Weekly Review #3

A French research team led by Helene Goulet published a study in Critical Care examining unexpected deaths of patients admitted through emergency departments. This multi-center retrospective study examined the patient records of 4 metro Paris hospitals for death within 72 hours of ED attendance. Exclusion criteria were: admission to ICU, expected death (ex: inoperable intracranial hemmorage), and presence of DNR. Primary endpoint was determining cause of preventable death, secondary endpoints were process breakdowns that may have contribute to death. Of the 208549 admissions during the study period 70 died unexpectedly. Due to incomplete ED records only 47 met full inclusion criteria. 24 of the 47 deaths (51%) were deemed preventable. 55% of these patients died in the ED, 40% in a medical ward. Delay in recognition and treatment of sepsis accounted for 38% of deaths, while under-triage or under-recognition of critical illness contributed to death in 4 (16%) patients. Of the process breakdowns the most common were: incorrect treatment choice (47%), failure to order correct diagnostics (38%), incorrect admission ward (47%), and incorrect triage (45%). Goulet et al acknowledge that previous studies of this nature have not shown sepsis death rates quiet as high, they don't offer specific recommendations other than to stress the importance of recognizing and treating sepsis. This study has some obvious limitations: it has a small sample size and didn't capture unexpected deaths of patients discharged/transferred from hospital. The reviewers were also aware of patient outcome (death), and as such would have been more critical in their reviews; combining this with the current practice changes associated with the Surviving Sepsis campaigns and EGDT could explain the higher than previous rates of mortality associated with sepsis. There was also no discussion on whether or not the unexpected deaths would have been prevented with correct treatment. From a nursing perspective this reinforces the need to be diligent in triage, and speaking up if obvious orders or treatments have been overlooked.

http://ccforum.com/content/19/1/154/abstract




There was a post by Josh Farkas on PulmCrit about sleep protective patient monitoring. The post is essentially suggesting that not all patients need nocturnal blood pressure or temperature monitoring- monitoring which wakes patients up and puts them at increased risk for delirium. As an alternative he suggests using urine output as a corollary measure of cardiac output, as good urine production is a reliable indicator of end organ perfusion. This approach is obviously only possible in patients with indwelling catheters, and should not be used with patients in shock, with cardiac problems, or on diuretics. From a nursing perspective we can all appreciate the frustration at having to wake a hemodynamically well patient from sleep to assess their BP, and this may provide an alternative. While it certainly can't override unit policy, it may provide a step from which to discuss the implications of "routine vital signs" order, and an alternative course of action.

http://www.pulmcrit.org/2015/04/sleep-protective-monitoring-to-reduce.html

There was a post by Ian Miller of The Nurse Path reviewing male Foley catheter and urinary drainage bag stabilization. It appears that there is differing opinion on catheter stabilization techniques: Either to the stomach; or to the thigh.  That it should be in a soft "S" shape is the common point in both methods. He discussed the potential for necrosis due to tension or bending of the penis. Unfortunately he didn't discuss the negative implication of not securing the catheter at all, as happens all too often, and is associated with increased rates of Catheter associated UTI 's, and penile trauma. This post is directly applicable to nursing practice, it questions routine practice, it describes good practices, and the survey could help inform determine where nurses are in their practice. It's worth looking at, and please remember to fill out the survey.

http://thenursepath.com/2014/10/31/are-you-securing-male-catheters-in-the-right-place/?utm_content=buffer6f208&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

http://thenursepath.com/2014/10/06/tips-on-catheter-and-leg-bag-management/?utm_content=buffer63604&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

http://www.nursingtimes.net/5003963.article




I came across a post by Barrier & Chow of Critical Caring about oxygen therapy. They have a very readable discussion on the pitfalls and negative effects of unnecessary oxygen use. Specifically they discuss how supplemental oxygen was harmful in neonates with patent ductus arteiosum (PDA). Oxygen in these patients can cause the PDA to prematurely close and result in worse outcomes. They also discuss how supplemental oxygen results in worse outcomes for patients with: STEMI, COPD, Stroke, ARDS, and mechanically ventilated patients in general. Barrier & Chow discuss the four types of hypoxia (there a great explanation on ER/Trauma 101), and how supplemental oxygen should be targeting hypoxemic hypoxia. This post is directly applicable  to nursing practice, we've all received a patient who is inexplicably on oxygen, oxygen is something many nurses give little thought to, and challenging complacency in these "routine" practices can yield great results. The bottom Line? Maybe the your patient can be weaned off of oxygen... or perhaps they don't need it all.

http://www.critical-caring.pro/2014/11/oxygen-savior-or-devil-in-green-dress.html

http://er-trauma101.blogspot.ca/2011/04/four-hypoxias.html



Suzuki et al., published a study on the effects of paracetamol on mortality in ICU patients. This was a retrospective observational study of 4 Australian ICU's, the largest of it's type. It examined approximately 15000 patients greater than 2 years of age who received > 1g paracetamol during their ICU stay. Patients were studied globally, and with additional analyses performed according to route of administration (IV/PO), service (medical/surgical/ICU), temperature (<35, >38, >38.3, >38.5, >39), patients with liver cirrhosis, patients with infections, and by illness severity. The average patient in both groups were male 64 years of age with similar illness scores. The average daily dose of paracetamol in the control arm was 1.9g with an average total dose of 3g. Overall 14% of patients died, patients who received paracetamol were less likely to die (adjusted OR 0.60, 95%CI 0.53-0.68), this relationship persisted throughout further analysis. There was little discussion as to causal factors, although the authors suggest that paracetamol administration may result in diversion away from opioids or NSAID's for analgesia. although this may be true; there were significant differences between arms that could could have contributed to the overall effect. Significantly more of the patients in the intervention arm were admitted after surgery (70 vs. 51%) many of which were elective (55 vs. 37%). Furthermore illness severity scores appear to have determined post-operatively. Surgical patients, especially those presenting for elective surgeries, are likely to be healthier overall than similar patients admitted for medical reasons, unfortunately there is no discussion or adjustment for this, which severely limits the findings of this research. From a nursing perspective this research seems to add little to the breadth of knowledge available for the safety of paracetamol. Fortunately there are some recent systematic reviews of the literature that suggest there is no difference in mortality in patients given paracetamol; and a RCT is underway.  

http://ccforum.com/content/19/1/162/abstract

Cremasteric Reflex

The cremasteric reflex is a superficial reflex that can be exceptionally useful in assessing testicular emergencies. The cremasteric reflex is a contraction of the cremaster muscle, in response to the stroking of the thigh, which results in retraction of the testicle. Absence of the reflex is an ominous sign when assessing an acute scrotum.

When assessing an acute scrotum, the most important condition to rule out is testicular torsion (Ringdahl & Teague 2006). Testicular torsion occurs when the testicle rotates within the scrotum, the twisting out the epididymis results in impaired blood flow, ischemia can ensue rapidly, and can eventually result in loss of the testicle (Ringdahl & Teague 2006).

Testicular torsion usually occurs in the absence of trauma, and without precipitating factors; although an abnormal attachment of the testicle to the scrotum "bell clapper" deformity, present in approximately 10% of males, puts an individual at increased risk. The overall incidence of testicular torsion is estimated at 1 per 4000 in males under age 25, with the highest incidence occurring during the first few days of life, and from age 12-18yrs. (EBMedicine, Ringdahl & Teague 2006). Testicular torsion requires emergency urology referral, as ischemia begins within 4 hours (Ringdahl & Teague 2006). It is precisely for this reason that knowing how to assess for a cremasteric reflex is essential.




When assessing an acute scrotum for testicular torsion one testicle may appear to be shortened due to the twisting of the epididymis, cremasteric reflex may be absent on this side, but the test should be performed bilaterally. To assess cremasteric reflex the thigh should be stroked with a finger, the handle of a reflex hammer, or most commonly with the blade of a tongue depressor. A normal finding is a retraction of at least 0.5 cm; an abnormal, or absent reflex needs immediate referral.





The cremasteric reflex, in the presence of scrotal pain has been estimated at 96-99% sensitive (Ringdahl & Teague 2006, Schmitz & Safranek, 2009); which is to say that the probability of having a false negative is approaching zero percent. Absent reflex is 66-88% specific for torsion, yielding a negative predictive value of 96% (EBMedicine). The caveat to these probabilities is that an absent cremasteric reflex can be considered normal in approximately 50% of infants under the age of 30 months (Ringdahl & Teague 2006). The importance of the high sensitivity from the nursing perspective is that we can be relatively certain that the odds of a false negative are low, and that there will likely be need for urgent referral of these patients.


Correction, or de-torsion of a testicle, can be performed manually with local or procedural sedation; however it is generally addressed through emergent surgical exploration and intervention. Salvage rates are time dependent: surgery within six hours is 90% successful in salvaging the testicle, successful salvage drops to 50% by hour 12, and less than 10% after 24 hours (Ringdahl & Teague 2006). For this reason there is a low threshold for referral and diagnostic studies.

As a nurse knowing how to assess cremasteric reflexes can be exceptionally useful because, in the presence of scrotal pain, an absent creamasteric reflex approaches 100% sensitivity for testicular torsion. Given the short window for surgical intervention, the risks of over-triage, or over treatment due to a false positives are far outweighed by the potential benefit that patients with testicular torsion will experience from rapid referral and intervention.

The cremasteric reflex is a low barrier, easily performed physical assessment. It is a highly sensitive screening tool for patients who need immediate physician attention and surgical referral.




Ringdahl, E., & Teague, L. (2006). Testicular Torsion. American Family Physician, 74(10).

Schmitz, D., & Safranek, S. (2009). How useful is a physical exam in diagnosing testicular torsion?. Clinical Inquiries, 2009 (MU).

EB Medicine Topics (EB Medicine Topics)., 
http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=113&seg_id=2275

Weekly Review #2

Sandroni et al., published a review of rapid response systems in Critical Care. They wanted to determine if there is compelling evidence for the use of in-hospital rapid response systems. Rapid response systems or Medical Emergency Teams (MET) are typically teams of physicians, nurses and allied health who respond to calls from within to assess and treat clinically unstable patients. They reviewed the MET system literature published between 2000-2014 to determine if MET teams had a meaningful impact on: unexpected cardiac arrest rates, unplanned ICU admission rates, and mortality. What they determined was: that MET teams do result in lower rates of unexpected cardiac arrest and ICU admission. Their critique; however, was that these findings are not clinically significant. The reason for this was beacuse the lower rate of "unexpected" cardiac arrest/ICU admission was attributed to patients being: reassigned a new code status after MET assessment, patient transfer to the ICU (as an "expected" transfer), and arrests being reclassified from "unexpected" to "expected" after MET team assessment. They further pointed out that the majority of studies reviewed were of a short time frame, single center, before-after designs, and therefore of poor quality. The one multi-center randomized trial, the Medical Emergency Response, Intervention and Therapy (MERIT) study, failed to find that MET teams had any impact on outcome measures. They did note; however, that with the studies finding benefit, the longer the MET systems were in place the greater the impact they seemed to have on patient outcomes. Sandroni et al., suggest that more long-term, multi center studies are needed. From a nursing perspective this evidence suggests that while the current evidence isn't robust there may be some benefit from MET team use, it also suggests that while MET teams may not reduce code rates, they do reduce "unexpected" codes, and more importantly inappropriate resuscitation attempts.  http://ccforum.com/content/19/1/104

Napolitano et al., released a systematic review of Transexaminic Acid (TXA) in trauma, surgery and postpartum hemorrhage. They found that TXA administration within three hours was associated with a 10% relative risk reduction in mortality for trauma patients compared to placebo, a 1.5% absolute reduction with an NNT of 67; there were no increases in adverse outcomes, with a secondary benefit of reduced myocardial infarction risk. TXA with scheduled and emergency surgery was associated with a 39% reduction in transfusion rates; although there was no impact on mortality. TXA was associated with the greatest reduction in mortality benefit for those who died of exsanguination, especially when administered early. TXA was associated with adverse outcomes as well: incensed risk for seizure, and increased all cause mortality when administered > 3hrs post injury. Causal links for these negative outcomes are not discussed unfortunately. From a nursing perspective this adds weight tithe growing body of evidence for TXA use, while providing specific recommendations for use: TXA for hemorrhage with SBP <75mmHg, HR> 110/min, <3hrs post injury. http://emcrit.org/wp-content/uploads/2012/02/TXA-in-trauma-How-should-we-use-it.pdf

A study by Lyon et al., in Critical Care examines a before/after cohort study of patients undergoing RSI by an English HEMS service. The two arms studied were patients intubated with either a full, or reduced dose (if hemodynamically compromised) of: Etomidate (0.3mg/kg / 0.15mg/kg) and Suxamethonium (1.5mg/kg) in arm one (before); or Fentanyl (3mcg/kg / 1mcg/kg), Ketamine (2mg/kg / 1mg/kg) and Rocuronium (1mg/kg) in arm two (after). Outcome measures were: changes in hemodynamics (HR/BP) and hemodynamic emergencies (changes in BP +/- 10% of baseline, changes in HR +/- 20% baseline);   Intubation success; survival to discharge, and laryngoscope view. On average all patients had a baseline increase in HR and BP with intubation, this was more pronounced in arm one (Etmoidate/Suxamethonium) MAP 31mmHg vs. 5mmHg. Hypertensive emergencies were more common in arm one  80% vs 35%; while more patients in arm two had hypotensive episodes 7% vs none in arm one. All intubations were successful within three attempts; but arm two had improved first pass success 100% vs. 95%. There was no difference in mortality between arms; but providers rated arm two as having better Cormack-\Lehane scores. There are some weaknesses in the design of this study. There was no blinding or randomization, the before/after periods were 5yrs apart (2007/8 vs 2012/13), and there was no reporting on the experience level of the clinicians. Additionally there were more patients in treatment arm one who received the lower dosing schedule than in arm two, with no discussion as to why this was the case. This research suggests that there is no clinically significant difference in patient outcomes between the two RSI medication protocols, however the confounders, lack of blinding and lengthy before after periods weaken the level of evidence it provides. From a nursing perspective it woulld this evidence would suggest that there is little difference in outcomes between drug choices, but that hypertension in RSI with Etomidate/Suxamethonium should be expected.   http://ccforum.com/content/19/1/134/abstract




Mike Cadogan reviews teaching procedural skills in the clinical setting on Life in The Fast Lane. "it is possible that having taught a procedure to a more junior colleague, [that]you may be the only person to ever directly supervise them". He discusses using a 6-stage "SETTUP" approach to teaching skills:

1- S- Setting the scene: Establish the clinical context and need for the procedure.

2- E- Establish prior experience: has the learner seen or performed this skill?

3- T- Talk through the procedure (learner leads): allows learners understanding of the steps to be assessed.

4- T- Tips & tricks: an opportunity to supply first hald knowledge.

5- U- Undertake procedure: This may be the learner performing the procedure independently, with assistance, or watching as you perform. 

6- P- Post procedure feedback: Immediate feedback will help cement good habits, and prevent bad habits from carrying forward.

This model is directly applicable to mentoring students or new new nurses, as well as for teaching skills to patients in the department or prior to discharge. http://lifeinthefastlane.com/teaching-practical-skills-with-sett-up/

Weekly Review #1

The Academic Life in Emergency Medicine (ALiEM) team, had a guest contributer Matthew Zuckerman discussing Lipid Rescue. Lipid rescue is an approach for reversing Local Anesthetic Systemic Toxicity (LAST) using 20% lipid emulsion. The best evidence for this therapy is with local anesthetics, (especially bupivicaine); but there are also case reports of lipid therapy being used for other lipophilic drug toxicities: atypical antidepressants/psychotics, TCA's, beta blockers, and calcium channel blockers. Dosing information as well as case reports can be found at lipidrescue.org. There are no unique nursing considerations for administering lipid rescue, but institutional policy should be consulted.  (http://www.aliem.com/lipid-rescue-why-arent-we-using-it/)





The National Trauma Triage Protocol (NTTP) is a US system used by EMS personnel to prioritize patients in the field. There is however; a 50% under-triage rate for patients >65 years of age, and a 4 fold increase in mortality for these patients compared to younger under-triaged patients. Brown et al. attribute this under-triage in part to poor sensitivity of current triage criteria. The current NTTP field triage tool uses a systolic blood pressure (SBP) < 90mmHg as criteria to transfer a trauma patient to the local trauma center. Brown et al. wanted to investigate if changing the SBP criteria for trauma patients > 65years to 110mmHg would decrease under-triage. To do so they reviewed trauma patients from the National Trauma Data Base and substituted 110mmHg for 90mmHg. These "re-triaged" patients were found to have similar mortality odds as younger patients triaged with the SBP < 90mmHg criteria. Using a higher SBP cutoff for patient >65years could reduce mortality and cost associated with geriatric trauma patients. This knowledge can be directly applied to the Canadian Traige Acuity Scale (CTAS) used by ED nurses which doesn't have empirical SBP triage criteria; but uses clinical gestalt to determine if there are "signs of shock" to assign a patient a higher tirage score. (http://www.ncbi.nlm.nih.gov/pubmed/25757122)





The Journal of Emergency Services (JEMS) had a review of an article published in Resuscitation on reverse trendelenberg position during CPR and the effects it had on intracranial pressure (ICP) in porcine model resuscitation. They found a significant decrease in ICP, and an increase in venous return from the brain, The team also found that there was improved neurological outcomes for the pigs in the treatment arms. While this hasn't been translated into human models, the challenge to accepted practice is exciting, especially given that the intervention can be implemented at effectively zero costs. (http://www.jems.com/articles/print/volume-40/issue-3/departments-columns/street-science/tilt-angle-significantly-affects-cpr.html)





A review on providing emergency care for obese patients by Haney Mallemat from emDocs was featured on Life in the Fast Lane. The article discusses the epidemiology of and physiological changes associated with obesity. Mallemat discusses treatment challanges and offers some clinical pearls about managing and supporting oxygenation. There are some nurse specific tips about patient positioning and vital sign assessment. (http://www.emdocs.net/em-care-of-the-obese-patient-pearls-pitfalls/)

There was an excellent editorial written by Brent Thoma of BoringEM challenging the current trend of "patient blaming" for long ED wait times. His critique is that the average "not sick" ED patient won't be admitted, and that "access block" should not be attributed to patients; but to poor policy decisions. The problem with "patient blaming" Thoma says is that it can dissuade those who need attention: the stoic unwell pt, those without access to primary care, and those who need access to urgent care (domestic abuse victims) from access the health care system. (http://boringem.org/2015/03/26/keep-emergency-for-emergencies/)

A group of researchers and the Boston Trauma Collaborative reviewed patients injured and treated with tourniquets during the Boston Marathon bombing in 2013. They identified a total of 66 patients identified with extremity injuries, of these 27 where treated with improvised tourniquets applied both by EMS and bystanders. The two groups were similar in injury type/severity, age and major vascular injury death. Although the outcomes were comparable between the two arms the authors believe this could be attributed to rapid evacuation times, access to trauma centers, and short period of time to definitive care. At one of the sites every improvised tourniquet needed to be replaced with a commercial product to correct paradoxical bleeding as venous only tourniquets can actually speed the bleeding process. It is important that nurses are vigilant in monitoring for this, and know how to apply commercial equivalents if available. The authors raise the question of why commercially available tourniquets weren't available. Commercially available tourniquets have a breadth of battlefield evidence showing superior results, and are being used by provincial EMS in Alberta, Canada, (http://www.ncbi.nlm.nih.gov/pubmed/25710432)

Nurse Assessments - Connecting education to practice

Physical assessment techniques have been a core component of undergraduate nursing curricula for the last 20 years; yet new research in the International Journal of Nursing Studies is adding to a growing body of evidence that suggests Registered Nurses aren't using the skills taught to them in university.

Osborne et al surveyed nurses across 40 acute care units in Australia to determine the frequency with which they used different physical assessment skills. The physical assessment inventory used in this study is a 133 modified skill inventory used by Giddens (2007), Birks et al., (2012), and Secrest, Norwood and DuMont (2005). Of the 133 skills on the inventory an average of only 10 skills (7.5%) were performed regularly (daily), the majority of which were required to take a complete set of vitals; an additional 18 skills (14%) are described as being used frequently; with a surprising total of 93 skills (70%) reported as never being used (Osborne,S et al., 2015).

Frequency	Description	Skill n=133 (%)
5- Regularly	Daily	10 (7.5)
4- Frequently	Every 2-5 shifts	8 (6)
3- Occasionally	A few times a year	10 (7.5)
2- Rarely	A few time in career	12 (9)
1- Never	Know how but have never performed	69 (51.9)
0- Never learned	Do not know how to perform	24 (18)

Several factors were identified that predicted rates of physical assessments performed by nurses. Medical/surgical nurses tended to perform more physical assessments than psychiatric/mental health nurses of similar age and experience level; Specialty areas tended to use more specific skills ex: maternity floors performing more abdominal assessment techniques. Physical assessment skill usage was also found to be inversely correlated with: time worked in the profession and years of education, this however; could be due to nurses having less patient contact as they move into supervisor/manager or educator positions.

The researchers used a "Regression coefficient" to determine the degree to which a barrier decreases the utilization of physical assessment skills by nurses. An increase of reliance on others, not performing nursing assessments that overlapped with physician roles, by one unit resulted in a core skill decrease of 36.5%. As confidence decrease of one unit resulted in a core skill use decrease of 11.9% (Osborne,S et al., 2015). This study unfortunately didn't offer any insight into other physical assessment techniques nurses were using; nor did the offer any suggestions on how nurses can increase their use of physical assessment techniques.

Of the six barriers to nurses performing physical assessment skills identified I believe reliance on others, and lack of confidence can be directly addressed by using online education services. This, as well as other studies of a similar design have identified a disconnect between education and practice. They have suggested that the reason nurses are performing so few of the skills in the assessment, is that few of the skills are relevant to nursing practice (Birks et al., 2013, Giddens, 2007, Osborne et al., 2015, Secrest, Norwood & Dumont, 2005), this too I believe can be addressed through online education.

Associations between barriers and use of core physical assessment skills adjusted for clinical role and work area (Osborne,S et al.,2015) .

Barrier subscale	Regression coefficient (b)	95% CI		F	p value
		Lower	Upper
Reliance on others and technology	−.411	−.483	−.328	62.9	<.001
Lack of time and interruptions	−.176	−.254	−.090	14.6	<.001
Ward culture	−.265	−.348	−.172	25.7	<.001
Lack of confidence	−.234	−.305	−.157	29.6	<.001
Lack of nursing role models	−.126	−.208	−.035	7.1	.008
Lack of influence on patient care	−.317	−.414	−.204	23.9	<.001
Specialty area	−.149	−.245	−.041	7.0	.008
Total barriers score	−.430	−.516	−.329	46.2	<.001

A role for Free Open Access education

Free Open Access Medical Education (FOAMed) is a movement with the goal of sharing information, connecting practitioners, and decreasing knowledge translation times using social media (Life In The Fast Lane). FOAMed has also started to cross into the traditional academic forums of peer reviewed journals, with an "impact" rating system now being  (Thoma et al, 2015). The fledgling nursing equivalent Free Open Access Nursing education (FOANed) is a continuation of the FOAM concept, with social media hosting of content applicable to Nursing. 

FOANed could be used to address some of the issues identified by Osborne et al. it can be used as a forum to share the education and resources necessary for nurses to learn new skills, and to connect nurses with mentors to role model positive behaviors. FOANed creates an opportunity for clinicians practicing at the bedside to engage in the education process, to elucidate the roles, responsibilities, and skills used in nursing. As this knowledge becomes more accessible, hopefully it will be translated back to academia, so adjustments to nursing curricula can be made.



References

Birks, M., Cant, R., James, A., Chung, C., & Davis, J. (2013). The use of physical assessment skills by registered nurses in Australia: Issues for nursing education. Collegian, 20(1), 27-33.

Giddens, J. F. (2007). A survey of physical assessment techniques performed by RNs: lessons for nursing education. The Journal of nursing education, 46(2), 83-87.

Osborne, S., Douglas, C., Reid, C., Jones, L., & Gardner, G. (2015). The primacy of vital signs–Acute care nurses’ and midwives’ use of physical assessment skills: A cross sectional study. International journal of nursing studies.

Secrest, J. A., Norwood, B. R., & Dumont, P. M. (2005). Physical assessment skills: a descriptive study of what is taught and what is practiced. Journal of Professional Nursing, 21(2), 114-118.

Thoma, B., Sanders, J., Lin, M., Paterson, Q., Steeg, J., & Chan, T. (2015). The Social Media Index: Measuring the Impact of Emergency Medicine and Critical Care Websites. Western Journal of Emergency Medicine.