Diazepam as a component of goal-directed sedation in critically ill trauma patients

Purpose

Limited information addressing the safety and efficacy of diazepam in the intensive care unit, particularly in trauma patients, is available. The purpose of this study is to evaluate the safety and efficacy of diazepam when used in routine clinical practice as a component of a goal-directed sedation regimen in critically ill trauma patients.

Material and methods

This is a prospective observational evaluation of adult trauma patients admitted to an intensive care unit with orders for as-needed midazolam or lorazepam followed by scheduled diazepam. Medication administration and Sedation-Agitation Scale scores were recorded.

Results

Twenty-four patients were evaluated. The most common diazepam dosage was 10 mg every 6 hours, and individual doses ranged from 5 to 30 mg. Sedation-Agitation Scale scores were recorded a median of 20 times per day (interquartile range, 15-24), and the majority (68%) were in the target range. No diazepam-related adverse events were observed.

Conclusions

Based on this limited sample, the use of diazepam as a component of goal-directed therapy appears safe and effective in providing adequate sedation in critically ill trauma patients using an average dosage of 40 mg/d.     

Advanced life support versus basic life support in the pre-hospital setting: a meta-analysis

Background

The scientific evidence of a beneficial effect of ALS in pre-hospital treatment in trauma patients or patients with any acute illness is scarce. The objective of this systematic review of controlled studies was to examine whether ALS, as opposed to BLS, increases patient survival in pre-hospital treatment and if so, to identify the patient groups that gain benefit.

Methods

A systematic review of studies published in the databases Medline (PubMed), EMBASE, Cochrane Library and Scopus up to July 31st, 2010. Controlled studies comparing survival after the pre-hospital ALS treatment versus BLS treatment in trauma patients or patients with cardiac arrest were included.

Results

We identified 1081 studies of which 18 met our inclusion criteria. In nine of 18 studies including 16,857 trauma patients in the intervention group, ALS care did not increase survival compared to BLS treatment (pooled OR 0.892, 95% CI, 0.775-1.026). In nine of 18 studies including 7659 patients with cardiac arrest in the intervention group, ALS care increased survival compared to BLS treatment (OR 1.468, 95% CI, 1.257-1.715). Most subgroup analyses revealed no significant interactions, but data from six trials, where ALS was provided by physicians, increases the probability of survival at hospital discharge even more (OR 2.047, 95% CI 1.593-2.631).

Conclusion

Implementation of ALS care to non-traumatic cardiac arrest patients can increase survival and further research is unlikely to change our confidence in the estimate of the effect. On the contrary, in trauma patients our meta-analysis revealed that ALS care is not associated with increased survival. However, only few controlled studies of sufficient quality and strength examining survival with pre-hospital ALS treatment exist.     

Traumatic pericardial effusion: Impact of diagnostic and surgical approaches

Introduction

In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion.

Patients and methods

Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center.

Results

Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome.

Conclusions

Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.     

The effect of the SAFE or SORRY? programme on patient safety knowledge of nurses in hospitals and nursing homes: A cluster randomised trial

Background

Patients in hospitals and nursing homes are at risk for the development of often preventable adverse events. Guidelines for the prevention of many types of adverse events are available, however compliance with these guidelines appears to be lacking. As a result many patients do not receive appropriate care. We developed a patient safety program that allows organisations to implement multiple guidelines simultaneously and therefore facilitates guideline use to improve patient safety. This program was developed for three frequently occurring nursing care related adverse events: pressure ulcers, urinary tract infections and falls. For the implementation of this program we developed educational activities for nurses as a main implementation strategy.

Objectives

The aim of this study is to describe the effect of interactive and tailored education on the knowledge levels of nurses.

Design

A cluster randomised trial was conducted between September 2006 and July 2008.

Settings

Ten hospital wards and ten nursing home wards participated in this study. Prior to baseline, randomisation of the wards to an intervention or control group was stratified for centre and type of ward.

Participants

All nurses from participating wards.

Methods

A knowledge test measured nurses’ knowledge on the prevention of pressure ulcers, urinary tract infections and falls, during baseline en follow-up. The results were analysed for hospitals and nursing homes separately.

Results

After correction for baseline, the mean difference between the intervention and the control group on hospital nurses’ knowledge on the prevention of the three adverse events was 0.19 points on a zero to ten scale (95% CI: −0.03 to 0.42), in favour of the intervention group. There was a statistically significant effect on knowledge of pressure ulcers, with an improved mean mark of 0.45 points (95% CI: 0.10-0.81). For the other two topics there was no statistically significant effect. Nursing home nurses’ knowledge did neither improve (0 points, CI: −0.35 to 0.35) overall, nor for the separate subjects.

Conclusion

The educational intervention improved hospital nurses’ knowledge on the prevention of pressure ulcers only. More research on long term improvement of knowledge is needed.

Trial registration

ClinicalTrials.gov ID [NCT00365430].     

Failure to achieve euglycemia despite aggressive insulin control signals abnormal physiologic response to trauma

Purpose

We hypothesize that a failure to normalize a patient's glucose on an automated euglycemia protocol signals an adverse response after trauma and that this response can identify patients with an increased mortality.

Materials and Methods

There were 1246 ventilated, critically ill trauma patients who were placed on an automated euglycemia. All glucose values collected both by laboratory serum measurements and by bedside arterial samples were included in the analysis.

Results

Forty six thousand two hundred eighteen data entries for glucose (mg/dL) were analyzed. Time to normalization, defined as the first value in the goal range of 80 to 110 mg/dL, was different between the 2 groups, survivors correcting significantly faster (396 vs 487 minutes; P = .003). Mortality in patients who normalized (80-110 mg/dL) in the first 6 hours of admission was 13.6% vs 18.3% in patients requiring greater than 6 hours (P = .02). Patients who never normalized also required significantly greater insulin doses despite there being no significant difference in demographic data between the 2 groups.

Conclusions

A posttraumatic patient's response to tight glycemic control revealed important prognostic information about the patients' physiologic status. Patients who failed to reach euglycemia in the first 6 hours of admission had an increased hospital mortality. The time to normalization is significantly longer in those patients who died. Patients who did not correct rapidly required significantly higher insulin doses, suggesting insulin resistance.     

A longitudinal evaluation of persons with disabilities: does a longitudinal definition help define who receives necessary care?

Chan L, Ciol MA, Shumway-Cook A, Yorkston KM, Dudgeon BJ, Asch SM, Hoffman JM. A longitudinal evaluation of persons with disabilities: does a longitudinal definition help define who receives necessary care?

Objective

To assess, using a longitudinal definition, the impact of disability on a broad range of objective health care quality indicators.

Design

Longitudinal cohort study following up with patients over several years. The first 2 interviews, 1 year apart, were used to determine each patient's disability status in activities of daily living (ADLs). Assessment of the health care indicators commenced after the second interview and continued throughout the survey period (an additional 1-3y).

Setting

National survey.

Participants

Participants (N=29,074) of the Medicare Current Beneficiary Survey (1992-2001) with no, increasing, decreasing, and stable ADL disability.

Interventions

Not applicable.

Main Outcome Measure

The incidence of 5 avoidable outcomes, receipt of 3 preventive care measures, and adherence to 32 diagnostically based indicators assessing the quality of treatment for acute myocardial infarction [AMI], angina, breast cancer, cerebrovascular accident, transient ischemic attack, cholelithiasis, chronic obstructive pulmonary disease [COPD], congestive heart failure, depression, gastrointestinal bleeding, diabetes, and hypertension.

Results

For most indicators, less than 75% of eligible patients received necessary care, regardless of disability status. For 5 indicators, less than 50% of patients received appropriate treatment. In a logistic regression analysis that controlled for patient age, sex, race, and income, disability status was a significant factor in 7 quality measures (AMI, breast cancer, COPD, diabetes, angina, pneumonia, annual visits).

Conclusions

Using a longitudinal definition of disability and objective health quality indicators, we found that disability status can be an important factor in determining receipt of quality health care in a broad range of diagnostic categories. However, the impact of disability status varies depending on the indicator measured. In this cohort of patients, the changing nature of a person's disability seems to have less impact than whether they ever have had any functional deficits.     

Advanced Trauma Life Support certified physicians in a non trauma system setting: is it enough?

Objective

The purpose of this study was to evaluate the impact of ATLS^® on trauma mortality in a non-trauma system setting. ATLS represents a fundamental element of trauma training in every trauma curriculum. Nevertheless, there are limited studies in the literature as for the impact of ATLS training in trauma mortality, especially outside the US.

Design

This is a prospective observational study. The primary end point was to investigate factors that affect mortality of trauma patients in our health care system. We performed a multivariate analysis for this purpose and we identified ATLS certification as a predictor of overall mortality. Following this finding we stratified patients according to the severity of injury as expressed by the ISS score and we compared outcome between those treated by an ATLS certified physician and those treated by non-certified ones.

Main outcome measures

Trauma volume and demographics of trauma patients, factors that affect mortality of traumatized patients and mortality between patients treated by ATLS^® certified and non-certified physicians.

Results

In total, 8862 trauma patients were included in the analysis. The majority of trauma patients (5988, 67.6%) were treated by a general surgeon, followed by those treated by an orthopedic surgeon (2194, 24.8%). There were 446 deaths in the registry but, 260 arrived dead in the Emergency Department and were excluded from the analysis. Multivariate analysis of the 186 deaths that occurred in the hospital revealed age, high ISS score, low GCS score, urban location of injury, neck injury and ATLS^® certification as factors predisposing to mortality. Cross tabulation of ATLS^® certification and ISS of the trauma patients shows that those treated by certified physicians died more often in all subcategories of ISS score (p < 0.05).

Conclusions

In Greece, with no formal trauma system implementation, ATLS^® certified physicians achieve worse outcomes than their non-certified colleagues when managing trauma patients. We believe that these findings must be interpreted in the context of the National health care system. There is considerable room for improvement in our country, and further analysis is required.     

Primary percutaneous coronary intervention and thrombolysis improve survival in patients with ST-elevation myocardial infarction and pre-hospital resuscitation

Background

Patients with ST-elevation myocardial infarction (STEMI) surviving pre-hospital resuscitation represent a selected subgroup of patients with a very high adverse event rate. Only few data on the outcome of primary percutaneous coronary intervention (primary PCI) and thrombolysis in such patients are available.

Methods

We analysed the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) Plus registry. 1529 survivors of pre-hospital resuscitation with STEMI were included. 593 (38.8%) of those patients did not receive early reperfusion therapy, 793 (51.9%) patients received thrombolysis and 143 (9.4%) patients received primary PCI. Hospital mortality in patients receiving primary PCI or thrombolysis was adjusted for confounding factors with a propensity score analysis.

Results

Primary PCI as well as thrombolysis in survivors of pre-hospital resuscitation with STEMI were associated with a significant reduction of hospital mortality (OR: 0.29, 95% CI 0.17-0.50; and 0.74, 95% CI 0.54-0.99, respectively), while primary PCI was superior compared to thrombolysis (OR 0.50, 95% CI 0.30-0.84).

Conclusion

Reperfusion therapy improves mortality of patients with STEMI surviving pre-hospital resuscitation, while primary PCI seems to be more effective than thrombolysis.     

Early risk stratification of patients with major trauma requiring massive blood transfusion

Background

There is limited evidence to guide the recognition of patients with massive, uncontrolled hemorrhage who require initiation of a massive transfusion (MT) protocol.

Objective

To risk stratify patients with major trauma and to predict need for MT.

Designs

Retrospective analysis of an administrative trauma database of major trauma patients.

A regional trauma Centre

A regional trauma centres in Hong Kong.

Patients

Patients with Injury Severity Score ≥9 and age ≥12 years were included. Burn patients, patients with known severe anemia and renal failure, or died within 24 h were excluded.

Main outcome measures

Delivery of ≥10 units of packed red blood cells (RBC) within 24 h.

Results

Between 01/01/2001 and 30/06/2009, 1891 patients met the inclusion criteria. 92 patients required ≥10 units RBC within 24 h. Seven variables which were easy to be measured in the ED and significantly predicted the need for MT are heart rate ≥120/min; systolic blood pressure ≤90 mmHg; Glasgow coma scale ≤8; displaced pelvic fracture; CT scan or FAST positive for fluid; base deficit >5 mmol/L; hemoglobin ≤7 g/dL; and hemoglobin 7.1-10 g/dL. At a cut off of ≥6, the overall correct classification for predicting need for MT was 96.9%, with a sensitivity of 31.5% and specificity of 99.7%, and an incidence of MT of 82.9%. The area under the curve was 0.889.

Conclusion

A prediction rule for determining an increased likelihood for the need for massive transfusion has been derived. This needs validation in an independent data set.     

Potential Clinical Impact of Compounded Versus Noncompounded Intrathecal Baclofen

Moberg-Wolff E. Potential clinical impact of compounded versus noncompounded intrathecal baclofen.

Objective

To assess the differences between commercial and pharmacy-compounded preparations of baclofen for intrathecal administration.

Design

Random sample.

Setting

Pharmacies in the United States advertising compounded intrathecal baclofen preparation.

Participants

Not applicable.

Interventions

Intrathecal baclofen (ITB) samples were collected from 1 Food and Drug Administration-approved commercial source and 6 compounding pharmacies. An independent analysis of drug concentration and density was conducted. Information regarding ordering process, manufacturing, packaging, storage, and expiration was collected.

Main Outcome Measure

Comparison of concentration and density variations.

Results

Twenty-nine ITB samples in concentrations of 2000, 3000, 4000, 5000, and 6000μg/mL were analyzed. Over 40% of compounded samples were more than 5% above or below labeled concentration. Twenty-two percent of compounded samples were more than 10% above or below labeled concentration. The only samples with no concentration deviation and consistent drug density were the commercially available, noncompounded products.

Conclusions

Compounding pharmacies have variable practices in the provision of ITB. A high incidence of concentration inaccuracy existed. The use of compounded ITB may result in unintended dose alterations. Variable clinical efficacy, or life-threatening overdose or withdrawal may occur in patients who are sensitive to slight dose fluctuations. Given the variability of these compounded ITB samples, informed consent to use these products and understanding of potential side effects should be reviewed with patients.     

Therapeutic use of botulinum toxin type A in treating neck and upper-back pain of myofascial origin: a pilot study

Lew HL, Lee EH, Castaneda A, Klima R, Date E. Therapeutic use of botulinum toxin type A in treating neck and upper-back pain of myofascial origin: a pilot study.

Objective

To determine the efficacy of botulinum toxin type A (BTX-A) in treating neck and upper-back pain of myofascial origin.

Design

A randomized, double-blind, placebo-controlled pilot study.

Setting

Outpatient physical medicine and rehabilitation clinic of a university-affiliated tertiary hospital.

Participants

A total of 29 subjects enrolled from among 45 screened patients. No subject withdrawal due to serious adverse events occurred.

Intervention

Subjects were evaluated at baseline, received a 1-time injection of either BTX-A (treatment group) or saline (control group), and were followed up at 2 weeks and at months 1, 2, 3, 4, and 6.

Main Outcome Measures

Visual analog scale (VAS) for pain, the Neck Disability Index (NDI), and the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36).

Results

Improvements in the VAS and NDI scores were seen in the treatment group but were not significant when compared with the controls. Statistically significant improvements for the treatment group were seen in the SF-36 bodily pain (at months 2 and 4) and mental health (at month 1) scales but not in the other scales, nor in the summary measures. No serious adverse events were reported.

Conclusions

Trends toward improvements in VAS and NDI scores of the BTX-A group are encouraging, but they were possibly due to a placebo effect and were not statistically significant. The BTX-A subjects, at certain time points, showed statistically significant improvements in the bodily pain and mental health scales of the SF-36 compared with controls. Our study had limited power and population base, but the results could be used to properly power follow-up studies to further investigate this topic.     

The association between nursing diagnoses, resource utilisation and patient and caregiver outcomes in a nurse-led home care service: longitudinal study

Background

The information generated by nurses through standardised nursing languages is insufficiently evaluated and exploited, mainly in home care services, as is its potential impact on outcomes.

Objectives

To find out how often nursing diagnoses are made during nursing home care visits, and to explore their relation with use of resources, mortality, institutionalisation and satisfaction.

Design

Observational, longitudinal follow-up study.

Settings

Home care services delivered by Primary Healthcare Districts in Málaga, Costa del Sol, Almería and Granada, in Spain.

Participants

Patients and caregivers who initiated the Home Care Programme.

Methods

The accumulated incidence of nursing diagnosis was analysed over 34 months of follow-up. Diagnoses were made by nurse case managers in their daily practice. Several regression models were devised to analyse their linkage with the use of resources, mortality, institutionalisation and satisfaction.

Results

Two hundred and forty-seven subjects were included (129 patients and 118 caregivers). 93.8 had been diagnosed (2.8 diagnoses per subject). Risk of caregiver strain and mobility impairment accounted for 40% of total home visits (p = 0.033). Significant differences were observed in the use of physiotherapy and rehabilitation services. The home visits for caregivers were, in 78% of cases, due to the recipient’s baseline functional status. No relation was detected for institutionalisation or for patient satisfaction. There was a higher rate of anxiety diagnosed in the caregiver when the recipient was at greater risk for mortality (RR: 2.08 CI 95%: 1.26-3.42) (p = 0.012).

Conclusions

These data confirm results from other studies which find nursing diagnoses to be sound predictors of resources use. Their synergy with other case-mix systems in home care should be investigated.     

The cost and benefits of employment: a qualitative study of experiences of persons with multiple sclerosis

Johnson KL, Yorkston KM, Klasner ER, Kuehn CM, Johnson E, Amtmann D. The cost and benefits of employment: a qualitative study of experiences of persons with multiple sclerosis. Arch Phys Med Rehabil 2004;85:201-9.

Objective

To attain a better understanding of the benefits and barriers faced by persons with multiple sclerosis (MS) in the workplace.

Design

Qualitative research methodology comprising a series of semistructured interviews.

Setting

Community-based setting.

Participants

Fourteen women and 2 men with MS living in the community who were employed or recently employed at the time of interviews.

Interventions

Not applicable.

Main outcome measure

Accounts of personal experiences related to employment.

Results

Four themes emerged: the cost-benefit economy of working; fatigue and cognitive changes; stress in the workplace; and accommodations made to address barriers. Although participants valued work highly, they were also aware of the cost of being employed. The consequences of unemployment or changing jobs were considered negative and appeared stressful. For persons with MS, employment had both costs and significant benefits. Accommodations in the workplace and modifications of roles and responsibilities at home made it possible for individuals to continue working.

Conclusions

Health care providers must consider the complexity and timing of decisions by people with MS to continue or leave employment before recommending either action. Identifying critical periods of intervention to stabilize this cost-benefit balance is a critical next step for understanding issues of employment and MS.     

Validity of a Functional Dynamic Walking Test for the Elderly

Lark SD, Pasupuleti S. Validity of a functional dynamic walking test for the elderly.

Objective

To determine the validity of a safe, quick, and simple method of measuring dynamic balance in the elderly during gait called the parallel walk test.

Design

Control study.

Setting

Outpatient clinic, community.

Participants

Twenty-seven elderly fallers (age 82±6y) registered at a falls clinic and 34 elderly nonfallers (age 76±7y) were recruited to this study based on Mini Mental State Examination and Barthel Index scores.

Interventions

Subjects were timed as they walked 6m between 2 parallel lines on the floor at 3 different widths (20, 30.5, 38cm) in their own footwear. They were scored for foot placement on the line (1 point) or outside the lines (2 points). Participants also performed a timed 6-m tandem walk test, a 30-second tandem stance, and a 30-second parallel stance.

Main Outcome Measures

Scores and time to complete the parallel walk test and tandem walk test along with the time of standing for tandem and parallel stance. Validity coefficients were calculated for the sensitivity and specificity of the parallel walk test.

Results

All subjects completed the parallel walk test, but few attempted and completed the tandem walk test. The fallers had significantly greater scores at 20 and 30.5cm and took significantly longer to complete the 6m at all widths. The 20-cm width was most discriminatory. The parallel walk test showed a significant correlation with the tandem stance.

Conclusions

All subjects attempted and completed the parallel walk test but not the tandem walk test. The time to completion and scoring accurately measures dynamic balance during gait in elderly fallers. The parallel walk test could be a useful tool in the clinical setting for assessing balance in gait pre- and postintervention.     

Differences in gait characteristics between persons with bilateral transtibial amputations, due to peripheral vascular disease and trauma, and able-bodied ambulators

Su P-F, Gard SA, Lipschutz RD, Kuiken TA. Differences in gait characteristics between persons with bilateral transtibial amputations, due to peripheral vascular disease and trauma, and able-bodied ambulators.

Objectives

To examine differences in gait characteristics between persons with bilateral transtibial amputations because of trauma and peripheral vascular disease (PVD); and to compare that with data from able-bodied controls that were previously collected and maintained in a laboratory database.

Design

Observational study of persons with bilateral transtibial amputations.

Setting

A motion analysis laboratory.

Participants

Nineteen bilateral transtibial amputees.

Intervention

No experimental intervention was performed. To standardize the effect of prosthetic foot type, subjects were fitted with Seattle Lightfoot II feet 2 weeks before quantitative gait analyses.

Main Outcome Measures

Temporospatial, kinematic, and kinetic gait data were recorded and analyzed.

Results

Results showed that the freely selected walking speeds of subjects with PVD and trauma were 0.69m/s and 1.11m/s, respectively, while that of able-bodied control subjects was 1.20m/s. When data were compared on the basis of freely selected walking speed, numerous differences were found in temporospatial, kinematic, and kinetic parameters between the PVD and trauma groups. However, when data from similar speeds were compared, the temporospatial, kinematic, and kinetic gait data demonstrated no statistically significant differences between the 2 amputee groups. Although not statistically significant, the PVD group displayed increased knee (P=.09) and hip (P=.06) flexion during the swing phase, whereas the trauma group displayed increased pelvic obliquity (P=.06). These actions were believed to represent different strategies to increase swing phase foot clearance. Also, the PVD group exhibited slightly greater hip power (P=.05) before toe-off.

Conclusions

Many of the differences observed in the quantitative gait data between the trauma and PVD groups appeared to be directly associated with their freely selected walking speed; the trauma group walked at significantly faster freely selected speeds than the PVD group. When their walking speeds were matched, both amputee groups displayed similar gait characteristics, with the exception that they might use slightly different strategies to increase foot clearance.     

Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: A report from the National Registry for Cardiopulmonary Resuscitation

Aim

To evaluate key pre-arrest factors and their collective ability to predict post-cardiopulmonary arrest mortality. CPR is often initiated indiscriminately after in-hospital cardiopulmonary arrest. Improved understanding of pre-arrest factors associated with mortality may inform advance care planning.

Methods

A cohort of 49,130 adults who experienced pulseless cardiopulmonary arrest from January 2000 to September 2004 was obtained from 366 US hospitals participating in the National Registry for Cardiopulmonary Resuscitation (NRCPR). Logistic regression with bootstrapping was used to model in-hospital mortality, which included those discharged in unfavorable and severely worsened neurologic state (Cerebral Performance Category ≥3).

Results

Overall in-hospital mortality was 84.1%. Advanced age, black race, non-cardiac, non-surgical illness category, pre-existing malignancy, acute stroke, trauma, septicemia, hepatic insufficiency, general floor or Emergency Department location, and pre-arrest use of vasopressors or assisted/mechanical ventilation were independently predictive of in-hospital mortality. Retained peri-arrest factors including cardiac monitoring, and shockable initial pulseless rhythms, were strongly associated with survival. The validation model's AUROC curve (0.77) revealed fair performance.

Conclusions

Predictive pre-resuscitation factors may supplement patient-specific information available at bedside to assist in revising resuscitation plans during the patient's hospitalization.     

Pre-hospital delay in patients with acute coronary syndrome: Factors associated with patient decision time and home-to-hospital delay

Background

Pre-hospital delays in patients experiencing acute coronary syndromes (ACS) remain unacceptably long.

Aims

To examine simultaneously a wide range of clinical, sociodemographic and situational factors associated with total pre-hospital delay and its two components.

Methods

Pre-hospital delay data were collected from 228 patients with ACS using patient's medical notes and semi-structured interviews. Total pre-hospital delay (symptom onset to hospital admission) was divided into 2 components: decision time (symptom onset to call for medical help), and home-to-hospital delay (call for help to hospital admission).

Results

Shorter total pre-hospital delays and decision times were associated with ST segment myocardial infarction (STEMI), recognizing symptoms as cardiac in origin, being married, symptom onset outside the home and the presence of a bystander. Shorter home-to-hospital delays were more likely among younger patients, those experiencing an STEMI, and patients reporting a greater number of symptoms. Initial contact with emergency medical services was related to shorter total delays and decision times.

Conclusions

Different factors were associated with shorter times in the 2 component phases. Greater understanding of the factors impacting on the component phases may help target interventions more effectively and reduce pre-hospital delays.     

Prehospital delay and its impact on time to treatment in ST-elevation myocardial infarction

Purposes

We performed this study to assess the impact of pre-hospital time on the patient’s outcome.

Procedures

Starting from the symptoms onset, “total time to treatment” was divided into less than or equal to 120 minutes and more than 120 minutes (“pre-hospital time” of ≤ or > 30 minutes respectively). Adverse patient’s outcomes were compared in the two subgroups.

Findings

Our patients had a mean age of 63 (±13) years. On-scene time (17.8 ± 9.4 minutes), was the biggest fraction of “pre-hospital time”. Comparing the groups with “Total time to treatment” of >120 minutes vs. ±120 minutes (“pre-hospital time” of >30 vs. ≤30 minutes), mortalities were 4 vs. 0 and transfers to a tertiary care facility were 3 vs.1.

Conclusions

Most of the pre-hospital time in STEMI was spent on the scene and we suggest “total time to treatment” as a core measure instead of “door to balloon time”.     

Prediction of Postoperative Ambulatory Status 1 Year After Hip Fracture Surgery

Hirose J, Ide J, Yakushiji T, Abe Y, Nishida K, Maeda S, Anraku Y, Usuku K, Mizuta H. Prediction of postoperative ambulatory status 1 year after hip fracture surgery.

Objectives

To assess the validity of Estimation of Physiologic Ability and Surgical Stress (E-PASS) for predicting the postoperative risk and ambulatory status long-term follow-up after hip fracture surgery and to establish an algorithm for predicting their ambulatory status.

Design

Cohort study.

Setting

Twelve hospitals belonging to the regional network for hip fracture in Japan.

Participants

The study population was composed of 421 patients; 268 underwent surgery between April 2004 and March 2006 (group A), and 153 were treated surgically between April 2006 and March 2007 (group B). All were operated at 3 surgical hospitals and, subsequently, transferred to 9 rehabilitation centers.

Interventions

Not applicable.

Main Outcome Measures

We evaluated various factors, including their E-PASS scores to determine whether there was a correlation with the patients' mortality rate and their ability to walk at discharge and 1 year after surgery (group A). Using multiple regression analysis, we then developed algorithms to predict the ability of elderly patients to walk after hip fracture surgery. We applied the algorithms to group B patients and compared their actual and predicted ambulatory status.

Results

In group A patients, the postoperative walking ability and mortality rate were highly correlated with their E-PASS scores and dementia status. In group B, our algorithms exhibited good correlations between the predicted and actual walking ability at both time points (ρ=0.6, P<.001).

Conclusions

In candidates for hip fracture surgery, the E-PASS scores exhibited a good correlation with the patients' functional and survival prognoses, and the algorithm including E-PASS scores and dementia status can accurately estimate the ambulatory status at discharge and 1 year after surgery.     

Pre-hospital cardiac arrest in Prague, Czech Republic—The Utstein-style report

Objective

This study aimed to report results of pre-hospital cardiopulmonary resuscitation (CPR) in the city of Prague in accordance with ‘Utstein-style’ recommendations.

Materials and methods

This is a prospective study of out-of-hospital cardiac arrest (OHCA) survival in the city of Prague treated by emergency medical service (EMS). EMS Prague is a typical municipal, two-tiered ambulance service, based on the presence of a physician on the scene in all life-threatening emergencies, especially in cardiac arrests, serious breathing problems, chest-pain cases, seizures, serious trauma, etc. Since 2002, all cases of OHCA CPRs performed by EMS Prague ambulance crew are evaluated in accordance with ‘Utstein-style’ recommendations, including hospital-outcome score as measured by Cerebral Performance Categories (CPCs).

Results

In 2008, our ambulance crew performed 493 CPRs. Return of spontaneous circulation (ROSC) was achieved in 278 cases (56.3%), survival of the event in 211 cases (42.8%) and survival to hospital discharge with good neurological outcome (CPC 1 or 2) in 74 cases (15.0%). Appropriate figures for patients with first shockable rhythm (n = 146) were 106 (72.6%) for ROSC, 91 (62.3%) for survived event and 51 (34.9%) for survival to discharge with good neurological outcome. Pre-hospital CPR incidence was 41.1 per 100,000 inhabitants.The majority of cases had a cardiac origin (363, 73.6%). The physician attending the arrest declared the reason unknown in 40 cases (8.1%), as a respiratory disease in 20 cases (4.1%) and in 36 cases (7.3%) the arrest was a result of trauma, drowning or poisoning.