Weekly Review #21

Brian Erikson hosted a couple of great guests on erNURSEpro. He discussed ED process improvement with Deb Delaney, and Delirium with Christina Shenvi.

Deb Delaney had some insight on improving ED through-put and made some specific suggestions about internal queues, flow facilitation, use of mid level providers, streamlined ancillary services, room utilization, huddle & hand-off processes, and communication. I've seen several departments use internal queuing, or intra-departmental waiting areas, to create a "fast-track" area and increase throughput of less acutely ill patients. The "flow facilitator" role is often performed by a charge nurse, in small departments this may work well, but in large centers, or during times of peak traffic it does not. Dedicating one person to this role, even if only during peak volume can help clear bottle necks, ensure patients are moving through the system, and ensure that the charge nurse isn't being removed from performing their function, I particularly like the push-pull model of moving patients, as well as bed-side handoffs and impromptu huddles. Delaney offers a few other suggestions, and likely has something that could be implemented at your department, a good review for any nurses working in a charge, or managerial role.

Brian also hosted a talk with Christina Shenvi, a physician and fellow in geriatric emergency medicine. Christina discusses a three step approach to patients with delirium: immediate stabilization and correction of rapidly reversible causes (hypoxia, hypovolemia, AMI), establishing a baseline for the patient (call family, support workers, or care home staff), and the process of ruling out possible causes of delirium using the DELIRIUM mnemonic (covered in weekly review #11). She then discussed possible causes, risk factors, and considerations for interacting with these patients. There are some great pearls on pain assessment, preventing delirium, and steps that can be taken to make an emergency department more friendly to geriatric patients. This is a great podcast, Brian includes some relevant links in the show notes, the discussion is straightforward and informative, and the content is applicable to almost all sub-specialties of nursing; if you're going to listen to only one podcast this week, make this the one!

http://www.ernursepro.com/#!ERNP-029-Become-a-Delirium-Rockstar-in-Your-Department/clp2/5636120a0cf2f97533d29a3d





There was a lot of FOAMed coverage this month on the new 2015 CPR/ECC guidelines. HEFTEMCAST, RebelEM, and BIJC, have all provided great summaries of the updates; but from a readability perspective I would like to highlight the review by Justin Morgenstern on First10EM. His post starts with a review of the evidence informing the changes, then discusses the key recommendations and changes by topic, starting with: CPR, medications, capnography, technology, post resuscitation care, and finally by special patient populations: pregnant, hypothermic, trauma, pediatric and neonate patients. The team at BoringEM also deserve a huge acknowledgement for their amazing infographic series which can be downloaded here, a fantastic review for any nurse that participates in cardiovascular resuscitation.

http://first10em.com/2015/10/21/acls-2015/

The Journal of Trauma and Acute Care Surgery published an analysis by Afshar et al., that examined the association of blood alcohol content with in hospital death, injury severity, and mechanism of injury. This is a retrospective examination of patients treated at an American shock trauma center between January 2002 and October 2011. The study assigned patients into 4 categories based on blood alcohol content (BAC): undetectable (<1mg/dL), moderate (1-100mg/dL), high (101-230mg/dL), or very high (>230mg/dL), then examined for severe injury (ISS >16), dichotomous injury pattern (blunt or penetrating), hypotension (MAP < 66mmHg), shock index (SBP/HR - greater/less than 1), and death.

There were 46,222 patient records examined, 44,502 (96%) had blood alcohol content (BAC) assessed, 12,535 (28.2%) were exposed to alcohol with the a median BAC of 167mg/dL (high). Baseline characteristics showed an increase in male representation with increasing BAC quartile (66, 77.5, 79.8, 83.1%). Patients with moderate BAC were more likely to have penetrating injury patterns (typically gunshot wounds), severe injury, hypotension, pulseless arrival, and in-hospital mortality compared to other groups. The very high BAC had the greatest proportion of blunt trauma, falls and fights, the lowest proportion of vehicle collisions, and the lowest odds for in-hospital mortality.

When I first read this research I was a little confused as to what it added to the overall knowledge of alcohol and trauma, other than to say that mechanism varied across intoxication levels. However when this research, on injury mechanisms by BAC quartile, is used in addition to previous research, on alcohol and mortality, we begin to understand why some of the noted effects are occurring. This may be interesting research for nurses working in trauma who are particularly keen on the epidemiology of trauma, but from a straightforward nursing perspective it has little to add to the general approach toward trauma patients.

http://www.ncbi.nlm.nih.gov/pubmed/26402540

I recently moved from a small rural ER to a large metro trauma center. On one of my first orientation shifts a patient in DKA was transferred to our department from a rural site. Some of the nurses made disparaging comments about the choice of SC insulin over IV insulin infusion, which started an interesting dialogue. Although I've typically seen these patients treated with IV insulin infusions I do know that the evidence, as well as CDA guidelines, acknowledge that either will produce similar outcomes. I've seen some support for the practice in EPMonthly, which acknowledged similar efficacy between the two, but a new review by EMPharmD offers not only a succinct review of the existing literature, but also a fresh perspective on titrating doses from rapid to a long acting insulin, an approach that if supported by evidence could significantly lower the amount of time and resources required to treat patients with DKA. A great read for nurses working ER/ICU or medicine, and one of my newly discovered favorite sources for FOAMed content.

http://empharmd.blogspot.ca/2015/10/just-little-prick-iv-vs-sq-insulin-for.html

On InjectableOrange Jesse Spurr hosted a post by fellow Canadian RN Jennifer Jackson on why nurses need to be politically active: to advocate for patients, to advance the nursing profession, and to effect change on our work environment - very timely given our recent federal election. He also posted some links and information for those lucky enough to attend the 2015 SMACC conference in Dublin.

I've reviewed a post by Ian on pre-filled syringes before and strongly feel that they are an effective way to prevent medication errors. One drug in particular where this is of concern is Epi. The differences in concentration between cardiac and anaphylaxis doses is 10 fold. Taft Micks offers a review on the differences between the two on  BoringEM, discussing the risks, and deciphering the labels of the two different doses.

EMin5 reviewed the different presentation, treatment and complications associated with parasitic skin infections. Anna Pickens reviewed the differences between scabies, lice (head, pubic, or body) and bedbugs. This five minute video offers up great photos, neatly summarizes the treatments, and includes a fantastic table that summarizes the video. An excellent review for emergency, correctional, camp, public health, or school nurses.

Weekly Review #12

I recently started using twitter, originally as a way to curate FOAMed and FOANed content, it didn't take long for me to want more. When I first started using it as a way to not only curate; but to connect with the FOANed community I was at a loss. I wasn't looking to have another social media account where I got game request and cute inspirational posters with cats and Minion characters; I wanted a resource for sharing knowledge. I wasn't sure what proper twitter etiquette was, how to connect with like minded individuals, compose tweets, or how to target my communications to the individuals and communities I wanted to engage with. I learned; but I would have appreciated a tutoridal. Jesse Spurr from Injectable Orange has made one. It's basically a curated set of 10-20 minute long video tutorials on how to interact on twitter. I would recommend it to anyone interested in using twitter in general, especially if they're interested in joining the FOAM/FOANed community.

http://injectableorange.com/2015/08/lose-the-egg-take-off-on-twitter/

There was a post by by Ryan Mason and Alex St.John on emDocs on wound irrigation that is highly applicable to nursing. In it they review the literature for the effectiveness and safety of sterile saline versus tap water, and the best practices for irrigation pressure and volume. Their results are clearly summarized and presented along with links to the source research. A Cochrane review found tap water (for cleaning small uncomplicated lacerations in otherwise well patients) is as safe and effective as saline in general. Other research suggested that tap water was associated with fewer infections, and that, unsurprisingly, yielded a ten fold reduction in cost compared to saline. The literature examining irrigation pressure suggests that ideal pressure of ~43PSI could be achieved using a 19 gauge needle attached to a 35 or 65cc syringe. Standard lab faucets have an average pressure of ~45psi: irrigation can be performed in the sink, saving supplies and clean up time, great! They were unable to find any data to support what ideal irrigation volumes are; but most texts suggest about 60ml/cm, or as high a volume as possible. From a nursing perspective this is great online content: it's well presented, easy to read, and highly applicable to nursing practice. Knowing that tap water is safe and effective for simple wounds is great; but knowing that tap water is faster, cheaper, an potentially even safer is awesome, from a nursing perspective this is certainly news worth sharing!

http://www.emdocs.net/antediluvian-methods-an-evidence-based-approach-to-wound-irrigation/




I'm fascinated with lipid therapy (see Weekly Review #1): it's not a widely used antidote, it's mechanism of action is not fully understood, and we're still determining what toxins it can be used for. This week I read a case series report by a Turkish group  who used intravenous lipid emulsion (ILE) to successfully reverse synthetic cannabinoid (SC) toxicity. Commercially available SC are known by many names (K2, Spice, Bonzai, Kronic) and have varying unknown compositions of mixtures of cannabinoid containing compounds. Cannabinoids are strongly lipophylic, can be 5 times as psychoactive as THC, and are associated with many different CNS/CVS effects. There were 4 patients reviewed in this case series; all of them presented with varying levels of CNS/CVS depression, and all were treated with a bolus dose of 1.5ml/kg of 20% lipid emulsion, followed by 0.25ml/kg/min for 60 minutes afterward.

Patient #1 was a 35 year old male, with a history of IV heroin use, who was found unconscious by family with empty SC packaging and brought to hospital. On arrival he was unresponsive, with unequal pinpoint pupils, a GCS of 3, was hemodynamically stable (BP 110/75, HR 95) with ECG showing LBBB; but in respiratory acidosis (SpO2 65%, pH 6.9, PaCO2 125mmHg). The patient was intubated and received ILE (but not narcan as it wasn't available). 5 minutes after the bolus dose of ILE ECG showed narrowing and normalizing QRS appearance. There was no improvement to GCS, and the patient eventually died of ARDS and multisystem failure.

Patient #2 was a 19 year old male brought to hospital after smoking SC. On arrival the patient was confused (GCS 14), hypotensive (70/30mmHg), and bradycardic (HR 42). A 2 liter bolus failed to correct the hypotension so the team initiated ILE therapy. 5 minutes after the bolus dose HR had increased to 50-55/min, by 60 minutes hypotension was resolved (BP 110/70mmHg), and by 2hrs confusion was resolved (CGS 15). The patient was discharged by 24hrs.

Patient #3 was a 15 year old male who had smoked SC. On arrival he was obtunded (GCS 8), and bradycardic (HR 36, BP 80/40mmHg). This patient also received a 2 liter IV bolus, and ILE. The patients bradycardia had resolved by 5 minutes post bolus dose ILE, by 2hrs GCS was 15, and at 24hrs the patient was discharged home.

Patient #4 was a 17 year old male who presented confused after smoking SC. On arrival his GCS was 13, vital signs were within normal limits, and ECG showed accelerated junctional rhythm with bigeminal PVC's. ILE therapy was initiated: PVC frequency was reduced by 5 minutes post ILE bolus, completely resolved (NSR) by 60 minutes, GCS was 15 by 4 hours, and the patient was discharged at 24hrs.

This case series details a novel approach to treating SC toxicity. The reported sample was small and homogenous, there were no controls, and SC toxicity usually presents with arterial hypertension; so caution should be used when attempting to generalize these findings. Given that there are no known antidotes for SC toxicity to date, ILE may become increasingly used as evidence to support it's use accumulates. Dosing information as well as additional case reports can be found at lipidrescue.org, and ALiEM. There are no unique nursing considerations for administering lipid rescue, but institutional policy should be consulted. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4442263/




Where I work the nurses tend apply the vast majority of back-slabs, immobilization devices, air boots, and casts. There was some great FOAM/FOANed content posted by Neil Long on Life in the Fast Lane (LITFL) this week. This is a straightforward post with links to videos showing how to place back-slabs, with tips and tricks on placement, and when each technique would be used. If you apply casts or back slabs on a regular basis this may serve as a handy go to reference.

http://lifeinthefastlane.com/practical-guide-to-the-backslab/

EMSWorld posted about a South Florida trial of heads up (Reverse trendelenberg) CPR. This will be an expansion of small scale trials performed by South Beach County Fire Rescue that have seen dramatic improvements in all-rhythm ROSC (an improvement from 16 to 48%). This trial will see responders elevating the head of the stretcher, and using automated CPR devices for OHCA. Reverse Trendelenberg CPR is something I've been watching with excitement develop for a while now (See Weekly Review #1). Previous animal studies have yielded promising results, showing that reverse trendelenberg CPR is associated with: a significant decrease in ICP, an increase in venous return from the brain, and improved neurological outcomes. I'm excited to see the innovation being put into practice by an EMS service, I would love to see a similar trial performed in hospital. The intervention is free, easy, and could potentially have a large impact on how we perform resuscitations.

http://www.emsworld.com/article/12088616/heads-up-cpr

Weekly Review #5

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.asp

Ian 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%2Fs11739-012-0839-0

Charlotte 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.html

BioMed 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