Naomi George

Palliative Care Screening and Assessment in the Emergency Department: A Systematic Review.

CONTEXT Emergency department (ED) providers and policy makers are increasingly interested in developing palliative care (PC) interventions for ED patients. Many patients in the ED may benefit from PC screening and referral. Multiple ED-based PC screening projects have been undertaken, but there has been no study of these projects or their effects. OBJECTIVES To conduct a systematic review and critical analysis to evaluate the methods, tools, and outcomes of PC screening and referral projects in the ED. METHODS Three reviewers independently selected eligible studies from the PubMed database. Eligible studies evaluated a PC screening tool, assessment, or referral modality aimed at identifying patients appropriate for PC. Four reviewers independently evaluated the final articles. Two reviewers extracted data on study characteristics, methodological quality, and outcomes. RESULTS Seven studies met inclusion criteria. Each was reviewed for methodological quality and strength. The studies were synthesized using a narrative approach. Each study developed an independent screening or evaluation tool for PC needs. Each required additional ED personnel to perform screening and referral, and success was limited by availability of specialized personnel. All the studies were successful in increasing rates of PC referral. CONCLUSION We have identified multiple studies demonstrating that screening and referral for PC consultation are feasible in the ED setting. The strengths and limitations of these studies were explored. Further evidence for the development of an effective, evidence-based PC screening, and referral process is needed. We recommend a screening framework based on a synthesis of available evidence.

Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathing critically-ill patients

Purpose: Measurement of inferior vena cava collapsibility (cIVC) by point‐of‐care ultrasound (POCUS) has been proposed as a viable, non‐invasive means of assessing fluid responsiveness. We aimed to determine the ability of cIVC to identify patients who will respond to additional intravenous fluid (IVF) administration among spontaneously breathing critically‐ill patients. Methods: Prospective observational trial of spontaneously breathing critically‐ill patients. cIVC was obtained 3 cm caudal from the right atrium and IVC junction using POCUS. Fluid responsiveness was defined as a ≥ 10% increase in cardiac index following a 500 ml IVF bolus; measured using bioreactance (NICOM™, Cheetah Medical). cIVC was compared with fluid responsiveness and a cIVC optimal value was identified. Results: Of the 124 participants, 49% were fluid responders. cIVC was able to detect fluid responsiveness: AUC = 0.84 [0.76, 0.91]. The optimum cutoff point for cIVC was identified as 25% (LR + 4.56 [2.72, 7.66], LR‐ 0.16 [0.08, 0.31]). A cIVC of 25% produced a lower misclassification rate (16.1%) for determining fluid responsiveness than the previous suggested cutoff values of 40% (34.7%). Conclusion: IVC collapsibility, as measured by POCUS, performs well in distinguishing fluid responders from non‐responders, and may be used to guide IVF resuscitation among spontaneously breathing critically‐ill patients. HIGHLIGHTSIVC collapsibility, as measured by POCUS, is able to detect fluid responsiveness.Use of a passive leg raise did not improve detection of fluid responsiveness.The optimum cutoff point for IVC collapsibility is cIVC = 25%.cIVC, measured by POCUS may be used to direct fluid resuscitation.

Shared Decision Making to Support the Provision of Palliative and End‐of‐Life Care in the Emergency Department: A Consensus Statement and Research Agenda

BACKGROUND Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED). OBJECTIVE The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED. METHODS Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement. CONCLUSION Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.

Content Validation of a Novel Screening Tool to Identify Emergency Department Patients With Significant Palliative Care Needs

BACKGROUND The emergency department (ED) is increasingly used by patients with life-limiting illness. These patients are frequently admitted to the hospital, where they suffer from poorly controlled symptoms and are often subjected to marginally effective therapies. Palliative care (PC) has emerged as the specialty that cares for patients with advanced illness. PC has been shown to reduce symptoms, improve quality of life, and decrease resource utilization. Unfortunately, most patients who could benefit from PC are never identified. At present, there exists no validated screening tool to identify significant unmet PC needs among ED patients with life-limiting illness. OBJECTIVES The objective was to develop a simple, content-valid screening tool for use by ED providers to identify ED patients with significant PC needs. A positive screen would result in an inpatient PC consultation. METHODS An initial screening tool was developed based on a critical review of the literature. Content validity was determined by a two-round modified Delphi technique using a panel of PC experts. The expert panel reviewed the items of the tool for accuracy and necessity using a Likert scale and provided narrative feedback. Experts responses were aggregated and analyzed to revise the tool until consensus was achieved. Greater than 80% agreement, as well as meeting Lawshes critical values, was required to achieve consensus. RESULTS Fifteen experts completed two rounds of surveys to reach consensus on the content validity of the tool. Three screening items were accepted with minimal revisions. The remaining items were revised, condensed, or eliminated. The final tool contains 13 items divided into three steps: 1) presence of a life-limiting illness, 2) unmet PC needs, and 3) hospital admission. The majority of panelists (86%) endorsed adoption of the final screening tool. CONCLUSIONS Use of a modified Delphi technique resulted in the creation of a content-validated screening tool for identification of ED patients with significant unmet PC needs. Further validation testing of the instrument is warranted.

Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda

Introduction Injury accounts for 9.6% of the global mortality burden, disproportionately affecting those living in low- and middle-income countries. In an effort to improve trauma care in Rwanda, the Ministry of Health developed a prehospital service, Service d’Aide Médicale Urgente (SAMU), and established an emergency medicine training program. However, little is known about patients receiving prehospital and emergency trauma care or their outcomes. The objective was to develop a linked prehospital–hospital database to evaluate patient characteristics, mechanisms of injury, prehospital and hospital resource use, and outcomes among injured patients receiving acute care in Kigali, Rwanda. Methods A retrospective cohort study was conducted at University Teaching Hospital – Kigali, the primary trauma centre in Rwanda. Data was included on all injured patients transported by SAMU from December 2012 to February 2015. SAMU’s prehospital database was linked to hospital records and data were collected using standardised protocols by trained abstractors. Demographic information, injury characteristics, acute care, hospital course and outcomes were included. Results 1668 patients were transported for traumatic injury during the study period. The majority (77.7%) of patients were male. The median age was 30 years. Motor vehicle collisions accounted for 75.0% of encounters of which 61.4% involved motorcycles. 48.8% of patients sustained injuries in two or more anatomical regions. 40.1% of patients were admitted to the hospital and 78.1% required surgery. The overall mortality rate was 5.5% with nearly half of hospital deaths occurring in the emergency centre. Conclusion A linked prehospital and hospital database provided critical epidemiological information describing trauma patients in a low-resource setting. Blunt trauma from motor vehicle collisions involving young males constituted the majority of traumatic injury. Among this cohort, hospital resource utilisation was high as was mortality. This data can help guide the implementation of interventions to improve trauma care in the Rwandan setting.

Prognosis After Emergency Department Intubation to Inform Shared Decision-Making.

To inform the shared decision‐making process between clinicians and older adults and their surrogates regarding emergency intubation.

Development of a trauma and emergency database in Kigali, Rwanda

Introduction Injuries account for 10% of the global burden of disease, resulting in approximately 5.8 million deaths annually. Trauma registries are an important tool in the development of a trauma system; however, limited resources in low- and middle-income countries (LMIC) make the development of high-quality trauma registries challenging. We describe the development of a LMIC trauma registry based on a robust retrospective chart review, which included data derived from prehospital, emergency centre and inpatient records. Methods This paper outlines our methods for identifying and locating patients and their medical records using pragmatic and locally appropriate record linkage techniques. A prehospital database was queried to identify patients transported to University Teaching Hospital – Kigali, Rwanda from December 2012 through February 2015. Demographic information was recorded and used to create a five-factor identification index, which was then used to search OpenClinic GA, an online open source hospital information system. The medical record number and archive number obtained from OpenClinic GA were then used to locate the physical medical record for data extraction. Results A total of 1668 trauma patients were transported during the study period. 66.7% were successfully linked to their medical record numbers and archive codes. 94% of these patients were successfully linked to their medical record numbers and archive codes were linked by four or five of the five pre-set identifiers. 945 charts were successfully located and extracted for inclusion in the trauma registry. Record linkage and chart extraction took approximately 1256 h. Conclusion The process of record linkage and chart extraction was a resource-intensive process; however, our unique methodology resulted in a high linkage rate. This study suggests that it is feasible to create a retrospective trauma registry in LMICs using pragmatic and locally appropriate record linkage techniques.

308: IVC COLLAPSIBILITY SHOWS PROMISE IN DETECTING FLUID RESPONSIVENESS AMONG CRITICALLY ILL PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) 95% CI, 1.023–1.105; p=0.002), and continuous NMB requirement (HR, 0.636; 95% CI, 0.422–0.957; p=0.030) compared to no NMB were associated with six-month mortality. However, the serum lactate level (p=0.658) and lactate clearance (p=0.440) were not different among NMB groups. Conclusions: Continuous NMB requirement rather than no NMB was associated with six-month survival in cardiac arrest survivors treated with TH. The method of NMB use was not associated with serum lactate level and lactate clearance.