Emergency and critical care imaging

Care for patients who have time-sensitive disease processes in the emergency department and critical care settings is optimized with rapid diagnosis and intervention. Recent advances in medical imaging have increased portability, decreased image acquisition time, improved data resolution, and increased use of noninvasive studies. This article discusses the use of portable imaging techniques such as bedside ultrasound and radiography as well as CT and CT angiography in the diagnosis and care of critically ill patients.     

End-of-life care in UK critical care units--a literature review

Aim: To appraise literature concerning end‐of‐life care (ELC) in adult critical care units in the UK in order to improve clinical practice. Objective: To understand the interplay between legal and ethical, political, societal aspects of ELC for sustainable quality care. Background: Significant changes in health care policy for the critically ill patient have occurred since 1999. Simultaneously, the government is committed to improving care for the dying by integrating the palliative care ethos across the National Institutes of Health (NHS) to include non‐cancer sufferers. Death continues to be a feature of critical illness, particularly following the decision to withhold/withdraw life‐prolonging treatments. Search strategy: A search of MEDLINE, BNI, CINAHL and PSYCinfo using key words revealed very few results; consequently, the search was broadened to include ASSIA, King’s Fund, TRIP, Healthstar, NHS Economic Evaluation Data, Cochrane, professional journals and government documents. Conclusions: The literature reveals a paradigm shift from critical to palliative care, in other words, from a reductionist approach to a more humanistic approach in the acute setting. When treatment is deemed futile, quality ELC involving the assessment, ongoing assessment and care after death becomes the new goal for the critical care team. To practice ELC competently, nurses require organizational and educational support at local and national levels. Relevance to clinical practice: Although medico‐legal decision‐making is not part of their professional role, critical care nurses have an extraordinary opportunity to make a difference to the dying patient and their family and their acceptance of death.     

Emergency department organisation for disasters: a review of emergency department disaster plans in public hospitals of Singapore

Disaster management plans of emergency departments (EDs) in four major public hospitals were reviewed. A comparison was made between these plans, and they were analyzed to gain an understanding of the differing objectives and doctrines behind the practices. These were summarized into five major management concepts, which are considered to be critical to the success of a disaster plan: 1) staff mobilization systems (cascading vs batch mobilization); 2) staff deployment systems; 3) team organization (surgeons vs residents); 4) area management (the role of the area manager); 5) casualty volume management (accommodation vs expansion vs extension concepts). The concepts derived should serve as a useful guide to the development of an ED disaster plan and potentially influence how new ED facilities could be planned.     

Research priorities in critical care medicine in the UK

OBJECTIVES: To establish priorities for research in critical care medicine in the UK using survey and nominal group (NG) techniques. DESIGN: The senior doctor and nurse from 325 intensive care units (ICUs) in the UK were invited to contribute up to ten research questions relevant to intensive care organisation, practice or outcomes. These were then ranked twice using a Likert scale by a panel (nominal group) consisting of ten doctors (two trainees) and two nurses from university teaching and district general (community) hospitals. The first ratings were performed privately, and the second after group discussion. Thirty questions, ten each with strong, moderate or weak support, were then returned for rating by the originating ICU staff and the results compared with those of the NG. RESULTS: One hundred eighty-five respondents (35.6 % university teaching, 62.1% district general, 2.3 % not stated) provided 811 questions of which 722 were research hypotheses. The most frequently identified topics were the evaluation of high dependency care, ICU characteristics, treatments for acute lung injury and acute renal failure, nurse:patient ratios, pulmonary artery catheterisation, aspects of medical and nursing practice, protocol evaluation, and interhospital transfers. These were condensed into 100 topics for consideration by the NG. Discussion and re-rating by the group resulted in strong support being offered for 37 topics, moderate support for 48, and weak support for 21. Following circulation of ten questions from each category, nine questions achieved strong support from both ICU staff and the NG. These were the effect on outcomes from critical illness of early intervention, high dependency care, nurse:patient ratios, interhospital transfers, early enteral feeding, optimisation of perioperative care, hospital type, regionalisation of paediatric intensive care and the use of pulmonary artery catheters. The absence of any questions relating to interventions targetting mediators of the immuno-inflammatory response could be a consequence of the failure of recent studies in sepsis to demonstrate benefits in outcome. CONCLUSIONS: The intensive care community in the UK appears to prioritise research into organisational aspects of clinical practice and practical aspects of organ-system support. Health services research and the biological sciences need to develop collaborative methods for evaluating interventions and outcomes.     

A critical discourse analysis of provision of end-of-life care in key UK critical care documents

This article highlights certain practical and professional difficulties in providing end-of-life (EOL) care for patients in critical care units and explores discourses arising from guidelines for critical care services. BACKGROUND: A significant number of patients die in critical care after decisions to withdraw or withhold treatment. Guidelines for provision of critical care suggest, wherever possible, moving patients out of critical care at the EOL. This may not necessarily be conducive to a 'good death' for patients or their loved ones. There is a moral responsibility for both nurses and doctors to ensure that decision-making around EOL issues is sensitively implemented, that decisions about care includes families, patients when able, nurses and doctors, and that good EOL care is provided. METHODS: A critical discourse analysis (CDA) of four key UK critical care documents published since 1996. FINDINGS AND RECOMMENDATIONS: The key documents give little clear guidance about how to provide EOL care in critical care. Discourses include the power dynamic in critical care between professions, families and patients, and how this impacts on provision of EOL care. Difficulties encountered include dilemmas at discharge and paternalism in decision-making. The technological environment can act as a barrier to good EOL care, and critical care nurses are at risk of assuming the dominant medical model of care. Nurses, however, are in a prime position to ensure that decision-making is an inclusive process, patient needs are paramount, the practical aspects of withdrawal lead to a smooth transition in goals of care and that comfort measures are implemented.     

重症医学科呼吸治疗师培养与使用

复旦大学附属中山医院重症医学科于2015年就呼吸治疗师团队的建设进行了实践与探索。在呼吸治疗师人员选拔、专业理论知识及操作技能培训、专业能力评价、呼吸治疗师临床工作开展的模式与流程等方面积累了一定的经验,形成了较为完善的组织架构与体系。     

Emergency department care: Cost awareness by health care providers

With the escalation of health care costs during the past decade, it has become increasingly important for the physician to be aware of the cost of various components of health care delivery. The following study was undertaken to ascertain the “cost awareness” of four different groups of health care providers. This was accomplished by having these groups estimate the cost of patient visits to an emergency department. Significant errors were observed in these cost estimations, and error trends were seen to occur that were independent of education and experience.     

Emergency department use among end-of-life home care clients

Emergency department (ED) use is a quality-of-care indicator for community-based end-of-life (EOL) care. This study examined ED use by EOL home care clients. The sample included all EOL home care clients who received care from one community care access centre in Ontario, Canada. Information on health was gathered using the interRAI instrument for palliative care. Data were collected between May 2009 and January 2010. The sample included 93 home care clients. Results showed that 35 percent of clients used the ED within 45 days of assessment. Multivariate analysis identified two determinants of ED use: excessive weight loss and previous hospitalization. Managing terminal illness is often a difficult task, and comprehensive, ongoing assessment of clients' changing status is critical. Client care and service planning for clients who have lost excessive amounts of weight or who have been recently hospitalized need to be monitored closely to prevent any future avoidable ED use.     

Post-resuscitation care at the emergency department with critical care facilities--a length-of-stay analysis

Aim of the study

An emergency department providing critical care will have an effect on outcome and intensive-care-units’ resources by avoiding unnecessary or futile intensive-care admissions and thereby save hospital expenses. The study focussed on this result.

Methods

The study employed a retrospective analysis of prospectively collected data of out-of-hospital cardiac arrest patients with return of spontaneous circulation, comatose on arrival. Outcomes and length of stay of patients who either stayed at the ‘emergency department only’ or were ‘transferred in addition to an intensive care unit’ were compared. Linear regression with log length of stay as outcome and ‘emergency department only’ as predictor with covariates was used for modelling.

Results

From 1991 to 2008, out of 1236 patients (age 57 ± 15 years, female 31%), the ‘emergency department only’ group (n = 349 (28%)) survived to discharge in 81(23%) cases, with a median length-of-stay in critical care of 1.7 (interquartile range 0.8; 3.1) days. The patients ‘transferred in addition to an intensive care unit’ (n = 887 (72%)), with a survival rate of 55% (n = 486, p < 0.001) stayed 10 (5; 18) days (p < 0.001). The length-of-stay in hospital was significantly shorter if patients were treated in the ‘emergency department only’ independent of other cardiac-arrest-related factors (regression coefficient −1.42, confidence interval −1.60 to −1.24).

Conclusions

An emergency department with critical care prevents admissions to intensive care units in 28% of patients with out-of-hospital cardiac arrest. It saves intensive-care-unit resources and shortens length of stay for comatose out-of-hospital cardiac-arrest survivors, regardless of their outcome.     

Partnership in care: a critical exploration of how this may be applied to children attending the Accident and Emergency department

Partnership in care is an emerging theme within children's nursing. There has, however, been much debate in the literature about what partnership in care is, but little consensus has been achieved as to its meaning. Partnership in care has been examined from the perspectives of both the parents and the nurses, although principally the work to date has focused on children's wards. More recently the work on partnership in care has examined how this may work in the children's out-patient department and also within community children's nursing. Little appears to have been written about partnership in care in the Accident and Emergency (A&E) environment, and some possible reasons for this have been postulated. Three aspects of partnership in care: negotiation and equality of care, parents as equal partners, and responsibility for care being shifted have all been examined and applied to the A&E setting. Suggestions for research are offered throughout the discussion. Finally, the role of the registered children's nurse is examined in view of the analysis.     

Routine delirium monitoring in a UK critical care unit

Introduction  

Delirium in the intensive care unit (ICU) is associated with increased morbidity and mortality. Using an assessment tool has been shown to improve the ability of clinicians in the ICU to detect delirium. The confusion assessment method for the ICU (CAM-ICU) is a validated delirium-screening tool for critically ill intubated patients. The aim of this project was to establish the feasibility of routine delirium screening using the CAM-ICU and to identify the incidence of delirium in a UK critical care unit.     

Emergency physicians in critical care: a consultant's experience

There is a growing interest in the interface between emergency medicine and critical care medicine. Previous articles in this journal have looked at the opportunities and advantages of training in critical care medicine for emergency medicine trainees. In the UK there are a small number of emergency physicians who also have a commitment to critical care medicine. This article describes a personal experience of such a job, looking at the advantages and disadvantages. Depending upon future developments in the role of emergency medicine in the UK, together with the proposed expansion in critical care medicine, such posts may become more common.