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/2014/10/06/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
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