A group of Chinese researchers compared silver sulfadiazine (Flamazine) to Mepilex Ag for treatment of deep partial thickness burns. This was a multi-center, open, parallel, randomized comparative study of patients with thermal burns to 2.5-25% TBSA (<10% TBSA third degree). Exclusion criteria were burns >36hrs from enrollment, infection, skin disorders, certain medical and immunological conditions, and immunomodulating medications. Primary outcome measure was time to healing; secondary measures were: percentage burn healed per visit, number of dressing changes, and number of burns requiring grafting. Nurse investigators performed debridement on day zero and as required, assessed wounds, performed dressing changes, while noting ease of dressing change and wound-dressing adherence. Patients in the Mepilex Ag had dressing change every 5-7 days depending on need, patients with SSD dressing had daily dressing changes. Patients were asked to report on anxiety of dressing change, pain of dressing change, and comfort of dressing during daily living. 153 patient met inclusion criteria 46% were assigned to Mepilex Ag. Average patient age was 36.2 yrs, 27% were female, all were Asian, all other baseline characteristics between the groups were similar. Between the two groups: healing times 16.2 (Mepilaex Ag) vs 17.0 days (SSD), and rates of successful healing (79%) were similar, additionally there was no difference in graft rates or total burn area healed by the ends of weeks 3-4. Mepilex Ag had higher patient satisfaction for comfort, anxiety, and pain of dressing change with pain and anxiety scores tending to be about half of the SSD group scores. There were fewer dressing changes required in the Mepilex Ag arm, and higher ratings by nurses for ease of application. There were more patients in the Mepilex Ag arm healed by week 2 (day 7), more patients in the SSD group who developed new infection of the burn (9 vs 6%), and more patients in the Mepilex Ag arm who required subsequent wound debridement: although this is likely due to lower rates of wound-dressing adhesion . These findings support previous studies of similar design, and suggest that there may be an opportunity for cost savings due to decreased material and labour costs. From a nursing perspective this research suggests that following standard practice of Flamazine and non-stick dressing, may not be to the benefit of the patient, provider or health care system.
http://journals.lww.com/jtrauma/Abstract/2015/05000/An_open,_parallel,_randomized,_comparative,.16.aspIan Miller from the Nurse Path posted a link on his twitter feed this week to NPS MedicineWise Education modules. These are free continuing education modules designed for physicians, pharmacists, and nurses. There is a broad selection of modules: case studies, medication reviews, laboratory test reviews, even modules on how to improve charting. These modules will count toward continuing education credits among Australian professional bodies, and offer free access to education materials for clinicians from other countries, worth a look.
http://www.nps.org.au/health-professionals/cpd/nurses
I was doing some research on triage and came across a 2012 article published in the Journal of Internal and Emergency Medicine that looked interesting. It was a before/after single center intervention to determine if a physician in triage would increase ED patient throughput. Secondary measures were length of stay, time to attending physician assessment, time to disposition, number of patient who left without being seen, and time on ambulance diversion. ED patient encounters during the 3 months preceding the intervention were retrieved from an electronic record database, and used as the control arm. During the study period one additional physician was added to triage, and one RN and ED technician were reassigned from other areas within the ED to the physician triage team daily from the hours of 1300-2100 for three months. This triage team would then order labs and diagnostics, administer medication, fluids and other treatments, after which the patient would move to another area of the department to be assessed by the attending physician. The physician in triage (PIT) would also supervise the physician assistant (PA) in the fast-track area, answer calls from referring physicians, and engage in administrative roles when not engaged in triage activities; the authors didn't specify what the RN or ED technician did during these periods. During the study period 17,631 patients met the inclusion criteria, 9,218 in the intervention group. The PIT evaluated an average of 37.8 patients per 8-hour period (15.1 seen and discharged with the PA, 4.9 seen and discharged as sole provider in fast-track, and 17.8 triaged to be seen by another attending physician). During the intervention period time to assessment by attending was reduced by 36 minutes (1:41-1:05); Length of stay (LOS) was reduced by 12 minutes (3:51-3:39). LOS and time to assessment were also decreased during the study period during the times the PIT was not present. The percentage of patients who left without being seen saw an insignificant decrease (1.47-1.33%), and the time spent on diversion decreased significantly during the intervention period (3.1-1.2%). While a PIT model is exciting there are a few shortcomings in this research: the intervention was the addition of a staff physician for 8 hrs a day (two full time physicians per year). Because there was an addition of extra staff there's little surprise that time measures were decreased, what wasn't assessed however was if there was any change in clinical outcomes. Unfortunately this study design doesn't provide any insight into what part of the intervention resulted in increased throughput: was it more staffing, faster initiation of diagnostics, or an integrated model of Physician/RN/ED Technician that resulted in faster access to care. From a nursing perspective this is exciting research, but it fails to reveal what the true cause of increased ED throughput was, and if it was clinically significant.
http://link.springer.com/article/10.1007%2Fs11739-012-0839-0Charlotte Davis from Paediatric Emergency Medicine put together a nice blog post on functional pediatric abdominal pain. Functional abdominal pain (pain with no identifiable medical cause), she suggests, could be responsible for as much as 25% of pediatric abdominal pain Davies has a a brief write up on some possible causes for this type of pain: duodenal ulcer, irritable bowel syndrome, and abdominal migraines. She also offers some suggestions for clinical work-ups, and red-flag findings. From a nursing perspective there is some insight to be gained from causes of pediatric abdominal pain, the red-flag findings may also be helpful for stratifying risk with pediatric populations during care or triage.
http://paediatricem.blogspot.ca/2015/06/functional-abdominal-pain.htmlBioMed Research International (a free open access journal) published some research on the effects of IV fluid volumes on mortality. The study by Hussmann et al., was a retrospective examination of the relationship between pre-hospital IV fluid replacement and mortality of patients from a German trauma registry. 7461 patients met inclusion criteria (admitted patients, age ≥16, ISS ≥16), and were cohorted into 5 groups according to total pre-hospital IV fluid received: (0-500mL, 501-1000mL. 1001-1500mL, 1501-2000mL, >2000mL). Multivariate mortality analyses were performed by: volume replacement, age, trauma score, type of trauma, pre-hospital interventions (chest tube/ETT insertion, pressor usage), and lab parameters (HgB, BE, PTT). They determined that there was a correlation between volume of fluid administered and overall mortality. However there are some aspects of the design and statistical findings that may limit it's usefulness to practice. All of the patients in this study were physician attended pre-hospital, which does not generalize to all EMS systems. As volume of fluids administered increased so too did injury severity, number of interventions performed and injury severity. It it likely that IV fluid administration not the causal factor in this correlation; rather, as severity of injury increased so too did the number of interventions performed, the time required to perform these interventions would increase, and therefore the period of time in which to administer fluid would increase, hence an increase in overall volume. Likely injury severity is causal factor in the outcome/ volume administered relationship. Unfortunately there are no The findings are hard to interpret as there was no specifics on average total volume administered per volume quintile, so it's possible that the majority of patients where clustered around cut-off points. Finally the statistical findings are not terribly convincing, as the majority of the confidence intervals for mortality odds ratios cross one in the general population. It is only the post hoc analysis for non-head injured patients that there is any statistical significance of increased risk associated with volume; however this may still not be clinically significant as it is more likely a result of increase in injury severity and patient acuity than an independent risk factor. From a nursing perspective this research has little to add, although the results are of questionable use it is a reminder that IV fluids should not be considered benign.
https://www.readbyqxmd.com/read/25949995/prehospital-volume-therapy-as-an-independent-risk-factor-after-trauma#.VV4fMVQNHz0.mailto
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