Background: A structured family meeting (FM) is recommended within 72 h of admission for trauma patients with high risk of mortality or disability. Multidisciplinary FMs (MDFMs) may further facilitate decision-making. We hypothesized that FM within three hospital days (HDs) or MDFM would be associated with increased use of comfort measures. Materials and methods:We reviewed all adult trauma deaths at an academic level 1 trauma center from December 2014 to December 2017. Death in the first 24 h or on nonsurgical services were excluded. Demographics, injury characteristics, FM characteristics, and outcomes such as length of stay (LOS) were recorded. Early FM was defined as occurring within three HDs; MDFM required attendance by two or more specialty teams.Results: A total of 177 patients were included. Median LOS was 6 d (interquartile range 4-12). FMs were documented in 166 patients (94%), with 57% occurring early. MDFM occurred in 49 (28%), but usually occurred later (median HD 5 and interquartile range 2-8). Early FM was associated with reduced LOS (5 versus 11 d, P < 0.001), ventilator days (4 versus 9 d, P < 0.001), and deaths during a code (1.2% versus 13.2%, P < 0.001). MDFM was associated with higher use of comfort measures (88% versus 68%, P < 0.05). Of patients who transitioned to comfort care status (n = 130, 73.4%), code status change occurred earlier if an early FM occurred (5 versus 13 d, P < 0.001).Conclusions: MDFM is associated with increased comfort care measures, whereas early FM is associated with reduced LOS, ventilator days, death during a code, and earlier comfort care transition.
Study Objectives: To study the effectiveness of a mobile app-based strategy to improve door-to-needle time in the treatment of acute ischemic stroke in an emergency department in Kerala, India.Methods: This was a study of consecutively presenting patients who were admitted to the emergency department at Baby Memorial Hospital between April 2017 -March 2018 with acute stroke. The mobile application (app) included fields for patient parameters, a timer, the NIH stroke scale (NIHSS), the thrombolysis checklist and a tPA (tissue plasminogen activator) dose calculator. The app also enabled team synchronization by notifying all on-call members and team leaders of the patient movement in real time, along with sharing of radiological images.Door to needle time (DNT) captured from the app was entered in a spreadsheet and compared to previous values from our center. Mean values were compared using the unpaired t test (2-tailed).Results: A total of 62 patients were thrombolysed during the time period using the mobile app. The mean DNT was 45 min with 89% being thrombolysed within 60 minutes and 57% being thrombolysed within 45 minutes.These patients were compared with 100 consecutive patients who were thrombolysed in the months prior to April 2017, where the mean DNT was 57 min, with 67% thrombolysed within 60 minutes and 47% being thrombolysed within 45 minutes.A mean DNT decrease of 12 minutes was seen with 1.3 x increase in DNT < 60 min. This difference was statistically significant (p¼0.0104, unpaired t test). The causes of delay were identified and included delays in patient shifting and imaging. Conclusions: We have been able to demonstrate significant improvement in doorto-needle time by using a mobile app as a tool to improve team performance; in addition, the app allowed us to identify causes of delay.
Background Missed documentation for critical care time (CCT) for dying patients may represent a missed opportunity for physicians to account for intensive care unit (ICU) services, including end-of-life care. We hypothesized that CCT would be poorly documented for dying trauma patients. Methods Adult trauma ICU patients who died between December 2014 and December 2017 were analyzed retrospectively. Critical care time was not calculated for patients with comfort care code status. Critical care time on the day prior to death and day of death was collected. Logistic regression was used to determine factors associated with documented CCT. Results Of 147 patients, 43% had no CCT on day prior to death and 55% had no CCT on day of death. 82% had a family meeting within 1 day of death. Family meetings were independently associated with documented CCT (OR 3.69, P = .008); palliative care consultation was associated with decreased documented CCT (OR .24, P < .001). Conclusions Critical care time is not documented in half of eligible trauma patients who are near death. Conscious (time spent in family meetings and injury acuity) and unconscious factors (anticipated poor outcomes) likely affect documentation.
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