Healthcare providers are facing a coronavirus disease pandemic. This pandemic may last for many months, stressing the Canadian healthcare system in a way that has not previously been seen. Keeping ...healthcare providers safe, healthy, and available to work throughout this pandemic is critical. The consistent use of appropriate personal protective equipment (PPE) will help assure its availability and healthcare provider safety. The purpose of this communique is to give both anesthesiologists and other front-line healthcare providers a framework from which to understand the principles and practices surrounding PPE decision-making. We propose three types of PPE including: 1) PPE for
droplet and contact
precautions, 2) PPE for general
airborne, droplet, and contact
precautions, and 3) PPE for those performing or assisting with
high-risk aerosol-generating medical procedures
.
Critical care teams can face a dramatic surge in demand for ICU beds and organ support during a disaster. Through effective preparedness, teams can enable a more effective response and hasten ...recovery back to normal operations. Disaster preparedness needs to balance an all-hazards approach with focused hazard-specific preparation guided by a critical care-specific hazard-vulnerability analysis. Broad stakeholder input from within and outside the critical care team is necessary to avoid gaps in planning. Evaluation of critical care disaster plans require frequent exercises, with a mechanism in place to ensure lessons learned effectively prompt improvements in the plan.
Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to ...expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.
Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems ...aimed at detecting and responding to such patients.
To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients.
The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines.
We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs).
The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system.
The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems ...aimed at detecting and responding to such patients.
To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients.
The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines.
We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs).
The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS).
The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.
Epidemiology of sepsis: An update Angus, Derek C; Wax, Randy S
Critical care medicine,
2001-July, Letnik:
29, Številka:
7 Suppl 1
Journal Article, Conference Proceeding
Recenzirano
OBJECTIVEWe review the case definition, occurrence, and outcome of sepsis. We discuss whether the epidemiology of sepsis has changed over time and discuss issues important to our understanding of ...sepsis.
DATA SOURCESLiterature review.
DATA SUMMARYOur understanding of the epidemiology of sepsis is hampered by the lack of a reliable case definition. Inconsistent application of sepsis definition criteria contributes to confusion and variability in the literature. Variability in the time course of sepsis also introduces difficulty. The Centers for Disease Control estimated an incidence of 73.6 per 100,000 population in 1979, rising to 175.9 per 100,000 in 1989. However, this study was of septicemia, not severe sepsis. There are several hospital-based studies of the occurrence of severe sepsis, defined using the American College of Chest Physicians/Society of Critical Care Medicine consensus criteria. These studies reported variable hospital and intensive care unit (ICU) occurrence rates, ranging from 2% to 11% of all hospital or ICU admissions. Most of these data are from academic, tertiary care centers, which limits generalizability. More population-based studies are required to better delineate the incidence and risk factors of sepsis in the general population.Hospital mortality from sepsis has ranged from 25% to 80% over the last few decades. Although mortality may be lower in recent years, sepsis is clearly still a very serious condition. Achieving a better understanding of whether the mortality rate for sepsis is falling, however, is confounded by the lack of a uniform definition. Risk factors for adverse outcome include the degree of physiologic derangement, organ dysfunction, underlying illness, site of infection, and microbiological etiology. We do not know, however, the factors that predict response to new therapies. This dilemma has led researchers to explore whether markers of the inflammatory cascade might be more specific for sepsis, more accurate for risk prediction, or more useful for predicting response to therapy. However, there as yet is no equivalent of the CPK-MB for acute myocardial infarction. Whether we will find such a marker as we develop a greater understanding of the genetic control of the inflammatory cascade is uncertain but promising.One might assume intuitively that the epidemiology of sepsis is changing. For example, the number of patients being treated in ICUs has increased over time, the technologies used in the ICU have changed, and the choice and the use of antibiotics have changed. Predisposing factors, such as chemotherapeutic regimens, have also changed, and there have been marked changes in antibiotic resistance. Furthermore, there have been wide changes in the microbiological etiologies of diseases such as pneumonia and acute exacerbations of chronic bronchitis. However, lacking good case definitions and true incidence studies, we can only make inferences about whether the epidemiology of sepsis is truly changing.
CONCLUSIONMany studies have documented many aspects of the epidemiology of sepsis. However, the composite picture they provide, although rich in many aspects, remains incomplete and emphasizes the heterogeneity of the condition. Unfortunately, few population-based prospective cohort studies exist that allow us to accurately delineate the risk factors for sepsis, its course, and its outcome. To place new information, such as the role of genetic predisposition, in the correct context, it is essential that such studies be conducted.
To assess recent advances in interfacility critical care transport.
PubMed English language publications plus chapters and professional organization publications.
Manuscripts including practice ...manuals and standard (1990-2021) focused on interfacility transport of critically ill patients.
Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport.
The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis.
Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.
OBJECTIVE:We aimed to determine internal medicine residents’ perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing ...acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal.
DESIGN:Cross-sectional postal survey.
SETTING:Canadian internal medicine training programs.
PARTICIPANTS:Internal medicine residents attending Canadian English-speaking medical schools.
INTERVENTIONS:A survey was mailed to internal medicine residents asking questions relating to four domainsadequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools.
MEASUREMENTS AND MAIN RESULTS:Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r = .085, p < .001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence.
CONCLUSIONS:The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders.
The recent outbreaks of avian influenza (H5N1) have placed a renewed emphasis on preparing for an influenza pandemic in humans. Of particular concern in this planning is the allocation of resources, ...such as ventilators and antiviral medications, which will likely become scarce during a pandemic.
We applied a collaborative process using best evidence, expert panels, stakeholder consultations and ethical principles to develop a triage protocol for prioritizing access to critical care resources, including mechanical ventilation, during a pandemic.
The triage protocol uses the Sequential Organ Failure Assessment score and has 4 main components: inclusion criteria, exclusion criteria, minimum qualifications for survival and a prioritization tool.
This protocol is intended to provide guidance for making triage decisions during the initial days to weeks of an influenza pandemic if the critical care system becomes overwhelmed. Although we designed this protocol for use during an influenza pandemic, the triage protocol would apply to patients both with and without influenza, since all patients must share a single pool of critical care resources.
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