BACKGROUND:Emergency physicians (EPs) perform critical actions while operating with diagnostic uncertainty. Point-of-care ultrasound (POCUS) is useful in evaluation of dyspneic patients. In prior studies, POCUS is often performed by ultrasound (US) teams without patient care responsibilities. OBJECTIVES:This study evaluates the effectiveness of POCUS in narrowing diagnostic uncertainty in dyspneic patients when performed by treating EPs vs. separate US teams. METHODS:This multicenter, prospective noninferiority cohort study investigated the effect of a POCUS performing team in patient encounters for dyspnea. Before-and-after surveys assessing medical decision-making were administered to attending physicians. Primary outcome was change in most likely diagnosis after POCUS. This was assessed for noninferiority between encounters where the primary or US team performed POCUS. Secondary outcomes included change in differential diagnosis, confidence in diagnosis, interventions considered, and image quality. RESULTS:There were 156 patient encounters analyzed. In the primary team group, most likely diagnosis changed in 40% (95% confidence interval 28-52%) of encounters vs. 32% (95% confidence interval 22-41%) in the US team group. This was noninferior using an a priori specified margin of 20% (p < .0001). Post-POCUS differential decreased by a mean 1.8 diagnoses and was equivalent within a margin of 0.5 diagnoses between performing teams (p = 0.034). Other outcomes were similar between groups. CONCLUSION:POCUS performed by primary teams was noninferior to POCUS performed by US teams for changing the most likely diagnosis, and equivalent when considering mean reduction in number of diagnoses. POCUS performed by treating EPs reduces cognitive burden in dyspneic patients.

BACKGROUND:COVID-19 has a widely variable clinical syndrome that is difficult to distinguish from bacterial sepsis, leading to high rates of antibiotic use. Early studies indicate low rates of secondary bacterial infections (SBIs) but have included heterogeneous patient populations. Here, we catalogue all SBIs and antibiotic prescription practices in a population of mechanically ventilated patients with COVID-19 induced acute respiratory distress syndrome (ARDS).METHODS:This was a retrospective cohort study of all patients with COVID-19 ARDS requiring mechanical ventilation from 3 Seattle, Washington hospitals in 2020. Data were obtained via electronic and manual review of the electronic medical record. We report the incidence and site of SBIs, mortality, and antibiotics per day using descriptive statistics.RESULTS:We identified 126 patients with COVID-19 induced ARDS during the study period. Of these patients, 61% developed clinical infection confirmed by bacterial culture. Ventilator associated pneumonia was confirmed in 55% of patients, bacteremia in 20%, and urinary tract infection (UTI) in 17%. Staphylococcus aureus was the most commonly isolated bacterial species. A total of 97% of patients received antibiotics during their hospitalization, and patients received nearly one antibiotic per day during their hospital stay.CONCLUSIONS:Mechanically ventilated patients with COVID-19 induced ARDS are at high risk for secondary bacterial infections and have extensive antibiotic exposure.

Introduction:The Emergency Critical Care Center (EC3) is an emergency department-based intensive care unit (ED-ICU) designed to improve timely access to critical care for ED patients.ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of ED-ICU clinicians.The timing of patient transfers to the ED-ICU may decrease the number of handoffs between main ED teams and have an impact on both patient outcomes and optimal provider staffing models, but has not previously been studied.We aimed to analyze patterns of transfer to the ED-ICU and the relationship with shift turnover times in the main ED.We hypothesized that the number of transfers to the ED-ICU increases near main ED shift turnover times.Methods: An electronic health record search identified all patients managed in the ED and ED-ICU in 2016 and 2017.We analyzed the number of ED arrivals per hour, the number of ED-ICU consults per hour, the time interval from ED arrival to ED-ICU consult, the distribution throughout the day, and the relationship with shift turnover times in the main ED.Results: A total of 160,198 ED visits were queried, of which 5308 (3.3%) were managed in the ED-ICU.ED shift turnover times were 7 am, 3 pm, and 11 pm.The mean number of ED-ICU consults placed per hour was 221 (85 standard deviation), with relative maximums occurring near ED turnover times: 10:31 pm -11:30 pm (372) and 2:31 pm -3:30 pm (365).The minimum was placed between 7:31 am -8:30 am (88), shortly after the morning ED turnover time.The median interval from ED arrival time to ED-ICU consult order was 161 minutes (range 6-1,434; interquartile range 144-174).Relative minimums were observed for patients arriving shortly prior to ED turnover times: 4:31 am -5:30 am (120 minutes [min]), 12:31 pm -1:30 pm (145 min), and 9:31 pm -10:30 pm (135 min).Relative maximums were observed for patients arriving shortly after ED turnover times: 7:31 am -8:30 am (177 min), 4:31 pm -5:30 pm (218 min), and 11:31 pm -12:30 am (179 min). Conclusion:ED-ICU utilization was highest near ED shift turnover times, and utilization was dissimilar to overall ED arrival patterns.Patients arriving immediately prior to ED shift turnover received earlier consults to the ED-ICU, suggesting these patients may have been preferentially transferred to the ED-ICU rather than signed out to the next team of emergency clinicians.These findings may guide operational planning, staffing models, and timing of shift turnover for other institutions implementing ED-ICUs.Future studies could investigate whether an ED-ICU model improves critically ill patients' outcomes by minimizing ED provider handoffs.

VanDyck, Tyler; Hebert, Christopher; Whitmore, Sage; Gunnerson, Kyle; Haft, Jonathan; Lynch, William; Waldvogel, John; Rooney, Deborah; Weinberg, Allison; Neumar, Robert Author Information

Background: Extracorporeal cardiopulmonaryresuscitation (ECPR) is emerging as a viable rescue strategy for refractory out-of-hospital cardiac arrest. In the U.S., limited training of emergency medicine providers is a barrier to widespread implementation. Aims: Test the hypothesis that emergency medicine physicians and nurses can acquire and retain the skills to rapidly and safely initiate ECPR using high-fidelity simulation. Study design: Prospective interventional study. Setting: U.S. tertiary academic medical center. Subjects: Emergency medicine physicians and nurses with no prior ECPR/ECMO experience. Methods: Teams of three physicians and three nurses underwent a two-day ECPR training course including didactics, hands-on training, and simulation. Teams were videotaped initiating ECPR in a high-fidelity simulation scenario before and after simulation training. The primary outcome was the proportion of simulations in which full ECPR support was achieved within 30 min of patient arrival. Results: Five teams completed the entire study. Full ECPR support was achieved within 30 min of patient arrival in 11/15, 15/15, and 15/15 attempts at baseline (B), post-testing (PT) and 3-month post-testing (3-PT), respectively (p = 0.06). Intervals (mean +/- sd) required to achieve full ECPR support at B, PT, and 3-PT were 25.8 15.3, 17.2 14.6, and 19.2 +/- 1.9 min respectively (p < 0.05 for B vs. PT and 3-PT). Conclusion: High fidelity simulation training is effective in preparing emergency medicine physicians and nurses to rapidly and safely initiate ECPR in a simulated cardiac arrest scenario, and should be considered when implementing an ED-based ECPR program.