Roger Daglius Dias

Patients with cirrhosis in the ED: early predictors of infection and mortality

BACKGROUND Patients with cirrhosis have high risk of bacterial infections and cirrhosis decompensation, resulting in admission to emergency department (ED). However, there are no criteria developed in the ED to identify patients with cirrhosis with bacterial infection and with high mortality risk. STUDY OBJECTIVE The objective of the study is to identify variables from ED arrival associated with bacterial infections and inhospital mortality. METHODS This is a retrospective single-center study using a tertiary hospitals database to identify consecutive ED patients with decompensated cirrhosis. Clinical variables and laboratory results were obtained by chart review. Logistic regression models were built to determine variables independently associated with bacterial infection and mortality. Scores using these variables were designed. RESULTS One hundred forty-nine patients were enrolled, most of them males (77.9%) with alcoholic cirrhosis (53%) and advanced liver disease (Child-Pugh C, 47.2%). Bacterial infections were diagnosed in 72 patients (48.3%), and 36 (24.2%) died during hospital stay. Variables independently associated with bacterial infection were lymphocytes less than or equal to 900/mm(3) (odds ratio [OR], 3.85 [95% confidence interval {CI}, 1.47-10]; P = .006) and C-reactive protein greater than 59.4 mg/L (OR, 5.05 [95% CI, 1.93-13.2]; P = .001). Variables independently associated with mortality were creatinine greater than 1.5 mg/dL (OR, 4.35 [95% CI, 1.87-10.1]; P = .001) and international normalized ratio greater than 1.65 (OR, 3.71 [95% CI, 1.6-8.61]; P = .002). Scores designed to predict bacterial infection and mortality (Mortality in Cirrhosis Emergency Department Score) had an area under the receiver operating characteristic curve of 0.82 and 0.801, respectively. The Mortality in Cirrhosis Emergency Department Score performed better than Model for End-Stage Liver Disease score. CONCLUSIONS In this cohort of ED patients with decompensated cirrhosis, lymphopenia and elevated C-reactive protein were related to bacterial infections, and elevated creatinine and international normalized ratio were related to mortality. Scores built with these variables should be prospectively validated.

Stress levels during emergency care: A comparison between reality and simulated scenarios

PURPOSE Medical simulation is fast becoming a standard of health care training throughout undergraduate, postgraduate and continuing medical education. Our aim was to evaluate if simulated scenarios have a high psychological fidelity and induce stress levels similarly to real emergency medical situations. MATERIALS AND METHODS Medical residents had their stress levels measured during emergency care (real-life and simulation) in baseline (T1) and immediately post-emergencies (T2). Parameters measuring acute stress were: heart rate, systolic and diastolic blood pressure, salivary α-amylase, salivary interleukin-1β, and State-Trait Anxiety Inventory score. RESULTS Twenty-eight internal medicine residents participated in 32 emergency situations (16 real-life and 16 simulated emergencies). In the real-life group, all parameters increased significantly (P < .05) between T1 and T2. In the simulation group, only heart rate and interleukin-1β increased significantly after emergencies. The comparison between groups demonstrates that acute stress response (T2 - T1) and State-Trait Anxiety Inventory score (in T2) did not differ between groups. CONCLUSIONS Acute stress response did not differ between both groups. Our results indicate that emergency medicine simulation may create a high psychological fidelity environment similarly to what is observed in a real emergency room.

Acute stress in residents during emergency care: a study of personal and situational factors

Abstract Providing care for simulated emergency patients may induce considerable acute stress in physicians. However, the acute stress provoked in a real-life emergency room (ER) is not well known. Our aim was to assess acute stress responses in residents during real emergency care and investigate the related personal and situational factors. A cross-sectional observational study was carried out at an emergency department of a tertiary teaching hospital. All second-year internal medicine residents were invited to voluntarily participate in this study. Acute stress markers were assessed at baseline (T1), before residents started their ER shift, and immediately after an emergency situation (T2), using heart rate, systolic, and diastolic blood pressure, salivary α-amylase activity, salivary interleukin-1 β, and the State-Trait Anxiety Inventory (STAI-s and STAI-t). Twenty-four residents were assessed during 40 emergency situations. All stress markers presented a statistically significant increase between T1 and T2. IL-1 β presented the highest percent increase (141.0%, p < .001), followed by AA (99.0%, p = .002), HR (81.0%, p < .001), DBP (8.0%, p < .001), and SBP (3.0%, p < .001). In the multivariable analysis, time of residency had a negative correlation with HR during the emergency (adjusted R-square = .168; F = 8.69; p = .006), SBP response (adjusted R-square = .210; F = 6.19; p = .005) and DBP response (adjusted R-square = .293; F = 9.09; p = .001). Trait anxiety (STAI-t) was positively correlated with STAI-s (adjusted R-square = .326; F = 19.9; p < .001), and number of procedures performed during emergency care had a positive association with HR response (adjusted R-square = .241; F = 5.02; p = .005). In the present study, emergency care provoked substantial acute stress in residents. Resident experience, trait anxiety, and number of emergency procedures were independently associated with acute stress response.

Intelligent Interruption Management System to Enhance Safety and Performance in Complex Surgical and Robotic Procedures

Procedural flow disruptions secondary to interruptions play a key role in error occurrence during complex medical procedures, mainly because they increase mental workload among team members, negatively impacting team performance and patient safety. Since certain types of interruptions are unavoidable, and consequently the need for multitasking is inherent to complex procedural care, this field can benefit from an intelligent system capable of identifying in which moment flow interference is appropriate without generating disruptions. In the present study we describe a novel approach for the identification of tasks imposing low cognitive load and tasks that demand high cognitive effort during real-life cardiac surgeries. We used heart rate variability analysis as an objective measure of cognitive load, capturing data in a real-time and unobtrusive manner from multiple team members (surgeon, anesthesiologist and perfusionist) simultaneously. Using audio-video recordings, behavioral coding and a hierarchical surgical process model, we integrated multiple data sources to create an interactive surgical dashboard, enabling the identification of specific steps, substeps and tasks that impose low cognitive load. An interruption management system can use these low demand situations to guide the surgical team in terms of the appropriateness of flow interruptions. The described approach also enables us to detect cognitive load fluctuations over time, under specific conditions (e.g. emergencies) or in situations that are prone to errors. An in-depth understanding of the relationship between cognitive overload states, task demands, and error occurrence will drive the development of cognitive supporting systems that recognize and mitigate errors efficiently and proactively during high complex procedures.

Prognostication in urgent intensive care unit referrals: a cohort study

Objectives Prognostication is an essential ability to clinicians. Nevertheless, it has been shown to be quite variable in acutely ill patients, potentially leading to inappropriate care. We aimed to assess the accuracy of physician’s prediction of hospital mortality in acutely deteriorating patients referred for urgent intensive care unit (ICU) admission. Methods Prospective cohort of acutely ill patients referred for urgent ICU admission in an academic, tertiary hospital. Physicians’ prognosis assessments were recorded at ICU referral. Prognosis was assessed as survival without severe disabilities, survival with severe disabilities or no survival. Prognosis was further dichotomised in good prognosis (survival without severe disabilities) or poor prognosis (survival with severe disabilities or no survival) for prediction of hospital mortality. Results There were 2374 analysed referrals, with 2103 (88.6%) patients with complete data on mortality and physicians’ prognosis. There were 593 (34.4%), 215 (66.4%) and 51 (94.4%) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p<0.001). Sensitivity was 31%, specificity was 91% and the area under the receiver operating characteristic curve was 0.61 for prediction of mortality. After multivariable analysis, severity of illness, performance status and ICU admission were associated with an increased likelihood of incorrect classification, while worse predicted prognosis was associated with a lower chance of incorrect classification. Conclusions Physician’s prediction was associated with hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect risk of poor prognosis.

Toward improving surgical outcomes by incorporating cognitive load measurement into process-driven guidance

This paper summarizes the accomplishments and recent directions of our medical safety project. Our process-based approach uses a detailed, rigorously-defined, and carefully validated process model to provide a dynamically updated, context-aware and thus, “Smart” Checklist to help process performers understand and manage their pending tasks [7]. This paper focuses on support for teams of performers, working independently as well as in close collaboration, in stressful situations that are life critical. Our recent work has three main thrusts: provide effective real-time guidance for closely collaborating teams; develop and evaluate techniques for measuring cognitive load based on biometric observations and human surveys; and, using these measurements plus analysis and discrete event process simulation, predict cognitive load throughout the process model and propose process modifications to help performers better manage high cognitive load situations. This project is a collaboration among software engineers, surgical team members, human factors researchers, and medical equipment instrumentation experts. Experimental prototype capabilities are being built and evaluated based upon process models of two cardiovascular surgery processes, Aortic Valve Replacement (AVR) and Coronary Artery Bypass Grafting (CABG). In this paper we describe our approach for each of the three research thrusts by illustrating our work for heparinization, a common subprocess of both AVR and CABG. Heparinization is a high-risk error-prone procedure that involves complex team interactions and thus highlights the importance of this work for improving patient outcomes.

Acute stress in residents playing different roles during emergency simulations: a preliminary study

Objectives To investigate acute stress response in residents playing nurse and physician roles during emergency simulations. Methods Sixteen second-year internal medicine residents participated in teams of four (two playing physician roles and two playing nurse roles). Stress markers were assessed in 24 simulations at baseline (T1) and immediately after the scenario (T2), using heart rate, systolic and diastolic blood pressure, salivary α-amylase, salivary cortisol and salivary interleukin-1β. The State-Trait Anxiety Inventory was applied at T2. Continuous data were summarized for the median (1st-3rd interquartile ranges), and the Mann-Whitney U Test was used to compare the groups. Results The percent variations of the stress markers in the physician and nurse roles, respectively, were the following: heart rate: 70.5% (46.0-136.5) versus 53.0% (29.5-117.0), U=89.00, p=0.35; systolic blood pressure: 3.0% (0.0-10.0) versus 2.0% (-2.0-9.0), U=59.50, p=0.46; diastolic blood pressure: 5.5% (0.0-13.5) versus 0.0% (0.0-11.5), U=91.50, p=0.27; α-amylase: -5.35% (-62.70-73.90) versus 42.3% (12.4-133.8), U=23.00, p=0.08; cortisol: 35.3% (22.2-83.5) versus 42.3% (12.4-133.8), U=64.00, p=0.08); and interleukin-1β: 54.4% (21.9-109.3) versus 112.55% (29.7-263.3), U= 24.00, p=0.277. For the physician and nurse roles, respectively, the average heart rate was 101.5 (92.0-104.0) versus 91.0 (83.0-99.5) beats per minute, U=96.50, p=0.160; and the state anxiety inventory score was 44.0 (40.0-50.0) versus 42.0 (37.50-48.0) points, U= 89.50, p=0.319. Conclusions Different roles during emergency simulations evoked similar participants’ engagement, as indicated by acute stress levels. Role-play strategies can provide high psychological fidelity for simulation-based training, and these results reinforce the potential of role-play methodologies in medical education.