Laryngeal injury from intubation is common in the ICU setting. Guidelines for laryngeal assessment and postextubation surveillance do not exist. A systematic approach to more robust investigations could increase knowledge of the association between particular injuries and corresponding functional impairments, improving understanding of both time course and prognosis for resolution of injury. Our findings identify targets for future research and highlight the long-known, but understudied, clinical outcomes from endotracheal intubation with mechanical ventilation in ICU.

Our findings are consistent with outcomes of studies in non-healthcare domains, but are contrary to a study of ED physicians, suggesting differential responses to interruptions by physicians and nurses. Future studies on interruptions in healthcare should thus be discipline specific. Though the effect of interruptions on intervention length is only about 2 min, in an ED setting, this can increase patient risks and costs. To better focus efforts to reduce interruptions future research should focus on further separation of interruption type (eg, urgent vs routine or unnecessary).

IMPORTANCEThe capacity of pediatric hospitals to provide treatment to large numbers of patients during a large-scale disaster remains a concern. Hospitals are expected to function independently for as long as 96 hours. Reverse triage (early discharge), a strategy that creates surge bed capacity while conserving resources, has been modeled for adults but not pediatric patients.OBJECTIVE To estimate the potential of reverse triage for surge capacity in an academic pediatric hospital. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, a blocked, randomized sampling scheme was used including inpatients from 7 units during 196 mock disaster days distributed across the 1-year period from December 21, 2012, through December 20, 2013. Patients not requiring any critical interventions for 4 successive days were considered to be suitable for low-risk immediate reverse triage. Data were analyzed from November 1, 2014, through November 21, 2016. MAIN OUTCOMES AND MEASURES Proportionate contribution of reverse triage to the creation of surge capacity measured as a percentage of beds newly available in each unit and in aggregate. RESULTS Of 3996 inpatients, 501 were sampled (268 boys [53.5%] and 233 girls [46.5%]; mean [SD] age, 7.8 [6.6] years), with 10.8% eligible for immediate low-risk reverse triage and 13.2% for discharge by 96 hours. The psychiatry unit had the most patients eligible for immediate reverse triage (72.7%; 95% CI, 59.6%-85.9%), accounting for more than half of the reverse triage effect. The oncology (1.3%; 95% CI, 0.0%-3.9%) and pediatric intensive care (0%) units had the least effect. Gross surge capacity using all strategies (routine patient discharges, full use of staffed and unstaffed licensed beds, and cancellation of elective and transfer admissions) was estimated at 57.7% (95% CI, 38.2%-80.2%) within 24 hours and 84.1% (95% CI, 63.9%-100%) by day 4. Net surge capacity, estimated by adjusting for routine emergency department admissions, was about 50% (range, 49.1%-52.6%) throughout the 96-hour period. By accepting higher-risk patients only (considering only major critical interventions as limiting), reverse triage would increase surge capacity by nearly 50%. CONCLUSIONS AND RELEVANCEOur estimates indicate considerable potential pediatric surge capacity by using combined strategic initiatives. Reverse triage adds a meaningful but modest contribution and may depend on psychiatric space. Large volumes of pediatric patients discharged early to the community during disasters could challenge pediatricians owing to the close follow-up likely to be required.

Background Early efforts to incorporate telemedicine into Emergency Medicine focused on connecting remote treatment clinics to larger emergency departments (EDs) and providing remote consultation services to EDs with limited resources. Owing to continued ED overcrowding, some EDs have used telemedicine to increase the number of providers during surges of patient visits and offer scheduled “home” face-to-face, on-screen encounters. In this study, we used remote on-screen telemedicine providers in the “screening-in-triage” role. Objective This study aimed to compare the efficiency and patient safety of in-person screening and telescreening. Methods This cohort study, matched for days and proximate hours, compared the performance of real-time remote telescreening and in-person screening at a single urban academic ED over 22 weeks in the spring and summer of 2016. The study involved 337 standard screening hours and 315 telescreening hours. The primary outcome measure was patients screened per hour. Additional outcomes were rates of patients who left without being seen, rates of analgesia ordered by the screener, and proportion of patients with chest pain receiving or prescribed a standard set of tests and medications. Results In-person screeners evaluated 1933 patients over 337 hours (5.7 patients per hour), whereas telescreeners evaluated 1497 patients over 315 hours (4.9 patients per hour; difference=0.8; 95% CI 0.5-1.2). Split analysis revealed that for the final 3 weeks of the evaluation, the patient-per-hour rate differential was neither clinically relevant nor statistically discernable (difference=0.2; 95% CI –0.7 to 1.2). There were fewer patients who left without being seen during in-person screening than during telescreening (2.6% vs 3.8%; difference=–1.2; 95% CI –2.4 to 0.0). However, compared to prior year-, date-, and time-matched data on weekdays from 1 am to 3 am, a period previously void of provider screening, telescreening decreased the rate of patients LWBS from 25.1% to 4.5% (difference=20.7%; 95% CI 10.1-31.2). Analgesia was ordered more frequently by telescreeners than by in-person screeners (51.2% vs 31.6%; difference=19.6%; 95% CI 12.1-27.1). There was no difference in standard care received by patients with chest pain between telescreening and in-person screening (29.4% vs 22.4%; difference=7.0%; 95% CI –3.4 to 17.4). Conclusions Although the efficiency of telescreening, as measured by the rate of patients seen per hour, was lower early in the study period, telescreening achieved the same level of efficiency as in-person screening by the end of the pilot study. Adding telescreening during 1-3 am on weekdays dramatically decreased the number of patients who left without being seen compared to historic data. Telescreening was an effective and safe way for this ED to expand the hours in which patients were screened by a health care provider in triage.