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/