Educational intervention in triage with the Swedish triage scale RETTS©, with focus on specialist nurse students in ambulance and emergency care – A cross-sectional study

AimTo determine the reliability of application of the RETTS© triage scale after an educational intervention using paper-based scenarios in emergency care education.BackgroundKnowledge about and education in triage are important factors in triagescale implementation. Presenting students with a large number of triage scenarios is a common part of triage education.MethodsIn this prospective cross-sectional study at two universities students undergoing education in emergency care used RETTS© to assess triage level in 46 paper-based scenarios.Results57 students in the study made 2590 final triage decisions. Fleiss Kappa for final triage was 0.411 which is in the lower range of moderate agreement. In 25 of 46 (53.4%) scenarios, final triage levels did not agree about whether the case was stable or unstable.Conclusion/ImplicationsApplication of the RETTS© triage scale after an educational intervention with paper-based simulation in emergency care education resulted in moderate agreement about the final levels of triage.     

Does ultrasonographic assessment of gastric antrum correlate with gastric residual volume in critically ill patients? A prospective observational study

Journal of Clinical Monitoring and Computing - This study aimed to evaluate the relationship between ultrasonographic gastric antral measurements and aspirated gastric residual volume (GRV) in...     

Exploring the secondary clinical activities of emergency nurse practitioners – a prospective multicentre study

New drug therapy for hepatitis C (HCV) with section 85 authority for community prescribing has provided an opportunity to improve historically poor treatment rates.The Remote Consult Request Form (RCRF) is part of a collaborative approach coordinated by Liver Nurses to facilitate treatment by general practitioners (GPs) in consult with Liver Specialists.     

Is the introduction of a student-centred, problem-based curriculum associated with improvements in student nurse well-being and performance? An observational study of effect

AIMS: To explore the impact of curriculum redesign and innovation on student well-being and performance, including essay and examination marks and sickness absence. BACKGROUND: While the emotional impact of preparing to be a health professional can be reduced by helping students to adapt, the positive effect of curriculum innovation and redesign is rarely evaluated. DESIGN, SAMPLE AND METHODS: Student nurse well-being and performance was compared at weeks 24/25 and 40/50 following course entry between comparable independent cohorts of students undertaking a traditional programme (N=406, 83% return rate) with those on an innovative, student-centred, problem-based educational programme (N=447, 79% return rate). The setting was a School of Nursing and Midwifery in the North-East of Scotland. Measures included stress and mental health outcomes and measures of performance including academic marks and sickness absence. RESULTS: At week 25 into the course students on the innovative course had fewer academic, clinical and personal worries than students in the previous more traditional programme and were more likely to report using adaptive direct, problem-solving coping at week 50. While students on the innovative course reported less distress in their first year of the course, they scored less well on comparable essay assignments and had reliably greater sickness absence totals than those educated by traditional methods. CONCLUSION: In this setting, curriculum innovation was associated with positive changes in student well-being but not on performance.     

Fluid management in patients with acute kidney injury – A post-hoc analysis of the FINNAKI study

PurposeWhether positive fluid balance among patients with acute kidney injury (AKI) stems from decreased urine output, overzealous fluid administration, or both is poorly characterized.Materials and methodsThis was a post hoc analysis of the prospective multicenter observational Finnish Acute Kidney Injury study including 824 AKI and 1162 non-AKI critically ill patients.ResultsWe matched 616 AKI (diagnosed during the three first intensive care unit (ICU) days) and non-AKI patients using propensity score. During the three first ICU days, AKI patients received median [IQR] of 11.4 L [8.0–15.2]L fluids and non-AKI patients 10.2 L [7.5–13.7]L, p < 0.001 while the fluid output among AKI patients was 4.7 L [3.0–7.2]L and among non-AKI patients 5.8 L [4.1–8.0]L, p < 0.001. In AKI patients, the median [IQR] cumulative fluid balance was 2.5 L [−0.2–6.0]L compared to 0.9 L [−1.4–3.6]L among non-AKI patients, p < 0.001. Among the 824 AKI patients, smaller volumes of fluid input with a multivariable OR of 0.90 (0.88–0.93) and better fluid output (multivariable OR 1.12 (1.07–1.18)) associated with enhanced change of resolution of AKI.ConclusionsAKI patients received more fluids albeit having lower fluid output compared to matched critically ill non-AKI patients. Smaller volumes of fluid input and higher fluid output were associated with better AKI recovery.     

Pre-hospital emergency nurse specialist’s experiences in caring for patients with non-specific chief complaints in the ambulance – A qualitative interview study

BackgroundPre-hospital emergency nurse (PEN) specialists are faced with patients presenting with non-specific chief complaints (NSC) to the emergency medical service (EMS) on a daily basis. These patients are often elderly and one in three has a serious condition and their acuity is not recognized.ObjectiveThe aim of the current study was to explore PEN specialists’ experiences in caring for patients presenting with non-specific chief complaints.DesignA qualitative study design with eleven individual interviews of PENs, between 2018 and 2020. Qualitative content analysis was used.ResultsThe analyses generated three categories including subcategories. The categories were “Unexplained suffering”. “Systematic approach and experience enhances medical safety”. “Organizational processes can be optimized”. The relation between the categories compiled as ́In-depth systematic assessment is perceived to reduce suffering and increases patient safetý.ConclusionThe PENs experiences in caring for patients presenting with non-specific chief complaints show that an in-depth systematic assessment may lead to a meaningful caring encounter which enables the identification of the cause of the chief complaint. Experience and a systematic approach were considered as essential to enhance medical safety. This could be strengthened through feedback on the nurse's care provided by care managers and employers. To optimize organizational processes, the development of the opportunity to convey the patient to different levels of care can be an important component.     

Prediction of success in the first-year exam in the study of medicine – a prospective survey

OBJECTIVE: To identify predictors of students' success in the first-year exam in a new curriculum in the study of medicine in Vienna. DESIGN: We tested 11 topics (including socio-demographic variables, family background, school performance, economic situation, living conditions, social integration and health, learning capacity, study motivation and ability to cope with stress) for their relevance in terms of study success in a prospective study of an unselected student sample. Data were collected from questionnaires filled in by 674 first-year students (50.8% of the total number of 1327 new students) who enrolled in the academic year 2002/03. MAIN OUTCOME: Comparison of students who passed the first-year exam with students who failed identified four predictors: male sex, German mother tongue, performance in secondary school and learning capacity. CONCLUSIONS: The new curriculum exerted subliminal selectivity; the predictive powers of school marks and subjective learning capacity were confirmed; the influence of a student's sex should be investigated further; the influence of mother tongue requires modification of pre-study courses for foreign students.     

The needs of patients with post–intensive care syndrome: A prospective,observational study

BackgroundThe needs of critical illness survivors and how best to address these are unclear.ObjectivesThe objective of this study was to identify critical illness survivors who had developed post–intensive care syndrome and to explore their use of community healthcare resources, the socioeconomic impact of their illness, and their self-reported unmet healthcare needs.MethodsPatients from two intensive care units (ICUs) in Western Australia who were mechanically ventilated for 5 days or more and/or had a prolonged ICU admission were included in this prospective, observational study. Questionnaires were used to assess participants' baseline health and function before admission, which were then repeated at 1 and 3 months after ICU discharge.ResultsFifty participants were enrolled. Mean Functional Activities Questionnaire scores increased from 1.8 out of 30 at baseline (95% confidence interval [CI]: 0–3.5) to 8.9 at 1 month after ICU discharge (95% CI: 6.5–11.4; P = <0.001) and 7.0 at 3 months after ICU discharge (95% CI: 4.9–9.1; P = < 0.001). Scores indicating functional dependence increased from 8% at baseline to 54% and 33% at 1 and 3 months after ICU discharge, respectively. Statistically significant declines in health-related quality of life were identified in the domains of Mobility, Personal Care, Usual Activities, and Pain/Discomfort at 1 month after ICU discharge and in Mobility, Personal Care, Usual Activities, and Anxiety/Depression at 3 months after ICU discharge. An increase in healthcare service use was identified after ICU discharge. Participants primarily identified mental health services as the service that they felt they would benefit from but were not accessing. Very low rates of return to work were observed, with 35% of respondents at 3 months, indicating they were experiencing financial difficulty as a result of their critical illness.ConclusionsStudy participants developed impairments consistent with post–intensive care syndrome, with associated negative socioeconomic ramifications, and identified mental health as an area they need more support in.     

Endostatin predicts mortality in patients with acute dyspnea – A cohort study of patients seeking care in emergency departments

BackgroundIncreased levels of circulating endostatin predicts cardiovascular morbidity and impaired kidney function in the general population. The utility of endostatin as a risk marker for mortality in the emergency department (ED) has not been reported.AimOur main aim was to study the association between plasma endostatin and 90-day mortality in an unselected cohort of patients admitted to the ED for acute dyspnea.DesignCirculating endostatin was analyzed in plasma from 1710 adults and related to 90-day mortality in Cox proportional hazard models adjusted for age, sex, body mass index, oxygen saturation, respiratory rate, body temperature, C-reactive protein, lactate, creatinine and medical priority according to the Medical Emergency Triage and Treatment System–Adult score (METTS-A). The predictive value of endostatin for mortality was evaluated with receiver operating characteristic (ROC) analysis and compared with the clinical triage scoring system and age.ResultsEach one standard deviation increment of endostatin was associated with a HR of 2.12 (95% CI 1.31–3.44 p < 0.01) for 90-day mortality after full adjustment. Levels of endostatin were significantly increased in the group of patients with highest METTS-A (p < 0.001). When tested for the outcome 90-day mortality, the area under the ROC curve (AUC) was 0.616 for METTS-A, 0.701 for endostatin, 0.708 for METTS -A and age and 0.738 for METTS-A, age and levels of endostatin.ConclusionsIn an unselected cohort of patients admitted to the ED with acute dyspnea, endostatin had a string association to 90-day mortality and improved prediction of 90-day mortality in the ED beyond the clinical triage scoring system and age with 3%.     

Does ED crowding decrease the number of procedures a physician in training performs? A prospective observational study

Purpose

The aim of the study was to determine whether the number of procedures performed by residents and medical students in the emergency department (ED) is affected by ED crowding.

Methods

In this single-center, prospective, observational study, standardized data collection forms were completed by both trainees and supervising emergency physicians (EPs) at the end of each ED shift from August 2009 to March 2010. Shifts with no trainees were excluded. All procedures that were offered to a trainee were recorded as well as the number of potential ED procedures that were, instead, referred to a consulting service. Emergency department crowding was measured in 2 ways: ED length of stay (LOS) and the EP's assessment of crowding during the shift. Poisson regression was used to assess the adjusted effect of ED crowding on the number of trainee procedures performed as well as on the number of procedures given away.

Results

There were 804 procedures performed by 113 trainees during 647 trainee shifts. Medical students comprised 51% of trainees. Median number of procedures performed per shift was 1.0 (Fine interquartile range, 0-2.0). Emergency department crowding was not associated with the adjusted number of procedures trainees performed using either the EP's assessment of crowding (P = .52) or ED LOS (P = .84). Emergency department crowding was associated with an adjusted 256% increase in the mean number of procedures given away (P = .02) when measured using physician assessment but was not associated with crowding when assessed using ED LOS (P = .06).

Conclusions

Crowding was not significantly associated with the number of procedures availed to ED trainees. In patients being considered for admission, however, when the managing EP felt that it was crowded, there was an association with giving procedures to consulting services.     

Adopting a vein assessment tool improves procedural outcomes in double dose platelet collections – A prospective study

BackgroundThis study aims to determine the phlebotomy and procedural outcomes using a vein assessment tool (VAT) in Double Dose Platelet (DDP) collections by apheresis.MethodsVAT was based on assessing vein visibility, palpation and size with maximum score of 12 and the least being 0 and the scores were graded as adequate and inadequate. A vein-viewer was used for studying cubital vein patterns (type 1–5). Phlebotomy outcome was defined based on need for re-puncture. Procedural outcomes in terms of target yield attained and RBC reinfusion completed. Chi square test and Mann- Whitney U test were used to assess the vein score and pattern against phlebotomy and procedural outcome.ResultsOut of 200 DDP collections, the phlebotomy was successful in 88 % with good procedural outcome in 94 % donations. The cut off in VAT scores for successful phlebotomy was ≥8 (AUC: 70 %). Median vein scores of the arm selected for phlebotomy was 9 and graded adequate in 154 (77 %) donations.Odds for successful phlebotomy was 3.7 times higher when donors had an adequate VAT grades(p = 0.003). Procedural outcomes was favourable when at least one arm had adequate VAT grade when compared to both arms being inadequate (98 % vs 82 %; p < 0.001). Phlebotomy failure was more with first time apheresis donors than repeat apheresis donors (p = 0.014).ConclusionThis study indicated that a VAT score with a cut off of ≥8 had better phlebotomy and procedural outcomes in DDP collections and that donor with at least one arm having the VAT score of ≥8 are preferred for DDP collections.     

Host–pathogen interactions and prognosis of critically ill immunocompetent patients with pneumococcal pneumonia: the nationwide prospective observational STREPTOGENE study

Purpose

To assess the relative importance of host and bacterial factors associated with hospital mortality in patients admitted to the intensive care unit (ICU) for pneumococcal community-acquired pneumonia (PCAP).

Methods

Immunocompetent Caucasian ICU patients with PCAP documented by cultures and/or pneumococcal urinary antigen (UAg Sp) test were included in this multicenter prospective study between 2008 and 2012. All pneumococcal strains were serotyped. Logistic regression analyses were performed to identify risk factors for hospital mortality.

Results

Of the 614 patients, 278 (45%) had septic shock, 270 (44%) had bacteremia, 307 (50%) required mechanical ventilation at admission, and 161 (26%) had a diagnosis based only on the UAg Sp test. No strains were penicillin-resistant, but 23% had decreased susceptibility. Of the 36 serotypes identified, 7 accounted for 72% of the isolates, with different distributions according to age. Although antibiotics were consistently appropriate and were started within 6 h after admission in 454 (74%) patients, 116 (18.9%) patients died. Independent predictors of hospital mortality in the adjusted analysis were platelets?≤?100 × 10⁹/L (OR, 7.7; 95% CI, 2.8–21.1), McCabe score?≥?2 (4.58; 1.61–13), age?>?65 years (2.92; 1.49–5.74), lactates?>?4 mmol/L (2.41; 1.27–4.56), male gender and septic shock (2.23; 1.30–3.83 for each), invasive mechanical ventilation (1.78; 1–3.19), and bilateral pneumonia (1.59; 1.02–2.47). Women with platelets?≤?100 × 10⁹/L had the highest mortality risk (adjusted OR, 7.7; 2.8–21).

Conclusions

In critically ill patients with PCAP, age, gender, and organ failures at ICU admission were more strongly associated with hospital mortality than were comorbidities. Neither pneumococcal serotype nor antibiotic regimen was associated with hospital mortality.

     

Is hyperchloremia associated with mortality in critically ill patients? A prospective cohort study

Purpose

The aim of the study was to determine if acid-base variables are associated with hospital mortality.

Materials and Methods

This prospective cohort study took place in a university-affiliated hospital intensive care unit (ICU). One hundred seventy-five patients admitted to the ICU during the period of February to May 2007 were included in the study. We recorded clinical data and acid-base variables from all patients at ICU admission. A logistic regression model was constructed using Sepsis-related Organ Failure Assessment (SOFA) score, age, and the acid-base variables.

Results

Individually, none of the variables appear to be good predictors of hospital mortality. However, using the multivariate stepwise logistic regression, we had a model with good discrimination containing SOFA score, age, chloride, and albumin (area under receiver operating characteristic curve, 0.80; 95% confidence interval, 0.73-0.87).

Conclusions

Hypoalbuminemia and hyperchloremia were associated with mortality. This result involving chloride is something new and should be tested in future studies.     

A prospective study investigating the impact of multiparametric MRI in biopsy-naïve patients with clinically suspected prostate cancer: The PROKOMB study

BackgroundIn patients with suspected prostate cancer (PCa) according to current guidelines systematic transrectal ultrasound (TRUS)-guided biopsy of the prostate is performed to verify or rule out PCa. However, TRUS-guided biopsy can result in underdetection of clinically significant cancers as well as diagnosis of clinically insignificant cancers. Multiparametric MRI (mpMRI) might improve the diagnostic pathway and help to avoid unnecessary biopsies.Design and methodsThe PROKOMB (Prostata – Kooperatives MRT-Projekt Berlin) study is a prospective two-arm multicentre study designed to evaluate the potential role of mpMRI as a triage test before biopsy. Up to 600 biopsy-naïve men with suspicion for PCa undergo mpMRI at two dedicated imaging centers. Only patients with equivocal or suspicious lesions on mpMRI undergo prostate biopsy including systematic as well as MRI-guided targeted biopsies at several different community-based urologists or hospitals. The PROKOMB study is designed to evaluate how many biopsies can be avoided, how many clinically insignificant cancers are diagnosed on prostate biopsy in patients with positive findings on mpMRI, and how many clinically significant cancers are missed using this alternative diagnostic pathway. For the purpose of this study clinically significant PCa is defined as Gleason ≥ 3 + 4 cancer. In addition, the detection rates of different techniques for MRI-guided biopsy are evaluated as well as psychological distress before mpMRI and after the diagnosis of PCa.ConclusionThe PROKOMB study might help in defining the role of mpMRI in biopsy-naïve patients with suspected PCa in an ambulatory care setting.     

Estimation of critically ill patients’ complaints by the nurse,the physician and the patient’s family: A prospective comparative study

ObjectivesTo evaluate the ability of the families of critically ill patients and of the intensive care team caring for the patient to communicate and accurately identify patients’ complaints.DesignThe complaints of critically ill patients were evaluated by a psychologist using a list of 12 items. The same day as the patient interview, the psychologist collected an estimation of the patient’s complaints from the family, the nurse and the physician.Setting20-bed Intensive Care Unit in a large University Hospital.Main Outcome MeasuresPatients’ complaints.Results51 patients were included. The most frequently reported complaints were insomnia, the inability to talk and presence of a tracheal tube. Patients reported a significantly higher prevalence of “misunderstanding” than that estimated by the nurses (55% vs 33%, p = 0.045). The reported prevalence of “inability to talk” as the main complaint was significantly higher among patients than estimated by nurses and physicians (16% vs 2%, p = 0.03 and 16% vs 2%, p = 0.03 respectively). For the analysis of the individual complaints, there was a poor agreement between the patients and the other respondents.ConclusionThis study found that the estimation of critically ill patients’ complaints by their families, nurses and physicians was largely suboptimal.