Interventions affecting blood pressure variability and outcomes after intubating patients with spontaneous intracranial hemorrhage

IntroductionSpontaneous intracranial hemorrhage (sICH) that increases intracranial pressure (ICP) is a life-threatening emergency often requiring intubation in Emergency Departments (ED). A previous study of intubated ED patients found that providing ≥5 interventions after initiating mechanical ventilation (pMVI) reduced mortality rate. We hypothesized that pMVIs would lower blood pressure variability (BPV) in patients with sICH and thus improve survival rates and neurologic outcomes.MethodWe performed a retrospective study of adults, who were transferred to a quaternary medical center between 01/01/2011 and 09/30/2015 for sICH, received an extraventricular drain during hospitalization. They were identified by International Classification of Diseases, version 9 (430.XX, 431.XX), and procedure code 02.21. Outcomes were BPV indices, death, and being discharged home.ResultsWe analyzed records from 147 intubated patients transferred from 40 EDs. Forty-one percent of patients received ≥5 pMVIs and was associated with lower median successive variation in systolic blood pressure (BP_SV) (31,[IQR 18–45) compared with those receiving 4 or less pMVIs (38[IQR 16–70]], p = 0.040). Three pMVIs, appropriate tidal volume, sedative infusion, and capnography were significantly associated with lower BPV. In addition to clinical factors, BP_SV (OR 26; 95% CI 1.2, >100) and chest radiography (OR 0.3; 95% CI 0.09, 0.9) were associated with mortality rate. Use of quantitative capnography (OR 8.3; 95%CI, 4.7, 8.8) was associated with increased likelihood of being discharged home.ConclusionsIn addition to disease severity, individual pMVIs were significantly associated with BPV and patient outcomes. Emergency physicians should perform pMVIs more frequently to prevent BPV and improve patients' outcomes.     

Perceived vs. actual distractions in the emergency department

IntroductionThe emergency department (ED) has been shown to be an interrupt-driven workplace fraught with potential for distractions and interruptions that increase the potential for medical error. Accuracy of provider perception of these distractions and interruptions has yet to be investigated.MethodsAn observational two-phase study was conducted over a 9-week period in the highest acuity zone of the ED at an urban, academic medical center with about 90,000 visits/year. Phase I, conducted over the initial 5-weeek period, consisted of observers recording the type and frequency of all overhead pages in the ED. In phase II, conducted over the final 4-week period, direct observation of faculty and residents was done to record all individual interruptions for different levels of training. Actual data was compared to provider perceptions, as determined by survey responses.Results2438 overhead pages were recorded and occurred, on average, 23.2 times per shift. The perceived rate of overhead pages was 43.2 per shift. 333 individual interruptions occurred, on average, 4.26 times per shift. The perceived rate was 53.5 per shift. Attending providers perceived a significantly higher number of individual interruptions compared to all resident providers.ConclusionThe perceived amount and rate of distractions and interruptions are significantly higher than the actual amount and rate of distractions and interruptions. Attending physicians both perceive and experience more distractions and interruptions. Further work should be done to evaluate the power of provider perception, and the potential contribution of inaccurate perception to medical error and provider burnout.     

Barriers to frostbite treatment at an academic medical center

The treatment of frostbite injuries has undergone a radical change over the past decade with a shift from supportive therapy and observation towards early and aggressive medical intervention with thrombolytics and vasodilators. Institutions that have implemented evidence-based protocols have significantly decreased their amputation rates (Bruen et al., 2007; Lindford et al., 2017a; Twomey et al., 2005). We present the case of a middle-aged male treated for frostbite of multiple fingers on both hands. Because there was no treatment protocol at our institution, there were multiple delays in the patient's care including imaging and initiation of intravenous (IV) prostanoids. This case illustrates the deleterious effects of delays in treatment and strongly suggests that all facilities located in areas of cold exposure should have protocols in place for such an occurrence.     

Shortened preprocedural fasting in the pediatric emergency department

Background

There is no evidence of an association between fasting time and the incidence of adverse events during procedural sedation and analgesia. Pediatric and adult emergency medicine guidelines support avoiding delaying procedures based on fasting time. General pediatric guidelines outside emergent care settings continue to be vague and do not support a set fasting period for urgent and emergent procedures.

Meaningful inclusion of diverse voices: The case for culturally responsive teaching in nursing education

Communication and diversity are essential features of safe and effective health care and of a safe and effective nursing workforce. Fostering diversity and meaningful inclusion of diverse perspectives in nursing school classrooms, labs and clinical learning environments are important steps toward building a stronger nursing workforce and health care system. This paper presents an argument for the importance of replacing the single, dominant voice in nursing education with culturally responsive teaching and offers strategies nurse educators can use to encourage students to share alternative perspectives and engage in alternative methods of discourse and communication. This essay reflects a review of the theoretical background to culturally responsive teaching and discusses how this method connects to nursing education. By engaging in culturally responsive teaching, nurse educators will prepare a nursing workforce that is ready to add multiple diverse voices to the health care team and contribute to the redesign of a safer and more effective health care system.     

Racial and ethnic disparities in the management of acute pain in US emergency departments: Meta-analysis and systematic review

ObjectiveThis review aims to quantify the effect of minority status on analgesia use for acute pain management in US Emergency Department (ED) settings.MethodsWe used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology to perform a review of studies from 1990 to 2018 comparing racial and ethnic differences in the administration of analgesia for acute pain. Studies were included if they measured analgesia use in white patients compared to a racial minority in the ED and studies were excluded if they focused primarily on chronic pain, case reports and survey studies. Following data abstraction, a meta-analysis was performed using fixed and random-effect models to determine primary outcome of analgesia administration stratified by racial and ethnic classification.Results763 articles were screened for eligibility and fourteen studies met inclusion criteria for qualitative synthesis. The total study population included 7070 non-Hispanic White patients, 1538 Hispanic, 3125 Black, and 50.3% female. Black patients were less likely than white to receive analgesia for acute pain: OR 0.60 [95%-CI, 0.43–0.83, random effects model]. Hispanics were also less likely to receive analgesia: OR 0.75 [95%-CI, 0.52–1.09].ConclusionThis study demonstrates the presence of racial disparities in analgesia use for the management of acute pain in US EDs. Further research is needed to examine patient reported outcomes in addition to the presence of disparities in other groups besides Black and Hispanic. Trial registration: Registration number CRD42018104697 in PROSPERO.     

The use of intranasal analgesia for acute pain control in the emergency department: A literature review

Background

Traditional routes for administration of pain medications include oral (PO), intravenous (IV), or intramuscular routes (IM). When these routes are not feasible, the intranasal (IN) route may be considered. The objectives of this evidence-based review were: to review the literature which compared the safety and efficacy of IN analgesia to traditional routes and to determine if IN analgesia should be considered over traditional routes for acute pain control in the ED.

The impact of IV alteplase on long-term patient survival: The Georgia Coverdell acute stroke registry's experience

Introduction

Intravenous alteplase reduces disability and improves functionality among acute ischemic stroke patients. Two decades after its approval, only a small fraction of patients get the treatment, and demonstrating its impact on mortality may make a strong case for its wider use. This study assessed the impact of thrombolytic treatment by alteplase on 1-year mortality and readmission among acute ischemic stroke patients.

Designing efficient emergency departments: Discrete event simulation of internal-waiting areas and split flow sorting

ObjectiveEvaluate nine different models, the interaction of three flow models (ESI, intake attending physician, and no split flow) and three physical design typologies (zero, one, and two internal-waiting areas), on Emergency Department (ED) flow and patient-centered metrics.MethodsDiscrete Event Simulation (DES) was used to systematically manipulate flow and physical design. Three base models were developed and validated using ED and patient specific data. Subsequently, systematic manipulations of flow and internal-waiting areas were performed on other models. Five outcomes of interest were tracked – length of stay (LOS), bed utilization rate, door to provider time, left without being seen rate, and number of movements per patient. Models were compared for statistical significance and effect size using ANOVA, and linear and non-linear regression.ResultsThe shortest LOS (mean 175.2 min) and highest bed utilization rate (5.02 patients/bed/day) were obtained with flow split by an intake attending physician with two internal-waiting areas. These represented improvements of 54 min and 1.48 patients/bed/day over the control model. Two-way ANOVA demonstrated that both physical design and flow type were statistically significant predictors of all outcomes of interest (p < .0001). Depending on flow type, adding one additional internal-waiting area resulted in decreased LOS (range 10.6–21.8 min), increased bed utilization (range 0.23–0.40 patients/bed/day), decreased D2P (range 1.3–4.8 min), and decreased LWBS (0.66%–2.0%).ConclusionBased on a DES model with empirical data from a single institution, combining flow split by an intake attending physician and multiple internal-waiting areas resulted in improved ED operational and patient-centered metrics.     

Association of health related quality of life domains with daytime sleepiness among elderly recipients of long-term services and supports

Excessive daytime sleepiness (EDS) is prevalent in older adults; however, data are lacking that examine EDS across living environments. The aims of this secondary data analysis were to identify the prevalence and predictors of EDS among older adults receiving long-term services and supports (LTSS) in assisted living communities (ALCs), nursing homes (NHs), and the community. Participants (n = 470) completed multiple measures including daytime sleepiness. Logistic regression modeling was used to identify EDS predictors. Participants were primarily female and white with a mean age of 81 ± 9 years. The overall prevalence of EDS was 19.4%; the prevalence differed across living environment. Older adults in ALCs and NHs had higher odds of EDS than those living in the community. Also, depressive symptoms and number of bothersome symptoms predicted EDS. Upon admission for LTSS, evaluating older adults, especially those in ALCs and NHs, for depression and bothersome symptoms may reveal modifiable factors of EDS.     

A unique case of bradycardia recognized by wearable technology as first presentation of complete heart block

Wearable technology has advanced significantly, and the proposed health benefits have been widely touted. Most of the discussion has been surrounding the identification and diagnosis of asymptomatic atrial fibrillation. However, the heart monitoring functions of the wearable technology can also identify other abnormalities as well. We present the first case of wearable technology identified bradycardia diagnosed as the primary presentation of complete heart block. Wearable technology has advanced significantly, but still poses questions regarding its use in screening for rare conditions. One remaining challenge is balancing the desire to screen for rare asymptomatic conditions without overburdening emergency departments with patients responding to alarms on their devices.     

Fostering scholarship in doctoral education: Using a social capital framework to support PhD student writing groups

The shortage of nurse scientists in the United States complicates nursing's ability to sustain research-intensive environments, build knowledge for translation, and advance nursing science. More emphasis is needed on the preparation of PhD doctoral students to better equip them for a career of scholarship. Four recent PhD graduates participating in a writing group, examined the influence of social capital on their ability to develop capacity for scholarship. They found that a strong social factor supported their efforts to engage as scholars, be accountable for their writing, and make contributions to the research community. Although the writing group provided a space to practice scholarly writing and increased scholarly productivity, the experience was transformative in building capacity for scholarship. This article includes recommendations for academic leaders to both create and support writing groups within doctoral nursing programs using a social capital framework. Strategies are provided using the three dimensions of social capital: structural, relational, and cognitive. Investing in strategies that build social capital within a community can directly impact the advancement of science by elevating capacity for scholarship.     

Pyogenic sacroiliitis: A rare complication of inflammatory bowel disease

Although sacroiliitis is not uncommon in patients with inflammatory bowel diseases (IBD), bacterial infection of the sacroiliac joint is rare. The diagnosis is often delayed because of low clinical suspicion, a vague clinical picture and poorly defined localization of symptoms. We report a case of pyogenic sacroiliitis in a patient with Crohn's disease caused by Clostridia spp. and discuss key clinical components and protocol for the successful evaluation, diagnosis, and treatment of this uncommon illness.