Lack of clinically evident signs of organ failure affects ED treatment of patients with severe sepsis

BACKGROUND: It is not known whether lack of recognition of organ failure explains the low compliance with the “Surviving Sepsis Campaign” (SSC) guidelines. We evaluated whether compliance was higher in emergency department (ED) sepsis patients with clinically recognizable signs of organ failure compared to patients with only laboratory signs of organ failure. METHODS: Three hundred twenty-three ED patients with severe sepsis and septic shock were prospectively included. Multivariable binary logistic regression was used to assess if clinical and biochemical signs of organ failure were associated with compliance to a SSC-based resuscitation bundle. In addition, two-way analysis of variance was used to investigate the relation between the predisposition, infection, response and organ failure (PIRO) score (3 groups: 1–7, 8–14, 15–24) as a measure of illness severity and time to antibiotics with disposition to ward or ICU as effect modifier. RESULTS: One hundred twenty-five of 323 included sepsis patients with new-onset organ failure were admitted to the ICU, and in all these patients the SSC resuscitation bundle was started. Respiratory difficulty, hypotension and altered mental status as clinically recognizable signs of organ failure were independent predictors of 100% compliance and not illness severity per se. Corrected ORs (95% CI) were 3.38 (1.08–10.64), 2.37 (1.07–5.23) and 4.18 (1.92–9.09), respectively. Septic ED patients with clinically evident organ failure were more often admitted to the ICU compared to a ward (125 ICU admissions, P < 0.05), which was associated with shorter time to antibiotics [ward: 127 (113–141) min; ICU 94 (80–108) min (P = 0.005)]. CONCLUSIONS: The presence of clinically evident compared to biochemical signs of organ failure was associated with increased compliance with a SSC-based resuscitation bundle and admission to the ICU, suggesting that recognition of severe sepsis is an important barrier for successful implementation of quality improvement programs for septic patients. In septic ED patients admitted to the ICU, the time to antibiotics was shorter compared to patients admitted to a normal ward

Historical, contemporary, and future perspectives on a coupled social-ecological system in a changing world: Canada’s historic Rideau Canal

Anthropogenic waterways and canal systems have been part of the cultural and natural landscape for thousands for years. As of the late 20th century, more than 63,000-km of canals exist worldwide as transport routes for navigation, many with barriers (e.g., locks, dams) that fragment the system and decrease connectivity. Fragmentation alone can have negative implications for freshwater biodiversity; by isolating populations and communities, other human-mediated disturbances associated with canals like poor water quality and invasive species can exacerbate these negative effects. As such, the capacity of these interconnected freshwater systems to support biodiversity is continuously degrading at a global level. One critical, highly complex issue that unites canals worldwide is the challenge of governing these systems in a holistic, unified way to both protect biodiversity and preserve historical elements. Managing historic canals involves multiple objectives across many agencies and stakeholders, often with different or conflicting objectives. Here, we use the Rideau Canal, a UNESCO World Heritage Site and National Historic Site of Canada, as a case study to demonstrate the importance of considering canals as social-ecological systems for effective and efficient governance. Historic canals are integrated systems of both humans (social) and the environment (ecological), linked by mutual feedbacks and coevolution, and must be managed as such to achieve conservation goals while maintaining commemorative integrity. We discuss the history of the Rideau Canal and its current governance, biodiversity in the waterway, different threats and issues (user conflicts, aquatic pollution, shoreline development, water management, species at risk, and invasive species), and conclude by outlining ways to address the challenges of managing it as a coupled social-ecological system. We present different research needs and opportunities that would enable better management, though above all, we propose a shift from the current governance structure – which at best can be considered “patchwork” – to a coordinated, multi-scalar and multi-stakeholder governance regime such that the Rideau Canal can be maintained for its historical integrity without compromising biodiversity conservation. Given that canals are now pervasive worldwide, this article is not only topical to the Rideau Canal, but also to other waterways in Canada and beyond.The accepted manuscript in pdf format is listed with the files at the bottom of this page. The presentation of the authors' names and (or) special characters in the title of the manuscript may differ slightly between what is listed on this page and what is listed in the pdf file of the accepted manuscript; that in the pdf file of the accepted manuscript is what was submitted by the author