Emergency surgery and Limitation of therapeutic effort in relation to neurologic deterioration in elderly patients – a survey of European surgeons

Background. In emergency surgery, a very heterogeneous approach is required in the decision making process, especially when considering the patient’s postoperative quality of life as well as medical, ethical, and legal factors. In some cases, the presence of an Advance Directive (AD) form may potentially help resolve the surgeon’s dilemma. Objectives. The primary objective of this survey was to investigate the opinions of surgeons across a representative cross-section of European countries regarding the decision making process using a specific case scenario so as to identify similarities and differences in practice. A secondary objective was to identify the possibility of establishing a more uniform approach and best practice. Method. A survey was conducted of surgeons from a range of European countries. Questionnaires were designed to obtain an overview of decision making in relation to the Limitation of Therapeutic Effort (LTE) using a specific case study and the level of awareness and practical use of ADs. Surveys were distributed via email to the members of the ESTES (European Society for Trauma and Emergency Surgery) and AEC (Association of Spanish surgeons), with voluntary, anonymous participation. Conclusions. Clear and additional support in the form of legal and ethical guidance with clinical protocols for surgical practice in such case scenarios is necessary. Wider use of ADs, together with education about their role and support for patients and relatives, would benefit the type of patient described in our scenario. A multidisciplinary team should play a more active role in decision making in order to avoid surgical procedures that are potentially futile. The concepts of LTE and Quality of life need a broader understanding among surgeons as well as more consistent application

Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Efficacy and Safety of Pediatric Critical Care Physician Telemedicine Involvement in Rapid Response Team and Code Response in a Satellite Facility

OBJECTIVES: Satellite inpatient facilities of larger children's hospitals often do not have on-site intensivist support. In-house rapid response teams and code teams may be difficult to operationalize in such facilities. We developed a system using telemedicine to provide pediatric intensivist involvement in rapid response team and code teams at the satellite facility of our children's hospital. Herein, we compare this model with our in-person model at our main campus. DESIGN: Cross-sectional. SETTING: A tertiary pediatric center and its satellite facility. PATIENTS: Patients admitted to the satellite facility. INTERVENTIONS: Implementation of a rapid response team and code team model at a satellite facility using telemedicine to provide intensivist support. MEASUREMENTS AND MAIN RESULTS: We evaluated the success of the telemedicine model through three a priori outcomes: 1) reliability: involvement of intensivist on telemedicine rapid response teams and codes, 2) efficiency: time from rapid response team and code call until intensivist response, and 3) outcomes: disposition of telemedicine rapid response team or code calls. We compared each metric from our telemedicine model with our established main campus model. MAIN RESULTS: Critical care was involved in satellite campus rapid response team activations reliably (94.6% of the time). The process was efficient (median response time 7 min; mean 8.44 min) and effective (54.5 % patients transferred to PICU, similar to the 45-55% monthly rate at main campus). For code activations, the critical care telemedicine response rate was 100% (6/6), with a fast response time (median 1.5 min). We found no additional risk to patients, with no patients transferred from the satellite campus requiring a rapid escalation of care defined as initiation of vasoactive support, greater than 60 mL/kg in fluid resuscitation, or endotracheal intubation. CONCLUSIONS: Telemedicine can provide reliable, timely, and effective critical care involvement in rapid response team and Code Teams at satellite facilities

An assessment of failure to rescue derived from routine NHS data as a nursing sensitive patient safety indicator (report to Policy Research Programme)

Objectives: This study aims to assess the potential for deriving 2 mortality based failure to rescue indicators and a proxy measure, based on exceptionally long length of stay, from English hospital administrative data by exploring change in coding practice over time and measuring associations between failure to rescue and factors which would suggest indicators derived from these data are valid.Design: Cross sectional observational study of routinely collected administrative data.Setting: 146 general acute hospital trusts in England.Participants: Discharge data from 66,100,672 surgical admissions (1997 to 2009).Results: Median percentage of surgical admissions with at least one secondary diagnosis recorded increased from 26% in 1997/8 to 40% in 2008/9. The failure to rescue rate for a hospital appears to be relatively stable over time: inter-year correlations between 2007/8 and 2008/9 were r=0.92 to r=0.94. No failure to rescue indicator was significantly correlated with average number of secondary diagnoses coded per hospital. Regression analyses showed that failure to rescue was significantly associated (p<0.05) with several hospital characteristics previously associated with quality including staffing levels. Higher medical staffing (doctors + nurses) per bed and more doctors relative to the number of nurses were associated with lower failure to rescue. Conclusion: Coding practice has improved, and failure to rescue can be derived from English administrative data. The suggestion that it is particularly sensitive to nursing is not clearly supported. Although the patient population is more homogenous than for other mortality measures, risk adjustment is still required

Managing clinical uncertainty: an ethnographic study of the impact of critical care outreach on end‐of‐life transitions in ward‐based critically ill patients with a life‐limiting illness

© 2018 Crown copyright. Journal of Clinical Nursing © 2018 John Wiley & Sons LtdRapid response teams, such as critical care outreach teams, have prominent roles in managing end-of-life transitions in critical illness, often questioning appropriateness of treatment escalation. Clinical uncertainty presents clinicians with dilemmas in how and when to escalate or de-escalate treatment. Aims and objectives: To explore how critical care outreach team decision-making processes affect the management of transition points for critically ill, ward-based patients with a life-limiting illness. Methods: An ethnographic study across two hospitals observed transition points and decisions to de-escalate treatment, through the lens of critical care outreach. In-depth interviews were carried out to elucidate rationales for practices witnessed in observations. Detailed field notes were taken and placed in a descriptive account. Ethnographic data were analysed, categorised and organised into themes using thematic analysis. Findings: Data were collected over 74 weeks, encompassing 32 observation periods with 20 staff, totalling more than 150 hr. Ten formal staff interviews and 20 informal staff interviews were undertaken. Three main themes emerged: early decision-making and the role of critical care outreach; communicating end-of-life transitions; end-of-life care and the input of critical care outreach. Findings suggest there is a negotiation to achieve smooth transitions for individual patients, between critical care outreach, and parent or ward medical teams. This process of negotiation is subject to many factors that either hinder or facilitate timely transitions. Conclusions: Critical care outreach teams have an important role in shared decision-making. Associated emotional costs relate to conflict with parent medical teams, and working as lone practitioners. The cultural contexts in which teams work have a significant effect on their interactions and agency. Relevance to practice: There needs to be a cultural shift towards early and open discussion of treatment goals and limitations of medical treatment, particularly when facing serious illness. With training and competencies, outreach nurses are well placed to facilitate these discussions.Peer reviewe

Diagnosis and management of pneumonia in the emergency department.

Pneumonia is a condition that is often treated by emergency physicians. This article reviews the diagnosis and management of pneumonia in the emergency department and highlights dilemmas in diagnostic testing, use of blood and sputum cultures, hospital admission decisions, infection control, quality measures for pneumonia care, and empiric antimicrobial therapy

Interfacility Transfer of Pediatric Patients to a Comprehensive Children\u27s Hospital

Practice Problem: Secondary transfers to pediatric centers have increased by 25% due to the regionalization of specialty care. Low pediatric volume and the lack of access to pediatric subspecialty confounds the need for transfer requests to comprehensive children’s hospitals. Referring hospitals rely on pediatric teams to determine the level of service and mode of transportation decisions due to a lack of comfort in caring for and managing pediatric patients. PICOT: This project was guided by the following question. In pediatric patients transferring from other healthcare facilities to a comprehensive children’s hospital (P), does the implementation of a nurse-led pediatric illness severity scoring tool (I) versus traditional phone triage (C), increase recognition and notification of ICU level patients (O) in 8-weeks (T)? Evidence: Triage transport tools have been studied in the pediatric population and are relied on to determine acuity and predict admission needs. Acuity tools allow for consistent resource allocation and improved transfers by removing the subjectiveness of physical findings and converting the assessments into objective metrics needed to make safe transport and admission decisions. Intervention: A pediatric transport acuity tool was implemented to standardize the reporting framework and was scored to identify high-acuity patients requiring transport for definitive care. Outcome: Improved identification of ICU-level patients requiring transport to a pediatric hospital from 63% pre-intervention to 97% post-intervention. Conclusion: This project increased recognition of ICU-level pediatric patients through use of the TRAP tool and also identified a broader impact, which is exposing referring hospitals to a triage tool that assists outside providers in identifying acutely ill pediatric patients

Identification of the severe sepsis patient at triage: a prospective analysis of the Australasian Triage Scale

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/Objective This study aims to investigate the accuracy and validity of the Australasian Triage Scale (ATS) as a tool to identify and manage in a timely manner the deteriorating patient with severe sepsis. Methods This was a prospective observational study conducted in five sites of adult patients. Keywords and physiological vital signs data from triage documentation were analysed for the ‘identified’ status compared with confirmed diagnosis of severe sepsis after admission to the intensive care unit. The primary outcome is the accuracy and validity of the ATS Triage scale categories to identify a prespecified severe sepsis population at triage. Secondary outcome measures included time compliance, antimicrobial administration and mortality prediction. Statistical analysis included parameters of diagnostic performance. Adjusted multivariate logistic regression analysis was applied to mortality prediction. Results Of 1022 patients meeting the criteria for severe sepsis, 995 were triaged through the emergency department, 164 with shock. Only 53% (n=534) were identified at triage. The overall sensitivity of the ATS to identify severe sepsis was 71%. ATS 3 was the most accurate (likelihood ratio positive, 2.45, positive predictive value 0.73) and ATS 2 the most valid (area under the curve 0.567) category. Identified cases were more likely to survive (OR 0.81, 95% CI 0.697 to 0.94, p4 (OR 1.63, 95% CI 1.10 to 2.89, p<0.001) and ATS 1 category (OR 1.55, 95% CI 1.09 to 2.35, p<0.005). Conclusions The ATS and its categories is a sensitive and moderately accurate and valid tool for identifying severe sepsis in a predetermined group, but lacks clinical efficacy and safety without further education or quality improvement strategies targeted to the identification of severe sepsis