Andrew Casamento

The role of the medical emergency team in end-of-life care : a multicenter, prospective, observational study

Objective:To investigate the role of medical emergency teams in end-of-life care planning. Design:One month prospective audit of medical emergency team calls. Setting:Seven university-affiliated hospitals in Australia, Canada, and Sweden. Patients:Five hundred eighteen patients who received a medical emergency team call over 1 month. Interventions:None. Measurements and Main Results:There were 652 medical emergency team calls in 518 patients, with multiple calls in 99 (19.1%) patients. There were 161 (31.1%) patients with limitations of medical therapy during the study period. The limitation of medical therapy was instituted in 105 (20.3%) and 56 (10.8%) patients before and after the medical emergency team call, respectively. In 78 patients who died with a limitation of medical therapy in place, the last medical emergency team review was on the day of death in 29.5% of patients, and within 2 days in another 28.2%.Compared with patients who did not have a limitation of medical therapy, those with a limitation of medical therapy were older (80 vs. 66 yrs; p < .001), less likely to be male (44.1% vs. 55.7%; p = .014), more likely to be medical admissions (70.8% vs. 51.3%; p < .001), and less likely to be admitted from home (74.5% vs. 92.2%, p < .001). In addition, those with a limitation of medical therapy were less likely to be discharged home (22.4% vs. 63.6%; p < .001) and more likely to die in hospital (48.4% vs. 12.3%; p < .001). There was a trend for increased likelihood of calls associated with limitations of medical therapy to occur out of hours (51.0% vs. 43.8%, p = .089). Conclusions:Issues around end-of-life care and limitations of medical therapy arose in approximately one-third of calls, suggesting a mismatch between patient needs for end-of-life care and resources at participating hospitals. These calls frequently occur in elderly medical patients and out of hours. Many such patients do not return home, and half die in hospital. There is a need for improved advanced care planning in our hospitals, and to confirm our findings in other organizations.

A comparison of therapeutic hypothermia and strict therapeutic normothermia after cardiac arrest

BACKGROUND AND AIMS In a recent high-quality randomised controlled trial (RCT), strict therapeutic normothermia (STN) following cardiac arrest with coma resulted in similar outcomes to therapeutic hypothermia (TH). We aimed to test the feasibility, reproducibility, and safety of the STN protocol outside of its RCT context. METHODS In two teaching hospital ICUs, we performed a before-and-after study comparing the previously International Liaison Committee on Resuscitation (ILCOR)-endorsed TH protocol to the recently studied STN protocol. The primary feasibility end point was the percentage of temperature recordings in the prescribed range in the first 24h of treatment. Secondary end points included pharmacological management and complications. RESULTS We studied 69 similar patients in each group. We found no difference in feasibility as shown by the proportion of within range temperatures. However, the median doses of midazolam (37mg vs. 9mg, p=0.02), fentanyl (883μg vs. 310μg, p=0.01) and the use of muscle relaxants (84.1% vs. 59.4%, p=0.001) was greater with the TH protocol. Furthermore, shivering (52.2% vs. 18.8%, p<0.001), a composite of other pre-defined complications (66.7% vs. 47.8%, p<0.03) and fever in the first 96h (55.1% vs. 33.3%, p=0.01) were also more common with the TH protocol. CONCLUSIONS The STN protocol was successfully reproduced outside of an RCT and appeared associated with fewer complications than the TH protocol. Our findings imply that the STN protocol may offer clinical advantages over the TH protocol.

The Melbourne epidemic thunderstorm asthma event 2016: an investigation of environmental triggers, effect on health services, and patient risk factors

BACKGROUND A multidisciplinary collaboration investigated the worlds largest, most catastrophic epidemic thunderstorm asthma event that took place in Melbourne, Australia, on Nov 21, 2016, to inform mechanisms and preventive strategies. METHODS Meteorological and airborne pollen data, satellite-derived vegetation index, ambulance callouts, emergency department presentations, and data on hospital admissions for Nov 21, 2016, as well as leading up to and following the event were collected between Nov 21, 2016, and March 31, 2017, and analysed. We contacted patients who presented during the epidemic thunderstorm asthma event at eight metropolitan health services (each including up to three hospitals) via telephone questionnaire to determine patient characteristics, and investigated outcomes of intensive care unit (ICU) admissions. FINDINGS Grass pollen concentrations on Nov 21, 2016, were extremely high (>100 grains/m3). At 1800 AEDT, a gust front crossed Melbourne, plunging temperatures 10°C, raising humidity above 70%, and concentrating particulate matter. Within 30 h, there were 3365 (672%) excess respiratory-related presentations to emergency departments, and 476 (992%) excess asthma-related admissions to hospital, especially individuals of Indian or Sri Lankan birth (10% vs 1%, p<0·0001) and south-east Asian birth (8% vs 1%, p<0·0001) compared with previous 3 years. Questionnaire data from 1435 (64%) of 2248 emergency department presentations showed a mean age of 32·0 years (SD 18·6), 56% of whom were male. Only 28% had current doctor-diagnosed asthma. 39% of the presentations were of Asian or Indian ethnicity (25% of the Melbourne population were of this ethnicity according to the 2016 census, relative risk [RR] 1·93, 95% CI 1·74-2·15, p <0·0001). Of ten individuals who died, six were Asian or Indian (RR 4·54, 95% CI 1·28-16·09; p=0·01). 35 individuals were admitted to an intensive care unit, all had asthma, 12 took inhaled preventers, and five died. INTERPRETATION Convergent environmental factors triggered a thunderstorm asthma epidemic of unprecedented magnitude, tempo, and geographical range and severity on Nov 21, 2016, creating a new benchmark for emergency and health service escalation. Asian or Indian ethnicity and current doctor-diagnosed asthma portended life-threatening exacerbations such as those requiring admission to an ICU. Overall, the findings provide important public health lessons applicable to future event forecasting, health care response coordination, protection of at-risk populations, and medical management of epidemic thunderstorm asthma. FUNDING None.

Point prevalence of general ward patients fulfilling criteria for systemic inflammatory response syndrome

The systemic inflammatory response syndrome (SIRS) is defined by abnormal temperature, heart rate, minute ventilation or white cell count and can be due to infectious or non‐infectious causes. In a single day, 23% of hospital ward patients fulfilled SIRS criteria. Patients with SIRS were more likely to be under medical than surgical units. One‐third of the patients had evidence of infection. There was no association between SIRS criteria and increased mortality or hospital length of stay.

Patient characteristics, incidence, technique, outcomes and early prediction of tracheostomy in the state of Victoria, Australia

Background: Tracheostomy is a relatively common procedure in Intensive Care Unit (ICU) patients. Aims: To study the patient characteristics, incidence, technique, outcomes and prediction of tracheostomy in the State of Victoria, Australia. Methods: We used data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) and the Victorian Admitted Episode Dataset (VAED) to identify and match patients who had received a tracheostomy from 2004 to 2014. Results: Between 1st January 2004 and 30th June 2014, 9750 patients received a tracheostomy with 7670 available for matching and 6010 (78.4%) successfully matched. Of the matched tracheostomy patients, median age was 61 years, median APACHE IIIJ score was 66 and overall hospital mortality was 21%. The incidence of tracheostomy almost halved over the decade with more than half of tracheostomies (53.5%) being percutaneous. Hospital mortality of patients receiving a tracheostomy decreased from 26.5% in 2004 to 16.5% in 2014 by an average decrease of 6%/year. No robust model could be developed to predict tracheostomy. Conclusion: The incidence of tracheostomy and the adjusted mortality rate of patients who received a tracheostomy have significantly decreased over a decade. Day of admission information could not be used to predict subsequent tracheostomy. HighlightsDescription of 6010 patients who received a tracheostomy over a 10‐year periodTracheostomy rate almost halved over this period.Intensive Care and hospital mortality decreased significantly over this period.A prediction model developed from ICU admission criteria performed inadequately.