What happens before patients arrive in the ICU? We know that status pre-ICU is associated with outcomes after patients leave the ICU. We also know that we want patients to come to the ICU only if it is needed. This ties in to having an adequate emergency medicine system and innovative techniques in trauma as well as monitoring hospital patients at risk of clinical deterioration. Our cover story on pre-ICU looks at some of the issues we need to consider before patients arrive in the ICU, from the clinical as well as organisational point of view.
First, Rinaldo Bellomo, a pioneer of the rapid response system concept, outlines the development of rapid response teams, reviews the evidence on their usefulness as well as current controversies and challenges. He observes that even though categorical evidence for their utility is not available, “the logic behind their development is compelling.”
Next, Tobias Gauss, Marc Maegele and Tim Harris address the challenges of pre-hospital coagulation management in trauma. They argue that there is a strong rationale for starting to treat trauma-induced coagulopathy (TIC) in the pre-hospital phase, and suggest what a pre-hospital TIC strategy should comprise.
Then two acute emergency medicine systems are described—from Norway and Greece. Guttorm Brattebø and Øyvind Østerås explain how acute healthcare is organised in Norway, where they observe that is it unusual for a patient to arrive in a hospital emergency department without seeing a general practitioner first. While the system is well-organised, in such a long, sparsely populated country, they acknowledge the constant need to identify patients in need of ICU care, and also to maintain quality of care at smaller hospitals that do not see trauma or seriously ill patients regularly. In recent years, Greece took in a large number of refugees, whilst dealing with its own severe financial crisis. Theodoros Aslanides describes how these challenges led to changes to pre-hospital emergency medicine services.
In the Matrix section, point-of-care ultrasound (POCUS) is the focus for the first article, from Gulrukh Zaidi and Seth Koenig, who remind us of how POCUS has changed ICU practice and argue the case for its use for physicians not yet converted.
Great advances have been made in liver support, both for patients with acute liver failure as well as acute-on-chronic liver failure. Mohammed Faisal Sheikh, Karla Lee and Rajiv Jalan describe the mechanism of action and science behind the types of extracorporeal liver assist devices now available, and take a look at emerging technologies currently being trialled.
Next, Ecaterina Scarlatescu and Dana R. Tomescu present a practical view on different aspects related to the management of bleeding in visceral and liver surgery. They emphasise the need for a comprehensive perioperative coagulation treatment algorithm adapted to the local conditions of each institution.
It is not uncommon for ICU patients to experience drug-induced immediate-type hypersensitvity. The incidence is not well known, but there are steps to take to manage reactions. Cristina Petrișor, Natalia Hagău and Nadia Onițiu-Gherman give practical advice on emergency treatment for hypersensitivity reactions as well as allergological investigations.
Mikhail Zamyatin, Vitaliy Gusarov, Natalia Petrova, Natalia Lashenkova, Maria Dementienko, Dmitriy Shilkin and Ekaterina Nesterova present the results of antimicrobial stewardship programme (ASP) implementation in their 600-bed multidisciplinary hospital. One outcome was a reduction of length of stay of patients with infection in the intensive care unit (ICU), and they note that an ASP is a permanent instrument for improving quality of care.
In the Management section, we continue our series of articles on the roles and responsibilities of the multidisciplinary ICU team. Jackie McRae describes the scope of practice of the speech and language therapist (SLT), with the aim of increasing awareness of the value of SLTs as part of the wider team. Allison Gonzalez and Robert Klugman explain how the ICU social worker can be an integral member of the critical care team. The skills and training of social workers make them invaluable additions to the holistic care of critically ill patients and their families, they note.
In our Interview section, we speak to Hussain Al Rahma, Head of the Emergency and Critical Care Services Directorate at Al Zahra Hospital in Dubai, United Arab Emirates. Prof. Al Rahma is also President of the International Pan-Arab Critical Care Medicine Society and President of the Emirates Intensive Care Society. He chairs the Emirates Critical Care Conference, which recently concluded its 14th event. As our Country Focus we share from our sister journal HealthManagement.org The Journal an interview with Temie Giwa-Tubosun, CEO and founder of LifeBank, which has developed crucial infrastructure in Nigeria to enable efficient transportation and storage of blood, saving thousands of lives. As always, if you would like to get in touch, please email [email protected]