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BACKGROUND: There is limited evidence on the clinical importance of the endotracheal tube (ETT) size selection in patients with status asthmaticus who require invasive mechanical ventilation. We set out to explore the clinical outcomes of different ETT internal diameter sizes in subjects mechanically ventilated with status asthmaticus. METHODS: This was a retrospective study of intubated and non-intubated adults admitted for status asthmaticus between 2014-2021. We examined in-hospital mortality across subgroups with different ETT sizes, as well as non-intubated subjects, using logistic and generalized linear mixed-effects models. We adjusted for demographics, Charlson comorbidities, the first Sequential Organ Failure Assessment score, intubating personnel and setting, COVID-19, and the first P aCO 2 . Finally, we calculated the postestimation predictions of mortality. RESULTS: We enrolled subjects from 964 status asthmaticus admissions. The average age was 46.9 (SD 14.5) y; 63.5% of the encounters were women and 80.6% were Black. Approximately 72% of subjects (690) were not intubated. Twenty-eight percent (275) required endotracheal intubation, of which 3.3% (32) had a 7.0 mm or smaller ETT (ETT ^7 group), 16.5% (159) a 7.5 mm ETT (ETT ^7.5 group), and 8.6% (83) an 8.0 mm or larger ETT (ETT 6 8 group). The adjusted mortality was 26.7% (95% CI 13.2-40.2) for the ETT ^7 group versus 14.3% ([(95% CI 6.9-21.7%], P 5 .04) for ETT ^7.5 group and 11.0% ], P 5 .02) for ETT 6 8 group, respectively. CONCLUSIONS: Intubated subjects with status asthmaticus had higher mortality than non-intubated subjects. Intubated subjects had incrementally higher observed mortality with smaller ETT sizes. Physiologic mechanisms can support this dose-response relationship

Conclusion: This study identified the increased demand placed on a tertiary referral public hospital emergency department during extreme heat events and the potential for overcrowding. Overcrowding has been shown to adversely affect patient service and care, fostering patient and caregiver dissatisfaction as well as lowering quality of care metrics, such as: time to pain control and time to antibiotic care and even increasing mortality. Methods: Stakeholder views on ED operational challenges can provide insights to the major challenges, their causes and ways of overcoming those challenges. Additionally, differences in perceptions between the stakeholders may themselves present a challenge. Face to face semi-structured interviews were conducted with 51 ED head nurses, ED directors and hospital directors of the 17 busiest EDs in Israel.Results: "Overcrowding" was assessed by interviewees to be the most prevalent and acute operational problem, followed by prolonged waits and lengths of stay. Interviewees considered overcrowding a symptom of other operational difficulties, but also a cause of additional operational and clinical difficulties. While few interviewees attributed operational difficulties to suboptimal process management and decision making, many suggested improving operations management, within the ED and in its hospital interactions as promising interventions. Despite agreement on most topics, a major view difference between ED and hospital managers concerned the importance of interventions to minimize ED boarding. Conclusion: All three interviewee groups mostly agreed with each other and with the recent literature regarding operational challenges and their causes. Disagreement was noted regarding minimizing ED boarding. Most interviewees suggested improving operations management within the ED and in its interfaces with the hospital.

Introduction: Acute ischemic stroke (AIS) patients often have the head-of-bed (HOB) elevated to 30 0 while in the Emergency Department (ED). Flat HOB positioning has been shown to impact cerebral flow. Whether this holds true in undifferentiated, ED stroke patients is unknown. Hypothesis: We tested the hypothesis that 0 0 HOB positioning improves middle cerebral artery (MCA) mean flow velocity (MFV) in AIS compared to 30 0 . We secondarily tested the hypothesis that lower cardiac output (CO) is associated with greater fluctuation of MFV. Methods: This was a quasi-experimental study with repeat measurements of MCA MFV at 30 0 and 0 0 HOB position. Patients > 18 years presenting to the ED within 12 hours of symptom onset and a NIHSS ≥ 4 were eligible. After applying non-invasive monitoring of mean arterial pressure (MAP) and CO, an investigator used transcranial Doppler to obtain bilateral MCA MFV at 30 0 and 0 0 HOB position. If a signal was unobtainable on the ischemic side, the contralateral MFV was used for analysis. The primary analysis comprised all subjects with confirmed stroke on subsequent imaging and included student t-test for continuous measures. Secondary analysis used multiple linear regression to test if baseline NIHSS, age, MAP and CO were associated with changes in MFV. Results: There were 38 subjects enrolled, of whom 32 had confirmed AIS and were included in analysis. The mean age was 66 (±15) years and NIHSS 7 (±6). Stroke location was mixed (50% lacunar, 25% posterior and 25% anterior circulation). Averaged across all subjects, the MFV did not significantly increase when changing the HOB position from a 30 0 to 0 0 (+0.7 cm/s, 95% CI -1.6 to 3.1). Nevertheless, 16% (95% CI 5-33%) of subjects had a ≥ 20% increase and 47% (95% CI 29-65%) had any increase in MFV at 0 0 compared to 30 0 HOB. Adjusting for age, NIHSS and MAP, lower CO was associated with greater change in MFV (+2 cm/s [95% CI 0.2-3.7 cm/s] for every 1 L/min lower cardiac output, p=0.03). Conclusions: In conclusion, in a mixed sample of ED AIS patients, lower HOB position does not significantly impact cerebral flow on average, yet a considerable proportion of individuals may benefit from lower HOB position. Low cardiac output may identify those that benefit most.

Conclusion: This study identified the increased demand placed on a tertiary referral public hospital emergency department during extreme heat events and the potential for overcrowding.