RESUMEN

According to surveys conducted over the last 10 years, more than 80 % of our population want to live with their loved ones at the end of life. With the ageing of the population and the success of medicine in the early stages of terminal illness, the trajectory and needs at the end of life are gradually changing. The need for health care support is increasing, and for most patients this means the need for 24/7 availability of health care, in this context in the home environment of the terminally ill patient. The question of how palliative care should be organised in an appropriate, meaningful and effective way, the role of specialised health care teams (mobile specialised palliative care), the role of general practitioners, and if, when and how the medical rescue service should/could/should effectively intervene in care, is becoming increasingly urgent. The article combines the experiences and views of an emergency physician and a doctor specialising in geriatrics and palliative medicine.

Asunto(s)

RESUMEN

Healthcare is awash with numbers, and figuring out what knowledge these numbers might hold is worthwhile in order to improve patient care. Numbers allow for objective mathematical analysis of the information at hand, but while mathematics is objective by design, our choice of mathematical approach in a given situation is not. In prehospital and critical care, numbers stem from a wide range of different sources and situations, be it experimental setups, observational data or data registries, and what constitutes a "good" statistical analysis can be unclear. A well-crafted statistical analysis can help us see things our eyes cannot, and find patterns where our brains come short, ultimately contributing to changing clinical practice and improving patient outcome. With increasingly more advanced research questions and research designs, traditional statistical approaches are often inadequate, and being able to properly merge statistical competence with clinical knowhow is essential in order to arrive at not only correct, but also valuable and usable research results. By marrying clinical knowhow with rigorous statistical analysis we can accelerate the field of prehospital and critical care.

Asunto(s)

RESUMEN

BACKGROUND: Patients who require emergency general surgery (EGS) are at a substantially higher risk for perioperative morbidity and mortality than patients undergoing elective general surgery. The acute care surgery (ACS) model has been shown to improve EGS patient outcomes and cost-effectiveness. A recent systematic review has shown extensive heterogeneity in the structure of ACS models worldwide. The objective of this study was to describe the current landscape of ACS models in academic centres across Canada. METHODS: We sent an online questionnaire to the 18 academic centres in Canada. The lead ACS physicians from each institution completed the questionnaire, describing the structure of their ACS models. RESULTS: In total, 16 institutions responded, all of which reported having ACS models, with a total of 29 ACS services described. All services had resident coverage. Of the 29, 18 (62%) had dedicated allied health care staff. The staff surgeon was free from elective duties while covering ACS in 17/29 (59%) services. More than half (15/29; 52%) of the services described protected ACS operating room time, but only 7/15 (47%) had a dedicated ACS room all 5 weekdays. Four of 29 services (14%) had no protected ACS operating room time. Only 1/16 (6%) institutions reported a mandate to conduct ACS research, while 12/16 (75%) found ACS research difficult, owing to lack of resources. CONCLUSION: We saw large variations in the structure of ACS models in academic centres in Canada. The components of ACS models that are most important to patient outcomes remain poorly defined. Future research will focus on defining the necessary cornerstones of ACS models.

Asunto(s)

Asunto(s)

RESUMEN

The digital transformation of healthcare in South Korea, accelerated by COVID-19, has led to increased focus on critically ill patients in large hospitals. To address this, a monitoring system was developed to ensure safe inpatient treatment and improve staff efficiency. This aligns with the Medical Data-Centric Hospitals initiative, which leverages data for healthcare innovation. The case study highlights the implementation of a ward critical care monitoring system, which has improved patient safety, work efficiency, and expanded patient monitoring scope. Key lessons include the importance of addressing technical and user challenges, aligning innovations with national policies, and the potential of data-driven solutions to tackle healthcare challenges.

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: Effective teamwork is crucial to providing safe and high-quality patient care, especially in acute care. Crew Resource Management (CRM) principles are often used for training teamwork in these situations, with escape rooms forming a promising new tool. However, little is known about escape room design characteristics and their effect on learning outcomes. We investigated the current status of design characteristics and their effect on learning outcomes for escape room-based CRM/teamwork training for acute care professionals. We also aimed to identify gaps in literature to guide further research. METHODS: Multiple databases were searched for studies describing the design and effect of escape rooms aimed training CRM/teamwork in acute care professionals and in situations that share characteristics. A standardized process was used for screening and selection. An evidence table that included study characteristics, design characteristics and effect of the escape room on learning outcomes was used to extract data. Learning outcomes were graded according to IPE expanded typology of Kirkpatrick's levels of learning outcome and Medical Education Research Study Quality Instrument (MERSQI) scores were calculated to assess methodology. RESULTS: Fourteen studies were included. Common design characteristics were a team size of 4-6 participants, a 40-minute time limit, linear puzzle organization and use of briefing and structured debriefing. Information on alignment was only available in five studies and reporting on several other educational and escape room design characteristics was low. Twelve studies evaluated the effect of the escape room on teamwork: nine evaluated reaction (Kirkpatrick level 1; n = 9), two evaluated learning (Kirkpatrick level 2) and one evaluated both. Overall effect on teamwork was overtly positive, with little difference between studies. Together with a mean MERSQI score of 7.0, this precluded connecting specific design characteristics to the effect on learning outcomes. CONCLUSIONS: There is insufficient evidence if and how design characteristics affect learning outcomes in escape rooms aimed at training CRM/teamwork in acute care professionals. Alignment of teamwork with learning goals is insufficiently reported. More complete reporting of escape rooms aimed at training CRM/teamwork in acute care professionals is needed, with a research focus on maximizing learning potential through design.

Asunto(s)

RESUMEN

PURPOSE OF REVIEW: Major outbreaks of infectious diseases, including epidemics and pandemics, are increasing in scope and frequency, threatening public health and straining the capacity of health systems worldwide. High-consequence infectious diseases (HCIDs), including highly pathogenic respiratory viruses and viral hemorrhagic fevers, are both contagious and virulent, and these pathogens thus are topics of special concern for pandemic planning. RECENT FINDINGS: The COVID-19 pandemic demonstrated how a major disease outbreak can negatively impact all aspects of hospital functioning. Identification of patients with HCIDs needs careful clinical evaluation and coordination with public health authorities. Staff safety and patient care require appropriate infection prevention precautions, including personal protective equipment. Surges of ill patients may lead to significant strain, with increased ICU patient mortality. Strategies to reduce the impact of surge appear to reduce mortality, such as tiered staffing models and load-leveling across health systems. SUMMARY: Pandemics and HCIDs are a significant threat to global health, and ICUs play a major role in the care of affected patients. Critical care professionals must work to ensure that our hospitals are prepared to identify and care for these patients in advance of the next emergency.

Asunto(s)

Asunto(s)

RESUMEN

Background: Family engagement in care is increasingly recognized as an essential component of optimal critical care delivery. However, family engagement strategies have traditionally involved in-person family participation. Virtual approaches to family engagement may overcome barriers to family participation in care. The objective of this study was to perform a scoping review of virtual family engagement strategies in the intensive care unit (ICU). Methods: Studies were included if they involved a virtual engagement strategy with family members of an ICU patient and reported either (1) outcomes, (2) user perspectives, and/or (3) barriers or facilitators to virtual engagement in the ICU. Study types included primary research studies and review articles. Study selection followed the Joanna Briggs Institute Methodology for Scoping Reviews guidelines without any cultural, ethnic, gender, or specific language restrictions. The source of evidence included Ovid MEDLINE, PubMed, CINAHL, and Cochrane Library databases from inception to November 17, 2023. Google scholar was searched on December 1, 2023. Data were extracted on virtual engagement strategy used, outcomes (patient-centered, family-centered, and clinical), perspectives (patient, family, and health care professional [HCP]), and reported barriers or facilitators to virtual engagement in the ICU. Results were categorized into adult or pediatric/neonatal ICU setting. Results: Virtual engagement strategies identified were virtual visitation, virtual rounding, and virtual meetings. Family and HCPs were generally supportive of virtual visitation and rounding strategies. Overall, virtual strategies were associated with improved patient, family, and HCP outcomes. There were a few randomized interventional studies evaluating the effectiveness of virtual engagement strategies. Family, HCP, technological, and institutional barriers to the implementation and conduct of virtual engagement strategies were reported. Conclusions: Virtual family engagement strategies are associated with improved outcomes for patients, family, and HCPs. Identified barriers to virtual family engagement should be addressed. Future studies are needed to evaluate the effectiveness of virtual family engagement strategies in a more rigorous manner.

Asunto(s)

RESUMEN

PURPOSE: Critical care pharmacists (CCPs) have been clearly established as value-added members of the interprofessional team, and their contributions positively impact patient outcomes in the intensive care unit (ICU). Despite this, not every critically ill patient in the US receives care from a CCP and the model through which CCPs practice is variable, which has important implications. The purpose of this primer is to review current CCP models and discuss elements of the optimal CCP practice model. SUMMARY: Current CCP practice models are defined, including the drug processing and dispensing model, clinical pharmacy specialist model, integrated pharmacy generalist model, and hybrid model, as well as unit-based vs service-based models. The optimal CCP practice model considers the Triple Domain of CCP workload, which includes direct patient care, indirect patient care, and professional service. Elements of the ideal CCP practice model including 24/7/365 CCP services, unit- vs service-based models, prescriptive authority, operational support, and CCP-to-patient ratio are discussed. Other vital elements include dedicated offline time, use of appropriate workload metrics, development of career ladders, opportunities for professional development, and providing wellness resources. The ideal CCP practice model must also be considered through the lens of the patient and medical team, the CCP, the institution, and professional organizations. Strategies for optimizing current CCP practice models are provided, and application of optimal CCP practice model elements is explored through 5 case studies. CONCLUSION: The optimal CCP practice model includes multiple elements and incorporates the viewpoints of patients, providers, CCPs, institutions, and professional organizations; this model will increase access of all ICU patients to CCPs, enhance the scope of CCP cognitive services, and ensure the economic sustainability of CCP practice while establishing CCP involvement in activities outside of patient care and in professional service.

Asunto(s)

Asunto(s)

RESUMEN

The intensive care unit (ICU) was born from the postanesthesia care unit (PACU). In today's hospital systems, there remains a lot of overlap in the care missions of each location. The patient populations share many similarities and many of the same care, technology, and care protocols apply to patients in both units. As shown by the COVID-19 pandemic, there is immense value in maintaining protocols, processes, and staffing models for the safe care of ICU patients in the PACU when ICU demands exceed capacity.

Asunto(s)

RESUMEN

Boarding of critically ill patients in the Emergency Department (ED) has increased over the past 20 years, leading hospital systems to explore ED-focused models of critical care delivery. ED-critical care delivery models vary between health systems due to differences in hospital resources and the needs of the critically ill patients boarding in the ED. Three published systems include an ED critical care intensivist consultation model, a hybrid model, and an ED-intensive care unit model. Paraphrasing the Greek philosopher, Plato, "necessity is the mother of invention." This proverb rings true as EDs are facing an increasing challenge of caring for boarding patients, especially those who are critically ill.

Asunto(s)

RESUMEN

Tele-intensive care unit (ICU), or Tele Critical Care (TCC), has been in active use for 25 years and has expanded beyond the original model to support critically ill patients beyond the confines of the ICU. Here, the author reviews the role of TCC in supporting rapid response events, critical care in emergency departments, and disaster and pandemic responses. The ability to rapidly expand critical care services has important capacity and care quality implications. Moreover, as TCC infrastructure becomes less expensive, the opportunities to leverage this care modality also have potentially important financial benefits.

Asunto(s)

RESUMEN

Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and preferences at each stage from detection, escalation, early decision making, treatment and organ support, followed by recovery and rehabilitation, within which all healthcare staff, and the patient are equal partners. The rapid response system incorporates monitoring and alerting tools, a multidisciplinary critical care outreach team and care bundles, supported with education and training, analytical and governance functions, which combine to optimise outcomes of critically ill patients, independent of location.

Asunto(s)

RESUMEN

OBJECTIVES: To inform workforce planning for pediatric critical care (PCC) physicians, it is important to understand current staffing models and the spectrum of clinical responsibilities of physicians. Our objective was to describe the expected workload associated with a clinical full-time equivalent (cFTE) in PICUs across the U.S. Pediatric Critical Care Chiefs Network (PC3N). DESIGN: Cross-sectional survey. SETTING: PICUs participating in the PC3N. SUBJECTS: PICU division chiefs or designees participating in the PC3N from 2020 to 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A series of three surveys were used to capture unit characteristics and clinical responsibilities for an estimated 1.0 cFTE intensivist. Out of a total of 156 PICUs in the PC3N, the response rate was 46 (30%) to all three distributed surveys. Respondents used one of four models to describe the construction of a cFTE-total clinical hours, total clinical shifts, total weeks of service, or % full-time equivalent. Results were stratified by unit size. The model used for construction of a cFTE did not vary significantly by the total number of faculty nor the total number of beds. The median (interquartile range) of clinical responsibilities annually for a 1.0 cFTE were: total clinical hours 1750 (1483-1858), total clinical shifts 142 (129-177); total weeks of service 13.0 (11.3-16.0); and total night shifts 52 (36-60). When stratified by unit size, larger units had fewer nights or overnight hours, but covered more beds per shift. CONCLUSIONS: This survey of the PC3N (2020-2022) provides the most contemporary description of clinical responsibilities associated with a cFTE physician in PCC. A 1.0 cFTE varies depending on unit size. There is no correlation between the model used to construct a cFTE and the associated clinical responsibilities.

Asunto(s)

RESUMEN

The COVID-19 pandemic caused tremendous disruption to the U.S. healthcare system and nearly crippled some hospitals during large patient surges. Limited ICU beds across the country further exacerbated these challenges. Telemedicine, specifically tele-critical care (TCC), can expand a hospital's clinical capabilities through remote expertise and increase capacity by offloading some monitoring to remote teams. Unfortunately, the rapid deployment of telemedicine, especially TCC, is constrained by multiple barriers. In the summer of 2020, to support the National Emergency Tele-Critical Care Network (NETCCN) deployment, more than 50 national leaders in applying telemedicine technologies to critical care assembled to provide their opinions about barriers to NETCCN implementation and strategies to overcome them. Through consensus, these experts developed white papers that formed the basis of this article. Herein, the authors share their experience and propose multiple solutions to barriers presented by laws, local policies and cultures, and individual perspectives according to a minimum, better, best paradigm for TCC delivery in the setting of a national disaster. Cross-state licensure and local privileging of virtual experts were identified as the most significant barriers to rapid deployment of services, whereas refining the model of TCC to achieve the best outcomes and defining the best financial model is the most significant for long-term success. Ultimately, we conclude that a rapidly deployable national telemedicine response system is achievable.

Asunto(s)

RESUMEN

Intermediate care (IC) is used for patients who do not require the human and technological support of the intensive care unit (ICU) yet require more care and monitoring than can be provided on general wards. Though prevalent in many countries, there is marked variability in models of organization and staffing, as well as monitoring and interventions provided. In this article, the authors will discuss the historical background of IC, review the impact of IC on ICU and IC patient outcomes, and highlight where future studies can shed light on how to optimize IC organization and outcomes.

Asunto(s)

RESUMEN

PURPOSE OF REVIEW: This article summarizes recent developments in the application of telemedicine, specifically tele-critical care (TCC), toward enhancing patient care during various types of emergencies and patient rescue scenarios when there are limited resources in terms of staff expertise (i.e., knowledge, skills, and abilities), staffing numbers, space, and supplies due to patient location (e.g., a non-ICU bed, the emergency department, a rural hospital) or patient volume as in pandemic surges. RECENT FINDINGS: The COVID-19 pandemic demonstrated the need for rapidly scalable and agile healthcare delivery systems. During the pandemic, clinicians and hospital systems adopted telemedicine for various applications. Taking advantage of technological improvements in cellular networks and personal mobile devices, and despite the limited outcomes literature to support its use, telemedicine was rapidly adopted to address the fundamental challenge of exposure in outpatient settings, emergency departments, patient follow-up, and home-based monitoring. A critical recognition was that the modality of care (e.g., remote vs. in-person) was less important than access to care, regardless of the patient outcomes. This fundamental shift, facilitated by policies that followed emergency declarations, provided an opportunity to maintain and, in many cases, expand and improve clinical practices and hospital systems by bringing expertise to the patient rather than the patient to the expertise. In addition to using telemedicine to maintain patient access to healthcare, TCC was harnessed to provide local clinicians, forced to manage critically ill patients beyond their normal scope of practice or experience, access to remote expertise (physician, nursing, respiratory therapist, pharmacist). These practices supported decades of literature from the telemedicine community describing the effectiveness of telemedicine in improving patient care and the many challenges defining its value. SUMMARY: In this review, we summarize numerous examples of innovative care delivery systems that have utilized telemedicine, focusing on 'mobile' TCC technology solutions to effectively deliver the best care to the patient regardless of patient location. We emphasize how a 'paradigm of better' can enhance the entirety of the healthcare system.

Asunto(s)