A Video Based Training Program Improves Defibrillator Inspection Compliance

A Video Based Training Program Improves Defibrillator Inspection Compliance

Research Forum Abstracts patients experiencing a single CA (RR=0.66 95%CI: (0.54,0.82)) Mean time to recurrence was 17hrs (SD 42.2 hrs) but median tim...

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Research Forum Abstracts patients experiencing a single CA (RR=0.66 95%CI: (0.54,0.82)) Mean time to recurrence was 17hrs (SD 42.2 hrs) but median time to recurrence was only 2.7 hours (IQR: 0.87-8.48 hours). While 58% of recurrences occurred in the ICU, 29% occurred in the ED. Controlling for other factors, ED arrest survivors were significantly more likely to survive until hospital discharge if their second arrest occurred in a cardiac catheterization lab (48%) than if it occurred in the ED or ICU (14%; RR=3.5 95% CI: (2.3,5.5)). Factors associated with sustaining recurrent cardiopulmonary arrest include younger age (60.9 vs. 64.1 years; p=0.000) and female gender (RR=1.2 95%CI: (1.0,1.4)). Initial rhythm was not associated with arrest recurrence, although patients who sustained a shockable rhythm initially were significantly more likely to have shockable rhythm on recurrence. Conclusion: Recurrent cardiac arrest is common in ED arrest survivors, and 75% of recurrent arrests occur within 8.5 hours. Patient factors and discharge survival outcome are different for single vs recurrent cardiac arrest patients in the ED.

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The Assessment of Lactate, Apache II Scores and the Revised Lactate Score to Predict Severity of Illness in Critically Ill Patients

Bilkovski R, Coghlan P, Smith M, Boyar E, Garcia AJ, DeMott M, Henry Ford Hospital, Detroit, MI

Study Objectives: The ability to adequately recognize critically ill patients and provide timely resuscitative interventions is the mainstay of the Early Goal Directed Therapy (EGDT) mantra. Previous research has demonstrated the predictive value of severity of illness scoring with respect to lactate, APACHE II scores as well as other variables. Patients with mismatch between oxygen delivery and oxygen consumption can be identified by measuring central venous oximetry (ScvO2) and this serves as a key resuscitation endpoint in the EGDT algorithm. The purpose of this study was to investigate the relationship of ScvO2 and a revised lactate as severity of illness markers. Methods: A prospective study between 10/10/2004 and 4/15/2005 was conducted at an urban ED with an annual patient volume over 90,000. Inclusion criteria: adults (O17 yoa) that required central venous access for the purposes of monitoring central venous pressure and/or central venous oximetry. Exclusion criteria: pregnancy. This was an observational, prospective study that collected data on: lactate, ScvO2, APACHE II scores, hospital length of stay (LOS), ICU LOS and hospital disposition. A revised lactate score was derived based on the following premise - given a normal ScvO2 of 70%, any deviation from this value is anticipated to portend a worse prognosis. The revised lactate score is calculated as follows: LACT(mod)=lactate/[1 - abs(ScvO2 - .70)]. Data were analyzed using descriptive statistics, sensitivity and specificity, as well as correlation analysis (where appropriate). Results: In total 47 patients were evaluated, with 46 having a lactate documented and 40 with ScvO2 monitoring in addition to lactate measurements. In these 40 cases, the mean APACHE II, lactate and ScvO2 were 20.0G8.0, 4.9G2.9, 64.3G18.3, respectively. Among these three variables, only APACHE II (r=0.51, p=0.001) and lactate (r=0.42, p=0.008) demonstrated significant correlations with hospital disposition(death). The revised lactate score demonstrated identical correlation to that of lactate. At the conventional lactate cutoff value of 4.0 mmol/L, we obtained sensitivity of 67% and specificity of 47% for mortality. The revised lactate at the same 4.0 cutoff realized sensitivity of 83% and specificity of 38%. Both values demonstrated increased LRC for mortality at increasing cutpoints. The lactate, however, demonstrated greater specificity and LRCat increased cutpoints (see Table). Conclusion: An elevated lactate above 4 mmol/L has been identified as a poor prognosticated indicator of patients with critical illness. In addition, abnormal ScvO2 levels identify abnormality in the balance between oxygen delivery and extraction which would infer greater perturbations of illness severity. Both lactate and revised lactate scores demonstrated increased liklihood for the detection of mortality with the former showing a greater benefit. The revised lactate score needs further evaluation across a wider number of patients to better elucidate its role as a severity of illness marker.

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Inter-Rater Agreement of a Non-Invasive Ultrasound Cardiac Output Monitoring (USCOM) Device in Emergency Department Patients

Losey T, Nguyen HB, Corbett SW, Wittlake WA, Loma Linda University, Loma Linda, CA

Objectives: The ultrasound cardiac output monitor (USCOM, USCOM Pty Ltd, Australia) has been shown to be a potential non-invasive alternative to the pulmonary artery catheter as a hemodynamic monitoring tool. The purpose of this study is to investigate the inter-rater agreement of the USCOM monitor when used in emergency department (ED) patients. Methods: This is a prospective study performed in a 32-bed adult ED of an academic tertiary center with approximately 60,000 annual patient visits. Patients were enrolled after verbal consent. The USCOM device operators included physicians, students, nurses and paramedics. Operators were instructed using a standard protocol. Paired measurements of cardiac index (CI) and stroke volume index (SVI) were obtained at the suprasternal notch by two blinded operators. Abnormal CI is defined as \2.5 L/min/m2 and abnormal SVI defined as \35 ml/m2. Pearson’s correlation and Kappa analysis were used to determine the inter-rater agreement between measurements. Results: A convenience sample of forty-nine (23 female and 26 male) patients with age 52.1G22.0 years was enrolled. Fifty-two paired measurements were performed in 44 (out of 49) patients in whom adequate ultrasound signal was obtainable. Amongst the 104 measurements, 29 were by attendings, 16 residents, 37 medical students, 19 nurses, and 3 paramedics. CI correlated between two operators with r2=0.87 (95% CI 0.83-1.04; p-value \0.001), and Kappa=0.84. SVI correlated between two operators with r2=0.84 (95% CI 0.80-1.03; p-value \0.001), and Kappa=0.80. Conclusions: The USCOM is a feasible non-invasive hemodynamic monitoring device in the ED with acceptable inter-rater agreement when utilized by ED personnel involved in patient care. Its ease of use suggests further study is needed to examine the utility of this device in the hemodynamic assessment and resuscitation of critically ill patients presenting to the ED.

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A Video Based Training Program Improves Defibrillator Inspection Compliance

Adams BD, Shih H, Stuffel E, Robinson A, Brooke Army Medical Center, San Antonio, TX

Introduction: Improperly maintained defibrillators comprise an important cause of defibrillation delay or failure during in-hospital cardiac arrest. We researched whether a brief training video of how to properly inspect crash carts and defibrillators would improve the quality and frequency of these inspections. Methods: The study was a before-after cohort design. We explicitly examined the crash cart inspection logs and interrogated the electronic archive records of the defibrillator. We compared the compliance and quality of inspections before and after implementation of the training video program. Results: The defibrillator missed inspection rate significantly improved from 6.9% to 8.9% (p=0.037) after video training program implementation. The crash cart missed inspection rate, however, actually worsened from 2.7% before to 8.0% (p=0.0001). Discussion: Introduction of a new crash cart inspection training video program improved the frequency and the quality of defibrillator inspections, but not crash cart inspections. Inspection of crash carts and defibrillators is a vital hospital task. Because training time for clinical personnel is limited, our 15 minute video can be viewed on a ward computer workstation at the most convenient time.

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The Effects Of Inducing Mild Hypothermia Via Peripheral Intravenous Fluids On Core Body Temperature

Vogrin TM, Callaway C, Hostler D, University of Pittsburgh, Pittsburgh

Objective: Studies have suggested that inducing mild hypothermia (32-34  C) improves neurologic outcomes after traumatic brain injury, major stroke, traumatic hemorrhage, and cardiac arrest. It has been suggested that one method to decrease core body temperature may be the rapid infusion of cold intravenous fluids. Our objective was to determine the effects of peripheral cold intravenous fluids on core body temperature. A second objective was to assess the effects of mild hypothermia on patient comfort. Methods: Eleven healthy subjects (ages 18 - 35, mean 25G4 years; 6 male, 5 female) were randomized to two study groups. A physical examination, urine

S18 Annals of Emergency Medicine

Volume 46, no. 3 : September 2005