Internal and emergency medicine
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An increasing number of elderly patients are admitted to the hospital for critical diseases and the gap between supply and demand of intensive care resources is a growing problem. To meet this challenge, 4 beds in a 24-bed acute care for the elderly (ACE) medical unit were dedicated to a subintensive care unit (SICU). Severely ill elderly medical patients, requiring a higher level of care than provided in ordinary wards, are admitted. The aim of the study was to describe the characteristics of the setting and to discuss its usefulness based on data obtained after the first period of implementation. ⋯ The SICU is an innovative method to treat frail elderly patients with more severe conditions. Low hospital mortality compared with that of severe patients in the ACE unit supports the usefulness of this model. It could be implemented in medical units of large hospitals in order to give optimal care and advanced interventions to the frail elderly and to avoid intensive care unit overcrowding.
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We believe that clinical ethics consultation (CEC) has as its goal the delivery of healthcare in a manner consistent with the moral rules and the moral ideals. Towards this end, CEC pursues the instrumental ends of clarifying the limits of acceptable ethical disagreement and facilitating a choice among ethically acceptable alternatives. In pursuing these ends, healthcare ethics consultation (HEC) and CEC services confront three broad categories of questions: (1) questions of professional duty; (2) questions of law; and (3) questions of general morality. ⋯ We submit that this has implications for the organization and structure of consultation services and HEC and for the methodology and processes employed in CEC. Thus: (1) questions of professional duty should be addressed only by physician members (whom we would distinguish by employing the term "ethicians") of the HEC or CEC service. The only role for non-ethicians under these circumstances would be in helping to resolve disagreements between/among professionals; (2) questions of law, in contrast, should be addressed only by the attorney member(s) of the HEC or CEC service; (3) questions of general morality may be addressed by the entire membership of the HEC or CEC service.
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Sepsis is a frequent and often lethal condition. Rapid identification and aggressive therapy in the emergency department (ED) are essential for outcome. Several indexes were found to be significantly related to short-term clinical outcome, but only bedside, rapidly available tests are thought to be useful in the ED. To define the prevalence and mortality of patients with severe sepsis presenting to the ED of a tertiary care hospital in Italy, we furthermore investigated the ability of bedside, non-invasive prognostic indexes to identify patients with adverse short-term clinical outcome. ⋯ Among critical patients admitted to an Italian ED, those with severe sepsis/septic shock represent about 1%, with a very high mortality rate. Bedside non-invasive prognostic indexes are able to identify with high accuracy patients with adverse short-term clinical outcome.
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Growing evidence supports the premise that adult trauma centers lower the risk of death for severely injured patients. The same principles have been applied to the pediatric population and mounting research suggests that, as in the adult population, gravely injured children have better outcomes at pediatric trauma centers where personnel trained and experienced in the specific needs and unique physiology of injured children provide care. As in the United States, acute traumatic injury represents an important public healthcare concern to the Tuscan regional government whose goal is to maximize clinical outcomes within available resources. In order to address this problem, the Tuscan regional government has created a new and innovative collaboration between the Meyer Pediatric Hospital/University of Florence School of Medicine and the Children's Hospital Boston/Harvard Medical School to build a pediatric trauma center and regional pediatric trauma referral system. ⋯ This long-term international initiative will seek to develop a demonstration model for pediatric trauma care that may later be replicated elsewhere. The initial goals of the project will focus on expanding the role of the pediatricians working in the emergency department to include the acute care of medical, surgical, orthopedic and multiple trauma patients. This new configuration will closely resemble the single provider model of emergency medical care commonly utilized in the United States. During this transition period to a more broadly trained emergency physician, a multi-disciplinary trauma team will be created and pediatric trauma clinical practice guidelines will be introduced into the emergency department and inpatient care units. Systems measurements will be achieved through a comprehensive quality improvement and risk management program. Ultimately, all Tuscan regional pediatric major trauma will be consolidated at the Meyer Pediatric Hospital in Florence.