Preventing Child Drowning in the Philippines: The Need to Address the Determinants of Health.

Drowning is a public health issue in the Philippines, with children at significantly increased risk. Determinants of health (DoH) such as education, socio-economic status, ethnicity, and urbanization are factors that impact drowning risk. As drowning is a multisectoral issue, a national drowning prevention plan can drive collaboration with relevant stakeholders. This study reports trends in unintentional child (0-14 years) drowning in the Philippines (incidence, rates, and trends over time for fatal and non-fatal (years lived with a disability (YLDs) and disability adjusted life years (DALYs) from 2008-2017 and conducts an analysis of the Philippines' Multisector Action Plan (MSAP) on Drowning Prevention. From 2008-2017, 27,928 (95%UI [Uncertainty Interval]: 22,794-33,828) children aged 0-14 years died from drowning (52.7% aged 5-14 years old). Rates of drowning have declined among both age groups, with greater reductions seen among 0-4 year olds (y = -0.3368x + 13.035; R2 = 0.9588). The MSAP has 12 child drowning-specific activities and 20 activities were identified where DoH will need to be considered during development and implementation. The MSAP activities, and work done to prevent drowning more generally, must consider DoH such as education, urbanization, water and sanitation health, and safe water transportation. A national drowning surveillance system and investment in research in the Philippines are recommended.

Emergency Department-based Intensive Care Unit Use Peaks Near Emergency Department Shift Turnover.

INTRODUCTION: The Emergency Critical Care Center (EC3) is an emergency department-based intensive care unit (ED-ICU) designed to improve timely access to critical care for ED patients. ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of ED-ICU clinicians. The timing of patient transfers to the ED-ICU may decrease the number of handoffs between main ED teams and have an impact on both patient outcomes and optimal provider staffing models, but has not previously been studied. We aimed to analyze patterns of transfer to the ED-ICU and the relationship with shift turnover times in the main ED. We hypothesized that the number of transfers to the ED-ICU increases near main ED shift turnover times. METHODS: An electronic health record search identified all patients managed in the ED and ED-ICU in 2016 and 2017. We analyzed the number of ED arrivals per hour, the number of ED-ICU consults per hour, the time interval from ED arrival to ED-ICU consult, the distribution throughout the day, and the relationship with shift turnover times in the main ED. RESULTS: A total of 160,198 ED visits were queried, of which 5308 (3.3%) were managed in the ED-ICU. ED shift turnover times were 7 am, 3 pm, and 11 pm. The mean number of ED-ICU consults placed per hour was 221 (85 standard deviation), with relative maximums occurring near ED turnover times: 10:31 pm-11:30 pm (372) and 2:31 pm-3:30 pm (365). The minimum was placed between 7:31 am - 8:30 am (88), shortly after the morning ED turnover time. The median interval from ED arrival time to ED-ICU consult order was 161 minutes (range 6-1,434; interquartile range 144-174). Relative minimums were observed for patients arriving shortly prior to ED turnover times: 4:31 am - 5:30 am (120 minutes [min]), 12:31 pm - 1:30 pm (145 min), and 9:31 pm - 10:30 pm (135 min). Relative maximums were observed for patients arriving shortly after ED turnover times: 7:31 am - 8:30 am (177 min), 4:31 pm - 5:30 pm (218 min), and 11:31 pm - 12:30 am (179 min). CONCLUSION: ED-ICU utilization was highest near ED shift turnover times, and utilization was dissimilar to overall ED arrival patterns. Patients arriving immediately prior to ED shift turnover received earlier consults to the ED-ICU, suggesting these patients may have been preferentially transferred to the ED-ICU rather than signed out to the next team of emergency clinicians. These findings may guide operational planning, staffing models, and timing of shift turnover for other institutions implementing ED-ICUs. Future studies could investigate whether an ED-ICU model improves critically ill patients' outcomes by minimizing ED provider handoffs.

Utilization of a Resuscitative Care Unit for Initial Triage, Management, and Disposition of Minor Intracranial Hemorrhage.

Management of minor intracranial hemorrhage typically involves ICU admission. ICU capacity is increasingly strained, resulting in increased emergency department boarding of critically ill patients. Our objectives were to implement a novel protocol using our emergency department-based resuscitative care unit for management of management of minor intracranial hemorrhage patients in the emergency department setting, to provide timely and appropriate critical care, and to decrease inpatient ICU utilization. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Single large academic medical center in the United States. PATIENTS: Adult patients presenting to the emergency department with management of minor intracranial hemorrhage managed via our resuscitative care unit-management of minor intracranial hemorrhage protocol from September 2017 to April 2019. INTERVENTION: Implementation of a resuscitative care unit-management of minor intracranial hemorrhage protocol. MEASUREMENTS AND MAIN RESULTS: Demographic data, need for vasoactive infusions in the emergency department, emergency department and hospital length of stay, emergency department disposition, and 30-day outcomes (readmission, mortality, need for neurosurgical procedure) were collected. Fifty-five patients were identified, with mean age 67.1 ± 20.0 years. Mean Glasgow Coma Scale on presentation was 14.8 ± 0.5, and 66% had a history of trauma. Locations of hemorrhage were subdural (42%), intraparenchymal (35%), subarachnoid (15%), intratumoral (7%), and intraventricular (2%). Nineteen patients (35%) were discharged from the emergency department, 22 (40%) were admitted to general care, and 14 (26%) were admitted to intensive care. In discharged patients, there was no mortality or neurosurgical interventions at 30 days. In a subgroup analysis of 36 patients with a traumatic mechanism, 18 (50%) were able to be discharged from the emergency department after management in the resuscitative care unit. CONCLUSIONS: Initial management of emergency department patients with minor intracranial hemorrhage in a resuscitative care unit appears safe and feasible and was associated with a substantial rate of discharge from the emergency department (35%) and a low rate of admission to an inpatient ICU (26%). Use of this strategy was associated with rapid initiation of ICU-level care, which may help alleviate the challenge of increasing emergency department boarding time of critically ill patients facing many institutions.

Ruptured subcapsular liver haematoma following mechanically-assisted cardiopulmonary resuscitation.

A 64-year-old man with a history of ascending aortic surgery and pulmonary embolus presented with shortness of breath. He rapidly decompensated, prompting intubation, after which he lost pulses. Manual resuscitation was initiated immediately, with subsequent use of a LUCAS-2 mechanical compression device. The patient was given bolus thrombolytic therapy and regained pulses after 7 min of CPR. Compressions were reinitiated with the LUCAS-2 twice more during resuscitation over the subsequent hour for brief episodes of PEA. After confirmation of massive pulmonary embolism on CT, the patient underwent interventional radiology-guided ultrasonic catheter placement with local thrombolytic therapy and experienced immediate improvement in oxygenation. He later developed abdominal compartment syndrome, despite cessation of thrombolytic and anticoagulation therapy. Bedside exploratory abdominal laparotomy revealed a ruptured subcapsular haematoma of the liver. The patient's haemodynamics improved following surgery and he was extubated 11 days postarrest with intact neurological function.

A framework for the prediction of scale-up when using compressible chromatographic packings.

Experimental data are given for the solid pressure distributions in chromatography columns of various column aspect ratios packed with four types of agarose-based resin. The loss of column wall support at large scales can result in unexpectedly high pressures caused by the compression of the matrix via drag forces exerted by fluid flow through the bed. The need for an accurate model to predict flow conditions at increasing scale is essential for the scaling-up of chromatographic processes and for avoiding bed compression during operation. Several studies have generated correlations that allow for the prediction of column pressure drops, but they either are mathematically complex, which impairs their practical use, or require a large number of experiments to be performed before they can be used. In this study an empirical correlation was developed based on a previously proposed model, which links the critical velocity of operation of a chromatographic system (microcrit), to the gravity-settled bed height (L0), the column diameter (D), the feed viscosity (micro), and the compressibility of the chromatographic media used (micro 10%). The methodology developed in this study is straightforward to use and significantly reduces the burden of preceding laboratory-scale experimentation. The approach can be used to predict the critical velocity of any chromatographic system and will be useful in the development of chromatographic operations and for column sizing.