Critical Care Delivery Solutions in the Emergency Department: Evolving Models in Caring for ICU Boarders

The National Academy of Medicine has identified emergency department (ED) crowding as a health care delivery problem. Because the ED is a portal of entry to the hospital, 25% of all ED encounters are related to critical illness. Crowding at both an ED and hospital level can thus lead to boarding of a number of critically ill patients in the ED. EDs are required to not only deliver immediate resuscitative and stabilizing care to critically ill patients on presentation but also provide longitudinal care while boarding for the ICU. Crowding and boarding are multifactorial and complex issues, for which different models for delivery of critical care in the ED have been described. Herein, we provide a narrative review of different models of delivery of critical care reported in the literature and highlight aspects for consideration for successful local implementation

Clinician Absences and Contributing Factors During a COVID-19 Surge: Potential Areas for Intervention and Planning

Introduction: Our goal was to quantify healthcare clinician (HCC) absenteeism in the emergency department (ED) during the coronavirus disease 2019 (COVID-19) surge and to identify potential interventions that may mitigate the number of absences.Methods: This was a retrospective, descriptive record review that included 82 resident physicians, physician assistants, and staff physicians who were scheduled to work more than three clinical shifts during March 2020 in an urban, academic ED that received a high number of coronavirus disease 2019 (COVID-19) patients. Exposure was defined as a healthcare clinician who was not wearing appropriate personal protective equipment (PPE) having contact with a confirmed COVID-19 positive patient in the ED. The main outcome was the number of HCC absences secondary to exposure to or symptoms concerning for COVID-19.Results: During March 2020, of 82 ED HCCs, 28 (34%) required an absence from clinical duties, totaling 152 absentee calendar days (N = 13 women [46%]; N = 15 men [54%]). Median HCC age was 32 years (interquartile range 28-39), and median number of days absent was four (interquartile range 3-7). While 16 (57%) of the total absences were secondary to a known exposure, 12 (43%) were symptomatic without a known exposure. A total of 25 (89%) absent HCCs received COVID-19 testing (N = 5 positive [20%]; N = 20 negative [80%]) with test results returning in 1-10 days. Eleven (39%) symptomatic HCCs had traveled domestically or internationally in the prior 30 days.Conclusion: Emergency departments should anticipate substantial HCC absences during the initial surge of a pandemic. Possible interventions to mitigate absences include early and broad use of PPE, planning for many asymptomatic HCC absences secondary to exposures, prioritizing HCC virus testing, and mandating early travel restrictions

Health care provider absences and intervenable areas during a COVID-19 surge

Background and Objectives: Health care provider (HCP) absenteeism during the initial phase of an epidemic or pandemic can lead to significant understaffing during a critical time. There is a paucity of literature that describes the effect that the initial phases of a pandemic have on emergency department (ED) HCP absences, or possible interventions that may curb the number of absences. This lack of data places frontline departments at undue risk for inadequate HCP staffing at a time when patient care needs are greatest. This study aimed to quantify HCP absenteeism in the ED during the initial Coronavirus Disease 2019 (COVID-19) surge and to identify potential interventions that may mitigate absences. Methods: This was a retrospective, descriptive record review that included 82 resident physicians, physician assistants, and staff physicians who were scheduled to work more than 3 clinical shifts during March 2020 in an urban, academic ED that received a high number of COVID-19 patients in March. The department created an external database during the pandemic to assist with staffing given the sudden increase in HCP absenteeism. This database included date of COVID-19 exposure, symptom onset, absence from and return to work, testing with result, age, gender, travel history, and admission history. Descriptive statistics and graphical representations superimposed with dated institutional policy changes were used in framing the progression of dependent variables. Results: During March 2020, of 82 ED HCPs, 28 (34%) required an absence from clinical duties, totaling 152 absentee calendar days (n = 13 women [46%]; n = 15 men [54%]). Median age was 32 years (interquartile range 28-39). Median number of days absent was 4 (interquartile range 3-7). While 16 (57%) of the total absences were secondary to a known exposure, 12 (43%) were symptomatic without a known exposure. A total of 25 (89%) absent HCPs received COVID-19 testing (n = 5 positive [20%]; n = 20 negative [80%]) with test results returning in 1 to 10 days. Eleven (39%) symptomatic HCPs had traveled domestically or internationally in the past 30 days. Conclusion: EDs should anticipate substantial HCP absenteeism during the initial surge of a pandemic. Possible interventions to mitigate absences include early and broad use of personal protective equipment, planning for many asymptomatic HCP absences secondary to exposures, prioritizing HCP testing, and mandating early travel restrictions

Sepsis-3 the Dysregulated Host Response and Cytokine Changes

RATIONALE: New Sepsis-3 definitions have been published, stating that sepsis is a “life-threatening organ dysfunction caused by a dysregulated host response to infection”. The Sepsis-3 authors identified that “Limitations of previous definitions included an excessive focus on inflammation and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria.” With the new definitions it was proposed that identification of septic patients with a dysregulated host response is aided by the use of a quick SOFA (qSOFA) score and not by the use of SIRS criteria. qSOFA score is considered abnormal when 2 of 3 criteria are met. These criteria include sytolic blood pressure \u3c 100mmHg, respiratory rate \u3e 24 and mental status changes. We re-examined an established data-base for patients with vasopressor dependent septic shock comparing SIRS criteria to qSOFA criteria in concern to available measured cytokine markers as indicator of a dysregulated host response. If qSOFA indicates an abnormal host response, prominent cytokine markers such as IL-1RA, IL-1α, IL-6, IL-8, IL-10 and TNF-α should show similar trends as SIRS criteria. METHODS: Re-examination of established IRB approved research data base for patients with vasopressor dependent septic shock with measured multiplex cytokine markers (Milliplex HCYTMAG-60K-PX29) as indicator of a dysregulated host response to infection in concern to SIRS criteria and newly established qSOFA score. RESULTS: For 174 patients data was re-examined. At the time of enrollment within 24 hours following shock onset the average qSOFA score was 1.47 and average SIRS criteria 2.06. Table 1 shows measured cytokine values in regard to number of either SIRS criteria or qSOFA score. The average values of measured cytokine markers increased with increasing number of SIRS criteria for IL-1RA, IL-1a, IL-6, IL-8, IL-10 and TNF-a. Similar cytokine increases in relation to the number of qSOFA score was only seen for IL-8, IL-10 and TNF-a.∗Average values shown as ng/mL (Table presented). CONCLUSION. In patients with vasopressor dependent shock increasing SIRS criteria are related to increases in measured circulating cytokine markers of inflammation. Circulating cytokine markers as indicator for an abnormal host response to infection do not increase with increasing qSOFA scores similar to the SIRS criteria and therefore may not be indicative of all aspects of this dysregulated host response

Combined X-ray and Raman Studies on the Effect of Cobalt Additives on the Decomposition of Magnesium Borohydride

Magnesium borohydride (Mg(BH4)2) is one of the most promising hydrogen storage materials. Its kinetics of hydrogen desorption, reversibility, and complex reaction pathways during decomposition and rehydrogenation, however, present a challenge, which has been often addressed by using transition metal compounds as additives. In this work the decomposition of Mg(BH4)2 ball-milled with CoCl2 and CoF2 additives, was studied by means of a combination of several in-situ techniques. Synchrotron X-ray diffraction and Raman spectroscopy were used to follow the phase transitions and decomposition of Mg(BH4)2. By comparison with pure milled Mg(BH4)2, the temperature for the \u3b3 \u2192 \u3b5 phase transition in the samples with CoF2 or CoCl2 additives was reduced by 10\u201345 \ub0C. In-situ Raman measurements showed the formation of a decomposition phase with vibrations at 2513, 2411 and 766 cm 121 in the sample with CoF2. Simultaneous X-ray absorption measurements at the Co K-edge revealed that the additives chemically transformed to other species. CoF2 slowly reacted upon heating till ~290 \ub0C, whereas CoCl2 transformed drastically at ~180 \ub0C