Evaluating the effectiveness of the Emergency Neurological Life Support educational framework in low-income countries.

BackgroundThe Emergency Neurological Life Support (ENLS) is an educational initiative designed to improve the acute management of neurological injuries. However, the applicability of the course in low-income countries in unknown. We evaluated the impact of the course on knowledge, decision-making skills and preparedness to manage neurological emergencies in a resource-limited country.MethodsA prospective cohort study design was implemented for the first ENLS course held in Asia. Knowledge and decision-making skills for neurological emergencies were assessed at baseline, post-course and at 6 months following course completion. To determine perceived knowledge and preparedness, data were collected using surveys administered immediately post-course and 6 months later.ResultsA total of 34 acute care physicians from across Nepal attended the course. Knowledge and decision-making skills significantly improved following the course (p=0.0008). Knowledge and decision-making skills remained significantly improved after 6 months, compared with before the course (p=0.02), with no significant loss of skills immediately following the course to the 6-month follow-up (p=0.16). At 6 months, the willingness to participate in continuing medical education activities remained evident, with 77% (10/13) of participants reporting a change in their clinical practice and decision-making, with the repeated use of ENLS protocols as the main driver of change.ConclusionsUsing the ENLS framework, neurocritical care education can be delivered in low-income countries to improve knowledge uptake, with evidence of knowledge retention up to 6 months

Atraumatic (pencil-point) versus conventional needles for lumbar puncture:a clinical practice guideline

Is the needle tip configuration important when performing a lumbar puncture for any indication? A systematic review published in the Lancet in December 2017 suggests that it is. The review found that using atraumatic (pencil-point) lumbar puncture needles instead of conventional lumbar puncture needles reduced the risk of post-dural-puncture headache and of return to hospital for additional pain control.1 This guideline recommendation aims to promptly and transparently translate this evidence to a clinical recommendation, following standards for GRADE methodology and trustworthy guidelines.2 The BMJ Rapid Recommendations panel makes a strong recommendation for the use of atraumatic needles for lumbar puncture in all patients regardless of age (adults and children) or indication instead of conventional needles.3 4 Box 1 shows the article and evidence linked to this Rapid Recommendation. The main infographic provides an overview of the absolute benefits and harms (although none were present here) of atraumatic needles. Table 1 below shows any evidence that has emerged since the publication of this guideline.publishedVersio

Processes and Structures of Care for Critically Ill Patients with Acute Brain Injury

Background: Examining the differences in quality and intensity of care within the context of ICU structure is needed to better understand the mortality differences observed between centers, and may help to improve the design of future trials for this neurocritically ill patient population. Methods: This dissertation uses several methods to examine the relationship between processes, organization of care and outcome for critically ill patients with acute brain injury. Results: First in a cohort study, I evaluated the association between centers rendering early decisions to withdraw life-sustaining therapies in severe traumatic brain injury (sTBI), as measured by time until death, and overall risk-adjusted mortality. After adjustment for case mix, care in a center with a preponderance of early deaths (within the first 5 days of ICU admission) was not associated with increased odds of death (adjusted odds ratio (OR) 0.95; 95% confidence interval (CI) 0.83-1.09). Secondly in a meta-analysis, I examined the relationship between the timing of tracheostomy in acutely brain injured patients and mortality. Early tracheostomy was associated with lower long-term mortality (risk ratio [RR] 0.57. 95% CI 0.36-0.90), reduced duration of mechanical ventilation (mean difference [MD] -2.72 days, 95% CI -1.29 to -4.15) and ICU length of stay (MD -2.55 days, 95% CI -0.50 to -4.59), but, was not associated with lower short-term mortality (RR 1.25; 95% CI 0.68-2.30), and, as expected, increased the probability of ever receiving a tracheostomy (RR 1.58, 95% CI 1.24-2.02). Lastly in a cohort study combined with survey data, I examined the association between dedicated neurocritical care units, the presence of standardized management protocols for sTBI, and mortality. Care in a dedicated neurocritical care unit was not associated with a lower risk-adjusted in-hospital mortality (OR 0.97 (95% CI 0.80-1.19), but the utilization of standardized TBI management protocols for these patients was associated with lower risk-adjusted in-hospital mortality (OR 0.77; 95% CI 0.63-0.93). Conclusions: Using several analytical approaches, these findings highlight important opportunities to reduce variability in care negatively impacting on acute brain injury outcomes.Ph.D.2018-12-19 00:00:0

Surrogate endpoints and competing risk of death in cardiac arrest research

Abstract We urgently need new therapies to improve outcomes after cardiac arrest. Initial studies typically target surrogate endpoints, and these studies help to inform subsequent larger trials that are powered to measure more patient-orientated clinical outcomes such as survival. The competing risk of death and premature assessment of neurological prognosis pose significant challenges to measuring these surrogate endpoints after cardiac arrest

The use of standardized management protocols for critically ill patients with non-traumatic subarachnoid hemorrhage: a protocol of a systematic review and meta-analysis

Abstract Background Caring for patients with subarachnoid hemorrhage (SAH) presents unique challenges, due in part to the severity of the underlying insult, competing systemic injuries, and unpredictable clinical course. Even when management occurs in dedicated critical care settings, treatment uncertainty often persists, and morbidity and mortality from the condition remain high. Complex decisions in SAH care may be simplified with the use of standardized management protocols (SMPs). SMPs incorporate evidence-based guidelines into a practical framework for decision-making, thereby providing clinicians with an algorithm for organizing treatments. But despite these potential advantages, it is currently unknown whether SMPs may improve outcomes in the critical care of patients with SAH. Methods We will conduct a systematic review of cohort studies and randomized control trials of adult patients with non-traumatic SAH who received care according to a standardized management protocol. Comprehensive search strategies will be developed for MEDLINE, EMBASE, WoS, CINAHL, and CENTRAL, to identify studies for review. The gray literature will be scanned for further eligible studies. Two reviewers will independently screen the material generated by the search to identify studies for inclusion. A standardized data extraction form will be used to collect information on study design, baseline characteristics, details of the management protocol employed, and primary and secondary outcomes. Where possible, meta-analyses with random-effects models will be used to calculate pooled estimates of effect sizes. Statistical heterogeneity will be evaluated with the I 2 statistics, and risk of bias and reporting quality will be assessed independently and in duplicate with standardized scales. Discussion We anticipate a significant degree of clinical heterogeneity in our review, as protocols will likely vary in their content, implementation, and ICU setting. We will aim to summarize the current literature in this domain to understand if SMPs, as a low-cost process-targeted intervention, improve outcomes for critically ill patients with SAH. Our review will additionally inform future research endeavors to improve the processes of care for this patient population. Systematic review registration CRD4201706917

Educational initiatives and implementation of electroencephalography into the acute care environment: a protocol of a systematic review

Abstract Background Use of electroencephalography (EEG) is currently recommended by the American Clinical Neurophysiology Society for a wide range of indications, including diagnosis of nonconvulsive status epilepticus and evaluation of unexplained disorders of consciousness. Data interpretation usually occurs by expert personnel (e.g., epileptologists, neurophysiologists), with information relayed to the primary care team. However, data cannot always be read in time-sensitive fashion, leading to potential delays in EEG interpretation and patient management. Multiple training programs have recently been described to enable non-experts to rapidly interpret EEG at the bedside. A comprehensive review of these training programs, including the tools used, outcomes obtained, and potential pitfalls, is currently lacking. Therefore, the optimum training program and implementation strategy remain unknown. Methods We will conduct a systematic review of descriptive studies, case series, cohort studies, and randomized controlled trials assessing training programs for EEG interpretation by non-experts. Our primary objective is to comprehensively review educational programs in this domain and report their structure, patterns of implementation, limitations, and trainee feedback. Our secondary objective will be to compare the performance of non-experts for EEG interpretation with a gold standard (e.g., interpretation by a certified electroencephalographers). Studies will be limited to those performed in acute care settings in both adult and pediatric populations (intensive care unit, emergency department, or post-anesthesia care units). Comprehensive search strategies will be developed for MEDLINE, EMBASE, WoS, CINAHL, and CENTRAL to identify studies for review. The gray literature will be scanned for further eligible studies. Two reviewers will independently screen the search results to identify studies for inclusion. A standardized data extraction form will be used to collect important data from each study. If possible, we will attempt to meta-analyze the quantitative data. If heterogeneity between studies is too high, we will present meaningful quantitative comparisons of secondary outcomes as per the synthesis without meta-analysis (SWiM) reporting guidelines. Discussion We will aim to summarize the current literature in this domain to understand the structure, patterns, and pitfalls of EEG training programs for non-experts. This review is undertaken with a view to inform future education designs, potentially enabling rapid detection of EEG abnormalities, and timely intervention by the treating physician. PROSPERO registration Submitted and undergoing review. Registration ID: CRD42020171208