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Intensive Care Unit Liaison Nurse roles are associated with improved clinical outcomes for patients and financial benefits for healthcare providers. However, there is little academic exploration of the ward nurses’ perspectives of the role and whether it can affect ward nurses’ confidence in identifying and managing the deteriorating patient. This study addresses this gap by examining both those perspectives. A qualitative descriptive approach was used, utilising semi-structured interviews to garner the perspectives of ward nurses.Interviewswere conducted with ward nurses who had been involved in a MedicalEmergencyTeam/Code Blue call;sought technical or clinical support;or had been at the bedside during a post intensive care unit discharge review. Data were analysed using thematic analysis. A private, not-for-profit, metropolitan acute care hospital. The participants identified four areas that contributed to improved patient care: reduced Medical Emergency Team/Code calls; improved ward based critical care knowledge through education; improved ward nurses’ confidence in dealing with the deteriorating patient and provision of technical support. The Intensive Care Unit Liaison Nurse role not only contributes to improved clinical patient outcomes; it also influences confidence levels of the ward nurses in managing deteriorating patients.

BACKGROUNDTimely escalation of care for patients experiencing clinical deterioration in the inpatient setting is challenging. Deterioration on a general floor has been associated with an increased risk of death, and the early period of deterioration may represent a time during which admission to the intensive care unit (ICU) improves survival. Previous studies examining the association between delay from onset of clinical deterioration to ICU transfer and mortality are few in number and were conducted more than 10 years ago.OBJECTIVEWe aimed to evaluate the impact of delays in the escalation of care among clinically deteriorating patients in the current era of inpatient medicine.DESIGN AND PARTICIPANTSThis was a retrospective cohort study that analyzed data from 793 patients transferred from non-intensive care unit (ICU) inpatient floors to the medical intensive care unit (MICU), from 2011 to 2013 at an urban, tertiary, academic medical center.MAIN MEASURES“Deterioration to door time (DTDT)” was defined as the time between onset of clinical deterioration (as evidenced by the presence of one or more vital sign indicators including respiratory rate, systolic blood pressure, and heart rate) and arrival in the MICU.KEY RESULTSIn our sample, 64.6 % had delays in care escalation, defined as greater than 4 h based on previous studies. Mortality was significantly increased beginning at a DTDT of 12.1 h after adjusting for age, gender, and severity of illness.CONCLUSIONSDelays in the escalation of care for clinically deteriorating hospitalized patients remain frequent in the current era of inpatient medicine, and are associated with increased in-hospital mortality. Development of performance measures for the care of clinically deteriorating inpatients remains essential, and timeliness of care escalation deserves further consideration.

BackgroundSeverally ill COVID-19 patients may require urgent transport to a specialized facility for advanced care. Prehospital transport is inherently risky; the patient’s health may deteriorate, and potentially fatal situations may arise. Hence, early detection of clinically worsening patients in a prehospital setting may enable selecting the best receiving facility, arranging for swift transportation, and providing the most accurate and timely therapies. The incidence and predictors of abrupt prehospital clinical deterioration among critically ill patients in Ethiopia are relatively limited.Study objectivesThis study was conducted to determine the incidence of sudden clinical deterioration during prehospital transportation and its predictors.MethodsA prospective cohort study of 591 COVID-19 patients transported by a public EMS in Addis Ababa. For data entry, Epi data V4.2 and SPSS V 25 were used for analysis. To control the effect of confounders, the candidate variables for multivariable analysis were chosen using a p 0.25 inclusion threshold from the bivariate analysis. A statistically significant association was declared at adjusted relative risk (ARR) ≠ 1 with a 95 % confidence interval (CI) and a p value < 0.05 after adjusting for potential confounders.ResultsThe incidence of prehospital sudden clinical deterioration in this study was 10.8%. The independent predictors of prehospital sudden clinical deterioration were total prehospital time [ARR 1.03 (95%; CI 1.00–1.06)], queuing delays [ARR 1.03 (95%; CI 1.00–1.06)], initial prehospital respiratory rate [ARR 1.07 (95% CI 1.01–1.13)], and diabetic mellitus [ARR 1.06 (95%; CI 1.01–1.11)].ConclusionIn the current study, one in every ten COVID-19 patients experienced a clinical deterioration while an EMS provider was present. The factors that determined rapid deterioration were total prehospital time, queueing delays, the initial respiratory rate, and diabetes mellitus. Queueing delays should be managed in order to find a way to decrease overall prehospital time. According to this finding, more research on prehospital intervention and indicators of prehospital clinical deterioration in Ethiopia is warranted.

Background Necrotizing enterocolitis (NEC) is a common devastating inflammatory gastrointestinal disease and frequently occurs in premature infants. Here, we reported a case of late-onset NEC in a term neonate with good outcome after surgery for long-term follow-up. Case presentation Ten-week-old male came to emergency unit due to prolonged diarrhea and abdominal distention. He was born at gestational age of 40 weeks with birth weight and Apgar score of 2800 g and 7/8, respectively. He had no history of formula feeding. Two weeks before admitted to the hospital, the patient had frequent diarrhea with fever. He was found lethargic with abdominal distention, absence of bowel sounds and abdominal tenderness. Plain abdominal x-ray and CT scan showed gastric and intestinal dilatation and gasless colon, suggesting a small bowel obstruction, and bowel wall thickening indicating peritonitis, without any free subdiaphragmatic air (pneumoperitoneum). Moreover, the patient did not have a congenital heart disease. While in intensive medical treatment, he showed a continuous clinical deterioration. All findings were suggestive of intestinal inflammation with clinical deterioration, and we decided to perform an emergency exploratory laparotomy and found an ischemia along the jejunoileal with a perforation at 25 cm above the ileocecal valve. Subsequently, we performed a double-barrel ileostomy through a separate incision from the laparotomy. Histopathological findings confirmed the diagnosis of NEC. We closed the stoma at postoperative day 43. The patient was discharged uneventfully a month after stoma closure. Conclusion Abdominal CT scan might be useful to establish an early recognition of late-onset NEC; thus, immediate surgical intervention might be performed to decrease its morbidity and mortality. Moreover, late-onset NEC in term neonates might occur without any risk factors or significant co-morbidities.

Under-triage is a major threat when admitting patients at the Intermediate Care Unit (IMCU). This study aims to identify risk factors and predict early deterioration of IMCU admissions, to reduce the risk of under-triage. This retrospective cohort study included all admissions to the mixed-surgical stand-alone IMCU of a tertiary referral hospital (2001–2015). Variables included were age, sex, admission indication, admitting specialty, re-admission, and nursing interventions. Early clinical deterioration was defined as ICU transfer or death ≤24 h of admission. Multinomial and logistic regression analyses were performed to identify risk factors and obtain predictions, for several frequently encountered subgroups. A total of 9103 admissions were included, of which 350 (3.8%) early deteriorated. Patients admitted for hemodynamic and respiratory instability had a high risk of early deterioration (OR 16.3 (CI 4.5-59.1)), probability 47.1%. Patients admitted with respiratory insufficiency and active diuresis or complicated sepsis had a high probability of early deterioration (≥29% and ≥26% respectively). The model had an optimism-corrected c-statistic of 0.79 (IQR 0.78-0.80). Patients with combined hemodynamic and respiratory instability should not be admitted to the IMCU. Patients with respiratory insufficiency and active diuresis, or complicated sepsis require close monitoring. •The presented nomogram can be used to assess the probability of early clinical deterioration•Patients with hemodynamic and respiratory instability should be admitted at the ICU•IMCU Patients with respiratory insufficiency and active diuresis, or complicated sepsis require close monitoring

Early recognition of clinical deterioration is crucial for timely intervention and improved patient outcomes in hospital settings. Nurse technicians play a vital role in monitoring patients and detecting signs of deterioration. This qualitative study explores the experiences and perspectives of nurse technicians in Saudi Arabian hospitals regarding the early recognition of clinical deterioration. Through semi-structured interviews with nurse technicians, the study aims to identify the challenges, facilitators, and strategies for enhancing the detection and response to clinical deterioration. The findings reveal that nurse technicians face various challenges, including high workload, limited training, and communication barriers. However, participants also highlight the importance of teamwork, clinical observation skills, and the use of early warning scoring systems in improving the recognition of deterioration. The study provides valuable insights into the experiences of nurse technicians and offers recommendations for healthcare organizations and policymakers to support the development of effective strategies for early recognition of clinical deterioration in Saudi Arabian hospitals.

BackgroundReliable outcome measures are vital for guiding immunoglobulin therapy in inflammatory neuropathy. Disease-specific outcome measures exist with statistically sound minimal clinically important difference (MCID) to detect change (I-RODS:+/-4; grip strength:+/-8kPa). Scores generally remain stable in well-treated disease but variation occurs.AimsTo appreciate random variability of serially assessed grip strength, RODS and MRC-SS in clinically stable CIDP/MMN patients and explore early identification of non-random trends.MethodsWe performed a longitudinal study of serial outcome measures from Manchester neurosciences immunoglobulin database (June 2009 - September 2012). We used first score on maintenance dosing as baseline, and increase in dose (g/kg/month) as indicative of meaningful clinical deterioration. We cal- culated mean/SD actual and percentage change(Δ) for grip(kPa), I-RODS(logit scale) and MRC-SS(/70) over periods of clinical stability.Results54/152 patients had sufficient stability: 39CIDP (9F), 15MMN (2F). Median age:66 years(mean:64.8, range:28–89). ΔRODS: 313 timepoints over 0.4–83.9months (median:27.4). Median change:0(0%), mean:- 0.08(0.17%), SD:4.3(8.9%). Δgrip: 569 timepoints over 0.9–98.1months (median:29.7). Δright grip median:- 1kPa(-0.11%), mean:-0.87(-0.96%), SD:5.34(5.9%). Δleft median:0kPa(0%), mean:-0.82(-0.91%), SD:5.70(6.3%).ΔMRC-SS: 75 timepoints over 1.9–52.7 months (median:10.7). Median change:0(0%), mean:0.59(0.83%), SD:4.73(6.8%). Analysis on trend identification and randomness is underway.ConclusionAppreciation of magnitude of normal variation is clinically important. Early identification of trends will influence dosing decisions.ryankeh@srft.nhs.uk|ABN Bursary95

Introduzione: l’accesso Intraosseo (IO) è una tecnica di accesso vascolare non collassabile, impiegata principalmente in situazioni di emergenza e urgenza, ma non è chiaro quanto l’accesso IO venga utilizzato e quanto possa essere utile nell’ambito delle degenze ordinarie. Lo scopo di questo protocollo di scoping review è di mappare le evidenze disponibili sull'utilizzo dell’accesso IO nei pazienti ricoverati in degenza ordinaria che mostrano un improvviso deterioramento delle loro condizioni cliniche. L’obiettivo è indagare quali siano le evidenze disponibili sull'accesso intraosseo nei pazienti con deterioramento clinico ricoverati nei reparti di degenza ordinaria. Materiali e Metodi: verranno presi in considerazione i lavori raccolti su PubMed, CINAHL, Scopus, Embase, Web of Science, Cochrane, Open Dissertations e CENTRAL. Saranno inclusi studi quantitativi, qualitativi e a metodo misto, revisioni della letteratura e letteratura grigia, oltre a linee guida e raccomandazioni di società scientifiche. La revisione sarà condotta seguendo le linee guida JBI e il processo di selezione sarà rappresentato nel diagramma di flusso PRISMA. I risultati saranno presentati in forma descrittiva, con grafici e figure quando appropriato, seguendo le linee guida PRISMA-ScR. Conclusioni: La presente scoping review potrà evidenziare eventuali lacune nella letteratura e definire future linee di ricerca. Introduction: Intraosseous (IO) access is a non-collapsible vascular access technique primarily used in emergency and urgent care settings. However, its utilisation and potential usefulness in general hospital wards remain unclear. The aim of this scoping review protocol is to map the available evidence on the use of IO access in hospitalised patients experiencing sudden clinical deterioration. The aim is to investigate what evidence is available on intraosseous access in patients with clinical deterioration admitted to ordinary wards. Materials and Methods: the databases PubMed, CINAHL, Scopus, Embase, Web of Science, Cochrane, Open Dissertations, and CENTRAL will be searched. The review will include quantitative, qualitative, and mixed-method studies, literature reviews, grey literature, as well as guidelines and recommendations from scientific societies. The review will be conducted following JBI guidelines, and the selection process will be illustrated using the PRISMA flow diagram. The findings will be presented descriptively, incorporating graphs and figures where appropriate, in accordance with PRISMA-ScR guidelines. Conclusions: this scoping review may identify gaps in the existing literature and contribute to defining future research directions.

An unresolved question for the understanding of Alzheimer’s disease (AD) pathophysiology is why a significant percentage of amyloid-β (Aβ)-positive cognitively unimpaired (CU) individuals do not develop detectable downstream tau pathology and, consequently, clinical deterioration. In vitro evidence suggests that reactive astrocytes unleash Aβ effects in pathological tau phosphorylation. Here, in a biomarker study across three cohorts ( n  = 1,016), we tested whether astrocyte reactivity modulates the association of Aβ with tau phosphorylation in CU individuals. We found that Aβ was associated with increased plasma phosphorylated tau only in individuals positive for astrocyte reactivity (Ast + ). Cross-sectional and longitudinal tau–positron emission tomography analyses revealed an AD-like pattern of tau tangle accumulation as a function of Aβ only in CU Ast + individuals. Our findings suggest astrocyte reactivity as an important upstream event linking Aβ with initial tau pathology, which may have implications for the biological definition of preclinical AD and for selecting CU individuals for clinical trials. Cross-sectional and longitudinal analyses of tau pathology in preclinical Alzheimer’s disease reveal that tau tangles accumulate as a function of amyloid-β burden only in individuals positive for an astrocyte reactivity biomarker.

IntroductionHeart failure hospitalisation (HFH) is related to increased morbidity1 and is a frequent endpoint in clinical HF trials. Focus has been recently placed on the importance of outpatient management of worsening heart failure (WHF) not requiring immediate admission. While data suggest this form of WHF is associated with a poor prognosis2, there are few data on the immediate outlook for patients stabilised in the community after an episode of WHF.MethodsThis is an updated interim analysis from an ongoing, prospective observational study of outpatient WHF, including all patients diagnosed with WHF in our HF clinic from August 2022-April 2023. We describe 1- and 3-month outcomes after initial outpatient stabilisation of an index WHF episode managed in the outpatient setting. Diagnosis was based on two definitions: 1. those meeting specific diagnostic criteria- ≥1 HF symptom, ≥1 HF physical sign and ≥1 other feature suggestive of WHF (second physical sign, natriuretic peptide rise ≥ 30%, oedema on chest x-ray, <50% inferior vena cava collapse on echocardiogram)- or 2. patients not meeting these criteria but deemed to have WHF on the discretion of the treating physician. Both definitions required escalation in diuretic therapy. All were initially treated as outpatients with escalation in oral diuretics and/or bailout therapies (metolazone and/or intravenous diuretic). Initial endpoints were stabilisation, hospitalisation or death. A patient was deemed to have stabilised if they had resolution of their symptoms and signs of WHF. 1- and 3-month outcomes were adjudicated from the time of stabilisation (table 1).Abstract 53 Table 1WHF worsening heart failure; NT-proBNP N-terminal pro-B-type natriuretic peptide. *including 2 patients who had a HF hospitalisation without being treated as an outpatient for WHF during 3-month follow-up. **NT-proBNP at time of diagnosis of index WHF episode; level available for 40 out of 54 patients who remained stable and 16 out of 17 patients who experienced recurrent WHFComparison of patients remaining stable vs. experiencing recurrent WHF at 3-month follow-up Patients remaining stable (n= 54) Patients with recurrent WHF* (n= 17) P Value Median age, years 77.5 81 0.51 Baseline NT-proBNP**, median ± IQR (pg/ml) 3111.5 ± 4024.5 2579.5 ± 3914 0.83 Patients who returned to baseline weight after index WHF episode 79.4% (27/34) 69.2% (9/13) 0.35 Patients who returned to baseline diuretic dose after index WHF episode 24.1% (13/54) 23.5% (4/17) 0.62 ResultsThis analysis includes 140 patients; 123 patients met definition 1 (above) for WHF. To date, 131 patients have reached an initial endpoint- 104 (79%) stabilised, 25 (19%) hospitalised including 16 (12%) HFH, and 8 (6%) died. Of the 104 who stabilised, 95 have reached 1-month follow-up and 76 completed 3-month follow-up. At 1 month, 6 (6%) had recurrent outpatient WHF with 1 patient requiring HFH. At 3 months, there were an additional 15 episodes (20%, 15/76) of recurrent outpatient WHF, and a further 5 HFH (7%, 5/76). Of patients with complete 1- and 3-month follow-up, a further 3 died. Since study commencement, there have been a total of 13 deaths (9%, 13/140) in the overall cohort- 10 cardiovascular (CV) deaths and 3 non-CV deaths (figure 1).Abstract 53 Figure 1One- and three-month outcomes after initial outpatient stabilisation of index episode of worsening heart failure. WHF worsening heart failure; HF heart failure; CV cardiovascular. *Three-month outcomes represent events occurring after 1 month and up to 3 months following initial stabilisation and are additional to any events which occured during the first month of follow-up[Figure omitted. See PDF]ConclusionThis interim prospective analysis of WHF demonstrates a persistently high morbidity burden in patients initially stabilised in the community, with over 20% experiencing recurrent outpatient WHF within 3 months. These data support the growing awareness of the prognostic significance of outpatient WHF and the need for more vigilant follow-up in the early period after stabilisation akin to that post-HFH. They also suggest that, while patients may be defined clinically as stabilised, many may have residual subclinical congestion increasing risk of early future clinical deterioration.