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Rachael W. Duncan Karen L. Smith Michelle Maguire Donald E. Stader 《The American journal of emergency medicine》2019,37(1):38-44
Objective
The objective of this study was to assess opioid use in an emergency department following the development and implementation of an alternative to opioids (ALTO)-first approach to pain management. The study also assessed how implementation affected patient satisfaction scores.Methods
This study compared data collected from October to December of 2015 (prior to implementation) to data collected between October and December of 2016 (after the intervention had been implemented). Emergency department visits during the study timeframe were included. Opioid reduction was measured in morphine equivalents (ME) administered per visit. Secondary outcomes on patient satisfaction were gathered using the Press Ganey survey.Results
Intravenous (IV) opioid administration during the study period decreased by >20%. The predicted mean ME use in 2016 was 0.25 ME less when compared to 2015 (95% CI ?0.27 to ?0.23). Estimated use for patients in the pre-implementation period was 1.45 ME mgs (SD 0.88), and 1.13 ME mg (SD 0.69) for patients in the post-implementation period. Patient satisfaction scores using the Press Ganey Scale also were assessed. There was no significant difference in the scores between 2015 and 2016 when patients were asked “How well was you pain controlled?” (?0.94, 95% CI ?5.29 to 3.4) and “How likely are you to recommend this emergency department?” (?1.55, 95% CI ?5.26 to 2.14).Conclusion
In conclusion, by using an ALTO-first, multimodal treatment approach to pain management, participating clinicians were able to significantly decrease the use of IV opioids in the emergency department. Patient satisfaction scores remained unchanged following implementation. 相似文献3.
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David H. Cisewski Cynthia Santos Alex Koyfman Brit Long 《The American journal of emergency medicine》2019,37(1):143-150
Introduction
Opioid use disorder (OUD) is increasing in prevalence throughout the world, with approximately three million individuals in the United States affected. Buprenorphine is a medication designed, researched, and effectively used to assist in OUD recovery.Objective
This narrative review discusses an approach to initiating buprenorphine in the emergency department (ED) for opioid-abuse recovery.Discussion
Buprenorphine is a partial mu-opioid receptor agonist with high affinity and low intrinsic activity. Buprenorphine's long half-life, high potency, and ‘ceiling effect’ for both euphoric sensation and adverse effects make it an optimal treatment alternative for patients presenting to the ED with opioid withdrawal. While most commonly provided as a sublingual film or tablet, buprenorphine can also be delivered via transbuccal, transdermal, subdermal (implant), subcutaneous, and parenteral routes. Prior to ED administration, caution is recommended to avoid precipitation of buprenorphine-induced opioid withdrawal. Following the evaluation of common opioid withdrawal symptoms, a step-by-step approach to buprenorphine can by utilized to reach a sustained withdrawal relief. A multimodal medication-assisted treatment (MAT) plan involving pharmacologic treatment, as well as counseling and behavioral therapy, is essential to maintaining opioid remission. Patients may be safely discharged with safe-use counseling, close outpatient follow-up, and return precautions for continued management of their OUD. Establishing a buprenorphine program in the ED involves a multifactorial approach to establish a pro-buprenorphine culture.Conclusions
Buprenorphine is an evidence-based, safe, effective treatment option for OUD in an ED-setting. Though successfully utilized by many ED-based treatment programs, the stigma of ‘replacing one opioid with another’ remains a barrier. Evidence-based discussions on the safety and benefits of buprenorphine are essential to promoting a culture of acceptance and optimizing ED OUD treatment. 相似文献5.
Benjamin D. Kulwicki Kasey L. Brandt Lauren M. Wolf Andrew J. Weise Lisa E. Dumkow 《The American journal of emergency medicine》2019,37(5):839-844
Purpose
It is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMPs) play an important role in ASP by working with providers to choose empiric antimicrobials. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community-acquired pneumonia (CAP) and intra-abdominal infections (CA-IAI).Methods
A retrospective cohort study was conducted evaluating adult patients admitted with CAP or CA-IAI. The primary outcome of this study was to compare guideline-concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in an early-ASP vs. established-ASP.Results
320 patients were included in the study (EMP n?=?185, no-EMP n?=?135). Overall empiric antibiotic prescribing was more likely to be guideline-concordant when an EMP was present (78% vs. 61%, p?=?0.001); this was true for both the CAP (95% vs. 79%, p?=?0.005) and CA-IAI subgroups (62% vs. 44%, p?=?0.025). Total guideline-concordant prescribing significantly increased between the early-ASP and established-ASP (60% vs. 82.5%, p?<?0.001) and was more likely when an EMP was present (early-ASP: 68.3% vs. 45.8%, p?=?0.005; established-ASP: 90.5% vs. 73.7%, p?=?0.005). Patients receiving guideline-concordant antibiotics in the ED continued appropriate therapy upon admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (p?<?0.001).Conclusion
The presence of an EMP significantly improved guideline-concordant empiric antibiotic prescribing for CAP and CA-IAI in both an early and established ASP. Inpatient orders were more likely to be guideline-concordant if appropriate therapy was ordered in the ED. 相似文献6.
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Objectives
Diagnostic tests are widely used for patients with syncope in the emergency department (ED). This study aimed to determine the diagnostic yield of neuroimaging in patients with syncope without high-risk symptoms.Methods
Adult patients who presented to the ED with syncope in 2016 were screened retrospectively. Patients who suffered from mild head trauma due to syncope were also included. Patients with neurological examination findings (confusion, amnesia, focal neurological deficit, severe headache, dizziness, nausea and vomiting), patients on anticoagulants, patients with known intracranial malignancies and those whose loss of consciousness was attributed to reasons other than syncope were excluded from the study.Results
A total of 1114 patients were included in the study. The median age was 48?years (IQR?=?34–66?years) and 576 (51.7%) of the patients were male. The neuroimaging tests performed were cranial computerized tomography (CT) in 694 (62.3%) cases and magnetic resonance imaging (MRI) in 114 (10.2%) cases. Mild head trauma due to syncope was observed in 116 (10.4%) patients. None of the neuroimaging studies revealed any clinically significant findings.Conclusion
Neuroimaging is not beneficial in patients whose medical history and physical examination do not indicate neurogenic syncope, even if the patient has mild head trauma. 相似文献10.
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Background
Leadership competency is required throughout nursing. Students have difficulty understanding leadership as integral to education and practice. A consistent framework for nursing leadership education, strong scholarship and an evidence base are limited.Purpose
To establish an integrated leadership development model for prelicensure nursing students that recognizes leadership as a fundamental skill for nursing practice and promotes development of nursing leadership education scholarship.Method
Summarizing definitions of nursing leadership, conceptualizing leadership development capacity through reviewing trends, and synthesizing existing leadership theories through directed content analysis.Discussion
Nine leadership skills form the organizing structure for the Nursing Leadership Development Model. Leadership identity development is supported via dimensions of knowing, doing, being and context.Conclusion
The Nursing Leadership Development Model is a conceptual map offering a structure to facilitate leadership development within prelicensure nursing students, promoting student ability to internalize leadership capacity and apply leadership skills upon entry to practice. 相似文献12.
Sandra Cristina Pillon Kelly Graziani Giacchero Vedana Jessica Adrielle Teixeira Leonardo Afonso dos Santos Roberto Molina de Souza Alessandra Diehl Goolam Hussein Rassool Adriana Inocenti Miasso 《Archives of Psychiatric Nursing》2019,33(1):70-76
Aim
To investigate the prevalence of depressive symptoms, psychological problems, suicidal behaviour and their associations in substance users in treatment.Methods
A cross-sectional study, with 307 substance users in an out-patient treatment facility, was undertaken. Socio-demographic data, psychoactive substances used, depressive symptoms, and suicide information were obtained.Results
70% of participants were depressed; of those, 8.1% were either under the influence of drugs or in withdrawal. Suicidal ideation was found to be present in those who had anxiety, were nervous, had depressive symptoms, or were under drug influence or in withdrawal.Conclusion
It is important to identify potential suicidal risk factors and implement the management of these conditions in substance users. 相似文献13.
Background
Violence is a large concern for mental health professionals: 90% of physicians and nurses working in mental health areas have been subject to violence from patients. Approximately 80% of violent acts from patients are directed toward nurses.Objective
The purpose of this integrative literature review was to identify violence risk–assessment screening tools that could be used in acute care mental health settings.Design
The Stetler model of evidence-based practice guided the literature search, in which 8 violence risk–assessment tools were identified, 4 of which were used for further examination.Results
The Brøset Violence Checklist and Violence Risk Screening-10 provided the best assessment for violence in the acute care mental health setting.Conclusions
Using a violence risk assessment screening tool helps identify patients at risk for violence allowing for quick intervention to prevent violent episodes. 相似文献14.
Georges Ambaraghassi Claire Béliveau Annie-Claude Labbé Christian Lavallée 《Diagnostic microbiology and infectious disease》2019,93(2):136-139
Objective
In an era of rising healthcare expenditures, it is critical to find ways to decrease cost. The objective of this study is to evaluate the number of repeated tests and the associated cost savings in a university-affiliated hospital.Methods
The following 7 microbiology analysis were assessed for nonrepeat testing: HCV antibody, HBV core antibody, CMV IgG, rubella IgG, Treponema pallidum antibodies, Clostridioides difficile toxin detection, and vancomycin-resistant enterococci PCR. Presence of a prior positive result leads to the cancellation of subsequent orders.Results
Percentages of not repeated test ranged from 0.1% to 21.4%. Rubella IgG had the highest proportion of unnecessary repeat testing. Total cost savings were estimated at $33,627 for 2016.Conclusion
Unnecessary repeated microbiologic test can account for a non-negligible part of total volume test. Use of an automated software to detect unnecessary repeated microbiologic test through laboratory information system can generate important savings. 相似文献15.
Beth E. Burbach Leeza A. Struwe Lufei Young Marlene Z. Cohen 《Journal of Professional Nursing》2019,35(1):44-50
Background
Simulation plays a vital role in nursing education, however, modifiable factors influencing students' simulation performance have not been sufficiently examined. The purpose of this study was examine relationships among anxiety, self-efficacy, nursing knowledge, and performance during simulation.Methods
The study used a mixed-methods design. Anxiety, self-efficacy, academic achievement, and performance during simulation were measured quantitatively; correlations between key variables were calculated. Qualitative data were collected during post-simulation debriefing and triangulated to inform quantitative findings.Results
Significant relationships were identified between knowledge of nursing care and simulation performance. Student qualitative reports of heightened anxiety and lack of confidence and uncertainty contrasted from quantitative measures. Potential reasons for this finding were explored.Conclusions
The relationship between knowledge of nursing care and simulation performance supports the effectiveness of simulation as a means to evaluate the application of knowledge in a clinical laboratory setting. Further research is needed to explain the complex relationships between anxiety, self-efficacy, and performance during simulation. 相似文献16.
Itay Zmora Yonit Wiener-Well Evan Avraham Alpert 《The American journal of emergency medicine》2019,37(5):1006.e5-1006.e7
Background
Purulent bacterial pericarditis is a rare and potentially fatal disease. The course may be fulminant, and the presentation may pose a diagnostic challenge.Case report
An otherwise healthy 75-year-old male was brought to the emergency department in a state of general deterioration, confusion, and shock. Bedside ultrasound showed a significant pericardial effusion. His condition quickly deteriorated and the resuscitation included emergent bedside pericardiocentesis. The drainage was purulent and later cultures grew out Streptococcus pneumoniae.Why should an emergency physician be aware of this?
Purulent pericarditis is extremely rare but should be considered in the patient with a fulminant infectious process (particularly pneumonia) and signs of pericardial effusion. Treatment should include appropriate antibiotics and early drainage. 相似文献17.
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Jae Yun Jung Eun Mi Ham Hyuksool Kwon Young Ho Kwak Do Kyun Kim Jin Hee Lee Jin Hee Jung 《The American journal of emergency medicine》2019,37(3):468-471
Background
Coronary artery dilatation (CAD) is a great concern with Kawasaki disease (KD). This study aimed to investigate the relationship between serum N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and CAD in patients with the hyperacute phase (≤4?days of fever) of KD.Methods
Serum NT-proBNP levels were compared between patients with and those without CAD, who underwent transthoracic echocardiography (TTE) within 24?h of the hyperacute phase of KD in the pediatric emergency department (PED). Electronic medical records of patients aged 1?month to 15?years who visited the PED were retrospectively assessed from January 2010 to December 31, 2014.Results
One hundred nine patients were enrolled in the study. Twenty-three of those patients had CAD within 24?h of TTE. Median serum NT-proBNP levels were significantly higher in patients with CAD (824.1?pg/ml; interquartile range [IQR], 515.4–1570.0184.8–767.8?pg/ml) than in patients without CAD (396.4?pg/ml; IQR, 184.8–767.8?pg/ml) (p?≤?0.001). The cutoff value of serum NT-proBNP, which predicted CAD during the hyperacute phase of KD, was 515.4?pg/ml, which yielded sensitivity of 78.26% and specificity of 61.63%. The area under the curve for NT-proBNP for predicting CAD during hyperacute KD was 0.749 (95% CI, 0.642–0.856).Conclusion
Serum NT-proBNP might be an additional laboratory marker for detecting early CAD during the hyperacute phase of KD in the PED. 相似文献19.
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Mollie E. Aleshire Alexandra Dampier Leslie Woltenberg 《Journal of Professional Nursing》2019,35(1):37-43