increases the risk of intubation, providers are wary to aggressively fluid-resuscitate septic patients who are at risk of fluid overload -namely, patients with congestive heart failure (CHF) or end-stage renal disease (ESRD). We sought to assess whether an initial fluid dose of 30 ml/kg in septic CHF or septic ESRD patients, compared to a fluidrestrictive strategy, leads to increased intubations. We also analyzed mortality rates and hospital length of stay (LOS).Methods: At our ED, data on septic patients > 17 years of age are prospectively tracked for quality metrics. Patients who trigger the sepsis flag are up-triaged for quicker provider evaluation to assess whether to implement a sepsis bundle, including whether or not to administer 30 ml/kg of fluids. All patients who are ultimately deemed to have had an infectious source that triggered the flag have multiple metrics logged and tracked. This prospectively collected set of data was retrospectively analyzed. Inclusion criteria were septic patients with past medical history of CHF or ESRD who were given fluids. Patients were excluded if they were under do-notresuscitate (DNR) or comfort-measures-only (CMO) status, as well as if amount of administered fluid was unknown. Primary outcome was intubation frequency. Secondary outcomes were hospital LOS and mortality. Student t-test and chi-square tests was used for analyses.Results: Table 1 demonstrates the outcomes in patients who were given at least 30 ml/kg compared to those who were not. In particular, there were no differences between groups in intubation rates. There were also no differences in hospital LOS or in mortality (although the sample was not sufficiently powered for mortality). Overall, 13.8% (95% CI 9.5%-19.2%) of septic patients with CHF and/or ESRD received 30 ml/kg of fluids in the ED whereas 21.0% (95% CI 18.7%-23.4%) of septic patients without either CHF or ESRD received 30 ml/kg of fluids in the ED (p<0.02).Conclusions: Our analysis suggests that patients with a history of CHF and/or ESRD who become septic and receive at least 30 ml/kg of fluids in the ED are not any more likely to be intubated than the patients who receive fluid-restrictive regimen of < 30 ml/kg. This analysis has limitations, including that there may be baseline differences between the patients who did receive 30 ml/kg of fluids in the ED vs. those who did not. However, our results are in line with some previously presented data. Therefore, an initial bolus of 30 ml/kg of fluids in septic CHF/ ESRD patients appears to be safe -possibly even beneficial -and can potentially be included in a triage bundle set for sepsis care in the ED. At our site, CHF/ESRD patients were significantly less likely to receive 30 ml/kg of fluids in the ED than non-CHF/ESRD patients, but adherence to the 30 ml/kg target was low for all patients. Implementing a 30 ml/kg fluid order from triage could enhance compliance with the Surviving Sepsis guidelines -and still leave providers the option of holding fluids when they clinically deem it appropriate.
Study Objectives: Escape rooms are physical adventure games developed circa 2006 gaining popularity across the world. The model uses players in a locked room that use elements of the room to solve a series of puzzles to escape the room. Escape rooms are increasingly more popular and have themes that vary from murder mystery to outer space odyssey, but currently not used in emergency medicine education.Objectives: Given the challenge to enhance conference didactics and improve residency education techniques, we proposed a medical escape room for our residents to participate in on a scheduled conference day in lieu of standard conference lectures.Methods: We conducted an escape exercise with 6-8 players per room (of incremental PG year) to participate at our Simulation Center. Given the size of our residency program, group start times were staggered so that each of the 8 groups would have 20 minutes to move onto the next room and start to solve the next case. The escape room is devised to have 4 cases of progressing severity of illness for a particular patient chief complaint. We utilized abdominal pain as this was the topic assigned for our EM model for that cycle. The residents included a residents from academic years 1-4 as well as an APD as the guide. Clues included physical exam findings on the SIM mannequin, lab abnormalities, EKG and radiographic imaging, which when diagnosed correctly would provided a diagnostic code number. When all the clues were solved, this would produce a phone number the group would call and disposition the patient. If the correct disposition was given, they would be given the location of the door key. Points are awarded similar to standard escape rooms where time to diagnosis and use of hints were weighted.Conclusions: It is already known that simulation-based education enhances learning. We believe this was a great team-building exercise for problem-based learning, and offers an opportunity for the resident as an educator. Residents truly enjoyed this approach and since faculty observed the entire exercise, future plans are for milestone evaluations.
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