Predicting death after CPR experience at a nonteaching community hospital with a full-time critical care staff

Background and Purpose: The FDA approved IV tPA in 1996 for the treatment of AIS. Its safety and efficacy have been demonstrated in community hospitals (CH) and it is now the standard of care; but intravenous Alteplase (IV tPA) remains underemployed. It is used in fewer than 5% of AIS patients. Short supply of neurologic manpower and concern over adverse effect contribute to this underutilization. Our hypothesis was that a combination of onsite neurohospitalists (NH), telestroke (TS), nurse stroke coordinator (NC), and education of staff and community would increase IV tPA use in a mid-sized CH PSC without compromise of safety or outcome. Methods: The hospital is a 197 bed nonprofit hospital located 60 miles from Atlanta serving a population of 350,000 in 10 counties. The hospital has been certified as a PSC since August 2004; however, the volume of AIS admissions and use of IV tPA remained low through 2008. The stroke program thus was reorganized in 2009: two full-time NH were hired to provide onsite coverage daily from 8am to 6pm, the REACH™ TS System was installed to provide the remainder of coverage, a NC was hired, and an education plan for staff and community was implemented. Patients treated with IV tPA via TS were admitted to the neuro-ICU by medical hospitalists initially with NH assuming primary care of these patients within hours. AIS admission and IV tPA use data for 2002- 2008 were compared with those for 2009 - 2012. Outcomes, assessed at discharge, 2009 - 2012 were also examined. Favorable outcome was defined as a mRS of 0 or 1. Results: From 2002-2008, 25 of 933 AIS were treated with IV tPA: 3.6 per year (2.7%). In contrast, from 2009-2012, 105 of 802 AIS received IV tPA: 26.25 per year (13%) with favorable outcome in 47 (45%). Of 64 patients treated by NH, 28 (44%) achieved favorable outcome as did 19 of 41 (46%) TS patients. These outcomes were not statistically different (p=0.92). There were 5 deaths (3 NH, 2 TS), none attributable to tPA. There were no sICH. Conclusions: A model combining NH, TS, NC, and education in a CH PSC significantly increased the use of IV tPA without compromising safety or effectiveness. Such a model may be an option where resources are limited.

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Letter to the Editor

PEDIATRICS ◽

10.1542/peds.50.3.497b ◽

1972 ◽

Vol 50 (3) ◽

pp. 497-497

Author(s):

Charles D. Cook ◽

Raymond S. Duff

Keyword(s):

Community Hospital ◽

Hospital Admissions ◽

House Staff ◽

Full Time ◽

Ivory Tower ◽

Community Hospitals ◽

Educational Value ◽

Professional Groups ◽

Letter To The Editor

We certainly agree with Dr. Rako that a fulltime Chief of Pediatrics in a Community Hospital should decrease unnecessary hospital admissions. We currently have an opportunity to reexamine the admission practices of one of the community hospitals studied earlier to see if such is the case; our preliminary findings suggest that the full-time chief, without a critical house staff, may have disappointingly little influence on the criteria used for admission. In regard to the comment of "I. M. Tired": we are having pediatricians from community hospitals review records from the "Ivory Tower" and from the community hospitals; hopefully this will have an educational value for both professional groups.

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Workforce demographics and unit structure in paediatric cardiac critical care in the United States

Cardiology in the Young ◽

10.1017/s1047951121004753 ◽

2021 ◽

pp. 1-5

Author(s):

Robin V. Horak ◽

Shasha Bai ◽

Bradley S. Marino ◽

David K. Werho ◽

Leslie A. Rhodes ◽

...

Keyword(s):

United States ◽

Critical Care ◽

Heart Surgery ◽

Age Groups ◽

The United States ◽

Work Hours ◽

Full Time ◽

Full Time Equivalent ◽

Unit Structure ◽

Cardiac Critical Care

Abstract Objective: To assess current demographics and duties of physicians as well as the structure of paediatric cardiac critical care in the United States. Design: REDCap surveys were sent by email from May till August 2019 to medical directors (“directors”) of critical care units at the 120 United States centres submitting data to the Society of Thoracic Surgeons Congenital Heart Surgery Database and to associated faculty from centres that provided email lists. Faculty and directors were asked about personal attributes and clinical duties. Directors were additionally asked about unit structure. Measurements and main results: Responses were received from 66% (79/120) of directors and 62% (294/477) of contacted faculty. Seventy-six percent of directors and 54% of faculty were male, however, faculty <40 years old were predominantly women. The majority of both groups were white. Median bed count (n = 20) was similar in ICUs and multi-disciplinary paediatric ICUs. The median service expectation for one clinical full-time equivalent was 14 weeks of clinical service (interquartile range 12, 16), with the majority of programmes (86%) providing in-house attending night coverage. Work hours were high during service and non-service weeks with both directors (37%) and faculty (45%). Conclusions: Racial and ethnic diversity is markedly deficient in the paediatric cardiac critical care workforce. Although the majority of faculty are male, females make up the majority of the workforce younger than 40 years old. Work hours across all age groups and unit types are high both on- and off-service, with most units providing attending in-house night coverage.

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Abstract 301: Identifying Critical Care Unit Organizational Factors That Impact Cardiac Arrest Incidence and Outcomes: A Report From the Pediatric Cardiac Critical Care Consortium

Circulation ◽

10.1161/circ.140.suppl_2.301 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Javier J Lasa ◽

Jeffrey A Alten ◽

Mousumi Banerjee ◽

Wenying Zhang ◽

Kurt Schumacher ◽

...

Keyword(s):

Cardiac Arrest ◽

Critical Care ◽

Critical Care Unit ◽

Organizational Factors ◽

Full Time ◽

Provider Education ◽

Multinomial Regression ◽

Clinical Registry ◽

The Impact ◽

Cardiac Critical Care

Introduction: Patient factors leading to cardiac arrest (CA) in the pediatric cardiac critical care unit (CICU) are well understood, but may be unmodifiable. Our understanding of the impact of CICU organizational factors (OFs) such as staffing models, health care provider education, and CICU bed management is limited. The association between these potentially modifiable CICU OFs on CA prevention and rescue outcomes is unknown. Hypothesis: CICU OFs associate with CA prevention and rescue. Methods: Retrospective analysis of Pediatric Cardiac Critical Care Consortium (PC4) clinical registry including data for all patients admitted to CICUs from August 2014 to March 2019. Prevention was defined as the prevalence of subjects not suffering CA. Rescue was defined as survival after CA. CICU OFs were captured via questionnaire distributed to PC4 participants in 2017 (100% response). Stratified, multivariable regression was used to evaluate associations between OFs and outcome in medical and surgical admission subgroups: competing time-to-events framework (to assess prevention) and multinomial regression (to assess rescue), accounting for clustering of patients within hospitals. Results: We analyzed 54,521 CICU admissions (59% surgical, 41% medical) from 29 hospitals with 1398 CA events (2.5%). We studied 12 OFs that varied across centers after accounting for collinearity. For both surgical and medical admissions, lower average daily occupancy (<80%) was associated with better arrest prevention for all admissions, and better rescue in the surgical cohort. Increased proportion of nurses with >2 years experience, increased proportion of nurses with critical care certification, % of full-time intensivists, % of intensivists with critical care training, dedicated respiratory therapists, quality/safety resources, and annual CICU admission volume were not associated with improved prevention or rescue. Conclusion: Our multi-institutional analysis suggests that lower average CICU occupancy was the only consistent OF evaluated that was associated with CA prevention and rescue. CICUs that have average daily occupancy >80% may need specific strategies to mitigate the risks of CA.

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Prolonged mechanical ventilation and delayed weaning

Challenging Concepts in Critical Care ◽

10.1093/med/9780198814924.003.0016 ◽

2019 ◽

pp. 243-258

Author(s):

Patrick B. Murphy ◽

Nicholas Hart

Keyword(s):

Critical Care ◽

Critical Care Unit ◽

Prolonged Mechanical Ventilation ◽

Daily Practice ◽

Care Staff ◽

Standard Textbook ◽

Long Term Ventilation ◽

Learning Points

This chapter is centred on a case study on long-term ventilation and weaning. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.

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Acute pancreatitis and renal replacement therapy

Challenging Concepts in Critical Care ◽

10.1093/med/9780198814924.003.0012 ◽

2019 ◽

pp. 179-190

Author(s):

Clinton Lobo ◽

Kim Gupta ◽

Matt Thomas

Keyword(s):

Critical Care ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Critical Care Unit ◽

Daily Practice ◽

Care Staff ◽

Evidence Based ◽

Standard Textbook ◽

Learning Points

This chapter is centred on a case study on pancreatitis and renal replacement therapy. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.

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Sedation and delirium

Challenging Concepts in Critical Care ◽

10.1093/med/9780198814924.003.0010 ◽

2019 ◽

pp. 145-160

Author(s):

Nim Pathmanathan ◽

Paul Nixon

Keyword(s):

Critical Care ◽

Intensive Care ◽

Case History ◽

Critical Care Unit ◽

Daily Practice ◽

Care Staff ◽

Evidence Based ◽

Standard Textbook ◽

Learning Points

This chapter is centred on a case study of sedation and delirium. This topic is one of the key challenging areas in critical care medicine and one that all intensive care staff will encounter. The chapter is based on a detailed case history, ensuring clinical relevance, together with relevant images, making this easily relatable to daily practice in the critical care unit. The chapter is punctuated by evidence-based, up-to-date learning points, which highlight key information for the reader. Throughout the chapter, a topic expert provides contextual advice and commentary, adding practical expertise to the standard textbook approach and reinforcing key messages.

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