Resus in the Harbour (RITH) Conference 2018
Participant Information
- Session Questions: Please either send to moderator (@DrMarkGarcia), or simply grab a microphone / shout out
Session Panel / Presenters
- Dr Natalie May (@_NMay)
- Dr Stephen Asha
- Dr Melanie Berry (@Mel1977)
- Dr Mark Garcia (@DrMarkGarcia)
- Dr Victoria Brazil (@SocraticEM)
- Dr Andrew Coggins (@Coggi33)
The List of Papers (Alphabetical)
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BHATT et al. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. 2017 Oct 1;171(10):957-964.
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BRENNER et al. Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg. 2018 May;226(5):730-740.
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CHENG et al. Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation. 2018 Jun 21. https://www.ncbi.nlm.nih.gov/pubmed/29930020
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FRANKLIN et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018 Mar 22;378(12):1121-1126
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LILOT et al. Relaxation before Debriefing during High-fidelity Simulation Improves Memory Retention of Residents at Three Months: A Prospective Randomized Controlled Study. Anesthesiology. 2018 Mar;128(3):638-649
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MELTZER et al. Association of Whole-Body Computed Tomography With Mortality Risk in Children With Blunt Trauma. JAMA Pediatr. 2018 Jun 1;172(6):542-549.
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PERKINS et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018 Aug 23;379(8):711-721.
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PIETILAINEN et al. Premorbid functional status as a predictor of 1-year mortality and functional status in intensive care patients aged 80 years or older. Intensive Care Med. 2018 Aug;44(8):1221-1229.
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ROSE et al. Charge nurse facilitated clinical debriefing in the emergency department. CJEM. 2018 May 7:1-5.
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WILSON et al. Noninvasive Ventilation in Patients With Do-Not-Intubate and Comfort-Measures-Only Orders: A Systematic Review and Meta-Analysis. Crit Care Med. 2018 Aug;46(8):1209-1216.
BHATT et al – Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children.
Abstract:
Procedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes.
Objective:
To examine the incidence and risk factors associated with sedation-related SAEs.
Design, Setting, and Participants:
This prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis.
Exposures:
The primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type.
Main Outcomes and Measures:
Four outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting.
Results:
Of the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions.
Conclusions and Relevance:
The incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.
Brenner et al – Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry.
Abstract
BACKGROUND:
Aortic occlusion is a potentially valuable tool for early resuscitation in patients nearing extremis or in arrest from severe hemorrhage.
STUDY DESIGN:
The American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry identified trauma patients without penetrating thoracic injury undergoing aortic occlusion at the level of the descending thoracic aorta (resuscitative thoracotomy [RT] or zone 1 resuscitative endovascular balloon occlusion of the aorta [REBOA]) in the emergency department (ED). Survival outcomes relative to the timing of CPR need and admission hemodynamic status were examined.
RESULTS:
Two hundred and eighty-five patients were included: 81.8% were males, with injury due to penetrating mechanisms in 41.4%; median age was 35.0 years (interquartile range 29 years) and median Injury Severity Score was 34.0 (interquartile range 18). Resuscitative thoracotomy was used in 71%, and zone 1 REBOA in 29%. Overall survival beyond the ED was 50% (RT 44%, REBOA 63%; p = 0.004) and survival to discharge was 5% (RT 2.5%, REBOA 9.6%; p = 0.023). Discharge Glasgow Coma Scale score was 15 in 85% of survivors. Prehospital CPR was required in 60% of patients with a survival beyond the ED of 37% and survival to discharge of 3% (all p > 0.05). Patients who did not require any CPR before had a survival beyond the ED of 70% (RT 48%, REBOA 93%; p < 0.001) and survival to discharge of 13% (RT 3.4%, REBOA 22.2%, p = 0.048). If aortic occlusion patients did not require CPR but presented with hypotension (systolic blood pressure <90 mmHg; 9% [65% RT; 35% REBOA]), they achieved survival beyond the ED in 65% (p = 0.009) and survival to discharge of 15% (RT 0%, REBOA 44%; p = 0.008).
CONCLUSIONS:
Overall, REBOA can confer a survival benefit over RT, particularly in patients not requiring CPR. Considerable additional study is required to definitively recommend REBOA for specific subsets of injured patients.
CHENG et al – Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association.
Abstract
The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.
How do you improve resuscitation training?
LIST FROM www.heart.org/EducationStatement:
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Practice until learners demonstrate mastery of skills
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Shorter, more frequent learning sessions
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Use of “real world” training experiences recognized by learners
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Contextual learning
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Providing structured opportunities for reflection and feedback
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Feedback and debriefing
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Measuring competency throughout a course with a variety of tools
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Assessment
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Exploration of gamification, social and digital platforms to make learning “stick”
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Innovative educational strategies
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Continuous coaching and training of instructors
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Localize programs to fit learners’ needs
Presenter Summary
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Knowing what we need to do in resuscitation is only part of the solution.
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This paper tells us how to translate that knowledge into action by individuals and teams.
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A ‘transmission approach’ to knowledge doesn’t work.
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What does mastery learning, spaced practice, feedback, assessment and faculty development for instructors, and education embeded in local context
FRANKLIN et al – A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis.
Abstract
BACKGROUND:
High-flow oxygen therapy through a nasal cannula has been increasingly used in infants with bronchiolitis, despite limited high-quality evidence of its efficacy. The efficacy of high-flow oxygen therapy through a nasal cannula in settings other than intensive care units (ICUs) is unclear.
METHODS:
In this multicenter, randomized, controlled trial, we assigned infants younger than 12 months of age who had bronchiolitis and a need for supplemental oxygen therapy to receive either high-flow oxygen therapy (high-flow group) or standard oxygen therapy (standard-therapy group). Infants in the standard-therapy group could receive rescue high-flow oxygen therapy if their condition met criteria for treatment failure. The primary outcome was escalation of care due to treatment failure (defined as meeting ≥3 of 4 clinical criteria: persistent tachycardia, tachypnea, hypoxemia, and medical review triggered by a hospital early-warning tool). Secondary outcomes included duration of hospital stay, duration of oxygen therapy, and rates of transfer to a tertiary hospital, ICU admission, intubation, and adverse events.
RESULTS:
The analyses included 1472 patients. The percentage of infants receiving escalation of care was 12% (87 of 739 infants) in the high-flow group, as compared with 23% (167 of 733) in the standard-therapy group (risk difference, -11 percentage points; 95% confidence interval, -15 to -7; P<0.001). No significant differences were observed in the duration of hospital stay or the duration of oxygen therapy. In each group, one case of pneumothorax (<1% of infants) occurred. Among the 167 infants in the standard-therapy group who had treatment failure, 102 (61%) had a response to high-flow rescue therapy.
CONCLUSIONS:
Among infants with bronchiolitis who were treated outside an ICU, those who received high-flow oxygen therapy had significantly lower rates of escalation of care due to treatment failure than those in the group that received standard oxygen therapy.
(Funded by the National Health and Medical Research Council and others; Australian and New Zealand Clinical Trials Registry number, ACTRN12613000388718 .).
LILOT et al – Relaxation before Debriefing during High-fidelity Simulation Improves Memory Retention of Residents at Three Months: A Prospective Randomized Controlled Study.
Abstract
BACKGROUND:
High-fidelity simulation is known to improve participant learning and behavioral performance. Simulation scenarios generate stress that affects memory retention and may impact future performance. The authors hypothesized that more participants would recall three or more critical key messages at three months when a relaxation break was performed before debriefing of critical event scenarios.
METHODS:
Each resident actively participated in one scenario and observed another. Residents were randomized in two parallel-arms. The intervention was a 5-min standardized relaxation break immediately before debriefing; controls had no break before debriefing. Five scenario-specific messages were read aloud by instructors during debriefings. Residents were asked by telephone three months later to recall the five messages from their two scenarios, and were scored for each scenario by blinded investigators. The primary endpoint was the number of residents participating actively who recalled three or more messages. Secondary endpoints included: number of residents observing who recalled three or more messages, anxiety level, and debriefing quality.
RESULTS:
In total, 149 residents were randomized and included. There were 52 of 73 (71%) residents participating actively who recalled three or more messages at three months in the intervention group versus 35 of 76 (46%) among controls (difference: 25% [95% CI, 10 to 40%], P = 0.004). No significant difference was found between groups for observers, anxiety or debriefing quality.
CONCLUSIONS:
There was an additional 25% of active participants who recalled the critical messages at three months when a relaxation break was performed before debriefing of scenarios. Benefits of relaxation to enhance learning should be considered for medical education.
MELTZER et al – Association of Whole-Body Computed Tomography With Mortality Risk in Children With Blunt Trauma.
Abstract
Although several studies have demonstrated an improvement in mortality for injured adults who receive whole-body computed tomography (WBCT), it is unclear whether children experience the same benefit.
Objective:
To determine whether emergent WBCT is associated with lower mortality among children with blunt trauma compared with a selective CT approach.
Design, Setting, and Participants:
A retrospective, multicenter cohort study was conducted from January 1, 2010, to December 31, 2014, using data from the National Trauma Data Bank on children aged 6 months to 14 years with blunt trauma who received an emergent CT scan in the first 2 hours after emergency department arrival. Data analysis was conducted from February 2 to December 29, 2017.
Exposures:
Patients were classified as having WBCT if they received CT head, CT chest, and CT abdomen/pelvis scans in the first 2 hours and as having a selective CT if they did not receive all 3 scans.
Main Outcomes and Measures:
The primary outcome was in-hospital mortality in the 7 days after ED arrival. To adjust for potential confounding, propensity score weighting was used. Subgroup analyses were performed for those with the highest mortality risk (ie, occupants and pedestrians involved in motor vehicle crashes, children with a Glasgow Coma Scale score lower than 9, children with hypotension, and those admitted to the intensive care unit).
Results:
Of the 42 912 children included in the study (median age [interquartile range], 9 [5-12] years; 27 861 [64.9%] boys), 8757 (20.4%) received a WBCT. Overall, 405 (0.9%) children died within 7 days. After adjusting for the propensity score, children who received WBCT had no significant difference in mortality compared with those who received selective CT (absolute risk difference, -0.2%; 95% CI, -0.6% to 0.1%). All subgroup analyses similarly showed no significant association between WBCT and mortality.
Conclusions and Relevance:
Among children with blunt trauma, WBCT, compared with a selective CT approach, was not associated with lower mortality. These findings do not support the routine use of WBCT for children with blunt trauma.
Dr Natalie May: Notes – http://stemlynsblog.org/jc-trauma-paediatric-wbc
PERKINS et al – A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest.
Abstract
BACKGROUND:
Concern about the use of epinephrine as a treatment for out-of-hospital cardiac arrest led the International Liaison Committee on Resuscitation to call for a placebo-controlled trial to determine whether the use of epinephrine is safe and effective in such patients.
METHODS:
In a randomized, double-blind trial involving 8014 patients with out-of-hospital cardiac arrest in the United Kingdom, paramedics at five National Health Service ambulance services administered either parenteral epinephrine (4015 patients) or saline placebo (3999 patients), along with standard care. The primary outcome was the rate of survival at 30 days. Secondary outcomes included the rate of survival until hospital discharge with a favorable neurologic outcome, as indicated by a score of 3 or less on the modified Rankin scale (which ranges from 0 [no symptoms] to 6 [death]).
RESULTS:
At 30 days, 130 patients (3.2%) in the epinephrine group and 94 (2.4%) in the placebo group were alive (unadjusted odds ratio for survival, 1.39; 95% confidence interval [CI], 1.06 to 1.82; P=0.02). There was no evidence of a significant difference in the proportion of patients who survived until hospital discharge with a favorable neurologic outcome (87 of 4007 patients [2.2%] vs. 74 of 3994 patients [1.9%]; unadjusted odds ratio, 1.18; 95% CI, 0.86 to 1.61). At the time of hospital discharge, severe neurologic impairment (a score of 4 or 5 on the modified Rankin scale) had occurred in more of the survivors in the epinephrine group than in the placebo group (39 of 126 patients [31.0%] vs. 16 of 90 patients [17.8%]).
CONCLUSIONS:
In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable neurologic outcome because more survivors had severe neurologic impairment in the epinephrine group.
(Funded by the U.K. National Institute for Health Research and others; Current Controlled Trials number, ISRCTN73485024 .).
Dr Natalie May Notes – http://stemlynsblog.org/jc-does-epinephrine-work-in-cardiac-arrest-st-emlyns
PIETILAINEN et al – Premorbid functional status as a predictor of 1-year mortality and functional status in intensive care patients aged 80 years or older.
Abstract
PURPOSE:
We assessed the association between the premorbid functional status (PFS) and 1-year mortality and functional status of very old intensive care patients.
METHODS:
Using a nationwide quality registry, we retrieved data on patients treated in Finnish intensive care units (ICUs) during the period May 2012‒April 2013. Of 16,389 patients, 1827 (11.1%) were very old (aged 80 years or older). We defined a person with good functional status as someone independent in activities of daily living (ADL) and able to climb stairs without assistance; a person with poor functional status was defined as needing assistance for ADL or being unable to climb stairs. We adjusted for severity of illness and calculated the impact of PFS.
RESULTS:
Overall, hospital mortality was 21.3% and 1-year mortality was 38.2%. For emergency patients (73.5% of all), hospital mortality was 28% and 1-year mortality was 48%. The functional status at 1 year was comparable to the PFS in 78% of the survivors. PFS was poor for 43.3% of the patients. A poor PFS predicted an increased risk of in-hospital death, adjusted odds ratio (OR) 1.50 (95% confidence interval, 1.07-2.10), and of 1-year mortality, OR 2.18 (1.67-2.85). PFS data significantly improved the prediction of 1-year mortality.
CONCLUSIONS:
Of very old ICU patients, 62% were alive 1 year after ICU admission and 78% of the survivors had a functional status comparable to the premorbid situation. A poor PFS doubled the odds of death within a year. Knowledge of PFS improved the prediction of 1-year mortality.
Presenter Notes:
This is a study looking at the functional status and survival of older patients who were admitted to ICUs in Finland between 2012-2013, I was interested at looking at this study to help me understand which of the patients coming into the ED who are very old will have a functionally meaningful recovery if they are admitted to the ICU. What’s good about this study, this study had measurable functional outcomes looking at what patients could do before and after they had been in ICU. Our question / If someone is very old but has no medical problems, comes in needing ICU, should they be offered it? Also, when asking about activities of daily living are there meaningful measurement questions one could ask. Firstly is this study generalisable to our population – Finish life expectancy 81.36 (WHO statistics), Population 5.3 million – Conclusion – This population is broadly generalisable to us, except we are fatter.
Take Homes:
o This study had meaningful easy to use assessments of function – if the patient couldn’t walk, or climb the stairs independently those factors could predict and increased risk of mortality at 1 year.
o Those coming through ED only 48% chance of being alive in 1 year. If they make it out, 70% of the medical emergency patients got back to previous functional status, 79% of surgical emergency patients got back to previous functional status
ROSE et al – Charge nurse facilitated clinical debriefing in the emergency department.
Abstract
This paper describes the development and implementation of the INFO (immediate, not for personal assessment, fast facilitated feedback, and opportunity to ask questions) clinical debriefing process. INFO enabled charge nurses to facilitate a group debriefing after critical events across three adult emergency departments (EDs) in Calgary, Alberta. Prior to implementation at our institutions, ED critical event debriefing was a highly variable event. Post-implementation, INFO critical event debriefings have become part of our ED culture, take place regularly in our EDs (254 documented debriefings between March 2016 and September 2017), with recommendations arising from these debriefings being introduced into clinical practice. The INFO clinical debriefing process addresses two significant barriers to regular ED clinical debriefing: a lack of trained facilitators and the focus on physician-led debriefings. Our experience shows that a nurse-facilitated debriefing is feasible, can be successfully implemented in diverse EDs, and can be performed by relatively inexperienced debriefers. A structured approach means that debriefings are more likely to take place and become a routine part of improving team management of high stakes or unexpected clinical events.
Presenter Summary:
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Debriefing requires development of a department or institutional program, as well as training for individual debriefers.
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This includes the balance between emotional support and quality improvement outcomes
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Have a script and a consistent process helps.
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Nurses might be best placed to do this
WILSON et al – Noninvasive Ventilation in Patients With Do-Not-Intubate and Comfort-Measures-Only Orders: A Systematic Review and Meta-Analysis.
Abstract
OBJECTIVES:
To assess the effectiveness of noninvasive ventilation in patients with acute respiratory failure and do-not-intubate or comfort-measures-only orders.
DATA SOURCES:
MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science from inception to January 1, 2017.
STUDY SELECTION:
Studies of all design types that enrolled patients in the ICU or hospital ward who received noninvasive ventilation and had preset do-not-intubate or comfort-measures-only orders.
DATA EXTRACTION:
Data abstraction followed Meta-analysis of Observational Studies in Epidemiology guidelines. Data quality was assessed using a modified Newcastle-Ottawa Scale.
DATA SYNTHESIS:
Twenty-seven studies evaluating 2,020 patients with do-not-intubate orders and three studies evaluating 200 patients with comfort-measures-only orders were included. In patients with do-not-intubate orders, the pooled survival was 56% (95% CI, 49-64%) at hospital discharge and 32% (95% CI, 21-45%) at 1 year. Hospital survival was 68% for chronic obstructive pulmonary disease, 68% for pulmonary edema, 41% for pneumonia, and 37% for patients with malignancy. Survival was comparable for patients treated in a hospital ward versus an ICU. Quality of life of survivors was not reduced compared with baseline, although few studies evaluated this. No studies evaluated quality of dying in nonsurvivors. In patients with comfort-measures-only orders, a single study showed that noninvasive ventilation was associated with mild reductions in dyspnea and opioid requirements.
CONCLUSIONS:
A large proportion of patients with do-not-intubate orders who received noninvasive ventilation survived to hospital discharge and at 1 year, with limited data showing no decrease in quality of life in survivors. Provision of noninvasive ventilation in a well-equipped hospital ward may be a viable alternative to the ICU for selected patients. Crucial questions regarding quality of life in survivors, quality of death in nonsurvivors, and the impact of noninvasive ventilation in patients with comfort-measures-only orders remain largely unanswered.
Presenter Notes:
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NIV has a survival benefit even in patients who are “not for intubation” –
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pooled hospital survival 56%
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pooled survival 1 year 1/3.
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Hospital survival was better in COPD patients, less so in cancer and pneumonia.
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More studies are required to assess quality of life when NIV is used in this cohort, it appears to be tolerated well.
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NIV has survival benefit when used in a ward setting vs ICU.
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