Common laboratory tests predict imminent death in ward patients

Objective

To estimate the ability of commonly measured laboratory variables to predict an imminent (within the same or next calendar day) death in ward patients.

Design

Retrospective observational study.

Setting

Two university affiliated hospitals.

Patients

Cohort of 42,701 patients admitted for more than 24 hours and external validation cohort of 13,137 patients admitted for more than 24 hours.

Intervention

We linked commonly measured laboratory tests with event databases and assessed the ability of each laboratory variable or combination of variables together with patient age to predict imminent death.

Measurements and main results

In the inception teaching hospital, we studied 418,897 batches of tests in 42,701 patients (males 55%; average age 65.8 ± 17.6 years), for a total of >2.5 million individual measurements. Among these patients, there were 1596 deaths. Multivariable logistic modelling achieved an AUC–ROC of 0.87 (95% CI: 0.85–0.89) for the prediction of imminent death. Using an additional 105,074 batches from a cohort of 13,137 patients from a second teaching hospital, the multivariate model achieved an AUC–ROC of 0.88 (95% CI: 0.85–0.90).

Conclusions

Commonly performed laboratory tests can help predict imminent death in ward patients. Prospective investigations of the clinical utility of such predictions appear justified.     

Injuries occurring in hospital staff attending medical emergency team (MET) calls—A prospective,observational study

Background

Clinical emergency response systems such as medical emergency teams (MET) have been implemented in many hospitals worldwide, but the effect that these systems have on injuries to hospital staff is unknown. The objective of this study was to determine the rate and nature of injuries occurring in hospital staff attending MET calls.

Methods

This study was a prospective, observational study, using a structured interview, of 1265 MET call participants, in a 650 bed urban, teaching hospital. Data was collected on the number and the nature of injuries occurring in hospital staff attending MET calls.

Results

Over 131 days, 248 MET calls were made. An average of 8.1 staff participated in each MET call. The overall injury rate was 13 (95% confidence interval (CI) 7–20) per 1000 MET participant attendances, and 70 (95% CI 38–102) per 1000 MET calls. One injured participant required time off-work, an injury requiring time off-work rate of 1 (95% CI 0–4) per 1000 MET participant attendances, or 4 (95% CI 0–27) per 1000 MET calls. The relative risk of sustaining an injury if the MET participant performed chest compressions, contacted patient body fluids on clothing or protective equipment, without direct contact to skin or mucosa, or lifted the patient or a patient body part was 11.0 (95% CI 4.2–28.6), 8.7 (95% CI 3.4–22.0) and 5.5 (95% CI 2.1–14.2), respectively.

Conclusion

The rate of injuries occurring to hospital staff attending MET calls is relatively low, and many injuries could be considered relatively minor.     

Documenting Rapid Response System afferent limb failure and associated patient outcomes

Objective

Describe afferent limb failure (ALF), defined as documented Rapid Response System (RRS) calling criteria, but no associated call, in the 24 h prior to an event.

Methods

Retrospective medical record and database review. Adult in-patients whose hospital length of stay (LOS) was greater than 24 h, an event being a cardiac arrest, Medical Emergency Team (MET) call or unanticipated Intensive Care Unit (ICU) admission.

Results

Over 6 months, there were 443 patients with 575 events, of which 35 (6.1%) were cardiac arrests, 395 (68.7%) MET calls, and 145 (25.2%) ICU admissions. 131 (22.8%) events had documented ALF, of which 47/131 (35.9%) had documented criteria across more than one time period. Patients with ALF, compared to those without ALF, were significantly more likely to have an unanticipated ICU admission (45/131 (34.4%) vs 100/443 (22.5%), p = 0.01), but be of similar age (71 years vs 72 years, p = 0.44), male gender (51.1% vs 53.2%, p = 0.38), APACHE 2 score (22.8 vs 21.4, p = 0.67), predicted risk of death (0.394 vs 0.367, p = 0.55), ICU LOS (2 days vs 2 days, p = 0.56), likelihood of not-for-resuscitation order during an event (4/131 (3.4%) vs 22/444 (5.0%), p = 0.34), and hospital mortality (42/107 (39.3%) vs 125/236 (37.2%), p = 0.70). Hospital mortality for patients with ALF across multiple, compared to single time periods was higher, 21/40 (52.5%) vs 22/69 (31.9%), p = 0.03.

Conclusions

RRS ALF is a useful performance measure for a mature RRS, and is associated with unanticipated ICU admissions. The duration of, and not timing of, ALF criterion occurrence may affect hospital mortality.     

Outcome of hypotensive ward patients who re-deteriorate after initial stabilization by the Medical Emergency Team

Purpose

We evaluated the outcome of hypotensive ward patients who re-deteriorated after initial stabilization by the Medical Emergency Team (MET) in our hospital, due to limited data in this regard.

Methods

One thousand one hundred seventy-nine MET calls in 32184 ward patients from January 2009 to August 2011 were evaluated. Four hundred ten hypotensive patients met study criteria and were divided into: (1)“Immediate Transfers (IT), n = 136”:admitted by MET to intensive care unit (ICU) immediately; (2)“Re-deteriorated Transfers (RDT) n = 72”:initially stabilized and signed off by MET, but later re-deteriorated within 48-hours and admitted to ICU; (3)“Ward Patients (WP) n = 202”: remained stable on ward after treatment.

Results

The RDT and IT had similar APACHE II scores (20.2 ± 5.1 vs. 19.8 ± 4.8; P= .57], but RDT showed hemodynamic stabilization with initial MET resuscitation. Patients who re-deteriorated were younger, took longer for eventual ICU transfer, had higher initial lactic acid and delayed normalization as compared to IT (P < .04). The re-deterioration predominantly occurred within 8-hours of MET evaluation. RDT had higher 28-day mortality than IT and WP; 42% vs. 27% vs. 7% respectively (P < .03). RDT also had a higher rate of endotracheal intubation and worse ICU mortality (P < .01).

Conclusion

Hypotensive ward patients who re-deteriorate after initial stabilization have higher mortality. METs should consider implementing at least an 8-hour follow-up in patients who are deemed stable to remain on the wards after hypotensive episodes.     

Use of physical restraints in acute hospitals in Germany: A multi-centre cross-sectional study

Background

Physical restraints are contrary to patients’ autonomy and freedom. Their justification for controlling psychomotor agitation and risk of falling is being questioned more and more often. Physical restraints are associated with many negative outcomes.The German law is explicit, allowing physical restraints in nursing only as an exception. Data on the use of physical restraints in acute hospitals in Germany are sparse.

Objectives

To investigate the prevalence of physical restraints and characteristics associated with physical restraint use in acute hospitals.

Design

Cross-sectional study.

Participants and setting

1276 patients (mean age 65 years, 45% women, 50% surgical) on 61 wards (n = 47 general; n = 14 intensive care) in four acute care hospitals in North Rhine-Westphalia, Germany.

Methods

One investigator visited each hospital ward at three randomly allocated time slots on randomly selected days within a period of three months. A total of 3434 direct observations on physical restraint status were collected. The study period lasted from October 2008 to March 2009. For analysis, one time slot per patient room was randomly chosen in order to avoid repeated analysis of the same patient.

Results

The prevalence of patients with at least one physical restraint was 11.8% (95%CI 7.8–15.7). The measures used most often were full bed rails (9.8%, 95%CI 6.5–13.1). There was pronounced prevalence variation throughout the wards (general wards: 0.0–31.3%; intensive care: 0.0–90.0%). The prevalence of physical restraints between hospitals ranged from 6.2 to 16.6%, the overall association with hospital was non-significant. Multivariate regression analysis revealed statistically significant characteristics for physical restraint use: age 80–99 years versus 18–54 years (adjusted odds ratio 4.34, 95%CI 2.18–8.64), feeding tube (2.70, 1.40–5.22), indwelling urinary catheter (6.52, 3.75–11.34), and staying in intensive care unit (3.39, 1.29–8.92). Sharing a multi-bed room (0.55, 0.35–0.89) and in situ central venous line were inversely associated (0.44, 0.19–0.98).

Conclusions

Physical restraints are apparently standard care in German acute hospitals. However, variation between wards indicates that hospital care with only few physical restraints is feasible. Respecting patients’ dignity and integrity warrants intervention programmes aimed at decreasing practice variation towards a general reduction of physical restraints in acute hospitals in Germany.     

Long-term effects of medical exercise therapy in patients with patellofemoral pain syndrome: Results from a single-blinded randomized controlled trial with 12 months follow-up

Objectives

To evaluate the long-term effect of high-dose, high-repetition medical exercise therapy (MET) in patients with patellofemoral pain syndrome (PFPS).

Design

Follow-up study one year after completion of a randomized, controlled trial.

Setting

Follow-up testing in the primary healthcare physiotherapy clinics, where intervention was undertaken.

Participants

Twenty-eight patients with PFPS completed follow-up testing, fourteen in each group.

Interventions

The groups received three treatments per week for 12 weeks: high-dose, high-repetition MET for the experimental group, and low-dose, low-repetition exercise therapy for the control group.

Main outcome measures

Pain measured using a visual analogue scale (VAS: 0–10 cm), and function measured using a step-down test (numbers of completed step-downs in 30 seconds) and the modified Functional Index Questionnaire (FIQ: 0 points indicates maximal disability, 16 points no disability).

Results

At baseline there were no differences between groups. After intervention, there were statistically significant (p < 0.05) and clinically important differences between groups for all outcome parameters, also when adjusting for gender and duration of symptoms: −1.6 for mean pain [95% confidence interval (CI) −2.4 to −0.8], 6.5 for step-down test (95% CI 3.8 to 9.2), and 3.1 for FIQ (95% CI 1.2 to 5.0). At follow-up the differences between groups were maintained and even increased for mean pain and step-down with significant differences (p < 0.05) between groups; −1.8 for mean pain (95% CI: −2.7 to −1.0) and 4.5 for step-down test (95%CI: 2.4 to 6.5). The difference between groups for FIQ at follow-up: 1.1 (95% CI: −1.1 to 3.3).

Conclusion

There appear to be long-term effects of high-dose, high-repetition MET in patients with PFPS with respect to pain and functional outcomes. One year after completed intervention the experimental group has continued to improve, while the control group has relapsed.Registered on http://www.clinicaltrials.gov (identifier: NCT01290705).     

Epidemiology and patient outcome after medical emergency team calls triggered by atrial fibrillation

Introduction

Atrial fibrillation (AF) in hospitalized patients may lead to activation of the medical emergency team (MET). We sought to assess the baseline characteristics and outcomes of the patients presenting AF as a cause of MET call activation.

Methods

Using a prospectively constructed MET database, we retrospectively reviewed all patients with AF as a trigger for MET activation between August 2005 and April 2010. Demographics, principal diagnostic and outcome of these patients were compared with those of a control group of patients matched for age, sex and ward of origin, randomly selected from the database.

Results

We studied 5431 MET calls of which 557 (10.3%), in 458 patients were triggered by AF. Mean age for AF patients was 74.8 years, 230 (50.2%) were female and 271 (59.1%) were in a surgical ward. 92 (20.1%) AF patients died in hospital compared with 131 (28.6%) in the control group. Among the 336 patients without limitations of medical therapy (LOMT), 46 (13.7%) died in hospital. In total, 46 (13.7%) patients were transferred to a higher level care ward while 290 (86.3%) remained on the ward. Only 2 (4.3%) of these patients died compared with 44 (15.2%) among those who remained in the general ward (p = 0.03).

Conclusions

In our hospital, AF triggers one tenth of MET activations and mortality associated with it is high even when issues of LOMT are excluded. The decreased mortality among patients admitted to a higher level ward suggests that some of these deaths may be avoidable.     

Hypothermia and associated outcomes in seriously injured trauma patients in a predominantly sub-tropical climate

Aim

This study aimed to determine factors linked to hypothermia (<35 °C) in Queensland trauma patients. The relationship of hypothermia with mortality, admission to intensive care and hospital length of stay was also explored.

Methods

A retrospective analysis of data from the Queensland Trauma Registry was undertaken, and included all patients admitted to hospital for ≥24 h during 2003 and 2004 with an injury severity score (ISS) > 15. Demographic, injury, environmental, care and clinical status factors were considered.

Results

A total of 2182 patients were included; 124 (5.7%) had hypothermia on admission to the definitive care hospital, while a further 156 (7.1%) developed hypothermia during hospitalisation. Factors associated with hypothermia on admission included winter, direct admission to a definitive care hospital, an ISS ≥ 40, a Glasgow Coma Scale of 3 or ventilated and sedated, and hypotension on admission. Hypothermia on admission to the definitive care hospital was an independent predictor of mortality (odds ratio [OR] = 4.05; 95% confidence interval [CI] 2.26–7.24) and hospital length of stay (incidence rate ratio [IRR] = 1.22; 95% CI 1.03–1.43). Hypothermia during definitive care hospitalisation was independently associated with mortality (OR = 2.52; 95% CI 1.52–4.17), intensive care admission (OR = 1.73; 95% CI 1.20–2.93) and hospital length of stay (IRR = 1.18; 95% CI 1.02–1.36).

Conclusions

Trauma patients in a predominantly sub-tropical climate are at risk of accidental and endogenous hypothermia, with associated higher mortality and care requirements. Prevention of hypothermia is important for all severely injured patients.     

Reduced in-hospital survival rates of out-of-hospital cardiac arrest victims with obstructive pulmonary disease

Aim

Out-of-hospital cardiac arrest (OHCA) due to sustained ventricular tachycardia/fibrillation (VT/VF) is common and often lethal. Patient's co-morbidities may determine survival after OHCA, and be instrumental in post-resuscitation care, but are poorly studied. We aimed to study whether patients with obstructive pulmonary disease (OPD) have a lower survival rate after OHCA than non-OPD patients.

Methods

We performed a community-based cohort study of 1172 patients with non-traumatic OHCA with ECG-documented VT/VF between 2005 and 2008. We compared survival to Emergency Room (ER), to hospital admission, to hospital discharge, and at 30 days after OHCA, of OPD-patients and non-OPD patients, using logistic regression analysis. We also compared 30-day survival of patients who were admitted to hospital, using multivariate logistic regression analysis.

Results

OPD patients (n = 178) and non-OPD patients (n = 994) had comparable survival to ER (75% vs. 78%, OR 0.9 [95% CI: 0.6–1.3]) and to hospital admission (56% vs. 57%, OR 1.0 [0.7–1.4]). However, survival to hospital discharge was significantly lower among OPD patients (21% vs. 33%, OR 0.6 [0.4–0.9]). Multivariate regression analysis among patients who were admitted to hospital (OPD: n = 100, no OPD: n = 561) revealed that OPD was an independent determinant of reduced 30-day survival rate (39% vs. 59%, adjusted OR 0.6 [0.4–1.0, p = 0.035]).

Conclusion

OPD-patients had lower survival rates after OHCA than non-OPD patients. Survival to ER and to hospital admission was not different between both groups. However, among OHCA victims who survived to hospital admission, OPD was an independent determinant of reduced 30-day survival rate.     

The effect of multi-professional education on the recognition and outcome of patients at risk on general wards

Aim

The aim of this study was to evaluate the effect of multi-professional full-scale simulation-based education of staff on the mortality and staff awareness of patients at risk on general wards.

Design, settings and patients

A prospective before-and-after study conducted on four general wards at Herlev Hospital, Denmark. In the pre-intervention period (June–July 2006) and post-intervention period (November–December 2007), all patients on the wards had vital signs measured in the evening by study personnel, who also asked nursing staff questions about patients with abnormal vital signs. The mortality of patients with abnormal vital signs was registered from the hospital database. Simplified medical emergency team calling criteria were used to define abnormal vital signs.

Intervention

In the intervention period (February–June 2007), 50% of medical and 70% of nursing staff on the wards (app. 220 members of staff) were trained in a 1-day multi-professional full-scale simulation-based course.

Results

In the pre- and post-intervention periods, 690 and 873 patients were included and of these 129 and 155, respectively, had abnormal vital signs. No significant differences were observed between the pre- and post-intervention periods concerning the incidence of patients with abnormal vital signs (p = 0.64), staff awareness of patients at risk (p = 0.80), 30-day mortality (p = 1.00), 180-day mortality (p = 1.00) or length of hospital stay (p = 0.11) among patients at risk.

Conclusions

This multi-professional education of staff did not affect the rate of mortality or staff awareness of patients at risk on the wards.     

Females of childbearing age have a survival benefit after out-of-hospital cardiac arrest

Background

There is controversy regarding the association between age and being female and survival to hospital discharge after out-of-hospital cardiac arrest (OHCA). We hypothesized that younger females (aged 12–49 years) would be independently associated with increased survival after OHCA when compared to other age and sex groups.

Methods

We conducted a secondary analysis of prospectively collected data from 29 United States cities that participate in the Cardiac Arrest Registry to Enhance Survival (CARES). Patients were included if they were ≥12 years of age and had a documented resuscitation attempt from October 1, 2005 through December 31, 2009. Hierarchical multivariable logistic regression analyses were used to estimate the associations between age and sex groups and survival to hospital discharge.

Results

Females were less likely to have a cardiac arrest in public, was witnessed, or was treatable with defibrillation. Females in the 12–49 year old age group had a similar proportion of survival to hospital discharge when compared to age-matched males (females 11.6% vs. males 11.2%), while males ≥50 years old were more likely to survive when compared to age matched females (females 6.9% vs. males 9.6%). Age stratified regression models demonstrated that 12–49 year old females had the largest association with survival to hospital discharge (OR 1.55, 95% CI 1.20–2.00), while females in the ≥50 year old age group had a smaller increased odds of survival to hospital discharge (OR 1.18, 95% CI 1.03–1.35), which only lasted until the age of 55 years (OR 1.12, 95% CI 0.97–1.29).

Conclusions

Younger aged females were associated with increased odds of survival despite being found with poorer prognostic arrest characteristics.     

Regular in situ simulation training of paediatric Medical Emergency Team improves hospital response to deteriorating patients

Aim of the study

The introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.

Methods

Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.

Results

Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p < 0.001), more often reviewed by consultants (45%/76%, p = 0.004), more often transferred to high dependency care (18%/37%, p = 0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). These improved responses by ward staff extended beyond direct involvement of pMET.There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p < 0.001).

Conclusions

These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics.     

Lower incidence of unexpected in-hospital death after interprofessional implementation of a bedside track-and-trigger system

Background

In-hospital patients may suffer unexpected death because of suboptimal monitoring. Early recognition of deviating physiological parameters may enable staff to prevent unexpected in-hospital death. The aim of this study was to evaluate short- and long-term effects of systematic interprofessional use of early warning scoring, structured observation charts, and clinical algorithms for bedside action.

Methods

A prospective non-randomized controlled study of unexpected in-hospital death before and after implementation of a clinical intervention in a medical and surgical ward setting at an urban Danish university hospital. Information was obtained over three four-month study periods – a pre-interventional one in 2009 (1st March–30th June), and two postinterventional ones in 2010 (1st September–31st December) and 2011 (1st March–30th June). The incidence of unexpected patient death, the primary study outcome, was calculated as the rate of unexpected patient mortality based on in-hospital risk time.

Result

The adjusted unexpected patient mortality rate was significantly lower during the second postinterventional study period than before the intervention, 17 versus 61 per 100 adjusted patient years (P = 0.013), corresponding to a rate ratio of 0.271 (95% confidence interval (CI) 0.097–0.762). A tendency to reduced unexpected mortality was found during the first postinterventional study period (25 versus 61 per 100 adjusted patient years, P = 0.053; rate ratio 0.404, CI 0.161–1.012).

Conclusion

Clinical intervention comprising systematic monitoring practice, early warning scoring, an observation chart, and an algorithm for bedside management, implemented by interprofessional teaching, training, and optimization of communication and collaboration, may significantly reduce unexpected in-hospital mortality.     

Predicting clinical deterioration in the hospital: The impact of outcome selection

Background

Clinical deterioration of ward patients can result in intensive care unit (ICU) transfer, cardiac arrest (CA), and/or death. These different outcomes have been used to develop and test track and trigger systems, but the impact of outcome selection on the performance of prediction algorithms is unknown.

Methods

Patients hospitalized on the wards between November 2008 and August 2011 at an academic hospital were included in the study. Ward vital signs and demographic characteristics were compared across outcomes. The dataset was then split into derivation and validation cohorts. Logistic regression was used to derive four models (one per outcome and a combined outcome) for predicting each event within 24 h of a vital sign set. The models were compared in the validation cohort using the area under the receiver operating characteristic curve (AUC).

Results

A total of 59,643 patients were included in the study (including 109 ward CAs, 291 deaths, and 2638 ICU transfers). Most mean vital signs within 24 h of the events differed statistically, with those before death being the most deranged. Validation model AUCs were highest for predicting mortality (range 0.73–0.82), followed by CA (range 0.74–0.76), and lowest for predicting ICU transfer (range 0.68–0.71).

Conclusions

Despite differences in vital signs before CA, ICU transfer, and death, the different models performed similarly for detecting each outcome. Mortality was the easiest outcome to predict and ICU transfer the most difficult. Studies should be interpreted with these differences in mind.     

Effects of a mandatory basic life support training programme on the no-flow fraction during in-hospital cardiac resuscitation: An observational study

Aim of the study

Many hospitals have basic life support (BLS) training programmes, but the effects on the quality of chest compressions are unclear. This study aimed to evaluate the no-flow fraction (NFF) during BLS provided by standard care nursing teams over a five-year observation period during which annual participation in the BLS training was mandatory.

Methods

All healthcare professionals working at Dresden University Hospital were instructed in BLS and automated external defibrillator (AED) use according to the current European Resuscitation Council guidelines on an annual basis. After each cardiac arrest occurring on a standard care ward, AED data were analyzed. The time without chest compressions during the period without spontaneous circulation (i.e., the no-flow fraction) was calculated using thoracic impedance data.

Results

For each year of the study period (2008–2012), a total of 1454, 1466, 1487, 1432, and 1388 health care professionals, respectively, participated in the training. The median no-flow fraction decreased significantly from 0.55 [0.42; 0.57] (median [25‰; 75‰]) in 2008 to 0.3 [0.28; 0.35] in 2012. Following revision of the BLS curriculum after publication of the 2010 guidelines, cardiac arrest was associated with a higher proportion of patients achieving ROSC (72% vs. 48%, P = 0.025) but not a higher survival rate to hospital discharge (35% vs. 19%, P = 0.073).

Conclusion

The NFF during in-hospital cardiac resuscitation decreased after establishment of a mandatory annual BLS training for healthcare professionals. Following publication of the 2010 guidelines, more patients achieved ROSC after in-hospital cardiac arrest.     

Using extracorporeal membrane oxygenation to rescue acute myocardial infarction with cardiopulmonary collapse: The impact of early coronary revascularization

Objectives

To investigate the therapeutic impact of combining extracorporeal membrane oxygenation (ECMO) and early coronary revascularization on acute myocardial infarction (AMI)-induced cardiopulmonary collapse.

Materials and methods

This retrospective study included 35 consecutive patients rescued by ECMO for AMI-induced cardiopulmonary collapse in a single institution between June 2003 and December 2011. Coronary revascularization was performed soon after ECMO initiation. Percutaneous coronary intervention (PCI) was the primary revascularization strategy. Coronary artery bypass grafting (CABG) was performed if an unsuitable anatomy or unsatisfactory result of PCI. Comparisons were performed in groups with different revascularization strategies and outcomes.

Results

Among the 35 patients, 16 underwent CABG and 1 was bridged to transplant after CABG. Compared to patients receiving PCI only, the CABG group showed similar results in ECMO weaning (58% vs. 69%, p = 0.51), hospital discharge (32% vs. 50%, p = 0.27), and left ventricular ejection fraction before discharge (45% vs. 49%, p = 0.92). Regardless of revascularization strategies, this protocol achieved an ECMO-weaning rate of 63% and a hospital discharge rate of 40%. Dialysis-dependent acute renal failure (OR 5.4, 95% CI: 1.1–27.5) and profound anoxic encephalopathy (OR 5.4, 95% CI: 1.1–27.5) predicted non-weaning of ECMO. Age > 60 years (OR 7.3, 95% CI: 1.1–51.0) and profound anoxic encephalopathy (OR 24.6, 95% CI: 2.3–263.0) predicted in-hospital mortality. The major cardiovascular adverse effect (MACE)–free survival was 77% in the first year after discharge.

Conclusion

Early revascularization on ECMO is practical to preserve myocardial viability and bridge patients collapsing with AMI to recovery.     

Adherence to ATLS primary and secondary surveys during pediatric trauma resuscitation

Study aim

Adherence to Advanced Trauma Life Support (ATLS) protocol has been associated with improved management of injured patients. The objective of this study is to determine factors associated with delayed and omitted ATLS primary and secondary survey tasks at a level 1 pediatric trauma center.

Methods

Video recorded resuscitations of 237 injured patients < 18 years old obtained over a four month period at our hospital were evaluated to assess completeness and timeliness of essential tasks in the primary and secondary survey of ATLS. Multivariate analyses were performed to identify features associated with decreased ATLS performance.

Results

Primary survey findings were stated less often in patients with burn injuries compared to those with blunt injuries (RR = 1.72; 95% CI: 1.26–2.35) and less often during the overnight shift [11 PM–7 AM] (RR = 1.22; 95% CI: 1.02–1.46). Secondary survey findings were verbalized less often in patients with penetrating injures (RR = 2.30; 95% CI: 1.06–5.00). Time to statement of primary surveys findings was delayed in patients with burn injuries (HR = 0.69; 95% CI: 0.48–0.98) and among those transferred from another hospital. Completeness and timeliness of ATLS task performance were not associated with age or injury severity score.

Conclusions

Mechanism of injury and hospital factors are associated with incomplete and delayed primary and secondary surveys. Interventions that address deficient ATLS adherence related to these factors may lead to a reduction in errors during this critical period of patient care.     

Predictors of long-term survival after out-of-hospital cardiac arrest: The impact of Activities of Daily Living and Cerebral Performance Category scores

Background

Current focus on immediate survival from out-of-hospital cardiac arrest (OHCA) has diverted attention away from the variables potentially affecting long-term survival.

Aim

To determine the relationship between neurological and functional status at hospital discharge and long-term survival after OHCA.

Methods

Prospective data collection for all OHCA patients aged >18 years in the Jerusalem district (n = 1043, 2008–2009). Primary outcome measure: Length of survival after OHCA. Potential predictors: Activities of Daily Living (ADL) and Cerebral Performance Category (CPC) scores at hospital discharge, age and sex.

Results

There were 52/279 (18.6%) survivors to hospital discharge. Fourteen were discharged on mechanical ventilation (27%). Interviews with survivors and/or their legal guardians were sought 2.8 ± 0.6 years post-arrest. Eighteen died before long-term follow-up (median survival 126 days, IQR 94–740). Six improved their ADL and CPC scores between discharge and follow-up. Long-term survival was positively related with lower CPC scores (p = 0.002) and less deterioration in ADL from before the arrest to hospital discharge (p = 0.001). For each point increment in ADL at hospital discharge, the hazard ratio of death was 1.31 (95%CI 1.12, 1.53, p = 0.001); this remained unchanged after adjustment for age and sex (HR 1.26, 95%CI 0.07, 1.48, p = 0.005).

Conclusions

One-third of the patients discharged from hospital after OHCA died within 30 months of the event. Long-term survival was associated both with better neurological and functional level at hospital discharge and a smaller decrease in functional limitation from before to after the arrest, yet some patients with a poor neurological outcome survived prolonged periods after hospital discharge.