Quality Evaluation of a Checklist for Intubation Preparation in Graduate Medical Education.

Background Rapid sequence intubation (RSI) is a multistep process that emergency physicians commonly perform. Unfortunately, there is little published in the graduate medical education literature regarding the use of checklists for RSI education. Methods We developed a pre-intubation checklist for RSI preparation and evaluated emergency medicine residents' use of it. We developed the checklist using a three-round modified Delphi process among a group of emergency medicine faculty physicians within our institution. Over a three-year period, residents were randomized into two groups: a "checklist group" and a "without-checklist group." Residents were then evaluated for RSI critical step completion in a simulated critically ill patient by two independent study investigators. Inter-rater reliability kappa scores were calculated. Following completion of the scenario, residents in both groups were asked to complete an anonymous survey. Both groups had access to the checklist at the time of the survey. The survey was used to determine if they found the checklist helpful. Odds ratios with p-values, at an alpha of 0.05 for significance, were computed for checklist items comparing the checklist and without-checklist groups. Data analysis was performed using SAS software (SAS, Cary, NC v 9.4). This study was approved by the authors' Institutional Review Board. Results Each assessment was completed by two investigators. Inter-rater reliability was substantial (κ=0.79). Residents having access to the checklist were more likely to verbalize a critical step with a p-value of < 0.0001 and an odds ratio of 2.17 (95% CI: 1.48, 3.19). The checklist group normalized vital signs prior to intubation in 25/28 (89%, 95% CI: 72.81, 96.29) versus only 6/29 (21%, 95% CI: 9.85, 38.39) with a p-value of <0.0001 in the without-checklist group. The checklist group evaluated for difficult laryngoscopy 26/28 (93%, 95% CI: 77.36, 98.02) versus only 21/29 (72%, CI 95% 54.28, 85.30) with p=0.0223 in the without-checklist group. All of the surveyed residents indicated that the checklist would be helpful for future use in the ED. Conclusion This RSI checklist improved adherence to preparatory steps of RSI. Utilizing a checklist increased evaluation for a difficult airway and normalizing vital signs. Residents found the checklist helpful for ED use.

Interannual variation in nitrous oxide emissions from perennial ryegrass/white clover grassland used for dairy production.

Nitrous oxide (N2 O) emissions are subject to intra- and interannual variation due to changes in weather and management. This creates significant uncertainties when quantifying estimates of annual N2 O emissions from grazed grasslands. Despite these uncertainties, the majority of studies are short-term in nature (<1 year) and as a consequence, there is a lack of data on interannual variation in N2 O emissions. The objectives of this study were to (i) quantify annual N2 O emissions and (ii) assess the causes of interannual variation in emissions from grazed perennial ryegrass/white clover grassland. Nitrous oxide emissions were measured from fertilized and grazed perennial ryegrass/white clover grassland (WC) and from perennial ryegrass plots that were not grazed and did not receive N input (GB), over 4 years from 2008 to 2012 in Ireland (52°51'N, 08°21'W). The annual N2 O-N emissions (kg ha(-1); mean ± SE) ranged from 4.4 ± 0.2 to 34.4 ± 5.5 from WC and from 1.7 ± 0.8 to 6.3 ± 1.2 from GB. Interannual variation in N2 O emissions was attributed to differences in annual rainfall, monthly (December) soil temperatures and variation in N input. Such substantial interannual variation in N2 O emissions highlights the need for long-term studies of emissions from managed pastoral systems.

Clinical outcome of older patients with acute coronary syndrome over the last three decades.

OBJECTIVE: To Evaluate the clinical outcome of patients with acute coronary syndrome (ACS) in the Coronary Care Unit (CCU) over three decades in Dunedin, New Zealand. DESIGN: Registry study. SETTING AND PATIENTS: all consecutive patients (n = 3,013) with ACS admitted to the CCU from 1979 to 1981 (n = 966) and from 1989 to 1991 (n = 1470) were included prospectively. Data on ACS patients managed in the CCU in 2001-2002 (n = 577) were obtained via medical chart review. RESULTS: There was a rising proportion of older (> or = 75 years of age) patients with ACS (3.8% in 1979-1981, 15.2% in 1989-1991 and 25.6% in 2001-2002, P < 0.0005). However, we observed a progressive reduction of in-hospital mortality for ACS (10.7, 7.3 and 5.0%, P < 0.005) and for ST-elevation myocardial infarction (STEMI) (18.4, 16.1 and 6.6%, P < 0.005). The progressive fall in mortality rate was also observed amongst older patients, both for ACS (27, 19.2 and 11.5%, P = 0.011) and for STEMI (34.8, 30.9 and 15.4%, P < 0.005). Of concern, only 10% of patients presented within 1 h of symptom onset and 50% within 5 h, and this has not changed over three decades. The variables associated with < 5 h from symptom onset to presentation were men [odds ratio (OR) 1.25, 95% confidence interval (CI) 1.10-1.42, P = 0.001], a history of ischaemic heart disease (OR 1.25, 95% CI 1.09-1.43, P = 0.002) and STEMI (OR 1.41, 95% CI 1.18-1.67, P < 0.0001). Advanced age was not a predictor for late presentation. CONCLUSIONS: Over the past three decades, more old patients were treated in the CCU. However, there was a decline in hospital mortality, particularly for STEMI. Further efforts are required to decrease the time to presentation.