Douglas et al turned 6 patients in acute respiratory failure from supine to prone and reported a mean increase in Pao2 of 69 mm Hg without changing any mechanical ventilation parameters such as tidal ...volume, oxygen concentration, or pressures.3 There was increasing interest in the maneuver as well as research in the decades to follow, but the studies failed to demonstrate important patient-focused outcomes such as improved survival4 until the 2013 Proning of Severe ARDS Patients (PROSEVA) controlled trial.5 In this randomized trial, Guerin et al5 employed long durations of prone ventilation (16 hours or more) in patients with moderate to severe ARDS to reduce the 28-day mortality from 32.8% in patients in the supine group to 16.0% in those in the prone group, resulting in a 16% absolute risk reduction in mortality (number needed to treat: 6 to save 1 life).Flipped Physiology Prone positioning has multiple beneficial effects for both ventilation and oxygenation. Adopting a prone position results in more homogeneous ventilation, decreases shunting, and improves ventilation and perfusion matching by offloading abdominal and cardiac weight from the lung tissues and by switching the dependent area of infiltrates away from the posterior lung tissues.6 More homogeneous ventilation is thought to also decrease lung injury by distributing mechanical force from the ventilator across the lung during inhalation more evenly.6 Evidence from small observational and retrospective studies suggests that prone positioning in nonintubated patients is feasible and associated with improved oxygenation.7-14 To date, there are no published randomized controlled trials that definitively demonstrate a mortality benefit of prone over supine positioning for awake and spontaneously breathing patients with COVID-19. The work by Wendt et al1 crosses boundaries between being a retrospective observational study and a report of a quality improvement (QI) project. Because of these blurred boundaries, the authors may have been well served to have used established reporting guidelines such as Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)19 or Standards for QUality Improvement Reporting Excellence (SQUIRE).20 These reporting guidelines would have ensured that the authors reported in a consistent manner and would have facilitated future comparisons among similar studies. Some studies describe a 1-hour period, repeated 5 times daily,14 whereas others used “as long as tolerated” durations, which resulted in a median duration of 75 minutes (range 30 minutes-480 minutes).13 Contraindications to proning from the literature include clinical or hemodynamic instability and recent thoracic or abdominal surgery.6 Patients with Do Not Resuscitate orders or advanced directives have been excluded from previous research studies on proning, and clinicians should apply proning as individualized comfort or palliative measures indicate for these patients.6 Be aware that cardiac arrests do occur in the prone position, they may be more difficult to detect,23 and they
•Personal protective equipment errors are common.•Bundled infection prevention control audits and continuous quality improvement may reduce pathogen spread.•Audits by trained observers (dofficers) ...can be used by outbreak response teams to identify opportunities for infection prevention and control quality improvement.•Real-time feedback from dofficers, and quality improvement feedback from an outbreak response team may be associated with a reduction in infection control errors.•Further research is needed to determine if dofficers are causally linked with error reductions.
In response to a facility-wide COVID-19 outbreak, our tertiary acute care hospital implemented an evidence-based bundle of infection control practices including the use of audits and trained observers “dofficers” to provide real-time constructive feedback.
We trained furloughed staff to perform the role of dofficer. They offered support and corrective feedback on proper PPE use and completed 21-point audits during a 4-week intervention period. Audits tracked appropriate signage, placement and availability of supplies (equipment), correct PPE use, enhanced environmental cleaning, along with cohorting and social distancing rates. Audit data was used to provide weekly quality improvement reports to units.
Nine hundred and sixty two separate audits recorded 36,948 observations, over 7,696 observer-hours. The most common errors were with environmental cleaning and PPE use; the least common were with regards to equipment availability and cohorting and social distancing. Mean error rates decreased from 9.81% to 2.88% (P < .001). The largest reduction, 22.57%, occurred in the category of PPE doffing errors.
Dofficer led audits effectively identified areas for improvement. Feedback through weekly reports and real-time correction of PPE errors by dofficers led to statistically significant improvements; however, error rates remained high. Further research is needed establish if these relationships are causal.
To identify and summarize the available science on prone resuscitation. To determine the value of undertaking a systematic review on this topic; and to identify knowledge gaps to aid future research, ...education and guidelines.
This review was guided by specific methodological framework and reporting items (PRISMA-ScR). We included studies, cases and grey literature regarding prone position and CPR/cardiac arrest. The databases searched were MEDLINE, Embase, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Scopus and Google Scholar. Expanded grey literature searching included internet search engine, targeted websites and social media.
Of 453 identified studies, 24 (5%) studies met our inclusion criteria. There were four prone resuscitation-relevant studies examining: blood and tidal volumes generated by prone compressions; prone compression quality metrics on a manikin; and chest computed tomography scans for compression landmarking. Twenty case reports/series described the resuscitation of 25 prone patients. Prone compression quality was assessed by invasive blood pressure monitoring, exhaled carbon dioxide and pulse palpation. Recommended compression location was zero-to-two vertebral segments below the scapulae. Twenty of 25 cases (80%) survived prone resuscitation, although few cases reported long term outcome (neurological status at hospital discharge). Seven cases described full neurological recovery.
This scoping review did not identify sufficient evidence to justify a systematic review or modified resuscitation guidelines. It remains reasonable to initiate resuscitation in the prone position if turning the patient supine would lead to delays or risk to providers or patients. Prone resuscitation quality can be judged using end-tidal CO2, and arterial pressure tracing, with patients turned supine if insufficient.
IntroductionThe first clinical interaction most patients have in the emergency department occurs during triage. An unstructured narrative is generated during triage and is the first source of ...in-hospital documentation. These narratives capture the patient’s reported reason for the visit and the initial assessment and offer significantly more nuanced descriptions of the patient’s complaints than fixed field data. Previous research demonstrated these data are useful for predicting important clinical outcomes. Previous reviews examined these narratives in combination or isolation with other free-text sources, but used restricted searches and are becoming outdated. Furthermore, there are no reviews focused solely on nurses’ (the primary collectors of these data) narratives.Methods and analysisUsing the Arksey and O’Malley scoping review framework and PRISMA-ScR reporting guidelines, we will perform structured searches of CINAHL, Ovid MEDLINE, ProQuest Central, Ovid Embase and Cochrane Library (via Wiley). Additionally, we will forward citation searches of all included studies. No geographical or study design exclusion criteria will be used. Studies examining disaster triage, published before 1990, and non-English language literature will be excluded. Data will be managed using online management tools; extracted data will be independently confirmed by a separate reviewer using prepiloted extraction forms. Cohen’s kappa will be used to examine inter-rater agreement on pilot and final screening. Quantitative data will be expressed using measures of range and central tendency, counts, proportions and percentages, as appropriate. Qualitative data will be narrative summaries of the authors’ primary findings.Patient and public involvementNo patients involved.Ethics and disseminationNo ethics approval is required. Findings will be submitted to peer-reviewed conferences and journals. Results will be disseminated using individual and institutional social media platforms.
Study objective Emergency department (ED) crowding is a common and complicated problem challenging EDs worldwide. Nurse-initiated protocols, diagnostics, or treatments implemented by nurses before ...patients are treated by a physician or nurse practitioner have been suggested as a potential strategy to improve patient flow. Methods This is a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated protocols in a busy, crowded, inner-city ED. The primary outcomes included time to diagnostic test, time to treatment, time to consultation, or ED length of stay. Results Protocols decreased the median time to acetaminophen for patients presenting with pain or fever by 186 minutes (95% confidence interval CI 76 to 296 minutes) and the median time to troponin for patients presenting with suspected ischemic chest pain by 79 minutes (95% CI 21 to 179 minutes). Median ED length of stay was reduced by 224 minutes (95% CI –19 to 467 minutes) by implementing a suspected fractured hip protocol. A vaginal bleeding during pregnancy protocol reduced median ED length of stay by 232 minutes (95% CI 26 to 438 minutes). Conclusion Targeting specific patient groups with carefully written protocols can result in improved time to test or medication and, in some cases, reduce ED length of stay. A cooperative and collaborative interdisciplinary group is essential to success.
Heat stroke is an emergent condition characterized by hyperthermia (>40 °C/>104 °F) and nervous system dysregulation. There are two primary etiologies: exertional which occurs during physical ...activity and non-exertional which occurs during extreme heat events without physical exertion. Left untreated, both may lead to significant morbidity, are considered a special circumstance for cardiac arrest, and cause of mortality.
We searched Medline, Embase, CINAHL and SPORTDiscus. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods and risk of bias assessments to determine the certainty and quality of evidence. We included randomized controlled trials, non-randomized trials, cohort studies and case series of five or more patients that evaluated adults and children with non-exertional or exertional heat stroke or exertional hyperthermia, and any cooling technique applicable to first aid and prehospital settings. Outcomes included: cooling rate, mortality, neurological dysfunction, adverse effects and hospital length of stay.
We included 63 studies, of which 37 were controlled studies, two were cohort studies and 24 were case series of heat stroke patients. Water immersion of adults with exertional hyperthermia cold water (14–17 °C/57.2–62.6 °F), colder water (8–12 °C/48.2–53.6 °F) and ice water (1–5 °C/33.8–41 °F) resulted in faster cooling rates when compared to passive cooling. No single water temperature range was found to be associated with a quicker core temperature reduction than another (cold, colder or ice).
Water immersion techniques (using 1–17 °C water) more effectively lowered core body temperatures when compared with passive cooling, in hyperthermic adults. The available evidence suggests water immersion can rapidly reduce core body temperature in settings where it is feasible.
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