FOANed Review #23

Salim Razie reviewed the Paediaric Acute Respiratory Interention Study (PARIS) on REBEL EM this week. The PARIS trial was an un-blinded, multi-center RCT that compared standard therapy to standard therapy with high flow nasal cannula (HFNC) in children less than one year of age with bronchiolitis. The results suggest that HFNC are a safe treatment option, and that infants treated with HFNC for bronchiolitis tended to have less escalations in care (transfer to ICU). The findings were even more pronounced in hospitals that didn't have access to pediatric ICU's - Good reading for anyone that looks after kids; great reading for those in rural or community settings where pediatric ICU admission means transfer.

http://rebelem.com/the-paris-trial-hfnc-in-infants-with-bronchiolitis/

There's a great case report by Jennifer Leckie and Minh Le Cong and Viran Kaul  that was published on prehospitalmed.com. It's a brief report of an Australian ICU nurse self administering nasal lidocaine to treat a cluster headache not relieved with her usual regimen of triptans, aspirin and acetaminophen. The nurse "snorted" a 5ml tube of 2% lidocaine (100mg), assumed the "Rose position" and allowed the gel to drip down her nasopharynx. The headache was completely resolved within 50 minutes of the treatment - This may not be applicable to your practice; but it's a fun read for all the self sufficient clinicians out there.

https://prehospitalmed.com/2018/04/06/a-novel-self-treatment-technique-for-cluster-headache/

There was a post on EMCrit this week that reopens the FOAMed discussion on the "unopposed alpha phenomena". Unopposed alpha blockade is the premise that treating stimulant toxicity (specifically cocaine) with beta-blockers puts the patients at risk for a situation where the heart's (beta driven) contractility is blocked to the point where it can't overcome the afterload generated by peripheral vascular tone (alpha driven). The EMCrit post by Jeff Lapoint is in direct response to an older post by John Richards on LITFL. Jeff raises interesting questions about equivalency fallacies, and whether we should just because we could use beta-blockers for cocaine toxicity. That being said the original LITFL post still poses a valid question in asking if blanket avoidance of bet-blockers in stimulant toxicities is indeed dogma - Regardless of which camp you're in; both posts are well worth the read for anyone interested in toxicology. 


https://emcrit.org/toxhound/cocaine-beta-blockers-dogmalysis-wont-hunt/

https://lifeinthefastlane.com/beta-blockers-cocaine-stimulant-toxicity-time-retire-old-dogma-not-care/




Gus Garmel posted some true FOANed clickbait on ALIEM with: "10 Tips to improve patient satisfaction in the emergency department". Here's the overview:

1. Greet everyone warmly
2. Connect with everyone in the room
3. Sit down if you can
4. Listen actively
5. Take your time
6. Ask for their perspective
7. Use at least one empathetic statement
8. Check in with your patient
9. Close the communication loop
10. Show kindness & respect

- There's probably a lot here you do already, but it's nice to have it presented in a way that's easy to connect to - an easy read that's applicable to all clinicians.

https://www.aliem.com/2018/03/10-tips-improve-patient-satisfaction/

Matt Douma offered up some experienced provider tips on ACLS at RescueScience. These tips and tricks are not intended for those new to, or attending their first ACLS class; rather it's further reading and the science behind the recommendations intended for those with ACLS "mastery". There are some good clinical pearls for maximising team dynamics: pre-charging the defibrillator, DSD pad placement, and how to cognitively offload the algorithm to focus on reversible causes - A great post for those comfortable with ACLS content and looking to augment whats taught on standard courses.


http://rescuescience.org/2018/04/11/advanced-life-support-course-2015-instructor-notes-for-aptil-10th-11th-class/

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.

Weekly Review #18

Matthew Limb discusses an Israeli study that examined the impact of rudeness on medical team performance. The research led by Arieh Riskin determined that incivility amongst healthcare professionals negatively impacts team performance, and could result in iatrogenesis. In this study physician/nurse teams were exposed to an introductory message, than assessed as they performed simulated care on an ill preterm infant. The teams exposed to incivility as part of the introductory message made 12% more errors in both procedural and diagnostic domains than those exposed to a neutral introductory message. The experimental arm had worse information sharing, reduced helpfulness, worse cognitive function, and decreased performance of collaborative processes. The unmeasured consequences of decreased performance due to incivility could potentially be huge. From a nursing perspective the message here is clear: if civility for the sake of it isn't enough reason to keep negative commentary to yourself perhaps the increased risk to patients and liscensure is.

http://careers.bmj.com/careers/advice/Rudeness_in_medical_teams_harms_clinical_performance,_study_finds




Jesse Spurr hosted a discussion this week on Injectable Orange with Damian Roland and Victoria Brazil on their recently published article "Top 10 ways to reconcile social media and 'traditional' education in emergency care". There is a 30 minute podcast with accompanying slides, in which the authors discuss each of the 10 points covered in the paper. Roland and Black argue that using social media is no different from using "traditional" approaches to education; and that the discussion about social media in medical education ought to be one that discusses FOAMed as a how (a means) rather than a what (a curriculum) of medical education. They suggest that education has always faced the challenges that are now present with learning using social media, and offer specific commentary on the critical appraisal skills and scrutiny that are required with FOAMed as well as traditional forms of literature. They highlight the particular effectiveness of social media at contextualizing research, of translating and distilling information into something that is easy for clinicians to connect with. There is additional commentary on the effectiveness of social media on reflective practice and faculty development. I would suggest that this discussion summarizes quiet nicely the similarities of FOAMed to traditional education, both in the sense of formal learning academic articles, and informal education (peer based learning): an excellent resource for nurses wanting to increase their understanding of the role of social media in clinical education.

http://injectableorange.com/2015/09/podcast-ep-6-reconciling-social-media-with-traditional-education/




The Annals of Internal Medicine published a systematic review of the science of cleaning hospital surfaces. It turns out we don't actually know a great deal about what we're doing. 80 studies were identified, 49 examined cleaning processes, 14 monitoring, and 17 implementation of strategies; of these only 5 were randomized controlled trials. Most of the studies on cleaning processes examined the effects of different cleaning agents on surface bacterial/spore levels: either as a preventive measure or in relation to infection incidence rates. Strategies for monitoring cleanliness assessed the percentage and frequency of targeted areas cleaned, and surface microbial burden. The studies examining implementation mostly used before/after designs and assessed surface contamination rates. Unfortunately the lack of studies directly comparing cleaning agents, the poorly articulated standard for defining "clean", the poorly standardized process for using cleaning agents, and our inability to isolate surface cleaning effects from hand hygiene effects prevent the authors from being able to synthesize the information, and from making specific recommendations about cleaning strategies. This review does highlights how little we actually know about cleaning; disappointing given the amount of time, labor, money, and administrative effort we put toward cleaning. Hopefully this review can identify some avenues for directly comparing agents, for standardizing processes, and may offer some suggestions on linking cleaning with meaningful clinical metrics.

http://annals.org/article.aspx?articleid=2424875

An article published in Nursing reviewed the effects of a mentorship program on student success and retention in a college practical nursing program. The mentorship model used third or fourth semester nursing students to provide peer support to first semester students. Mentors received 3 hours of training, mentored 2 "mentees", and were in turn supported by two faculty staff members. The mentor began by discussing the mentorship program, outlining expectations, and by helping to set goals for the mentee, they would than reach out to the mentee at times of peak stress, and at an as needed basis (an average of 6 times/semester). There was a significant impact on success rates with those who were mentored, with 76% completing the semester, and 83% the term. Those not mentored averaged only a 36% success rate for the semester, and a 56% rate for the term. Menteees also reported higher grades, more confidence, and less stress. The results of this study, as well as anecdotal experience would suggest that mentorship programs, in general, are beneficial; however I would be hesitant to say that this research contributes meaningfully to our net understanding of these programs in any way. The students in the intervention arm self selected to join the program, as a result the intervention arm may likely be more motivated individuals, which will confound the results. We know that there were 23 students in the intervention arm, we don't know how large the total population of students is, so assessing a population impact is impossible. In addition to the confounding variables, and the poorly articulated population, the extremely high fail rate (44-64%) of this private college likely outstrips the average of publicly funded institutions, and limits the generalizability of the findings. This study set out to show the benefit of a peer mentorship program, which they did, although the findings are much too weak to generaelize. What they also did however was show an extremely high fail rate at their nursing school. I think this study raises some questions about not only their quality of nursing education, their student recruiting practices, and the ethics of what would appear to a predatory process of recruiting and accepting tuition from students that are unlikely to succeed.

http://journals.lww.com/nursing/Citation/2015/09000/A_peer_mentorship_program_boosts_student_retention.6.aspx

In keeping with the spirit of civility Rob Bryant contributed to the EM mindset series on emDocs. His post: "seven rules to make me nicer" offers, unsurprisingly, 7 tips that will not only make you nicer to work with; but also perhaps a better clinician. This post is approachable and is general enough for all healthcare professions to have something to take home.

Anna Pickens discussed cardiogenic shock in a video posted on EMin5. The video begins by describing the physiology of cardiogenic shock, how to determine the cause, and suggestions for maintaining blood pressure. She offers some specific recommendations about NIPPV, fluid therapy and balancing pressors and ionotropes to correct hypotension. A very approachable 4 minute video.

Ian Miller linked to a TedTalk on palliative care by a HPC physician BJ Miller, who discusses the difference between pathology vs patient centered care, the difference between loss and regret, and the power of changing our perspective on death: from one of repugnance; to one where we accept that dying is an integral part of living. A great talk on medicine not as simply removing suffering,  but as tending to human dignity.

Ian Bodford posted a great review on emDocs this week that reviews toxic alcohol poisoning. Toxic alcohols are non-ethanol bases alcohols and include methanol (windshield washer fluid), isopropyl (rubbing alcohol), and ethylene glycol (antifreeze). Bodford offers some suggestions on maintaining a degree of suspicion with all inebriated patients, suggests some lab studies, and highlights treatment options for patients with toxic alcohol poisoning. A good review for ED nurses, and a good reminder to avoid assumptions when dealing with inebriated patients.

Laurie Bickhoff's post "Sending Nursing Education Viral" on Defining Nursing serves as a nice adjunct to Jesse Spurr's video on social media in education. This post offers some nursing applications for social media and highlights it's usefulness as a tool for: continuing education, engaging and networking with peers, conducting research, and curating clinical resources.

Weekly Review #17

This is an older post, by Micheal Douma, of a NENA presentation on abdominal-pelvic trauma. The presentation at it's core is a summary of basic hemorrhage control, and a discussion about the degree of force required to provide adequate compression to control hemorrhage. Specifically though Douma discusses controlling abdominal pelvic hemorrhage with External Aortic Compression (EAC). EAC is, in short, pressure applied to the aorta using a fist (landmarking from the umbilicus) with arms locked as though providing CPR. Effective aortic occlusion requires 80-120lbs of force, and requires constant pressure (Douma has a great graph on occlusion techniques).

Maintaining this pressure is of course difficult during transportation and resuscitation, so Douma covers some of the emerging technologies that seek to accomplish this task (REBOA, junctional clamps and tourniquets, and stasis foams). Unfortunately there is no discussion about when to use EAC, perhaps due to the research being in it's infancy, but it's something you might consider when faced with extremity or pelvic hemorrhage not controlled by binding, or tourniquet.

There are two messages here that I think are important for nurses: the first is obviously that there is a role for direct arterial pressure in hemorrhage control, which sometimes needs to be applied proximal to the injury, even if that means occluding the aorta. The second point is that controlling hemorrhage begins with basic techniques performed well, which requires a surprising amount of force - if your bandages are soaking through, you need to press harder. Douma quantifies what we would often teach in TCCC, the use of knees to provide this consistent pressure, he shows that it provides extremely effective transfer of weight, as an added benefit it frees your hands up for other tasks.

I often see hemorrhage control poorly performed (bandages aren't for absorbing blood, they're for providing pressure), I've seen the deadly consequences of pelvic trauma with overt or occult hemorrhage, and would encourage all nurses to pay attention to the messages in this post.

http://rescuescience.org/2015/06/06/nena-external-aortic-compression-presentation/




BoringEM had a post by Martin Badowski this week discussing delirium. Delirium is an acute, fluctuating change in cognition that effects ~10% of older adults in the ED, it's associated with a three fold increase in 6 month mortality and is identified in less than half of the patients (17-35%) who present with it. This post discusses the diagnostic strengths and weaknesses of different diagnostic tools (CAM, CAM-ICU, mCAM-ED, MMSE, DTS+bCAM), and offer a mnemonic to approach differentials: I WATCH DEATH

Infection - UTI, pneumonia,
Withdrawal - BZD, EtOH, hypnotics,
Acute Metabolic - Hyper/hypoglycemia, electrolyte derangement,
                           Toxins - Alcohol, recreational drugs, or prescription interactions,
                           CNS - Tumor/lesions, CVA, Infection,
                           Hypoxia - anemia, hypotension, pulmonary/cardiac failure,
                           Deficiencies - Thiamine, B12,
                           Endocrine - Adrenal, thyroid, parathyroid,
                           Acute Vascular - Shock,
                           Trauma,
                           Heavy Metals.

I have found other mnemonic a little easier to remember when it comes to assessing delirium (see AliEM post on Weekly Review 11), but this post really shines in it's discussion of the diagnostic tools, where it discusses the predictive value for each in detail. A great post for nurses working in emergency to brush up on delirium screening.

http://boringem.org/2015/09/07/medical-concept-delirium-tips-and-tools/

In an older post on Pacific Emergency Medical Training Doug Fraser discusses "big vs. small box" EMS education. The small box approach Fraser says is the classic protocol driven reductionist approach to EMS: defining your role by the "things you can do". On the other hand the "big box" approach to providing care requires that an appreciation of your role within the system as a whole, and by necessity the roles of others. This may mean building an understanding of procedures that are beyond your scope of practice, and understanding aspects of practice that you are not part of. When we do this he asserts we open the door to sharing knowledge with other professionals, we learn from them in either a direct or an indirect manner. and become better at our own job. He uses a person example of airway management, discussing how as a BLS paramedic he's learned the finer points of ventilating from anesthesiologists, while being able to bring new ideas to ALS paramedics. This idea spans all health care professions, and echos the very core message of FOAMed, as indeed upstairs care downstairs can only happen when we take an interest in what others are doing.

http://www.pacificemergencymedicaltraining.com/?page_id=15

Seth Trueger from MDAware contributed to the ongoing EM mindset series on emDocs. He discusses the role of addressing the mundane in EM, stratifying risk, and coordinating care, and his unifying theme of balancing limited time with clinical uncertainty is a great message for all healthcare providers. Truger discusses the mental process for deciding if patients need intervention, diagnostics, or transfer and suggests that if you're spending a prolonged amount of time making the decision you should probably err to the side of caution and go for it; this message I think is directly translatable to nursing. I've witnessed nurses debate calling a physician about a deteriorating patient: if there's that much question go ahead, do it, then use your mental effort and time doing something that helps the patient. His idea that the time spent doing something unimportant takes away from the you have to do something important is spot on, a great take home message.

http://www.emdocs.net/em-mindset-seth-trueger-resuscitation-risk-stratification-care-coordination/




There was a discussion on Taming the SRU by Matthew Stull about approaching the undifferentiated patient. This is a great discussion about how to perform a history and physical assessment in the ED, what he himself always does in clinical practice, and what can be omitted. I really appreciated the opening discussion about avoiding corollary information before assessing the patient. By avoiding reading too in depth into the chart Stull asserts that you're less likely to become biased toward the patient and their presentation. I think this is important because cognitive anchoring can easily lead a clinician to wrongly attribute signs and symptoms to chronic conditions and previous visits. I think this is a great message for nurses, we all have repeat patients who present with intoxication, but it doesn't mean that those people aren't presenting with acute conditions such as head injuries.

http://www.tamingthesru.com/blog/bread-and-butter/undifferentiated-patient

EMin5 discussed preparing for RSI using the SOAPME mnemonic (Suction, Oxygen, Airway, Positioning, Meds, Equipment/EtCO2). A nice succinct review of how to set up your equipment, medications, and patient.

It's been a couple of weeks since having a post on caring for obese patients. If you're needing a fix check out this EMC podcast. It has a great overview on adjusting your practice in relation to vitals, airway interventions, and medication dosing.

Check out the discussion on BIJC about the difference between hemoglobin and hematocrit values (spoiler alert: there is none).

There's some new research this week from Matthew Douma on the efficacy of "double-barreled" dual IO therapy, there's a nice review of this research on the Trauma Pro's blog.

A St.Emlyn's post discussed strategies for maximizing your sleep. It offers suggestions on sleep hygiene, discusses the negative consequences of sleep deficit, and offers tips for adjusting to rotating day night schedules. This is something many nurses may find helpful.

And finally, a 7 year prospective population study in China published in the BMJ found that those who more frequently ate spicy food had lower all cause mortality than those who did not. This study includes a large number of patients (half a million) and examined consumption of fresh or dried chili when assessing for spicy food. There are of course a number of factors (urban vs rural) that could be confounders in this study, and it's not really FOANed per-se; but hey it's a reason to eat some hot wings this weekend.

Weekly Review #15

I've worked in sites that use recorded shift reports - they're ridiculous: first you spend 10 minutes recording it, then I spend 10 minutes listening to it, and then we end up talking about it for another 10 minutes so you can answer my questions and give me updates. 30 minutes instead of just a 15 minute in-person handover! I've always hated them; but now I have some evidence to support my dislike for them: an article by Judymae Ofori-Atta discussing the superiority of person to person bedside reports (BSR). Bedside reports are given between nurses in the presence of the patient and family they've been shown to improve work flow and patient safety, as well as patient involvement and satisfaction: a win all round, and applicable to all nurses. Hopefully this helps you bury the voice recorder for good!

http://journals.lww.com/nursing/Fulltext/2015/08000/Bedside_shift_report__Implications_for_patient.20.aspx

There was an online article published in the Journal of Emergency Medical Services by Douglas Dixon and Darren Braude on managing the airway of bariatric patients. Nursing considerations of bariatric patients has become a recurrent theme here: last week I discussed a REBELCast review of the accuracy of the Broslow Tape in estimating weight in obese children, and a review from the Nurse Path post on surgical considerations in weekly review 8. This article focuses specifically on airway management. Dixon and Braude start with a brief overview of the epidemiology of obesity and the physiological changes that accompany it: a reduced functional residual capacity due to decreased chest wall compliance and reduced diaphragm movement. Because of these changes obese patients will more quickly become hypoxic and will need extra attention paid to optimizing their ventilatory effort. They make some suggestions on positioning (ramped, or reverse trendelenberg), discuss how three handed BVM ventilation may be necessary to maintain good mask seal and overcome increased airway resistance, how to provide apneic oxygenation with high flow nasal cannula, and how drug dosing for RSI may need to be adjusted from total to ideal body weight (the Nurse Path post has a great overview of this). This is a good starting point if you're looking for tips for bariatric patients, and a good reminder to attend to patient position, especially for nurses working in the ED where patients may not always be able to adjust the position of the cot on their own.

http://www.jems.com/articles/print/volume-40/issue-8/features/bariatric-airway-management-is-about-more-than-intubation.html?cmpid=jemsnowenl08202015&eid=288528567&bid=1157558  




There was a great mnemonic (MADE NICER) created by Anali Maneshi and Matthew Cherian posted on BoringEM this week. It's a mnemonic to help assess possible differentials for geriatric patients presenting with weakness:

Medication - Screen for medication causes: steroids, statins, antipsychotics, diuretics, insulin, opioids, and sedatives; assess for recent dosage changes,
Anemia - Either due to blood loss (overt or occult), or impaired production malignancy, nutritional deficiency,
Dehydration - Diarrhea, diuretics, or vomiting,
Endocrine - Hyper/hypoglycemia, adrenal insufficiency, hypothyroidism can all cause glucose/electrolyte derangement,
Neurological conditions - Acute (stroke, SAH) and chronic conditions (lesion, MS, Parkinsons, etc) can result in weakness,
                                 Infection - Any infection can result in weakness,
                                 Cardiac - Presyncope from cardiac cause, angina or atypical MI presentation (malaise), and CHF may present as weakness,
                                 Electrolyte imbalance
                                 Rheumatological - SLE temporal arteritis

The typical ED will see a large number of geriatric patients, they're less capable of tolerating challenges to their systems, may be multiply co-morbid, and may have medications masking or contributing to their physical findings; having a mnemonic to help work through differential causes for a common presenting complaint is useful for all ED nurses when attempting to triage a vague complaint.

http://boringem.org/2015/08/24/tiny-tips-weakness-made-nicer/

There's been an increasing number of deaths in Canada recently from intentional and unintentional use of fentanyl. There is starting to be some reaction from the medical community, as studies are showing a 4% mortality rate associated with prescribed large doses of opioids. However there is still a large volume of diverted narcotics that are finding their way into other recreational drugs. The news is likely not news for many; but it is an excellent segue to highlight some more research on low dose titrated naloxone for opioid toxicity in the ED. A summary and how to for titrated naloxone can be found in a post by ALiEM. Worth a read for nurses working in the ED, also worth remembering is that obtunded patients without a history of narcotic use may still have unintentionally ingested fentanyl. . 

http://www.cbc.ca/news/canada/edmonton/alberta-slow-to-react-to-sharp-rise-in-fentanyl-deaths-critics-say-1.3191075



There was a podcast by Brian Ericson on erNURSEpro posted this week discussing hyponatremia, one of the most common electrolyte imbalances seen in the ED. The discussion begins with a discussion about the difference between acute and chronic hyponatremia, classification and explanation of  the differences between hypo/hyper/normo-tonic and hypo/hyper/eu-volemic hyponatremia. There is a discussion about the causes of hyponatremia: pre-renal (excess sweating/diarrhea/burns etc); versus renal (CRF/addisons disease/etc), neurogenic causes (SIADH), treatment, as well as the complications associated with correcting sodium. Brian discusses the difference in acute vs. chronic hyponatremia, and offers a great clinical pearl on suspecting hyponatremia in seizing patients who are not responding to benzo's. This is a great podcast, a little too in depth to fully absorb while driving; but worth the 25 minutes when you have some time to dedicated to listening. 

http://www.ernursepro.com/#!podcast-episodes/c1enr

I came across a blog called Rescue Science) by Matthew Douma with some great posts that I'm looking forward to reviewing in more detail in coming weeks. There's some standout posts on dead space in IV extensions, methods for pushing adenosine, and a fantastic review of the role for external aortic pressure in junctional bleeds to check out. Some of these have been out for a while, but they're directly applicable to nursing practice, thorough and well written. An awesome resource, I'm looking forward to future posts.

Check out Injectable Orange this week for a review of Sketchy EBM. I would also like to congratulate Jesse on winning the Symplur Signals Research Challenge. 

Ian Miller from the Nurse Path has 28 step guide to hanging an IV that is pretty well spot on for your first shift back, as well as some tips for handling messy situations. I'm glad to see you up and running on Facebook again!

CriticalEd had a discussion about the role of a "nurse curator" in staff development: what it is, what the role would include, what to call it etc. An exciting idea to suggest a formalized role for FOANed in clinical practice. Give it a read, he's looking for feedback and suggestions if you have any. 

Weekly Review #13

I quite like the EM in 5 site, they have brief, to the point tutorials discussing clinical topics. this week Anna Pickens discussed the assessment of chest pain, and ruling out the "deadly 6": Acute MI, pneumothorax, myocarditis/pericarditis/pericardial effusion, aortic dissection, and esophageal rupture. This post is a short video that starts by discussing a general approach to physical assessment and history taking, moves on to discussing the clinical features for each of the deadly differentials, and finishes with suggestions on diagnoses using cardinal findings, labs, and diagnostic imaging methods. I think this is a great review for nurses: it's clear, concise, and reviews foundational knowledge, well worth the 5 minutes.

http://emin5.com/2015/08/05/approach-to-chest-pain/




There was a nice review of managing asthma exacerbation by Anand Swaminathan posted simultaneously on both Core EM and REBEL EM this week. The post starts with a discussion of the epidemiology and pathophysiology of asthma exacerbation, discusses typical presentation features, reviews the fundamentals of medical management, and finishes with follow-up and discharge recommendations. This is a clear and concise review of the medications typically used for acute asthma exacerbations, their doses, mechanisms of action, and side effects. A great review for any nurse working in emergency.

http://coreem.net/core/basic-asthma-management/





Julie Miller published a review in Nursing 2015 of some dogmatic practices and controversies "sacred cows" of nursing practice. In this article she discusses the results of a 2356 nurse survey designed to assess nurses understanding of current best practices. This article is very readable, the content is presented as the original true/false question (as seen on the questionnaire), the percentage of responses as true/false, and a discussion of the correct answer with accompanying rationale and relevant research. This is a quick easy read, and the content reviewed is applicable to almost all fields of nursing. This is FOANed at it's finest!

http://journals.lww.com/nursing/Fulltext/2015/08000/20_questions__Evidence_based_practice_or_sacred.13.aspx

There are new NICE (National Institute for Health and Care Excellence) trauma guidelines out. St.Emlyn's provides links to the source documents: the full guidelines, key recommendations, and evidence behind the recommendations; as well as a brief synopsis of some of the recommendations. They strongly (thankfully) recommend against crystalloid fluids in actively hemorrhaging patients, endorse restrictive approaches to volume resuscitation, support early IO access, and TXA within 3 hours of injury. Well worth a read for all nurses working in Emergency/Trauma to keep abreast of current practice recommendations.


http://stemlynsblog.org/speak-up-nice-guidance-major-trauma/


St. Emyln's also had a two part review of the value of respiratory rate as a vital sign in the pediatric population. In these two posts Natalie May discusses a couple of articles that came out this month discussing raised respiratory rate in infants. She discusses and summarizes the key points discussed in the studies:

- Tachypnea can be a normal finding: Periodic breathing,
- That respiratory rate should be assessed using auscultation, and by listening for 60 seconds (In part two there's a great discussion about how terminal digit preference shows that we're not),
- Some tips on physical assessments and diagnostics to rule out life threatening processes,
- Suggestions on follow up once life threatening processes have been ruled out.

This is a great review, the source content is freely available, the review is succinct and highly applicable to nurses working in emergency, another great read.

http://stemlynsblog.org/jc-dont-write-off-the-respiratory-rate-1/

http://stemlynsblog.org/jc-dont-write-off-the-respiratory-rate-2/

Weekly Review #7

Eve Purdy posted on BoringEM about critical appraisal of research. Critical appraisal tools equip readers of research with a method of interpreting the rigor of the methods, and a way of examining if the results are meaningful: both statistically and clinically. There are some links in the post to the Center for Evidence Based Medicine (CEBM) at Oxford: which has great tools for assessing research, as well as brief explanations on some of the statistical tools used in EBM. There is also some links to access YouTube hosted videos on statistical tools, and some other web based education opportunities. I think that the ability to critically interpret research is fundamental to becoming a proficient end user of research, I've discussed different tools that are available to help use statistics in health care previously (see diagnostic test calculor in weekly review #6, and Liklihood Ratio Database in Weekly Review #4) because there's so much research being produced that it's not only difficult to ensure that all of the research is high quality, but that it's also relevant to the question at hand. I would also suggest reading some previous posts by ScanCrit, emlitofnote, and BoringEM, which all do a great job of highlighting the disconnect that can occur between statistical and clinical significance.

http://boringem.org/2015/03/06/boringem-research-week-skimming-the-top-off-researchclinepi-foam/




A Dutch study examined the effects of Crew Resource Management (CRM) training on ICU mortality and complication rates. CRM is a training program used in aviation to examine human factors in adverse outcomes and create system solutions to prevent them from occurring. The CRM intervention consisted of two days of training in CRM for all staff, the designation of CRM team leaders, and the identification of, and strategies for dealing with, 8 key human factors that result in adverse outcomes.




The 8 key areas were:
1. Situational awareness: and recognizing adverse situations;
2. Human errors and non-punitive responses to them;
3. Communication, briefing and debriefing techniques;
4. Providing and receiving performance feedback;
5. Stress management, workload and fatigue;
6. Creating and maintaining team  structures and environments;
7. Leadership in a flat hierarchy;
8. Risk management and decision making.


Strategies became topics of discussion at all staff meetings, and staff created new checklists for key points in patient care: Central line placement, ET intubation, patient handover at transitions in care, and team training.

The study was a single center 3 year before/during/after prospective cohort design, there was no control arm, and all the data for the study was pulled from the Dutch NICE registry. Approximately 2230 to 2500 patients were included in each of the three years, and were assessed for 18 key complications.

With the introduction of the CRM training: overall complication rates decreased, mortality decreased, cardiac arrest rates went down, CPR success increased from 19% at base line to 55 in the intervention year and 67 in the post implementation year, and staff perceived the work environment to be safer in general. There were no differences in LOS or ICU LOS.



These findings are encouraging; however. there are some limitations to this study: it's single center, has a small population, and no control so the quality of the evidence could be stronger. There is no standardized approach to CRM training in health care, so applying this model to another site could prove difficult, therefore reproducibility may be poor. The study ICU also changed location in the first month of the post-implementation year: while the authors acknowledge that the ICU used the same equipment, the change in environment could have improved work flow and contributed to improved outcomes. Finally if we examine the patients year on year we can see that there was a decrease in cardiac patients and patients with chronic cardiac conditions which certainly could have attributed to the decreased cardiac arrest rates. Overall rates of vasopressors and mechanical ventilation use decreased; while trauma admissions increased, which certainly could have a large effect on the overall mortality and complication rates. From a nursing perspective there is some encouraging news here, if due to the intervention, the reduction in  complications/cardiac arrests and increase in CPR success is substantial. Certainly the intention is good: addressing systems processes to prevent human error. However; Until there's larger studies and standardized CRM training it will be difficult to determine if CRM training is a worthy intervention.

http://onlinelibrary.wiley.com/doi/10.1111/aas.12573/pdf





There was a ton of information and MedEd sharing happening last week with the social media and critical care (smaccUS) conference happening in Chicago. Too much to cover everything in detail, but there are a few pieces that I found particularly interesting and relevant to nursing:


@HEFTEMCAST had a great post on the utility of urinalysis on detection of UTI. This links nicely to earlier discussions on understanding test probabilities and evidence based medicine. In this post they discuss the sensitivity and specificity of the different parts of the urine-dip, and the risks for false positive if pre-test probability is not used in determining the likelihood ratio. The take-home message here is that bacteriuria is relatively common in elderly patients, especially females, and doesn't always warrant antibiotics. I think a review of urine dip testing is particularly relevant for nurses, as I inwardly cringe every time I hear a colleague discussing a "dirty" urine dip on an asymptomatic patient.

http://www.heftemcast.co.uk/urine-testing-who-gets-the-antibiotics/
http://www.sign.ac.uk/pdf/sign88.pdf





A problem for all clinicians is how to deal with patients who have presented with dubious conditions, requesting opioid analgesics. For nurses this is somewhat less of an issue, from a liability perspective, than it it for our medical counterparts. However dealing with these patients can be frustrating. There are some slides made available from a smaccUS talk discussing the myths and realities of prescription opioid use, the current state of evidence, red/yellow flags for spotting potential opioid abuse/abusers, as well as some phrases to help in communicating with these patients. From a nursing perspective I think the flags will likely recap some of the obvious clues that many nurse will already have identified, there may be a few flags you had not thought of, and even more helpful it may provide some useful terminology to describe the behaviour of patients who are gaming the system for narcotics. Most important information however is directed at clinicians themselves, an honest critique of poor clinical practice, and the myths of opioid pain control: That narcotics are non-addicting in patients experiencing pain, that we should seek pain scores of zero, and that opioids are effective for chronic pain. If you click on only one link from this post, make this the one!

http://emupdates.com/helpcard-and-opioid-misuse/
http://emupdates.com/wp-content/uploads/2015/06/Strayer-Opioid-Misuse-SMACC-Slideset.pdf




ICEBlog posted their smaccUS notes on clinical education online. There's some great information here for anyone involved in providing or receiving clinical education (everyone). There is a review of teaching/learning styles, some myth busting about clinical education, and a framework model for delivering clinical education. There is also a small teaser on social knowledge, something they unfortunately didn't expand upon.

http://icenetblog.royalcollege.ca/2015/06/26/education-theory-for-the-meded-clinician/





More reasons to use IO access: A great post on ScanCrit about the use of IO access for RSI medications. This is a review of British combat medicine review from Afghanistan, published in the Emergency Medical Journal, on prehospital intubation of injured soldiers. The successful first pass rate for RSI was 97%. The quality of evidence is relatively poor (sample size less than 40, limited generalizability outside of combat helivac operations); but it certainly adds to the growing body of first hand evidence suggesting that IO access is a viable first line choice for gaining vascular access and administering drugs.

http://www.scancrit.com/2015/06/29/io-drugs-quick-iv/

Weekly Review #6

The New England Journal of Medicine published a review of a Swedish intervention to increase the rates of bystander initiated CPR. The intervention in this study was the use of cellular technology to dispatch CPR trained bystanders who were within 500m to the cardiac arrest calls received by EMS dispatch systems. There were 5989 CPR trained bystanders recruited. The rate of bystander CPR was 17% higher in the intervention group, considering that bystander CPR may almost double chances for survival this could translate to many lives saved. This technology is available through a mobile app created by PulsePoint. PulsePoint allows responders to register to provide CPR, as well as to register the location of AED's. This could be an excellent public health measure, I would encourage everyone check to see if the service is available in your area, and to sign up if it is.

http://www.nejm.org/doi/full/10.1056/NEJMoa1406038



There was a new systematic review and meta-analysis of Rapid Response Systems (RRS) published in Critical Care this month that observed a reduction in mortality associated with RRS teams. In this study CINAHL, PubMed, EMBASE and the Cochrane Collaboration were searched using RRS team keywords. 29 articles published between 1990 and 2013 were included, representing 2,160,213 patients (1,107,492 in the intervention arm). 65.5% of studies had 24/7 physician RSS team staffing. 25 of the studies were single center (21 in academic centers). RRS activation rates averaged 16.3/1000 admissions (95%CI 9.0-23.7), 33% (95%CI 23-43%) of these patients were transferred to ICU, and 9.7% (95%CI 4.5-14.9%) had changes made to their code status (DNAR). This study observed a decrease in mortality (RR 0.87, 95 %CI 0.81-0.95, p<0.001), as well as cardiac arrest rates (RR 0.65, 95%CI 0.61-0.70, p<0.001), with no effect on ICU admission rates (RR 0.90, 95%CI 0.70-1.16 p=0.43).
These findings are contrary to both a 2010 systematic review and meta-analysis by Chan et al., and a review by Sendroni et al., published in Critical Care this year (see weekly review #2). This review included an additional 13 articles not included in the 2010 review, and 12 not reviewed by Sendroni et al. However if you take the three reviews and compare them side by side this review includes just 4 studies that where not in either of the other reviews. Two of the four articles excluded cardiac arrest within the ICU, and two of which were before/after and one a time series with no control, and therefore of relatively poor methodological strength. It would appear that the difference in findings between this review and the two preceding reviews are either due to two studies, both of which somewhat weak methodology (before/after without control), exclusion of patents who had in-ICU cardiac arrest, or a difference in interpreting the statistics.
I would be hesitant to say that this review is the final word on RRS teams. Likely we will need a well designed longitudinal study to assess for the impact of RRS systems on overall mortality; as both the MERIT trial and Sandroni review have noted that the longer a RRS system is in place, the more effective they become. From a nursing perspective RRS teams are useful: they channel patients that need ICU care into the ICU, they address inappropriate code statuses preventing expensive resuscitations, and, as time passes they may very well prove to have mortality benefit in general.

http://www.ccforum.com/content/pdf/s13054-015-0973-y.pdf

Ian Miller from the Nurse Path shared an Australian best practice guideline for prevention of pressure ulcers in critically ill patients. There is a link within the page to the complete NSW Agency for Clinical Innovation best practice document as well as a summary of the recommendations for assessment, prevention, and treatment. Although this is geared toward the critical care environment this is information that is applicable to all nurses, and is worth the time required for a quick review.

http://thenursepath.com/2015/06/05/pressure-injury-prevention-for-critically-ill-adults/ 

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0014/240152/ACI14_PIP_1-1.pdf

In Richard Lehman's NEJM journal review this week he discusses the implications of increased surveillance in the UK for cognitive decline. The increased surveillance comes at the recommendations of the National Institute for Health and Care Excellence (NICE) to screen for cognitive decline. Unfortunately the most commonly used tool for screening is the Mini Mental Status Exam (MMSE). The MMSE unfortunately has a poor diagnostic power (Sensitivity 81%, Specificity 89%). While these numbers may seem not too bad at first glance once one needs to keep in mind that it's being used at a population level for screening. Lehman uses this observation to suggest that there are better tools for the job, indeed there are, and a new systematic review published in JAMA has more great info on the subject. Even more importantly and generally speaking however are the ramifications of not using a Bayesian approach in using screening tools. For example if we use the diagnostic performance measures provided by JAMA for the MMSE (Sensitivity 81%, Specificity 89%), and apply them to the NICE provided estimates for alzheimers rates of  4.9/1000 (about 0.5% for people over 65 years old in the UK). Assuming it's used in a non-selective manner for patients over 65 years old as a screening tool we will have 109 false for every 4 true positives. This disconnect between test sensitivity and actually likelihood ratios is nothing new, it's been covered by ScanCrit and emlitofnote, both of whom have great write ups and case studies they covered last year. Services such as the Likelihood Ratio Database, and Diagnostic Test Calculator (screenshot below) can help to make sense of the mess, but from a clinical perspective it's important to not use these tools inappropriately in the absence of clinical findings.

http://blogs.bmj.com/bmj/2015/06/15/richard-lehmans-journal-review-15-june-2015/




The BBC ran a story this week discussing older adult patients being "trapped" in the hospital acute care system. The story discusses a report from Age UK, showing that a large number of patients in the acute care system are not only waiting for long term care or assisted living beds; but also home care services, social work services,or even just assistive devices at home such as stair lifts. While this is not really news for anyone working in health care, what is new is the shift in language away from patient blaming language. This news piece, refreshingly, changes the lens from: discussing these patients as "bed blockers" who "aren't sick"; to one that examines the system itself, and the inappropriate mix of services that leave patients with no other choice than to use higher acuity, more expensive beds to meet their basic needs. As a nurse working in emergency I'm well aware of the fact that patients are inappropriately channeled into the acute care system: visiting the ED for sore throats because they don't have access to primary health care, or dropping off their elderly relatives because the burden of caring for them has become to great. It's frustrating and easy to blame the patient for no knowing better than to use acute care services. Unfortunately patients already know better, they're accessing care the only way the can. It's time for health care systems to stop blaming patients for using the wrong service; especially when we're not offering them the services they need.

http://www.bbc.com/news/health-33154093