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Emergency Medicine Physician in Einstein Medical Center Philadelphia
Keynote: Electronic Trigger Tool Improves Early Identification, Management, and Survivorship of Emergency Department Severe Sepsis Patients
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John J. Kelly is an Emergency Medicine Physician in Einstein Medical Center Philadelphia Department of Emergency Medicine 5501 Old York Road Philadelphia.
Background: Sepsis identification and timely management is critical, yet it can be difficult to efficiently assess the individual vital signs and lab values that indicate sepsis, as data may arrive at disparate times. We implemented an electronic sepsis tool as part of our EMR triggered by SIRS and sepsis organ dysfunction criteria. The purpose of our study is to determine if our electronic tool will result in increased identification of patients with sepsis, successful completion of the 3-hour bundle (blood cultures drawn, antibiotics given, 30cc/kg normal saline), and improved survivorship compared to previous bedside checklist.
Methods: We performed a prospective, observational study of patients in our ED between March 2016 and December 2017, before and after the implementation of an electronic screening tool in January 2016. In 2016, providers screened for evidence of SIRS/Sepsis and completed the 3-hour bundle using a bedside checklist tool. In January 2017, an electronic sepsis alert was implemented using: (Temp >38.4°C or < 36°C; HR >110; Resp Rate >28, WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands), lactate level >2 mmol/l, Δ Creatinine ≥ 0.5, INR ≥ 2.0, and bilirubin >2.1 mg/dcl. The alert would prompt the use of an electronic checklist consisting of the 3-hour bundle requirements. Outcomes measured included: the number of patients identified use of the electronic sepsis tool, confirmed cases of sepsis, compliance with the 3-hour bundle, in addition to survivorship.
Results: Between March 2016 and December 2016, a bedside checklist identified 143 patients meeting SIRS criteria, and 137 patients were confirmed sepsis (96%). During this period, 63 (44%) had the 3-hour bundle completed. Between January 2017 and December 2017, the implementation of an electronic trigger tool identified 760 patients meeting sepsis alert criteria; 520 (68%) were confirmed cases of sepsis, and 401 (77%) were compliant with the 3-hour bundle. Prior to the implementation of the electronic trigger tool survivorship for severe sepsis and/or septic shock was 65.23%. Following the implementation of the trigger tool survivorship improved to 73.25%.
Conclusion: The implementation of an electronic screening tool at our institution substantially increased identification of patients with potential and confirmed sepsis, increased compliance in the 3-hour bundle, and survivorship. Based on our study, the electronic sepsis tool is a superior screening tool over a bedside tool and traditional reliance on providers’ awareness and identification of patients with possible sepsis
Medical Director, Emergency Care Training, Hong Kong and Shenzhen
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Au Kin Heng Constantine is an emergency specialist from Hong Kong who used to work at Queen Elizabeth Hospital, Hong Kong. Together with Dr. Gary Chu, Constantine founded the emergency room at the University of Hong Kong-Shenzhen Hospital, Shenzhen. Constantine is now the Medical Director of ECT-HK/SZ. In terms of experience in medical coverage, Constantine served in the Oxfam Trailwalker, Hong Kong, from 2002 to 2010, the Beijing 2008 Summer Olympic Games (Equestrian Event), the East Asian Games 2009 (Hong Kong), the 16th Asian Games (Guangzhou, 2010) and Rugby 7, Nanjing 2014 Youth Olympics (YOG).
Medical coverage at mass events, especially sports events, is a popular sub-branch of care among emergency physicians and emergency nurses in Hong Kong. There is often a misconception that sports event coverage depends on the expertise of orthopedic surgeons. As generalists, emergency physicians and emergency nurses can handle medical emergencies such as exercise-induced asthma, cardiac arrest and gastroenteritis outbreak, and traumas such as joint dislocation and wounds. In addition, emergency physicians and emergency nurses are familiar with both prehospital care service and emergency room service. The Hong Kong College of Emergency Medicine has established a Sports Medicine Subcommittee for more than ten years. In terms of work, medical coverage involves the pre-event stage, the event stage and the post-event stage. The pre-event stage involves recruitment of personnel, training and drills and preparation of equipment. The event stage involves skills beyond those found in the emergency room. The most important concept is to take care of the sick but not to overcrowd an already busy emergency room. The post-event stage involves evaluation and improvement of service. In terms of mentality, medical coverage involves consideration of clinical needs, logistics and politics (power and relationships). Clinical consideration is relatively easy for emergency physicians and emergency nurses. With respect to logistics and politics, things are not that straightforward. I would like to share my experience in the medical coverage of the Rugby 7, Nanjing 2014 Youth Olympics (YOG).
Northwest London Hospital NHS Trust, London, United Kingdom
Keynote: Do-Not-Attempt-Cardiopulmonary-Resuscitation practices in acute care for older adults – a qualitative study
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Dr Sofia Cavill has completed her medical school training at Guy’s Kings & St Thomas’ School of Medicine, London where she achieved an honours in her MBBS degree. She then went on to complete her postgraduate studies at Kings College London where she obtained an MSc in Gerontology and Ageing in 2017, as well as a Post-graduate diploma (PGDip) in Clinical Dermatology from Queen Mary University London (QMUL) in 2015. She is currently a Senior Specialist Registrar in Acute and General Internal Medicine with a special interest in Frailty and Geriatrics in the Acute Medical Unit and is a member of the Royal College of Physicians (MRCP (UK)).
Background: Older adults are more likely to receive Do-not-attempt-cardiopulmonary-resuscitation (DNACRP) orders when they are admitted to hospitals compared to younger patients, yet little is known of the impact these orders have on the every day care of older patients.
Objectives: To understand staff perceptions on issues surrounding current DNACPR practices involving older adults in the acute setting, and elicit the influences of DNACPR decisions on care for older adults.
Design: A qualitative approach was used. Semi-structured interviews were conducted with 15 health professionals from multiple disciplines, working in geriatric medicine wards, in a district general National Health Service (NHS) hospital in the United Kingdom (UK).
Results: All participants supported the use of DNACPR orders in older adults but agree on the unintended repercussions to care beyond what the order stipulates. Four key themes have been identified surrounding DNACPR practices in older adults including: complex decision-making, challenging discussions, staff’s reflections of its impact on care and its benefits to geriatric medicine.
Conclusion: Hospital DNACPR practices in older adults can be variable with DNACPR decisions having unintended negative influences to care. Nevertheless, staff in geriatric medicine strongly support its use in older adults which staff felt led to a more holistic care with discussions often used as platforms for conversations on wider aspects of care. Perhaps incorporating DNACPR decisions into formal care plans, and increasing staff education on resuscitation policies may help standardize practices and remedy its negative influence on care.