Primary aim is to improve early recognition of critically ill patients and delivering optimal academic patient care for this group of vulnerable patients requires a multidisciplinary and evidence-based approach. Research and education is essential to provide excellent patient care in this fast moving field. This ACE represents collaboration at three levels: research, patient care and education.
Using advanced imaging technology as well as contemporary biomarkers, new pathways for accurate and efficient triage of patients with chest pain and possible acute coronary syndromes are being validated; Efficient identification of patients with high risk of pulmonary embolism is studied; Assessment of hypovolemia in the Emergency Department is assessed with non-invasive monitoring.
All studies are multidisciplinary, most of them combining clinical with fundamental or epidemiological research. Treatment of the critically ill patient is covered in the following projects: Several biomarkers for infectious diseases are currently being validated in an emergency department patient population and on the ICU.
The future aim is to identify and validate new biomarkers for infectious disease. Furthermore we aim to develop rapid diagnostics of [emerging] virus infections in patients presenting at the emergency department and optimize treatment strategies; the efficacy of antidotes for patients with life threatening bleedings due NOACs is studied. Collaborations with national top scientific centers such as LUMC and AMC exist. Translational research is performed in animal models regarding emergency and critical care around the central theme "tissue oxygenation and oxygen metabolism". Novel monitoring technologies are being developed, e.g.for monitoring mitochondrial oxygenation and function, which will soon become available for clinical research.
The departments in this ACE participate in multidisciplinary bachelor (Ba) and master (Ma) education programs for medical students. Acute medicine training in Ba years 1,2 and 3 is supervised by specialists from different departments. Participation of the different departments in several minors involving critical care in Ba years 2 and 3, hands on simulation training during Ma year 1 with emphasize on working and communication in multidisciplinary teams at the ED and in the 'BAZ' (basiscursus acute zorg), mandatory for all new A(N)IOS after graduation form medical school.
The ACE participates in the development of the Medical Track at the Erasmus University College, which is attended by national and international students. The different departments work together in the development and implementation of the Emergency Nursing Training program for the Zorgacademie. Evaluations are performed by the medical school and the student counsel and frequently discussed by all departments involved.
Suggestions for improvement are evaluated and implemented. Resident training is evaluated the same way through SetQ, Direct and other feedback measures. Research masters and PhDs are trained by all participating members of the ACE. And (inter)national students rotate through the departments.
Societal Relevance to Research, Education and Patient Care
Many patients with acute infections, presented for emergency care, have a history of chronic underlying illness and (multiple) co-morbidities. As the number of patients with chronic conditions in the Netherlands will grow from more than 5 million (of these more than 2 million have chronic multimorbidity) in 2011, till 7 million (of which 3 million with chronic multimorbidity) in 2030, this forms a serious societal problem.
On the ICU over 50% of all admitted patients have multimorbidity next to the acute reason for admission. This complicates mortality, morbidity, outcome, quality of life after survival and discharge from the ICU and hospital, prompting to difficult decision-making. Research in this category of patients shall reveal valuable information for future patient care, triage and decision-making. Young physicians and nurses should be educated in delivering acute care in this complex group of patients.
Outcome of research in this category of patients can be of great importance of health care providers in the first line of care, policy makers and society. Professional guidelines for triage and patient selection for advanced medical care using scarce resources is under constant revision and discussion. This ACE can offer valuable fuel for the development of these guidelines and standards.
Viability of Research, Education and Patient Care
The care for the critically ill patient is multidisciplinary and generally is not confined within the borders of one department. Typically a patient might present at the ED before being transferred to the ICU and often they do require some sort of surgical or otherwise invasive procedure under anesthesia. The advantage of a well-coordinated cooperation between the departments of anesthesiology, intensive care and emergency care has already been acknowledged within the thema SPIN. To further integrate the mutual efforts aimed at improving care for the critically ill patient regarding patient care, research and education in a formal ACE seems a natural further development.
The ACE covers a central theme in academic emergency and critical care medicine and not a rare and specialized 'niche'. Therefore, although specific research lines might rely on an individual's expertise, the continuity of the ACE as a whole seems warranted irrespective of individual members. The departments involved in the ACE have an active policy toward development of talents. For example, several staff members recently followed the "Persoonlijk Leiderschapsprogramma". In line with this policy, next to providing opportunities to do (PhD) research and participate in education the ACE seeks to gradually increase its number of assistant and associate professors.
Key and relevant publications of the last five years
- Procalcitonin guided antibiotic therapy in patients presenting with fever in the emergency department.Limper M, van der Does Y, Brandjes DP, De Kruif MD, Rood PP, van Gorp EC.
- Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study. Dedic A, Lubbers MM, Schaap J, Lammers J, Lamfers EJ, Rensing BJ, Braam RL, Nathoe HM, Post JC, Nielen T, Beelen D, le Cocq d'Armandville MC, Rood PP, Schultz CJ, Moelker A, Ouhlous M, Boersma E, Nieman K. J Am Coll Cardiol. 2016 Jan 5;67(1):16-26.
- A randomized trial of intraarterial treatment for acute ischemic stroke.Berkhemer OA, Fransen PS, et al.; MR CLEAN Investigators. N Engl J Med. 2015 Jan 1;372(1):11-20.
- Cutaneous Mitochondrial PO2, but Not Tissue Oxygen Saturation, Is an Early Indicator of the Physiologic Limit of Hemodilution in the Pig. Römers LH, Bakker C, Dollée N, Hoeks SE, Lima A, Raat NJ, Johannes T, Stolker RJ, Mik EG. Anesthesiology. 2016 Jul;125(1):124-132.
- Non-invasive monitoring of mitochondrial oxygenation and respiration in critical illness using a novel technique. Harms FA, Bodmer SI, Raat NJ, Mik EG. Crit Care. 2015 Sep 22;19:343.
- Acute normovolemic hemodilution in the pig is associated with renal tissue edema, impaired renal microvascular oxygenation, and functional loss. Konrad FM, Mik EG, Bodmer SI, Ates NB, Willems HF, Klingel K, de Geus HR, Stolker RJ, Johannes T. Anesthesiology. 2013 Aug;119(2):256-69.
- Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. Zondag W, Mos IC, Creemers-Schild D, Hoogerbrugge AD, Dekkers OM, Dolsma J, Eijsvogel M, Faber LM, Hofstee HM, Hovens MM, Jonkers GJ, van Kralingen KW, Kruip MJ, Vlasveld T, de Vreede MJ, Huisman MV; Hestia Study Investigators.J Thromb Haemost. 2011 Aug;9(8):1500-7.
- The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded. van Es J, Mos I, Douma R, Erkens P, Durian M, Nizet T, van Houten A, Hofstee H, ten Cate H, Ullmann E, Büller H, Huisman M, Kamphuisen PW.Thromb Haemost. 2012 Jan;107(1):167-71.
- On the treatment of new oral anticoagulant-associated gastrointestinal hemorrhage. Holster IL, Hunfeld NG, Kuipers EJ, Kruip MJ, Tjwa ET. J Gastrointestin Liver Dis. 2013 Jun;22(2):229-31. Review.
- An observational study on a protocol for withdrawal of life-sustaining measures on 2 non-aceadmid intensive care units in the Netherlands. J.L. Epker et al. 2015. JPSM
PhD theses of the last five years
- Biomarkers of fever: from bench to bedside. M. Limper 2014
- Serious games and blended learning. M.E.W. Dankbaar 2015
- Death and dying in the intensive care unit. J.L. Epker 2015
- Improving decision making in intensive care. I.A. Meynaar 2012
- Towards non-invasive monitoring of mitochondrial function. Harms 2014
- 1500 vingers drukken in 40 ziekenhuizen: Grootste eendaagse onderzoek ooit. J. Alsma, 2016