Orthostatic vitals

Figure 1

I hate assessing postural vitals! Personally, I think there's nothing more damaging to a clinicians credibility than to reflexively order postural vitals on all patients over the age of 70. Because I'm willing to vent my anger on this topic to anyone willing to listen, I feel the need to keep the stats that support my self righteous nerd-anger fresh in my mind. One of the best articles for this is a 2015 narrative review by James Frith "Diagnosing orthostatic hypotension: a narrative review of the evidence". While the article doesn't directly address the causes of orthostatic hypotension; it does, in my opinion, offer the best summation of the futility of performing postural vitals.  

As the title suggests this is narrative review of English language articles discussing orthostatic hypotension (OH). Unfortunately this isn't a systematic review, so we don't know the exact search strategy, inclusion or exclusion criteria, the number of articles reviewed, or the exact data extraction process. 

Frith starts by summarizing current guidelines on the diagnosis of OH which vary slightly depending on the national committee. The European Federation of Neurological Sciences (EFNS) guidelines (figure 1), although of poor quality (level C), are the most comprehensive and complete of the guidelines, and align well with the available evidence.

Figure 2

Frith reviewed and evaluated the evidence used to:

• define baseline blood pressure, 
• the method used to illicit the orthostatic challenge (sit to stand vs tilt table etc), 
• the frequency and duration of BP testing (how often to cycle the BP cuff, and how long to wait before starting and finishing the test), 
• and the cutoff for defining BP drop. 

Frith determined that all the data came from low quality heterogeneous studies. Frith points out that the diagnostic power of the tool is questionable: the sensitivity varies from 25- 37%, that the inter-rater reliability is low (kappa 0.12-0.32); and that the prevalence of OH is high (up to 59%). Based on the synthesized evidence he made the following recommendations for assessing OH (figure 2). The recommendations align well with, and add considerable clarity to, the EFNS guidelines.

I think the evidence presented in this article clarifies the finer points of how to "properly" assess postural vitals; but more importantly I think it does an excellent job of pointing out the fallibility of the test: it highlights the high prevalence of OH, the low sensitivity of postural vitals, and poor inter-rater reliability of the test. 

I would suggest that the most important take home point here is that the only "proper" way to assess for OH is to simply stand the patient up and see if they become dizzy!

Frith, J. (2015). Diagnosing orthostatic hypotension: a narrative review of the evidence. British medical bulletin, 115(1), 123-134.

If you're looking for additional FOAMed resources to fuel your postural BP hatred you may also like:

http://ccareanywhere.blogspot.com/2015/01/did-you-get-orthostatics-yet.html

https://lifeinthefastlane.com/futility-orthostatic-measurements/

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.

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/

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.