B.G. Fikkers

Emergency cricothyrotomy: a randomised crossover trial comparing the wire-guided and catheter-over-needle techniques

In a randomised crossover trial, we compared a wire‐guided cricothyrotomy technique (Minitrach) with a catheter‐over‐needle technique (Quicktrach). Performance time, ease of method, accuracy in placement and complication rate were compared. Ten anaesthesiology and 10 ENT residents performed cricothyrotomies with both techniques on prepared pig larynxes. The catheter‐over‐needle technique was faster than the wire‐guided (48 compared to 150u2003s, pu2003<u20030.001) and subjectively easier to perform (VAS‐score 2.1 vs. 5.6, pu2003<u20030.001). Correct positioning of the cannula could be achieved in 95% and 85%, respectively (NS). There was one complication in the catheter‐over‐needle group compared to five in the wire‐guided group. We conclude that the wire‐guided minitracheotomy kit is unsuitable for emergency cricothyrotomies performed by inexperienced practitioners. On the other hand, the catheter‐over‐needle technique appears to be quick, safe and reliable.

Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands

Objective:To describe the effect of implementation of a rapid response system on the composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death. Design:Pragmatic prospective Dutch multicenter before-after trial, Cost and Outcomes analysis of Medical Emergency Teams trial. Setting:Twelve hospitals participated, each including two surgical and two nonsurgical wards between April 2009 and November 2011. The Modified Early Warning Score and Situation-Background-Assessment-Recommendation instruments were implemented over 7 months. The rapid response team was then implemented during the following 17 months. The effects of implementing the rapid response team were measured in the last 5 months of this period. Patients:All patients 18 years old and older admitted to the study wards were included. Measurements and Main Results:In total, 166,569 patients were included in the study representing 1,031,172 hospital admission days. No differences were observed in patient demographics between periods. The composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death per 1,000 admissions was significantly reduced in the rapid response team versus the before phase (adjusted odds ratio, 0.847; 95% CI, 0.725–0.989; p = 0.036). Cardiopulmonary arrests and in-hospital mortality were also significantly reduced (odds ratio, 0.607; 95% CI, 0.393–0.937; p = 0.018 and odds ratio, 0.802; 95% CI, 0.644–1.0; p = 0.05, respectively). Unplanned ICU admissions showed a declining trend (odds ratio, 0.878; 95% CI, 0.755–1.021; p = 0.092), whereas severity of illness at the moment of ICU admission was not different between periods. Conclusions:In this study, introduction of nationwide implementation of rapid response systems was associated with a decrease in the composite endpoint of cardiopulmonary arrests, unplanned ICU admissions, and mortality in patients in general hospital wards. These findings support the implementation of rapid response systems in hospitals to reduce severe adverse events.

Rapid Response Systems in the Netherlands

Sixty-three (approximately 80%) of the 81 hospitals that responded to a survey sent to all hospitals in The Netherlands with nonpediatric intensive care units had a rapid response system (RRS) in place or were in the final process of starting one. Among many other findings regarding RRS infrastructure and implementation, only 38% of the hospitals allowed nurses to activate the rapid response team without physician consent.