FOANed Review #22

I recently started a new position as an RN at a metro trauma center. Moving cities created it's own time constraints, but so too did the formal education and informal learning required to practice in a new clinical environment. The pressure created strains in all aspects of my life, but from a professional stance it placed engaging with the online FOAM/FOANed community of practice against my clinical practice environment. My day job won out (obviously); a recent editorial by David Oliver, published in this months BMJ Open discussed the same conflict at a higher level. His editorial is critical of nursing management within the NHS, he is critical of its refusal to adopt minimum staffing levels suggested by NICE, and his perceived lack of opposition coming from the heads of nursing at large health trusts. Oliver suggests that part of the problem is that the individuals at the managerial level of nursing no longer "experience the job": that nurses in managerial roles tend to "leave the bedside", which distances them from the clinical realities of nursing. I would suggest that the lack of "job experience" extends beyond nursing management to nursing education, policy development and research as well. As an outsider I can't claim to appreciate the intricacies of English health care; nor can I support his critique of nurse managers within the NHS, but I do think that he has hit upon an important issue in nursing: which is our professions struggle to reconcile education, management and research with clinical practice.

http://www.bmj.com/content/352/bmj.i978



The American Journal of Medicine published a study that examined the relationship between inadequate physician assessment and medical errors. The study used a questionnaire that was emailed to approximately 5000 physicians that solicited clinical vignettes of instances where oversights in physical examination led to errors, and asked providers to answer several multiple choice questions about their examples. The most reported inadequacy was a failure to perform the physical exam (63%), the most common negative outcomes were delayed or missed diagnosis (76%), delayed treatments (42%), and unnecessary diagnostic costs and radiation (25% & 17%). Unfortunately the design of this study is quite weak: the questionnaire was widely circulated (it's unknown precisely how many providers were solicited), response rates were low 263/5000 (~5%), many of the responses were excluded (55, 0.21, n=208), the findings are difficult to generalize without provider demographics, and the vignettes reveal little about the root causes of error. Those weaknesses however do not detract from the fact that this is an important area for research. It would be difficult to capture how well clinicians perform physical assessments in their practice, how often they fail to perform an assessment, and how often it would lead to a negative outcome. This may hopefully provide a basis apon which future research could be built, and a call to all providers to not become over reliant on technology for treating patients.

http://www.ncbi.nlm.nih.gov/pubmed/26144103

The European and American critical care societies (ESICM-SCCM) sepsis task force released their third international consensus definition of sepsis this week in JAMA. The key points in this update are changes to the definition of
sepsis, and a shift in the screening tools used. The definition has dropped the idea of "severe sepsis", and the use of the SIRS criteria in defining sepsis. The screening tool likewise has moved from a SIRS based model to one using the SOFA/qSOFA (Sequential Organ Failure Assessment tool). Discussion on Social Media and in the FOAMed community has been dominated by this topic for the last week, so rather than delving into the topic on this review I would suggest checking out RebelEM, and St.Emlyn's for their great summaries, and First10EM and EmCrit/PulmCrit for critiques, I've also weighed in on the topic here. This is a topic that I'm sure will continue to be discussed, and hopefully validated with a prospective study.

http://jama.jamanetwork.com/article.aspx?articleid=2492875






There was a post by Jennifer Jackson on the InjectableOrange discussing her masters thesis. Her topic examines the relationship between workplace stress, and the transition to resilience or burnout. Jackson discusses some personal and systematic factors that impact resilience, particularly when it comes to managing stressors. This is an issue I'm sure almost all nurses have experienced, either personally or amongst co-workers. There are links in the post to the full thesis, as well as to video summaries. This is a great post, and a great example of the spirit of FOANed, I hope that more academics will look to engage with their communities of practice at large through online and social media platforms.

Brian Ericson released a compilation of his top FOANed resources on erNURSEpro, it's worth taking a look at, you might find a new site worth following!

First10EM had a great post discussing the clinical approach to an unconscious patient with a discussion of red flags, and of course AEIOU TIPS! this is a common ED presentation, and the topic is always worth reviewing

HEFTEMCAST provided a review of the new NICE guidelines for trauma, an excellent post for any professional working with trauma patients.

The New York Times ran a summary of a study that examined the prevalence of genital warts in American HPV vaccinated adolescents. It would appear that the vaccine is quite effecive, it would also appear that the the public health system in Rwanda is doing better (93%) than it's western counterparts in adopting evidence based immunization policy.