success of the BLS process access pilot has functioned as a platform for the redesign of other mandatory education programs and will be of interest to hospitals with mandatory training requirements that are already facing healthcare challenges and demands on staff time. Full article

Objectives: In the prehospital setting, endotracheal intubation (ETI) is sometimes required to secure a patient’s airways. Emergency ETI in the field can be particularly challenging, and success rates differ widely depending on the provider’s training, background, and experience. Our aim was to evaluate the ETI success rate in a resident-staffed and specialist-physician-supervised emergency prehospital system. Methods: This retrospective study was conducted on data extracted from the Geneva University Hospitals’ institutional database. In this city, the prehospital emergency response system has three levels of expertise: the first is an advanced life-support ambulance staffed by two paramedics, the second is a mobile unit staffed by an advanced paramedic and a resident physician, and the third is a senior emergency physician acting as a supervisor, who can be dispatched either as backup for the resident physician or when a regular Mobile Emergency and Resuscitation unit (Service Mobile d’Urgence et de Réanimation, SMUR) is not available. For this study, records of all adult patients taken care of by a second- and/or third-level prehospital medical team between 2008 and 2018 were screened for intubation attempts. The primary outcome was the success rate of the ETI attempts. The secondary outcomes were the number of ETI attempts, the rate of ETI success at the first attempt, and the rate of ETIs performed by a supervisor. Results: A total of 3275 patients were included in the study, 55.1% of whom were in cardiac arrest. The overall ETI success rate was 96.8%, with 74.4% success at the first attempt. Supervisors oversaw 1167 ETI procedures onsite (35.6%) and performed the ETI themselves in only 488 cases (14.9%). Conclusion: A resident-staffed and specialist-physician-supervised urban emergency prehospital system can reach ETI success rates similar to those reported for a specialist-staffed system. Full article

Neonatal resuscitation demands that healthcare professionals perform cognitive and technical tasks while working under time pressure as a team in order to provide efficient and effective care. Neonatal resuscitation teams simultaneously process and act upon multiple data streams, perform ergonomically challenging technical procedures, and coordinate their actions within a small physical space. An understanding and application of human factors and ergonomics science broadens the areas of need in resuscitation research, and will lead to enhanced technologies, systems, and work environments that support human limitations and maximize human performance during neonatal resuscitation. Full article

Neonatal mortality in Africa is among the highest in the world. In Liberia, providers face significant challenges due to lack of resources, and providers in referral centers need to be prepared to appropriately provide neonatal resuscitation. A team of American Heart Association health care providers taught a two-day neonatal resuscitation curriculum designed for low-resource settings at a regional hospital in Liberia. The goal of this study was to evaluate if the curriculum improved knowledge and comfort in participation. The curriculum included simulations and was based on the Neonatal Resuscitation Protocol (NRP). Students learned newborn airway management, quality chest compression skills, and resuscitation interventions through lectures and manikin-based simulation sessions. Seventy-five participants were trained. There was a 63% increase in knowledge scores post training (p < 0.00001). Prior cardiopulmonary resuscitation (CPR) training, age, occupation, and pre-intervention test score did not have a significant effect on post-intervention knowledge test scores. The median provider comfort score improved from a 4 to 5 (p < 0.00001). Factors such as age, sex, prior NRP education, occupation, and post-intervention test scores did not have a significant effect on the post-intervention comfort level score. A modified NRP and manikin simulation-based curriculum may be an effective way of teaching health care providers in resource-limited settings. Training of providers in limited-resource settings could potentially help decrease neonatal mortality in Liberia. Modification of protocols is sometimes necessary and an important part of providing context-specific training. The results of this study have no direct relation to decreasing neonatal mortality until proven. A general resuscitation curriculum with modified NRP training may be effective, and further work should focus on the effect of such interventions on neonatal mortality rates in the region. Full article