Objective: Employers in service industries (e.g., healthcare) seek employees whose values align with serving others. To facilitate evaluation of these values, our objective was to develop and provide validity evidence for a simple tool for assessing people’s propensity to serve others and how serving others makes them feel. Methods: We developed a 12-item tool, the New Helping Attitude Scale, and performed psychometric validity testing in two independent representative samples of the general adult U.S. population using a web-based platform. Results: In a sample of 975 adults studied in three phases, we found that the 12 items of the New Helping Attitude Scale load on a single factor with all factor loadings >0.6 and good fit indices (Comparative Fit Index = 0.95; Tucker-Lewis Index = 0.94; Standardized Root Mean Squared Residual = 0.04). Internal consistency was excellent (Cronbach’s α = 0.92). In this report, we present normative data to aid in the interpretation of results. Conclusion: The 12-item New Helping Attitude Scale is a simple, psychometrically sound, and reliable tool to assess people’s values related to serving others. Future research to determine its value in predicting job performance among employees in service industries such as healthcare is warranted.

Background:Psychological safety is a critical component of effective learning and team performance in medical education. However, no tool with validity evidence currently exists to measure it specifically among graduate medical education (GME) trainees. Objective:To develop a concise, trainee-centered survey tool to measure psychological safety in GME settings and to examine its content and internal structure among graduate medical trainees. Methods:We created 9 candidate items based on existing literature and expert feedback. These were incorporated into an annual institution-wide trainee survey at a single academic health care system. Responses were randomly divided into derivation and validation cohorts. Exploratory and confirmatory factor analyses were conducted to produce and obtain validity evidence for the most effective and concise set of items. Results:Of the 480 trainees invited to take the survey, 400 (83%) returned completed responses. During the derivation phase (n=200), 4 items were removed for low tolerance, improving model fit. The final 5 items showed strong loading on a single factor. The 5 items assessed trainees' comfort level with sharing ideas, giving and receiving feedback, expressing uncertainty, and viewing mistakes as learning opportunities. In validation testing (n=200), confirmatory factor analysis supported a unidimensional structure (Comparative Fit Index=0.99, Tucker-Lewis Index=0.97, and standardized root mean squared residual=0.02). The composite score correlated positively with an external measure of psychological safety (r=0.67) and demonstrated high internal reliability (McDonald's omega=0.91). Conclusions:The scores on this 5-item scale demonstrated evidence of validity and reliability for assessing psychological safety among trainees.

BACKGROUND:Healthcare system distrust-patients' belief that the healthcare system may not act in their best interests-is a recognized social determinant of health and is associated with poor health outcomes, decreased adherence to treatment, and heightened health disparities, especially among marginalized populations. Compassion from clinicians may be a modifiable factor that can foster trust in healthcare systems, but its association with system-level distrust, particularly in emergency department (ED) settings, remains underexplored. METHODS:We conducted a nested cross-sectional study enrolling adult patients treated at two urban academic EDs in the United States between September 2023 to May 2024. We separately measured patient experience of physician and nursing staff compassion using the validated 5-item compassion measure, and patient healthcare system distrust using the Healthcare System Distrust Scale. Multivariable linear regression models, adjusted for demographics and study site, tested associations between perceived compassion and distrust, including subgroup analyses by race, gender, and other sociodemographic factors. RESULTS:The primary analysis included 779 patients. Both physician (median score 20 [IQR 17-20]) and nursing staff compassion (median score 20 [IQR 17-20]) were highly rated. Higher compassion scores for both physicians (β = -0.62, 95% CI 0.80 to -0.44) and nursing staff (β = -0.24, 95% CI 0.38 to -0.09) were independently associated with lower healthcare system distrust. Compared to non-Hispanic White patients, Black patients reported higher healthcare system distrust, driven by values (i.e., honesty, motives, and equity)-based distrust rather than competency-based distrust, but did not report lower compassion scores. The association between compassion and reduced distrust was consistent across demographic subgroups. CONCLUSION:Greater experience of compassion from ED physicians and nursing staff is independently associated with lower healthcare system distrust. Interventions to enhance clinician compassion have the potential to foster trust and may reduce health disparities in emergency care settings.

BACKGROUND: Patient perception of physician compassion may be associated with improved health outcomes, yet it is unclear whether it is associated with postoperative pain reduction or improved patient experience metrics in same-day surgery patients. We hypothesized that higher anesthesiologist compassion during the preanesthesia interview, rated by patients, is associated with lower postoperative pain via the anxiety pathway in same-day surgery patients. We also performed exploratory correlation analysis to assess whether compassion was associated with less opioid consumption and improved patient experience in same-day surgery patients. METHODS: We conducted a single-center, prospective, observational cohort study in American Society of Anesthesiologists (ASA) physical status I to III patients scheduled to undergo same-day surgery with anesthesia. Compassion was scored using a validated 5-item tool. State anxiety (SA) and trait anxiety (TA) were measured using the State-Trait Anxiety Inventory. Pain scores were obtained using a 0 to 10 Likert scale. Daily opioid use was recorded. Patient experience was assessed using the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) and the Surgical Care CAHPS. Mediation analysis was used to assess the association between compassion and pain scores via the anxiety pathway. Spearman correlation was performed to test for association between the compassion score and the secondary outcomes. RESULTS: A total of 147 subjects completed the study with a median age of 50 years and 81% female. Fifty percent underwent breast surgery, 35% abdominal surgery, and the rest underwent gynecological and urological surgeries. The median (Q1–Q3) postoperative pain scores on postoperative days 0 and 3 days later were 4 (1.5–6) and 3 (1–5), respectively. Mediation analysis results showed a same-day anxiety-mediated effect (95% confidence interval [CI]) of compassion on pain of −0.08 (−0.13 to −0.02), attributing to 9% of the total effect. On postoperative day 0, an increase in compassion was associated with a significant average drop in pain of between 0.02 and 0.13. In addition, higher compassion was correlated with better patient experience metrics (ρ= −0.53 [95% CI, −0.64 to −0.39]). CONCLUSIONS: The study results suggest that an anxiety-mediated pathway exists through which compassionate care may help improve the patient’s perception of postoperative pain on the day of surgery (before discharge from the hospital). Higher compassion was also associated with better patient experience metrics.

Our objective was to validate a 5-item compassion measurement tool as a reliable measure of patient assessments of clinician compassion in the pediatric outpatient setting. We completed a cross-sectional study in a U.S. academic healthcare system consisting of six pediatric clinics between February and September 2023. We adapted the original 5-item tool to elicit responses regarding the pediatric patient. The measure was disseminated with the Clinician and Group Consumer Assessment of Healthcare Providers and System (CG-CAHPS) survey. We included patients aged <18 years old who had an outpatient clinic visit and had a parent complete the CG-CAHPS survey. Validity testing of the 5-item tool was performed using confirmatory factor analysis. Internal reliability was tested using Cronbach's α, and convergent validity with overall provider rating questions from the CG-CAHPS survey was evaluated using Spearman correlation. We analyzed 640 responses. The median (interquartile range) patient age was 8 (3-13) years, and 47% of patients were female. Sixty-one percent of patients were White/Caucasian and 25% were Black/African American. Confirmatory factor analyses found a good fit. The compassion measure demonstrated good internal consistency (α = 0.97) and convergent validity with overall provider rating (rs = 0.63 (95% confidence interval 0.56-0.70)) but reflected a patient experience domain distinctly different from what is currently captured in CG-CAHPS surveys. Our results suggest that the 5-item compassion measure is a valid tool that can reliably and distinctly measure patient assessments of clinician compassion in the pediatric outpatient setting.

Objectives Trauma exposures and high rates of burnout are widespread among emergency department (ED) clinicians and patients. Trauma-informed care (TIC) education promotes resilience for patients and clinicians. However, there remains a scarcity of data on the impact of TIC on ED clinician outcomes. The objectives of this study were to evaluate post-COVID-19 pandemic professional quality of life among ED clinicians and to test if participation in a TIC education initiative among ED clinicians (1) improves professional quality of life and (2) decreases bias toward patients who misuse opioids. Methods This was a single center, prospective, parallel before-and-after pilot study conducted at a single academic medical center ED. All ED clinicians at our institution participated in a TIC education series and were given the option to participate in the education series in April-May 2023 or be waitlisted to participate in June-July 2023. The validated Professional Quality of Life (ProQOL) scale – V was used to assess compassion satisfaction, burnout, and secondary traumatic stress at baseline (March 2023) and again after the intervention group completed the TIC education (June 2023). The three-month change in the ProQOL subscale scores were compared between the two groups using repeated measures mixed-effects linear regression models. Results Of the 67 included clinicians, 56 selected to receive the TIC education early and 11 subjects selected to be waitlisted. Overall, no clinicians reported a high degree of burnout, secondary traumatic stress, or lack of compassion satisfaction. We did not find a statistically significant difference in the change in scores between the two groups. Conclusions We did not find the TIC education impacted ProQOL scores. This may be due to the low degree of burnout and secondary stress in our cohort.

Physician compassion is associated with improvement in a variety of patient outcomes, but it remains unclear which individual physician behaviors affect patients’ experience of compassion. To determine which physician behaviors are most associated with patients’ experience of compassion. We conducted a cross-sectional study at two urban academic emergency departments (ED) from September 2023 to May 2024. Participants completed questionnaires with a previously validated 5-item compassion measure and questions about whether the patient’s physician exhibited any of 27 behaviors previously proposed to be associated with compassion. We enrolled adult (age 18 years or older) patients presenting to each ED. The primary outcome was patient experience of physician compassion using the 5-item compassion measure. We used the machine learning algorithm LASSO to identify the group of actions that best predict the 5-item compassion measure. We performed exploratory analyses using linear regression with interaction terms to test for differences by patient race (White vs Black) and gender. A total of 1025 patients completed the questionnaire (717 from site 1; 308 from site 2). The action with the strongest association with greater compassion was “Listen carefully to what you had to say” [β = 5.67 (95

OBJECTIVES:Fear of enacted stigma (fear of discrimination or being treated unfairly) is associated with decreased health care-seeking behaviors among patients with opioid use disorder (OUD). We sought to describe the prevalence of fear of enacted stigma among patients presenting to the emergency department (ED) with OUD and to test whether experiencing greater compassion from ED staff is associated with lower fear of enacted stigma. METHODS:We conducted a cross-sectional study in the ED of an academic medical center between February and August 2023. We included adult patients with OUD presenting to the ED and assessed patient experience of compassion from ED staff using a previously validated 5-item compassion measure (score range 5-20). The primary outcome measure was fear of enacted stigma in the ED, measured using the validated 9-item subscale of the Substance Abuse Self-Stigma Scale (score range 9-45). RESULTS:Of the 116 subjects enrolled, 97% (95% confidence interval [CI] 91%-99%) reported some degree of stigma, with a median (interquartile range) score of 23 (16-31). In a multivariable model adjusting for potential confounders, patient experience of greater ED compassion was independently associated with lower fear of enacted stigma, β = -0.66 (95% CI -1.03 to -0.29), suggesting that every 1-point increase in the 5-item compassion measure score is associated with a 0.66-point decrease in the fear of enacted stigma score. CONCLUSIONS:Among ED patients with OUD, fear of enacted stigma is common. Patient experience of compassion from ED staff is associated with lower fear of enacted stigma. Future research is warranted to test if interventions aimed at increasing compassion from ED staff reduce patient fear of enacted stigma among patients with OUD.

Objective Anxiety is common among patients attending an initial oncology consultation. The objective of this trial was to test if an enhanced compassion video emailed to patients prior to their initial oncology consultation reduces anxiety compared with being sent an information-only introduction video.Methods and analysis We conducted a randomised control trial at a single university-based cancer centre between May 2021 and October 2023. We enrolled adult patients scheduled for an initial cancer consultation. Subjects underwent simple 1:1 randomisation to receive either a standard introduction video or an enhanced compassion video via email. Investigators and subjects were blinded to allocation. The primary outcome was degree of anxiety on arrival to the initial oncology consultation, measured using the Hospital Anxiety and Depression scale (HADS).Results Of 1005 subjects randomised to the standard video and 1038 to the enhanced compassion video, 183 and 179 subjects completed the HADS-anxiety in each group, respectively. Only 25% reported watching their assigned video. There was no difference in degree of anxiety between the standard or compassion video groups using intention to treat analysis (median (IQR) 7 (4-10) vs 7 (4-10), p value=0.473)) or per-protocol analysis (limited to subjects who reported watching the video) (median (IQR) 7 (4-10) (n=45) vs 7 (5-10) (n=46), p value=0.997).Conclusion Receiving an enhanced compassion video did not reduce anxiety compared with a standard introduction video. Given 25% of subjects reported watching their assigned video, future research should focus on identifying interventions at the point-of-care to reduce anxiety.Trial registration number NCT04503681.

Twenty‐five percent of patients presenting to the emergency department (ED) for a respiratory or cardiovascular medical emergency develop clinically significant posttraumatic stress disorder (PTSD) symptoms. It is possible that development of PTSD symptoms in this cohort is associated with subsequent adverse physical health events. Our objective was to test whether clinically significant PTSD symptoms 30 days postdischarge are associated with increased risk for hospital readmission within 24 months after discharge among patients presenting to the ED for a respiratory or cardiovascular emergency.

Objective: Employers in service industries such as healthcare seek employees whose values align with serving others. To facilitate evaluation of these values, our objective was to develop and validate a simple tool for assessing people’s propensity to serve others and how serving others makes them feel.Methods: We developed a 12-item tool, the New Helping Attitude Scale, and performed psychometric validation in a representative sample of the general adult U.S. population using a web-based platform (SurveyMonkey Audience). Results: In a sample of 639 adults studied in two phases, we found that the 12 items of the New Helping Attitude Scale load on a single factor with all factor loadings >0.6 and good fit indices (Comparative Fit Index = 0.95; Tucker-Lewis Index = 0.94; Standardized Root Mean Squared Residual = 0.04). Internal consistency was excellent (Cronbach’s α = 0.92). In this report, we present normative data to aid results interpretation. Conclusion: The New Helping Attitude Scale is a simple, psychometrically valid and reliable tool to assess people’s values related to serving others.

Figure: firearm injury, compassion, violence preventionFigureFigureThe mission of firearm injury reduction of AFFIRM at the Aspen Institute is rooted in compassion for others, not only for the victims of firearm injury but also for those at risk of becoming perpetrators. One of AFFIRM's explicit aims is to employ evidence-based practices, and we believe this begs the question: Does compassion really matter? Of course, compassion is a cornerstone of the art of medicine, but do the evidence-based effects of compassion belong in the science of medicine? Compassion is the emotional response to another's pain and suffering with an authentic desire to help. (Psychol Bull. 2010;136[3]:351; https://bit.ly/3CxF9uO.) It is distinct from empathy, which is understanding another's pain and suffering, and takes responsive action: empathy and action equal compassion. We set out to investigate the scientific evidence for compassion in medicine, not ethically or emotionally but through the lens of science. We curated data from more than 1000 scientific abstracts and more than 250 original science research papers in our book, Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference. (Studer Group: Pensacola, FL 2019.) Loss of Compassion An important first question: Do we have a problem? Research shows an erosion of the relationship between those providing health care and their patients, specifically a loss of compassion. Nearly half of Americans believe that health care providers are not compassionate. (Health Aff [Millwood]. 2011;30[9]:1772.) Studies across specialties have reported that physicians miss most opportunities to respond to patients with compassion. (JAMA. 2000;284[8]:1021; https://bit.ly/3lGCw2H.) Research finds that one-third of physicians are so burned out that they suffer from depersonalization, an inability to make a personal connection. (Mayo Clin Proc. 2015;90[12]:1600.) This can result in callous or uncaring behavior. This compassion crisis prompted us to analyze the scientific data on the effects of compassion on patients, patient care, and caregivers. Is compassion just nice to have in caring for patients or does it belong in evidence-based medicine? We found that compassionate care coupled with clinical excellence has been associated with improved outcomes for many conditions, including the common cold, migraine headaches, chronic low back pain, and diabetes. How? Human connection can modulate physiology, such as stress-mediated disease, the immune response, and a patient's experience of pain. Compassion can also improve outcomes through enhanced patient self-care, such as better adherence to therapy. (J Am Board Fam Med. 2013;26[4]:40.) When health care providers care deeply about patients, patients are more likely to follow physicians' advice, including adherence to treatment recommendations. (J Gen Intern Med. 2006;21[6]:661; https://bit.ly/3nQe9Cl.) A randomized trial also found that compassionate care decreased repeat visits to the ED among homeless patients. (Lancet. 1995;345[8958]:1131.) Compassion can also improve psychological outcomes for patients, relieving the anxiety, depression, and emotional distress from serious illness. Preliminary research from our group shows that nearly a third of survivors of a life-threatening medical emergency due to respiratory failure subsequently developed posttraumatic stress disorder (PTSD), and caregiver compassion in the ED was associated with significantly lower rate of development of those symptoms. (Intensive Care Med. 2019;45[6]:815.) Measurable Benefits This may be a result of reducing patients' fear and psychological trauma. Connecting with patients at such a pivotal moment in their lives can have lasting effects. Research shows that years after a life-threatening emergency, patients vividly remember how they were made to feel, and a caregiver's compassion (or lack of) is one of the most salient memories. (Int Emerg Nurs. 2015;23[2]:115.) Compassion matters not only in meaningful ways but also in measurable ones, and its benefits have not only a measurable beneficial effect for patients but for caregivers too. Most evidence supports an inverse association between compassion and burnout. (Burn Res. 2017;6:18; https://bit.ly/3zlaa2Y.) These data do not allow us to infer cause and effect directly but suggest that compassion may be protective. Connecting with compassion and the meaningful relationships that flow from it can be a positive, fulfilling experience that counteracts burnout and builds resilience. (Soc Cogn Affect Neurosci. 2014;9[6]:873; https://bit.ly/3AqTDvC.) Neuroscience research shows that compassion for others activates a reward center in the brain. (Soc Cogn Affect Neurosci. 2015;10[9]:1291; https://bit.ly/3nRwcby; Cereb Cortex. 2013;23[7]:1552.) Compassion can heal the healer. Research from our group and others indicates that change is possible if clinicians want to grow their compassion and realize these benefits (PLoS One. 2019;14[8]:e0221412; https://bit.ly/3lGX8YI), and that empathy and compassion are malleable. (J Pers Soc Psychol. 2014;107[3]:475.) This supports that clinicians can get better at being compassionate, just like they improve at the technical aspects of care, through intentionality and practice. Fortunately, research shows that meaningful compassion takes less than one minute (J Clin Oncol. 1999;17[1]:371), and that investing time in helping others can increase the feeling that you have plenty of time. (Psychol Sci. 2012;23[10]:1233.) We are still in the throes of a pandemic, a burnout epidemic, and now an unprecedented health care workforce shortage, and we believe that compassion matters now more than ever. (Emsi. “The Demographic Drought;” https://bit.ly/2XuTAAo.) This is especially true in our compassion for our coworkers. One of the clearest messages we gleaned from our journey through the evidence is that relationships are key to resilience. In stressful environments, leaning in to relationships with colleagues and connecting more (and in meaningful ways) can buffer stress and promote resilience and resistance to burnout. Of course, we did not need scientific evidence to tell us what we know intuitively, that we need to take care of each other in this crisis. But the science illuminates that taking good care of those around you may be the best medicine for yourself. (Wonder Drug: 7 Scientifically-Proven Ways That Serving Others Is the Best Medicine for Yourself; to be published in 2022.)? Dr. Trzeciakis an intensivist and the chief of medicine at Cooper University Health Care and a professor of medicine and emergency medicine and the chair of the department of medicine at Cooper Medical School of Rowan University in Camden, NJ. Follow him on Twitter@StephenTrzeciak. Dr. Mazzarelliis an emergency physician, the co-president/CEO of Cooper University Health Care, and an associate professor of emergency medicine at Cooper Medical School of Rowan University in Camden. Follow him on Twitter@AJMazzarelli.

INTRODUCTION:Patients diagnosed with cancer commonly have a high degree of anxiety during an initial oncology consultation, which may interfere with a patient's ability to retain information required to make informed treatment decisions. A previous study randomised breast cancer survivors (volunteers) to view either (a) a brief video depicting a standard initial consultation from an oncologist or (b) an identical consultation with the addition of compassionate statements from the oncologist, and found the compassionate statements reduced anxiety among the volunteers. However, while compassionate statements reduced anxiety during simulation, it is currently unknown whether watching a video containing compassionate statements from an oncologist prior to an initial oncology consultation will reduce anxiety among patients referred to a cancer centre. The aim of this randomised control trial is to test whether watching a brief video containing compassionate statements from an oncologist, compared with watching a standard introduction video, prior to an initial oncology consultation will reduce the degree of anxiety among patients referred to a cancer centre.METHODS AND ANALYSIS:This is a prospective, randomised controlled clinical trial at an academic cancer centre. We will enrol adult patients scheduled for an initial oncology consultation. Subjects will be randomly assigned to receive a standard introduction video or enhanced compassion video for viewing prior to the initial oncology consultation. On arrival to the cancer centre, we will measure anxiety severity using the Hospital Anxiety and Depression Scale (HADS). The HADS has two 7-item subscales (HADS anxiety and HADS depression) and is well-validated among oncology patients. We will use Wilcoxon rank-sum test to test for a difference in the HADS subscales between the two video groups.ETHICS AND DISSEMINATION:The Cooper University Hospital Institutional Review Board approved this study. The results from this randomised control trial will be submitted for publication to a peer-reviewed journal.TRIAL REGISTRATION NUMBER:NCT04503681.

BACKGROUND:We previously validated a 5-item compassion measure to assess patient experience of clinician compassion in the outpatient setting. However, currently, there is no validated and feasible method for health care systems to measure patient experience of clinician compassion in the inpatient setting across multiple hospitals.OBJECTIVE:To test if the 5-item compassion measure can validly and distinctly measure patient assessment of physician and nurse compassion in the inpatient setting.DESIGN:Cross-sectional study between July 1 and July 31, 2020, in a US health care network of 91 community hospitals across 16 states consisting of approximately 15,000 beds.PATIENTS:Adult patients who had an inpatient hospital stay and completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.MEASUREMENTS:We adapted the original 5-item compassion measure to be specific for physicians, as well as for nurses. We disseminated both measures with the HCAHPS survey and used confirmatory factor analysis for validity testing. We tested reliability using Cronbach's alpha, as well as convergent validity with patient assessment of physician and nursing communication and overall hospital rating questions from HCAHPS.RESULTS:We analyzed 4756 patient responses. Confirmatory factor analysis found good fit for two distinct constructs (i.e., physician and nurse compassion). Both measures demonstrated good internal consistency (alpha > 0.90) and good convergent validity but reflected a construct (compassionate care) distinct from what is currently captured in HCAHPS.CONCLUSION:We validated two 5-item tools that can distinctly measure patient experience of physician and nurse compassion for use in the inpatient hospital setting in conjunction with HCAHPS.

Introduction Clinician empathy is a vital component of high-quality healthcare. Healthcare disparities may reflect a societal lack of empathy for disadvantaged persons in general, and recent research suggests that socioeconomic disparities exist in patient satisfaction with clinicians. However, it is currently unclear if there are disparities in patient experience of empathy from clinicians. Our objective is to systematically analyse the scientific literature to test the hypothesis that racial and socioeconomic status (SES) disparities exist in patient-reported experience of clinician empathy. Methods and analysis In accordance with published methodological guidelines for conducting a systematic review, we will analyse studies reporting patient assessment of clinician empathy using the Consultation and Relational Empathy (CARE) measure, which to date is the most commonly used and well-validated methodology in clinical research for measuring clinician empathy from the patient’s perspective. We will use a standardised data collection template and assess study quality (risk of bias) using the Newcastle-Ottawa Scale. We will abstract data for the CARE measure stratified by race and SES, and we will contact the corresponding authors to obtain stratified data by race/SES if not reported in the original manuscript. Where appropriate, we will pool the data and perform quantitative meta-analysis to test if non-white (compared to white) patients and low SES (compared to high SES) patients report lower scores for clinician empathy. Ethics and dissemination No individual patient-level data will be collected and thus the proposed systematic review does not require ethical approval. This systematic review will test if racial and SES differences exist in patient experience of clinician empathy, and will inform future research to help promote healthcare equity. PROSPERO registration number CRD42019142809.

BACKGROUND:Perform a scoping review of (1) pre-clinical studies testing the physiological effects of higher PaCO2 levels in the setting of sepsis models and (2) clinical investigations testing the effects of hypercapnia on clinical outcomes in mechanically ventilated patients with sepsis.METHODS:We performed a search of CENTRAL, PUBMED, CINAHL, and EMBASE. Study inclusion criteria for pre-clinical studies were: (1) bacterial sepsis model (2) measurement of PaCO2 , and (3) comparison of outcome measure between different PaCO2 levels. Inclusion criteria for clinical studies were: (1) diagnosis of sepsis, (2) receiving invasive mechanical ventilation, (3) measurement of PaCO2 , and (4) comparison of outcomes between different PaCO2 levels. We performed a qualitative analysis to collate and summarize the physiological and clinical effects of hypercapnia according to the recommended methodology from the Cochrane Handbook.RESULTS:Fifteen pre-clinical and nine clinical studies were included. Among pre-clinical studies, the individual studies found higher PaCO2 augments tissue blood flow and oxygenation, and attenuates inflammation and lung injury; however, all pre-clinical studies were found to have some degree of risk of bias. Six of the nine clinical studies were deemed to be good quality. Among clinical studies hypercapnia was associated with increased cerebral perfusion and oxygenation; however, there were conflicting results testing the association between hypercapnia and mortality.CONCLUSION:While individual pre-clinical studies identified potential mechanisms by which changes in PaCO2 levels could affect pathophysiology in sepsis, there is a paucity of clinical data as to the optimal PaCO2 range, demonstrating a need for future research.REGISTRATION:PROSPERO number CRD42018086703.

BACKGROUND Our objectives were to test if during a potentially life-threatening medical emergency, perceived threat (a patient's sense of life endangerment) in the emergency department (ED) is common and associated with the subsequent development of posttraumatic stress disorder (PTSD) symptoms. METHODS ED-based prospective cohort study in an academic hospital. We included adult patients requiring acute intervention in the ED for resuscitation of a potentially life-threatening medical emergency, defined as respiratory or cardiovascular instability. We measured patient perceived threat in the ED using a validated patient self-assessment measure (score range 0-21, with higher scores indicating greater perceived threat). We performed blinded assessment of PTSD symptoms 30 days after discharge using the Post-traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders (PCL-5). RESULTS Ninety-nine of 113 (88%) patients completed follow up, with 98% reporting some degree of perceived threat, median [interquartile range (IQR)] perceived threat score 12 (6-17), and 72% reported PTSD symptoms in relation to their ED visit, median (IQR) PCL-5 score 7 (0-30). Patients with respiratory instability had higher median (IQR) perceived threat scores [16 (9-18) vs. 9 (6-14)] and PCL-5 scores [10 (2-40) vs. 3 (0-17)] compared to patients without respiratory instability. In a multivariable linear regression model adjusting for potential confounders, greater perceived threat in the ED was independently associated with higher PCL-5 scores, β = 0.79 (95% CI 0.15-1.42). Among the individual perceived threat items, the feeling of helplessness during resuscitation had the strongest association with PCL-5 score, β = 5.24 (95% CI 2.29 - 8.18). CONCLUSIONS Perceived threat during potentially life-threatening emergencies is common and independently associated with development of PTSD symptoms. Additional research to test if reduction of perceived threat in the ED attenuates the development of PTSD symptoms following potentially life-threatening emergencies is warranted.

We tested the hypothesis that, during a life-threatening medical emergency, patient perception of healthcare provider (HCP) compassion is associated with the subsequent development of post-traumatic stress disorder (PTSD) symptoms.