Faculty Bibliography

Despite improvements in the management of in-hospital cardiac arrest over the past decade, in-hospital cardiac arrest continues to be associated with poor prognosis. This has led to the development of rapid response systems, hospital-wide efforts to improve patient outcomes by centering on prompt identification of decompensating patients, expert clinical management, and continuous quality improvement of processes of care. The rapid response system may include cardiac arrest teams, which are centered on identification and treatment of patients with in-hospital cardiac arrest. However, few evidence-based guidelines exist to guide the formation of such teams, and the degree of their variation across the United States has not been well described.

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30

OBJECTIVES/OBJECTIVE:To characterise the variation in composition, leadership, and activation criteria of rapid response and cardiac arrest teams in five north-eastern states of the USA. DESIGN/METHODS:Cross-sectional study consisting of a voluntary 46-question survey of acute care hospitals in north-eastern USA. SETTING/METHODS:Acute care hospitals in New York, New Jersey, Rhode Island, Vermont, and Pennsylvania. PARTICIPANTS/METHODS:Surveys were completed by any member of the rapid response team (RRT) with a working knowledge of team composition and function. Participants were all Medicare-participating acute care hospitals, including teaching and community hospitals as well as hospitals from rural, urban and suburban areas. RESULTS:Out of 378 hospitals, contacts were identified for 303, and 107 surveys were completed. All but two hospitals had an RRT, 70% of which changed members daily. The most common activation criteria were clinical concern (95%), single vital sign abnormalities (77%) and early warning score (59%). Eighty one per cent of hospitals had a dedicated cardiac arrest team.RRT composition varied widely, with respiratory therapists, critical care nurses, physicians and nurse managers being the most likely to attend (89%, 78%, 64% and 51%, respectively). Consistent presence of critical care physicians was uncommon and both cardiac arrest teams and teams were frequently led by trainee physicians, often without senior supervision. CONCLUSIONS:As the largest study to date in the USA, we have demonstrated wide heterogeneity, rapid team turnover and a lack of senior supervision of RRT and cardiac arrest teams. These factors likely contribute to the mixed results seen in studies of RRTs.

Desmopressin, a synthetic vasopressin analog, is used to treat central diabetes insipidus, hemostatic disorders such as von Willebrand's disease, and nocturnal enuresis. We present the case of a 69-year-old man who developed severe hyponatremia during treatment with intranasal desmopressin at 10 µg twice daily for chronic polyuria and nocturia thought to be due to central diabetes insipidus. After 5 months of therapy, the patient noticed progressive fatigue, anorexia, dizziness, weakness, light-headedness, decreased concentration, and new-onset falls. At 6 months of therapy, the patient was brought to the emergency department for altered mental status and was found to be severely hyponatremic with a serum sodium level of 96 mmol/L, down from a value of 134 mmol/L at the initiation of therapy. The intranasal desmopressin was discontinued and the patient was admitted to the intensive care unit where the hyponatremia was slowly corrected over the next week to 132 mmol/L, never increasing by more than 8 mmol/L a day, with careful fluid management. This included infusion of over 11 L of 5% dextrose to account for a high urine output, which peaked at 7.4 L in 1 day. However, while the recommended rate for sodium correction was followed, the patient's magnetic resonance imaging of the brain obtained after discharge displayed evidence of central pontine myelinolysis. Despite this finding, the patient eventually returned to his baseline mental status with no permanent neurologic deficits.

PURPOSE: Our overall goal is to create a sustainable ultrasound(US) intervention in resource-limited settings in Dhaka, Bangladesh. Our baseline needs-assessment of the intensive care unit (ICU) of Dhaka Medical College Hospital (DMCH) found that reliable imaging is not available, including ultrasound. The lack of adequate imaging was found to be a deterrent to the proper care of patients. The growing use of point-of-care ultrasound in the ICU as a tool for rapid diagnosis and management led to the creation of the Bangladesh Ultrasound Initiative. This project is designed to bring a successful point-of-care ultrasound training program to physicians in the ICU and emergency room of DMCH. METHODS: Participants were recruited via posters and emails. Training workshops spanned the course of two days. All sessions included individuals that represented all levels of physician training. The following topics were covered: technical aspects, basic echocardiography, pleural ultrasound, DVT and IVC assessment, US-guided CVL placement, US-guided thoracentesis and FAST exam. Training sessions were divided into three parts: lecture-based learning (2 hours), image interpretation with normal and pathological images shown to participants(1.5 hours), and hands-on practical use with the aid of volunteers(2.5 hours). A pre-test and post-test with the same questions was distributed before and after each workshop respectively. Statistical analysis was completed with the use of a chi-square test and paired t-test. RESULTS: Fifty individuals were included in the final analysis. The pre-test/post-test had a total of 37 questions, 25 of which were knowledge-based. Knowledge-based questions were grouped into the topics covered as listed in the methods section. There was a statistically significant (p<0.05) difference between pre- and post-test scores; the mean pre-test score was 3 (SD=3) and the mean post-test score was 12 (SD=3). A 5-point Likert scale was used to ask questions regarding level of confidence. The mean confidence level on the pre-test was 1 (very unconfident) in every category to 5 (very confident) in the post-test(p<0.05). A subgroup analysis showed no difference in mean pre-test and post-test scores of participants who had attended an ultrasound course at any point prior to our intervention compared to those who had never attended a previous ultrasound course. CONCLUSIONS: The results of this study show that a simple workshop in point-of-care ultrasound, using lectures and hands-on practice, can improve knowledge and confidence with statistical significance. This study also shows that the pre- and post-test scores are similar despite some participants having had training in ultrasound prior to the current intervention