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Improving Clinical Performance of an Interprofessional Emergency Medical Team through a One-day Crisis Resource Management Training

Teodora Sorana Truța1, Cristian Marius Boeriu1, Marc Lazarovici2, Irina Ban3, Marius Petrișor1, Sanda-Maria Copotoiu1

1 University of Medicine and Pharmacy of Tîrgu Mureș, Street Gheorghe Marinescu 38, 540139 Tîrgu Mureș, Mureș, Romania
2 Institut für Notfallmedizin und Medizinmanagement – INM, Klinikum der Universität, Ludwig-Maximilians-Universität München, Schillestraße 53, 80336 München, Germany
3 Department of Medicine, University of Padova, Via V. Galluci, 13-35121, Padova, Italy

DOI: 10.2478/jccm-2018-0018

Introduction: Errors are frequent in health care and Emergency Departments are one of the riskiest areas due to frequent changes of team composition, complexity and variety of the cases and difficulties encountered in managing multiple patients. As the majority of clinical errors are the results of human factors and not technical in nature or due to the lack of knowledge, a training focused on these factors appears to be necessary. Crisis resource management (CRM), a tool that was developed initially by the aviation industry and then adopted by different medical specialties as anesthesia and emergency medicine, has been associated with decreased error rates.
The aim of the study: To assess whether a single day CRM training, combining didactic and simulation sessions, improves the clinical performance of an interprofessional emergency medical team.
Material and Methods: Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through two in situ simulated exercises. The exercises were videotaped and were evaluated by two assessors who were blinded as to whether it was the initial or the final exercise. Objective measurement of clinical team performance was performed using a checklist that was designed for each scenario and included essential assessment items for the diagnosis and treatment of a critical patient, with the focus on key actions and decisions. The intervention consisted of a one-day training, combining didactic and simulation sessions, followed by instructor facilitated debriefing. All participants went through this training after the initial assessment exercises.
Results: An improvement was seen in most of the measured clinical parameters.
Conclusion: Our study supports the use of combined CRM training for improving the clinical performance of an interprofessional emergency team. Empirically this may improve the patient outcome.

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Online Information about Stroke – A Soft Challenge for Critical Care Professionals

Septimiu-Daniel Popescu1, Mihaela Dănilă2, Valentin Nădășan3

1 Department of Radiology and Imaging, Emergency County Hospital Tîrgu Mureș, Romania
2 Cardiovascular and Transplant Emergency Institute Tîrgu Mureş, Romania
3 University of Medicine and Pharmacy, Tîrgu Mureș, Romania

DOI: 10.2478/jccm-2018-0017

According to “The Burden of Stroke in Europe” report, Romania had, in 2015, the highest incidence and highest mortality due to stroke per 100,000 inhabitants [1]. Moreover, the Central and Eastern European Stroke Society Working group reported that, in 2015, in Romania, only about 1% of stroke patients had access to stroke units [2].
Critical care professionals are familiar with the phrase “time is brain” and are well aware that even a couple of minutes delay in delivering thrombolytic intravenous treatment or endovascular thrombectomy can have an enormous impact on patients’ survival rates and the length of disability-free life [3,4]. [More]

 

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Hospital Resilience: A Recent Concept in Disaster Preparedness

Boeriu Cristian

University of Medicine and Pharmacy Tîrgu Mureș, Department of Emergency Medicine, Tîrgu Mureș, Romania

DOI: 10.2478/jccm-2018-0016

Planning for a disaster must anticipate how demands imposed by a disaster equate with the capacity of the available facilities. Resources must be organized before an event occurs so that they are best prepared in every way to treat as many victims as possible. The actual number of victims is less relevant than the extent receiving facility can be adjusted to meet the appropriate requirements of victims. Multiple casualty incidents (MCIs) are defined as a large number of casualties generated over a short period that are appropriately managed with existing or extended resources. Mass casualty events (MCEs), in contrast, are major medical disasters that erode organized community support mechanisms and result in casualty numbers which overwhelm resources [1].
Due to the increased frequency and impact of disasters, including natural disasters, pandemics and terrorism, the concept of disaster resilience is accepted as being of increasing importance.
The notion of resilience can be defined as the capacity to adapt to unexpected challenges and the flexibility to revert to normality. Additionally, the issues learned from the experience should be incorporated into protocols which would allow for better preparedness for future challenges [2,3]. [More]

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Acute Pulmonary Embolism in a Teenage Female – A Case Report

Iulia Armean1, Lorena Elena Meliț1,2, Iunius Simu3, Carmen Duicu1,2

1 Emergency Clinical County Hospital Tîrgu Mureș, Pediatrics Clinic No. 1, Tîrgu Mureş, Romania
2 University of Medicine and Pharmacy Tîrgu Mureș, 1st Department of Pediatrics, Tîrgu Mureş, Romania
3 Emergency Clinical County Hospital Tîrgu Mureș, Radiology Department, Tîrgu Mureş, Romania

DOI: 10.2478/jccm-2018-0015

Thrombophilia represents a tendency towards excessive blood clotting and the subsequent development of venous thromboembolism (VTE). VTE is a rare condition in children that comprises both deep venous thrombosis (DVT) and pulmonary embolism (PE). This paper reports the case of a 16-year-old girl, admitted to the Pediatrics Clinic No. 1, Tîrgu Mureș, Romania, for dyspnea, chest pain and loss of consciousness. Her personal history showed that she had had two orthopedic surgical interventions in infancy, two pregnancies, one spontaneous miscarriage and a recent caesarian section at 20 weeks of gestation for premature detachment of a normally positioned placenta associated with a deceased fetus. Laboratory tests showed increased levels of D-dimers. Angio-Computed Tomography (Angio-CT) showed multiple filling defects in both pulmonary arteries, establishing the diagnosis of PE. The laboratory tests were undertaken to assist in the diagnoses of a possible thrombophilia underlined a low level of antithrombin III. Antiphospholipid syndrome was ruled out and genetic tests revealed no specific mutation. Anticoagulant therapy was initiated with unfractionated heparin and afterwards subcutaneously low molecular heparin was prescribed for three months. Later it has been changed to oral therapy with acenocoumarol. The patient was discharged in good general status with the recommendation of life-long anticoagulation therapy. Thrombophilia is a significant risk factor for PE, and it must be ruled out in all cases of repeated miscarriage.

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Transplant Critical Care: Is There A Need for Sub-specialized Units? — A Perspective

Sujit Vijay Sakpal1,2,3, Suresh Kumar Agarwal4, Hector Saucedo-Crespo1,2, Christopher Auvenshine1,2, Robert N. Santella1,3, Steven Donahue2, Jeffery Steers1

1 Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery. Sioux Falls, South Dakota, USA
2 Department of Surgery, University of South Dakota. Sioux Falls, South Dakota, USA
3 Department of Internal Medicine, University of South Dakota. Sioux Falls, South Dakota, USA
4 Division of Acute Care, Trauma, Surgical Critical Care. Department of Surgery. Duke University. Durham, North Carolina, USA

DOI: 10.2478/jccm-2018-0014

The critical care involved in solid-organ transplantation (SOT) is complex. Pre-, intra- and post-transplant care can significantly impact both – patients’ ability to undergo SOT and their peri-operative morbidity and mortality. Much of the care necessary for medical optimization of end-stage organ failure (ESOF) patients to qualify and then successfully undergo SOT, and the management of peri-operative and/or long-term complications thereafter occurs in an intensive care unit (ICU) setting. The current literature specific to critical care in abdominal SOT patients was reviewed. This paper provides a contemporary perspective on the potential multifactorial advantages of sub-specialized transplant critical care units in providing efficient, comprehensive, and collaborative multidisciplinary care.

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Emerging Infection with Elizabethkingia meningoseptica in Neonate. A Case Report

Manuela Arbune1,2, Silvia Fotea1,3, Aurel Nechita1,3, Victorita Stefanescu1,3

1 “Dunarea de Jos” University, Medicine and Pharmacy Research Centre, Romania
2 Infectious Diseases Clinical Hospital Galati, Romania
3 Emergency Pediatric Clinical Hospital Galati, Romania

DOI: 10.2478/jccm-2018-0013

Background: Elizabethkingia meningoseptica are Gram-negative rod bacteria which are commonly found in the environment. The bacteria have also been associated with nosocomial infections, having been isolated on contaminated medical equipment, especially in neonatal wards.
Case report: Here, we present the case of a premature female infant born at 33 weeks’ gestational age, with neonatal meningitis. The onset was marked by fever, in the 5th day of life, while in the Neonatal Intensive Care Unit. The patient was commenced on Gentamicin and Ampicillin, but her clinical condition worsened. Psychomotor agitation and food refusal developed in the 10th day of life, and a diagnosis of bacterial meningitis was made based on clinical and cerebrospinal fluid findings. A strain of Elizabethkingia meningoseptica sensitive to Vancomycin, Rifampicin and Clarithromycin was isolated from cerebrospinal fluid. First-line antibiotic therapy with Meropenem and Vancomycin was adjusted by replacing Meronem with Piperacillin/Tazobactam and Rifampicin. The patient’s clinical condition improved, although some isolated febrile episodes were still present. The cerebrospinal fluid was normalized after 6 weeks of antibiotic treatment, although periventriculitis and tetraventricular hydrocephalus were revealed by imaging studies. Neurosurgical drainage was necessary.
Conclusion: Elizabethkingia meningoseptica can cause severe infection, with high risk of mortality and neurological sequelae in neonates. Intensive care and multidisciplinary interventions are crucial for case management.

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Effects of Fibrinogen Levels and Platelet Counts on Viscoelastic Testing in Cirrhotic Patients

Dana Tomescu1,2, Mihai Popescu1,2, Alexander Vitin3

1 “Carol Davila” University of Medicine and Pharmacy, Department of Anaesthesia and Critical Care Medicine, Bucharest, Romania
2 Fundeni Clinical Institute, Anaesthesia and Critical Care Department III, Bucharest, Romania
3 Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA

DOI: 10.2478/jccm-2018-0012

Introduction. Cirrhotic patients have been considered for decades to have a pro-haemorrhagic pattern and were treated as such based on the results from standard coagulation tests. The aim of our study was to determine the effects of platelet count and fibrinogen levels on rotational thromboelastometry (ROTEM) parameters.
Methods. We prospectively included 176 patients with End-Stage Liver Disease (ESLD) admitted to our Intensive Care Unit prior to liver transplantation. Collected data consisted of severity scores, liver, renal and standard coagulation tests, fibrinogen levels, platelet counts and ROTEM parameters. Four ROTEM assays were performed (ExTEM, InTEM, ApTEM and FibTEM) and the following parameters included: CT – clotting time, CFT – clot formation time, MCF – maximum clot firmness, ML – maximum lysis, alpha angle, TPI – thrombin potential index, MaxV – maximum velocity of clot formation (MaxV), MaxVt – time to MaxV, MCE- maximum clot elasticity and AUC – area under the curve.
Results. Statistical analysis demonstrated a linear correlation between platelet counts and ExTEM TPI (R2 linear =0.494), ExTEM MaxV (R2 linear =0.253), ExTEM MCE (R2 linear = 0.351) and ExTEM MCF (R2 cubic = 0.498). Fibrinogen levels correlated linearly with ExTEM MCF (R2 linear = 0.426), ExTEM TPI (R2 linear = 0.544), ExTEM MaxV (R2 linear = 0.332), ExTEM MCE (R2 linear = 0.395) and non-linearly with ExTEM CFT (R2 cubic = 0.475).
Conclusion. Fibrinogen levels and platelet counts had an important effect on both standard and derived ROTEM parameters. Further analysis is required in order to determine clinically oriented cut-off values below which severe coagulopathy would develop.

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Endotracheal Tube Biofilm and its Impact on the Pathogenesis of Ventilator-Associated Pneumonia

Olguța Diaconu1, Ianis Siriopol1, Laura Iulia Poloșanu2, Ioana Grigoraș1,3

1 Anesthesia and Intensive Care Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
2 Microbiology Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
3 Anesthesia and Intensive Care Department, Regional Institute of Oncology, Iași, Romania

DOI: 10.2478/jccm-2018-0011

Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection in mechanically ventilated patients and results in high mortality, prolonged intensive care unit- (ICU) and hospital-length of stay and increased costs. In order to reduce its incidence, it is imperative to better understand the involved mechanisms and to identify the source of infection. The role of the endotracheal tube (ET) in VAP pathogenesis became more prominent over the last decades, along with extensive research dedicated to medical device-related infections and biofilms. ET biofilm formation is an early and constant process in intubated patients. New data regarding its temporal dynamics, composition, germ identification and consequences enhance knowledge about VAP occurrence, microbiology, treatment response and recurrence.
This paper presents a structured analysis of the medical literature to date, in order to outline the role of ET biofilm in VAP pathogenesis and to review recommended methods to identify ET biofilm microorganisms and to prevent or decrease VAP incidence.

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