Weekly Review #7

Eve Purdy posted on BoringEM about critical appraisal of research. Critical appraisal tools equip readers of research with a method of interpreting the rigor of the methods, and a way of examining if the results are meaningful: both statistically and clinically. There are some links in the post to the Center for Evidence Based Medicine (CEBM) at Oxford: which has great tools for assessing research, as well as brief explanations on some of the statistical tools used in EBM. There is also some links to access YouTube hosted videos on statistical tools, and some other web based education opportunities. I think that the ability to critically interpret research is fundamental to becoming a proficient end user of research, I've discussed different tools that are available to help use statistics in health care previously (see diagnostic test calculor in weekly review #6, and Liklihood Ratio Database in Weekly Review #4) because there's so much research being produced that it's not only difficult to ensure that all of the research is high quality, but that it's also relevant to the question at hand. I would also suggest reading some previous posts by ScanCrit, emlitofnote, and BoringEM, which all do a great job of highlighting the disconnect that can occur between statistical and clinical significance.

http://boringem.org/2015/03/06/boringem-research-week-skimming-the-top-off-researchclinepi-foam/




A Dutch study examined the effects of Crew Resource Management (CRM) training on ICU mortality and complication rates. CRM is a training program used in aviation to examine human factors in adverse outcomes and create system solutions to prevent them from occurring. The CRM intervention consisted of two days of training in CRM for all staff, the designation of CRM team leaders, and the identification of, and strategies for dealing with, 8 key human factors that result in adverse outcomes.




The 8 key areas were:
1. Situational awareness: and recognizing adverse situations;
2. Human errors and non-punitive responses to them;
3. Communication, briefing and debriefing techniques;
4. Providing and receiving performance feedback;
5. Stress management, workload and fatigue;
6. Creating and maintaining team  structures and environments;
7. Leadership in a flat hierarchy;
8. Risk management and decision making.


Strategies became topics of discussion at all staff meetings, and staff created new checklists for key points in patient care: Central line placement, ET intubation, patient handover at transitions in care, and team training.

The study was a single center 3 year before/during/after prospective cohort design, there was no control arm, and all the data for the study was pulled from the Dutch NICE registry. Approximately 2230 to 2500 patients were included in each of the three years, and were assessed for 18 key complications.

With the introduction of the CRM training: overall complication rates decreased, mortality decreased, cardiac arrest rates went down, CPR success increased from 19% at base line to 55 in the intervention year and 67 in the post implementation year, and staff perceived the work environment to be safer in general. There were no differences in LOS or ICU LOS.



These findings are encouraging; however. there are some limitations to this study: it's single center, has a small population, and no control so the quality of the evidence could be stronger. There is no standardized approach to CRM training in health care, so applying this model to another site could prove difficult, therefore reproducibility may be poor. The study ICU also changed location in the first month of the post-implementation year: while the authors acknowledge that the ICU used the same equipment, the change in environment could have improved work flow and contributed to improved outcomes. Finally if we examine the patients year on year we can see that there was a decrease in cardiac patients and patients with chronic cardiac conditions which certainly could have attributed to the decreased cardiac arrest rates. Overall rates of vasopressors and mechanical ventilation use decreased; while trauma admissions increased, which certainly could have a large effect on the overall mortality and complication rates. From a nursing perspective there is some encouraging news here, if due to the intervention, the reduction in  complications/cardiac arrests and increase in CPR success is substantial. Certainly the intention is good: addressing systems processes to prevent human error. However; Until there's larger studies and standardized CRM training it will be difficult to determine if CRM training is a worthy intervention.

http://onlinelibrary.wiley.com/doi/10.1111/aas.12573/pdf





There was a ton of information and MedEd sharing happening last week with the social media and critical care (smaccUS) conference happening in Chicago. Too much to cover everything in detail, but there are a few pieces that I found particularly interesting and relevant to nursing:


@HEFTEMCAST had a great post on the utility of urinalysis on detection of UTI. This links nicely to earlier discussions on understanding test probabilities and evidence based medicine. In this post they discuss the sensitivity and specificity of the different parts of the urine-dip, and the risks for false positive if pre-test probability is not used in determining the likelihood ratio. The take-home message here is that bacteriuria is relatively common in elderly patients, especially females, and doesn't always warrant antibiotics. I think a review of urine dip testing is particularly relevant for nurses, as I inwardly cringe every time I hear a colleague discussing a "dirty" urine dip on an asymptomatic patient.

http://www.heftemcast.co.uk/urine-testing-who-gets-the-antibiotics/
http://www.sign.ac.uk/pdf/sign88.pdf





A problem for all clinicians is how to deal with patients who have presented with dubious conditions, requesting opioid analgesics. For nurses this is somewhat less of an issue, from a liability perspective, than it it for our medical counterparts. However dealing with these patients can be frustrating. There are some slides made available from a smaccUS talk discussing the myths and realities of prescription opioid use, the current state of evidence, red/yellow flags for spotting potential opioid abuse/abusers, as well as some phrases to help in communicating with these patients. From a nursing perspective I think the flags will likely recap some of the obvious clues that many nurse will already have identified, there may be a few flags you had not thought of, and even more helpful it may provide some useful terminology to describe the behaviour of patients who are gaming the system for narcotics. Most important information however is directed at clinicians themselves, an honest critique of poor clinical practice, and the myths of opioid pain control: That narcotics are non-addicting in patients experiencing pain, that we should seek pain scores of zero, and that opioids are effective for chronic pain. If you click on only one link from this post, make this the one!

http://emupdates.com/helpcard-and-opioid-misuse/
http://emupdates.com/wp-content/uploads/2015/06/Strayer-Opioid-Misuse-SMACC-Slideset.pdf




ICEBlog posted their smaccUS notes on clinical education online. There's some great information here for anyone involved in providing or receiving clinical education (everyone). There is a review of teaching/learning styles, some myth busting about clinical education, and a framework model for delivering clinical education. There is also a small teaser on social knowledge, something they unfortunately didn't expand upon.

http://icenetblog.royalcollege.ca/2015/06/26/education-theory-for-the-meded-clinician/





More reasons to use IO access: A great post on ScanCrit about the use of IO access for RSI medications. This is a review of British combat medicine review from Afghanistan, published in the Emergency Medical Journal, on prehospital intubation of injured soldiers. The successful first pass rate for RSI was 97%. The quality of evidence is relatively poor (sample size less than 40, limited generalizability outside of combat helivac operations); but it certainly adds to the growing body of first hand evidence suggesting that IO access is a viable first line choice for gaining vascular access and administering drugs.

http://www.scancrit.com/2015/06/29/io-drugs-quick-iv/