Finally time for rapid response systems to be well MET in Europe?

Abstract

Time is life. In medicine there are many "time-dependent" diseases: sepsis and cardiac arrest to name but two [1,2]. In order to improve patient outcome, it is imperative to define and characterize hospital workflows to facilitate good process of care. Several factors need to be synchronized, including coordination between different departments in the hospital [3]. Early communication and a multidisciplinary approach can dramatically change the management of patients. The goal of modern intensive care medicine is to optimize and maximize quality of patient care. It is desirable to foster an overview of the process of critical care and base it on clinical need of patients and less on hospital location. Clinical management and monitoring of severely ill patients before admission to intensive care units (ICU) have frequently been shown to be suboptimal [4,5]. Delays in patient admission to ICU are associated with a longer hospital stay and worse outcome. Recently, Harris et al. prospectively analysed the outcome of a large UK population from 48 hospitals and concluded that the deteriorating ward patient has a high short-term mortality; however, with early ICU admission an impressive 50 % reduction of 90-day mortality is possible [6].Clinical conditions at risk are usually preceded by pathophysiological alterations that are both detectable and preventable. As early as the late 1990s, patient-atrisk teams, medical emergency teams (METs) or rapid response teams (RRT) were created to early detect patients at risk on general wards [7]. In the USA, the Institute for Healthcare Improvement (IHI) recommended, more than 10 years ago, that hospitals should implement RRTs and/or METs for the identification of non-ICU patients at risk of deterioration [8,9].Meta-analyses, including 30 before-after studies, cohort studies and cluster randomized trials found that implementation of an RRT/MET is associated with a reduction in non-ICU cardiopulmonary arrests but the effect on hospital mortality is less clear [10,11]. In the UK, early warning scores (EWS) based on "track and trigger" systems have for several years been used to flag and alert patients at risk and develop a rapid response by in-hospital teams with critical care skills to stabilize patients and expedite admission to ICU [12].Thus far the evidence on MET/RRT adoption has mainly originated from outside continental Europe [13]. In a recent article in Intensive Care Medicine, Jung and colleagues retrospectively analysed patients' outcomes after RRT implementation in one hospital (RRT hospital) and compared these to outcomes from three other hospitals (non-RRT hospitals) in the south of France [14]. In essence, the authors replicated a system that was developed 25 years ago and recommended by current resuscitation guidelines [15]. The study showed an impressive decrease in hospital mortality in the hospital with RRT implementation. There are not many interventions in ICU that can be attributed to a similar decrease in mortality and the authors should be congratulated for s...

Impact of Coal Fly Ash Addition on Combustion Aerosols (PM2.5) from Full-Scale Suspension-Firing of Pulverized Wood

“…2 Whereas aerosol formation and release of key elements from, for example, grate-fired biomass units have been studied intensively during the last decades, 7,[9][10][11]16,17 the knowledge about aerosol formation in suspension-firing of biomass is still very limited. 3,4,12,18 The reason why only limited investigations have been published on large-scale firing of pure biomass in pulverized fuel-fired boilers is mainly due to the fact that biomass has traditionally been fired in grate or fluidized bed boilers, while suspension firing of biomass is still a fairly new technology.…”

“…The aerosol particles act as carriers of corrosive alkali chlorides to superheater surfaces, 3,11 and as the alkali chlorides have low melting temperatures, they cause the ash to be sticky, thus aggravating ash deposition problems. 2,3,5,13 Furthermore, accelerated deactivation of the SCR catalysts may take place when significant amounts of aerosols are present in the fly ash. 5,6 One way to abate/minimize the ash-related operational problems is to utilize additives, which are able to bind the potassium into relatively large particles with higher melting temperatures, while releasing the chlorine in the gas phase as HCl.…”

“…5,6 The ash-related operational problems are induced by the release of inorganic elements such as alkali metals and chlorine present in the wood, and the subsequent aerosol formation and/or condensation of inorganic vapors on heat exchanger surfaces. 3,4,7 When biomass such as wood is combusted, the ash forming elements, such as K, Cl, and S, will vaporize to some degree, 8−10 and the potassium released into the gas phase during combustion subsequently forms ultrafine particles− aerosols−highly enriched in potassium, sulfur, and chlorine. 3,7,11 Following the definition of Jimeńez and Ballester, 12 combustion aerosols are here defined as fine particles with an aerodynamic diameter below 2.5 μm, formed primarily by the vaporization and subsequent condensation of inorganic species in the fuel.…”

“…3,4,7 When biomass such as wood is combusted, the ash forming elements, such as K, Cl, and S, will vaporize to some degree, 8−10 and the potassium released into the gas phase during combustion subsequently forms ultrafine particles− aerosols−highly enriched in potassium, sulfur, and chlorine. 3,7,11 Following the definition of Jimeńez and Ballester, 12 combustion aerosols are here defined as fine particles with an aerodynamic diameter below 2.5 μm, formed primarily by the vaporization and subsequent condensation of inorganic species in the fuel. The aerosol particles act as carriers of corrosive alkali chlorides to superheater surfaces, 3,11 and as the alkali chlorides have low melting temperatures, they cause the ash to be sticky, thus aggravating ash deposition problems.…”

“…3,7,11 Following the definition of Jimeńez and Ballester, 12 combustion aerosols are here defined as fine particles with an aerodynamic diameter below 2.5 μm, formed primarily by the vaporization and subsequent condensation of inorganic species in the fuel. The aerosol particles act as carriers of corrosive alkali chlorides to superheater surfaces, 3,11 and as the alkali chlorides have low melting temperatures, they cause the ash to be sticky, thus aggravating ash deposition problems. 2,3,5,13 Furthermore, accelerated deactivation of the SCR catalysts may take place when significant amounts of aerosols are present in the fly ash.…”