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/

The throw-up throw-down

The Annals of Emergency Medicine published a study by April et al., that compared inhaled isopropyl alcohol to oral ondansetron for acute nausea. Although this isn't the first time isopropyl aromatherapy for nausea has been assessed; it is the best designed study, and assessed patients over a longer period than had been previously studied. This was a single center randomized, blinded placebo controlled trial that enrolled 122 nauseated adults who didn't require IV access into one of three arms:

1. inhaled isopropyl plus 4mg oral ondanseton 
2. inhaled isopropyl plus oral placebo 
3. inhaled saline plus 4 mg oral ondansetron 

A convenience sample of 208 patients with a presenting chief complaint of nausea or vomiting were screened for inclusion with 122 meeting inclusion/exclusion criteria.

• age > 18years
• presenting complaint of nausea or vomiting with a severity of 3/10 or greater

Exclusion criteria were:

• Isopropyl or ondansetron allergy
• inability to inhale through nose
• recent ingestion of medication contraindicated with alcohol
• altered mental status
• history of prolonged QTc
• suspected or known pregnancy
• patients who had IV access established
• Provider discretion

Reported nausea scores (0-100) were collected from patients at the 0, 10, 20, and 30 minute points. Initial nausea scores were similar across all three treatment arms. The findings noted a significant reduction in need for rescue antiemetic and patient reported nausea within both isopropyl aromatherapy arms; but not in the saline plus ondansetron arm.

This was a well designed study of emergency department patients who presented with a common emergency complaint, the clinical findings are impressive and are significant when considered in association with previous research on the topic. The results of this study alone should be interpreted with caution, however given that it was a single center trial with a small sample size. Additionally there was no discussion of statistical power, the confidence intervals were large and often crossed zero (although this could be due to an under-powered sample size), and that patients were often able to deduce which treatment they had received.

Despite the lack of statistical power this is a study that has the potential to change nursing practice: it suggests that isopropyl aromatherapy may be effective for a prolonged period, that it may show superiority to ondansetron and that it seems to be safe for people with mild to moderate nausea. This is a cheap easily executed therapy, one that doesn't require a prescription, it could be used effectively as a temporizing measure, or as an adjunct to other antiemetics. 


April, M. D., Oliver, J. J., Davis, W. T., Ong, D., Simon, E. M., Ng, P. C., & Hunter, C. J. (2018). Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial. Annals of emergency medicine.

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/

Adult Oral Rehydration

The New England Journal of Medicine this month discussed a hospitals experience using an adult oral rehydration protocol in a large American metropolitan emergency department. This protocol was originally implemented as a result of IV fluid shortages. The protocol saw patients receive analgesia and antiemetics, as necessary, followed by directions to drink 30ml of the fluid of their choice every 3-5 minutes, 20 minutes after treatment.

Inclusion criteria were:

1. Acute Gastroenteritis
2. Hyperemesis Gravidum
3. Viral URTI/Pharyngitis

Exclusion Criteria were:

1. Moderate or severe dehydration
2. Contraindications to oral fluids (ex: bowel obstruction)

Reported outcomes:

1. 30% reduction in volume of IV fluids administered in the ED
2. 15% reduction in the number of physician orders for IV fluids. 

Unfortunately this protocol and accompanying data weren't published as a study, so there's limited baseline demographics, outcome measures, or comparison group information. They also unfortuantely didn't release patient specific measures such as satisfaction, need for rescue medication, or clinical outcomes - which limit the generalizability of this data.  

The hospital itself Brigham and Women's Hospital (one of the largest research hospitals in the world) may also suggest limits to the generalizability of this protocol (well funded tertiary centers); however, the practice is well established in pediatric patients (with a large systematic review) and is used in resource limited settings. 

This is a timely study, it addresses a current problem (IV fluid shortage); it also raises the question if IV fluids are superior to PO for mild dehydration, and what the impact of PO over IV rehydration strategies would have on patient satisfaction, care costs, length of stay and patient specific outcomes.

Patiño, A. M., Marsh, R. H., Nilles, E. J., Baugh, C. W., Rouhani, S. A., & Kayden, S. (2018). Facing the Shortage of IV Fluids—A Hospital-Based Oral Rehydration Strategy. New England Journal of Medicine.

Hartling, L., Bellemare, S., Wiebe, N., Russell, K. F., Klassen, T. P., & Craig, W. R. (2006). Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. The Cochrane Library.

OPA sizing

Orolpharyngeal Airways (OPA's) are one of the most simple and commonly used supraglottic airways in emergency medicine. OPA's are a semi-rigid tube that maintain the airway patency of unconscious patients by preventing the tongue from relaxing back and occluding the glottis. They have been in use since 1933 (Guedel), yet there is little consensus as to the best method for estimating the correct size.

There are several landmarking methods recommended internationally, with differing bodies suggesting one or more of the following techniques:

         1. Corner of the mouth to the angle of the mandible (MM) - AHA

         2. Corner of the mouth to the tip of the earlobe (ME)- Red Cross

         3. Front of the maxillary incisors to the angle of the mandible (IM) - ERC

These landmarking guides have been in use for quiet some time; although there has been no direct evidence, until now, on how well each measuring method approximates the patients actual airway length.

A group from Yonsei university has helped to shed some light on this dogmatic practice. Their study, recently published a study in the European Journal of Anesthesiology, examined how closely two different OPA sizing techniques estimated a patients overall airway length. The two methods used were: the corner of the mouth to angle of the mandible (MM); and tip of the maxillary incisors to the angle of the mandible (IM). Primary outcome measures were adequacy of ventilation, degree of airway obstruction, trauma to the airway, and distance of the OPA from the epiglottis. This was a prospective randomized crossover study of 113 patients. The population was drawn from a pool of individuals undergoing elective surgery. Patients with any form of functional limitation, airway abnormality, history of difficult intubation, c-spine injury, dental problems, or anticipated difficulty were excluded. The patients were than randomly assigned to have and OPA sized and inserted using either the MM or the IM method of sizing. Prior to surgery all patients had standard monitoring (NIBP, Pulse Oximetry, and ECG) initiated and anesthesia induced. Once paralysis was confirmed a physician blinded to experimental group ventilated each patient without an airway; both manually with a BVM, as well as mechanically, and graded the compliance of the patients airway  (control). OPA's were than inserted in a uniform manner (inverted with 180 degree rotation at the hard palate) and airway compliance was again graded using both manual and mechanical ventilations. Airway placement was than assessed using bronchoscopy to determine the difference between the OPA length and the tip of the epiglottis. The OPA was than removed and the airway was examined for any trauma.

Although both techniques for OPA insertion yielded better ventilation compliance than no airway at all, the IM group tended to have better ventilatory compliance and closer approximation to actual airway size. Because the IM group tended to receive longer airways there were instances of the OPA passing beyond the epiglottis (is this a risk?), although the shorter length airway in the MM group saw ~38% of patients have a fully occluded airway.


This study appears to be the first one that examines the correlation between anatomical measurements and airway length. It is well designed in that it uses patients as their own control. However it has a small sample size, and the patients were all well without airway difficulties. Additionally the sizing method may not fairly represent the commonly held method as airway size was rounded down to the nearest size; whereas, anecdotally at least, I have always been taught to round up to the nearest size, Furthermore the airway obstructions impacted only the mechanically ventilated patients, as all manually provided breaths were successful. These concerns notwithstanding this is the first study to validate how well different OPA sizing methods are. It would seem to suggest that the IM method for estimating OPA size is superior to the MM method, because this an easily disseminated and adopted practice, and there is an absence of foreseeable harm associated with one technique over the other I would suggest that this is a practice change that should be embraced by clinicians across all levels of care.







Deakin, C. D., Nolan, J. P., Soar, J., Sunde, K., Koster, R. W., Smith, G. B., & Perkins, G. D. (2010). European resuscitation council guidelines for resuscitation 2010 section 4. Adult advanced life support. Resuscitation,81(10), 1305-1352.

Guedel, A. E. (1933). A nontraumatic pharyngeal airway. Journal of the American Medical Association, 100(23), 1862-1862.

Kim, H. J., Kim, S. H., Min, N. H., & Park, W. K. (2016). Determination of the appropriate sizes of oropharyngeal airways in adults: correlation with external facial measurements: A randomised crossover study. European journal of anaesthesiology.

Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L., Shuster, M., Callaway, C. W., ... & Passman, R. S. (2010). Part 8: Adult advanced cardiovascular life support 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.Circulation, 122(18 suppl 3), S729-S767.

Red Cross

Sepsis 3.0

The European and American critical care societies (ESICM-SCCM) sepsis task force released their third international consensus definition of sepsis this week in the Journal of the American Medical Association (JAMA). The key points in this update are changes to the definition of sepsis, and a shift in the screening tools used.

The new task force definition of sepsis is: "life threatening organ dysfunction due to dysregulated host response to infection": a change from the previous SIRS + suspected infection definition. I think that this is, from a semantics perspective, a good decision; it moves our appreciation of sepsis away from a definition based on inflammation (a process) toward one that focuses on a clinical endpoint (organ dysfunction). The new definition drops the idea of severe sepsis (which I think is great) as any "level" of sepsis is associated with poor outcomes (mortality >10%), suggesting that all cases of sepsis should be considered severe. Both of these changes are good from a "defining sepsis" or "defining a diagnosis" perspective: the definition is more clear cut, it describes the clinical endpoint of a process, as opposed to a constellation of finding that are part of a process. The problem with the new definition, in my opinion, is primarily with the scoring tool it uses to define sepsis, the SOFA score (Sequential Organ Failure Assessment), and the evidence used to support these changes.

The current recommendation is a move from away from SIRS to SOFA/qSOFA as a diagnostic criteria. The recommendation is based upon a post hoc noted improvement in the overall precision of predicting mortality both in the ICU (AUROC 0.64 vs. 0.74/0.66) and outside of the ICU (AUROC 0.76 vs. 0.79/0.81) using SOFA/qSOFA compared to SIRS in retrospective analyses. The shift in screening tool seems great at first glance, simplified indicators and clinical acumen that yields greater predictive power - great! seems almost too good to be true- primarily because it is.

Keep in mind that this is a retrospective review of evidence. In each of the studies included the cohort examined was examined because they had an infection. Furthermore the period of time in which the studies were conducted (2008-2013) was also a time of intense interest in sepsis, a time when the current best practice was to screen patients using the SIRS criteria. The net effect of these points is that this retrospective analysis was not of undifferentiated patients; rather it was of patients with a confirmed (or suspected) infection, who in all likelihood had been screened using the SIRS criteria. The net effect is that this analysis is likely comparing the screening tools of SIRS alone to SIRS with the addition of SOFA/qSOFA. The fact that adding an additional screening tool to the process of  screening and diagnosing a patient yielded marginally better predictive value (AUROC:SIRS 0.76, SOFA 0.79, qSOFA 0.81) is not surprising.

So what does it all mean from a nursing perspective? It means that from a disease definition perspective our new "definition" of sepsis focuses on an endpoint as opposed to a process, and that it recognizes all "stages" of sepsis as bad by dropping severe, both of which I think are good changes. It also recommends a move from SIRS to qSOFA as a screening tool. From a nursing perspective, until qSOFA is endorsed by groups of emergency providers, and until it is validated prospectively, it is not likely to change practice in a meaningful way. I would suggest that appreciating the commonalities between qSOFA, SIRS, and plain old clinical acumen (suspected infection with abnormal vital signs) is the important take home message, and that from a practical perspective the process of triaging and treating patients with suspected sepsis is unlikely to change over the short term as a result of this study.

There has been a good number of different takes on the changes by the FOAMed community, with more sure to follow. I would reommend the great summaries available on RebelEM, St.Emyln's, FOAMCAST and LITFL, as well as critique by Justin Morgenstern on First10EM. Of course the original research should also be read before arriving at any conclusions, the link to the original article can be found below.

http://jama.jamanetwork.com/article.aspx?articleid=2492875

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 #20

A systematic review in the BMJ examined how well health professionals understand diagnostic tests. Using “statistics”, “healthcare”, and “accuracy” keywords the reviewers searched EMBASE, PsycINFO, and MEDLINE databases identifying 4818 hits. 74 were reviewed as potentially relevant based on title and abstract, with 28 meeting full inclusion criteria. Due to the heterogeneity of studies the systematic review was limited to presenting its findings in narrative format. The authors categorized the findings into four themes: self-rating, accuracy of definition, Bayesian reasoning, and presentation format categories. 

Two studies examined clinicians’ self-reported familiarity of statistical measures. In one study 13/50 clinicians reported understanding sensitivity, specificity, and positive predictive value; although only one was able to provide a correct definition when asked to do so. The other study found that only 58% of clinicians actually used statistical measures in their practice (although 82% claimed to do so). 

6 studies examined clinicians’ understanding of statistical definitions; they found that on average clinicians could provide a correct definition for sensitivity 76-88% of the time, specificity 80-88% of the time, but only 17% could correctly identify the correct definition for likelihood ratios.

22 studies examined how well clinicians’ were able to use pre-test probability and test accuracy to determine post-test probability (Bayesian reasoning). The studies found that in general clinicians had a poor understanding of Bayesian reasoning and were unable to determine post-test likelihood the majority of the time (0-61% success), clinicians also tended to overestimate post-test probability by 46-73%, and in one study clinicians inverted the likelihoods incorrectly interpreting patients with negative results as having a higher post-test likelihood of having a disease.

The 5 studies that examined presentation format found that healthcare providers were more accurate in their post-test estimates if the findings were expressed as natural frequencies (50 out of 100) rather than as probabilities (50%). The use of graphical aides improved clinician post-test accuracy to 73% compared to 48% when natural frequencies alone were used to communicated test power, or 23% when probabilistic language was used to describe tests.

This systematic review suggests that not only are we as healthcare providers poor at using probabilistic reasoning; but that we’re also oblivious to our weakness in this area. As a nurse I know that the preparation I received in school to interpret and use statistics was severely lacking. This research, which focused primarily on physicians, would suggest that this is a common area of weakness. This research highlights how little we all know about the tools we use on a daily basis, it may also shed some light on why so few of our colleagues engage with research, and I would suggest that most importantly it empirically shows that we could all use some brushing up on how to use statistics. I’ve covered some great resources to help with this is a few previous weekly reviews (#4 & #6) and would suggest that anyone looking for a brief intro into using Bayesian statistics take a look at the first few chapters of this online book. 

http://www.ncbi.nlm.nih.gov/pubmed/26220870

Steve Mathieu reviewed the HEAT trial of acetaminophen for fever in critically ill patients on The Bottom Line Review. This study was a double blind RCT of 700 patients that sought to determine if the administration of paracetamol to critically ill patients had any effect on: ICU free days, mortality, length of stay (LOS), number of days on organ support, and its effect on lab values and temperature. Patients were block randomized to receive either 1g IV paracetamol, or IV D5W every 6hrs for 28 days or until: ICU discharge, fever resolution, cessation of antibiotics, death, or contraindication. The study found no statistical difference in mortality, LOS, ICU free days, or organ support, although patients who received paracetamol had a lower (0.25C) average temperature. This research is contrary to a retrospective study published earlier this year that found a mortality benefit associated with paracetamol administration, it has a much higher quality design, and is one that I've been waiting to see published. Mathieu's summary of this research is concise, easy to interpret, and very timely; the summaries on this site are consistently of very high quality, this review and the site in general are a fantastic resource.

http://www.wessexics.com/The_Bottom_Line/Review/index.php?id=7257804966227311886

A retrospective analysis of tourniquet use in the pre-hospital setting was published in the Journal of Acute Care Surgery this month. Ode et al., examined the EMS use of tourniquets in a metro North Carolina ambulance service during 2012-2013. They examined patients with uncontrolled hemorrhage to determine the frequency of “correct” tourniquet (Tk) application, the efficacy of Tk as a treatment, and the frequency of Tk related adverse outcomes. 98 patients met the inclusion criteria (uncontrolled hemorrhage), 42 were excluded because they were treated outside of the metro area. Of the remaining 56 patient: 24 received a Tk (19 Combat Application Tourniquet, 5 improvised), although 5 were deemed unnecessary (the patients weren’t in shock - SBP>80mmHg) and 4 were delayed. Of the 32 who didn’t receive tourniquets three were indicated, but did not receive treatment.

The patients treated with a Tk, compared to those not, had significantly higher rates of: shock (50 vs 12.5%), vascular injury (69.6 vs 25.8%), blood transfusion (37.5 vs 9.4%), rates of admission (77.3 vs 38.7%), and mortality (8.3 vs 3.1%). None of these findings are surprising given that the protocol for application of a Tk was quiet conservative, requiring patients to be in shock, and therefore significantly sicker. Secondary analyses showed that patients who were indicated to receive a Tk but didn’t had higher incidence of shock compared to those who did (85.7 vs 60%), and that those who weren’t indicated (not in shock) but did receive a treatment by tourniquet had no adverse outcome as a result.

Due to the overly conservative treatment protocols, the small sample size, and the lack of an equivalent control arm the primary results of this study have little to contribute to the overall body of evidence for Tk use in civilian trauma. The secondary analysis does show worse outcomes for patients with missed Tk’s, and no complications associated with liberal Tk (non-indicated) use; although the numbers (n=22) are too small to reach statistical significance. From a clinical perspective this research would seem, in a small way, to support that liberal Tk use isn’t associated with worse outcomes, and that even extremely conservative (only once shock becomes apparent) Tk use imparts benefit. From a practical perspective this research provides weak evidence to support Tk use in civilian trauma, it also suggests that the current military research may be generalizable to the civilian population, and indirectly it would seem to suggest the need for a liberalization of Tk protocols among EMS services. 

http://www.ncbi.nlm.nih.gov/pubmed/26402532

Using the current VW emission scandal as a comparison piece Richard Smith offered a critique of scientific misconduct on his BMJ blog, and suggests that scientists should face criminal charges if found guilty. Criminal charges have been used to punish scientific misconduct before, as was the case with June Dong-Pyou Hon’s faking of HIV immunization results; and Smith offers three additional reasons why misconduct should be investigated criminally: Because inappropriate use of research funding is financial fraud, because universities are poorly equipped to conduct investigations, and because investigations by the university would be a conflict of interest. I would also suggest that there is a basis for criminal charge based on harm to the patient, for example the intentional non-disclosure of the increased risk for suicide when paroxetine is used to treat pediatric depression, and Andrew Wakefield's fabrication of evidence that immunizations result in autism. A thoughtful and timely piece by Smith, maybe one that will find increased traction.

http://blogs.bmj.com/bmj/2015/09/28/richard-smith-if-volkswagen-staff-can-be-criminally-charged-so-should-fraudulent-scientists/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+bmj%2Fblogs+%28Latest+BMJ+blogs%29&g=w_blogs_bmj-com

On the Trauma Professionals Blog Micheal McGonigal discusses the reflexive way that many clinicians treat low oxygen saturation readings. He discusses factors that can result in artificially low reading, patient groups where a low reading is normal, the absence of a good definition of "normal values", and suggests that if the patient is not distressed on examination they likely don't need supplemental oxygen. This is a quick reminder to treat the patient and not the number.

Mark Culver discussed the differences between intermittent and continuous PPI therapy for UGIB on Emergency Medicine PharmD. There has been a fair bit of research into this topic lately, and UpToDate had suggested changing practice from continuous to intermittent PPI therapy last year; however the practice remains widespread. This post offers a great review of the research behind the change in recommendations. The cost savings, and reduction in nurse time this practice change could result in make this post well worth the read.

There was a podcast review of fluid resuscitation in hemorrhagic shock on HEFTEMCAST. This podcast reviews the key evidence and discusses the concepts of: damage control resuscitation: permissive hypotension, hemostatic resuscitation, and damage control surgery. The review includes seminal work from the military as well as evidence from civilian trauma, it nicely summarizes the key literature, and provides links to the source research. This 16 minute review is well worth a review for anyone working in an emergency settings.

Josh Farkas offered a well balanced review of the SPLIT trial on PulmCrit. The SPLIT trial examined the differences between PlasmaLyte and Saline in patients admitted to the ICU, and found that there was no significant difference between the two fluids. Farkas acknowledges that the findings are valid among the patients reviewed, but critiques the external validity of the study; he points out that the small volumes of fluid received, the admission reason (elective post-operative), and the low illness severity observed among the patients in this cohort are not generalizable to the typical ICU population.

Weekly Review #19

Rob Orman posted a great podcast on ercast called "is my patient suicidal". The podcast discusses the intricacies of differentiating suicidal ideation from intent. Orman uses the Columbia Suicide Severity Rating Scale as a framework for discussing the questions to ask a patient to determine suicidal intent. He offers some great suggestions for how to phrase the questions, how one questions will lead into the next, how to assess for protective factors, and a great clinical pearl on including family and friends to increase the sensitivity of the interview tool. Orman offers some suggestions about why removing the means for suicide (specifically firearms) is important, and offers some interesting evidence to support his claim. This is an excellent post on a topic that doesn't receive a great deal of attention: the podcast is engaging, the post is concise and easy to read, there are links to the screening tools, and he offers additional information and links to resources. I would recommend this for all triage nurses as separating suicidal ideation from intent is the key to accurate triage of these patients.

http://blog.ercast.org/is-my-patient-suicidal/




Ian Miller discussed mini-jets or prefilled syringes in a post this week on the Nurse Path. Ian reviewed an Australian study that examined the speed of administration and error rates when using adrenaline packaged in ampule (1:1000, and 1:10,000) vs pre-filled syringe form. The study showed superior speed of administration and greater dose accuracy when using pre-filled syringes. I would be surprised if the difference in administration speed was relevant clinically, but the increase in dosing errors certainly is. The study mentions previous research into this subject, and I personally have had near miss errors when both cardiac (1:10,000) and IM (1:1000) Epi are stocked in the crash cart. Pre-filled syringes ensure that cardiac and IM formulations are not confused, and this alone is enough to justify their existence.

http://thenursepath.com/2015/09/22/i-praise-of-the-pre-filled-syringe/

St. Emlyn's Journal club reviewed a study published in the September edition of the Emergency Medical Journal that examined the best methods for extricating patients from vehicles. The experimental study used biomechanical sensors and high speed cameras to assess for c-spine movement along 3 planes as trained crews removed simulated patients from a vehicle. 16 patients of differing height and weight were extricated by professional paramedics and firefighters using 6 different methods:


1. Self extrication without C-collar                    
2. Self extrication with C-collar
3. C-collar and long spine board - drivers side  
4. C-collar and long spine board - passenger side
5. C-collar and long spine board - rear window  
6. C-collar + short extrication jacket lifted through drivers door

The patients extricated through the rear window had the smallest degree of movement, although the difference was insignificant when compared to self extrication techniques. They also found that an increase in patient size (both height and weight) resulted in more movement. This is a small study using healthy volunteers, it was performed in a controlled setting and with optimal staffing levels, and it's findings are therefore not generalizable to clinical practice. The findings do however suggest that self extrication could be a safe possibility, and do raise the question of whether or not current practice is evidence based.

http://stemlynsblog.org/jc-self-extrication-vs-assisted-extrication-st-emlyns/

A fantastic post on Pediatric Emergency Playbook reviews intranasal (IN) medication administration. I love using IN medications in pediatric patients: it's fast, safe, prevents unnecessary IV's, and allows you to provide if not permanent; than at the least temporary, pain control as you set up for something more definitive. In this podcast Tim Thoreczko discusses IN drugs, dosing, administration and timing, specifically: ketamine, midazolam, fentanyl, sufentanyl, or dexmedetomidine. Thorseczko discusses dosing and onset times (which can differ significantly from IV), and the methods of administration. IN administration uses a syringe and atomizer inserted into the nostril, to deliver volume doses of 0.25-0.3ml (max 1ml) per nare. Tim offers some practical advice about placing the patient into the sniffing position, seeking out the highest concentration possible, ensuring you adjust for the dead space of the atomizer, and to depress the plunger as forcefully as possible to atomize the medication. I've seen all of these medications used nasally with great results, the exceptions being sufentanyl (which we used buccaly for palliative incident pain control) and dexmedetomidine (a drug similar to clonidine that's used for sedation), as well as naloxone although it's not discussed here. Worth a review for anyone working with pediatric patients.  

http://pemplaybook.org/podcast/intranasal-medications-and-you/

Anand Swaminathan posted "A simplified Approach to Tachydysrhythmias" on CoreEM. Oddly the part about this post that I like best is that it isn't oversimplified. Unlike the ACLS algorithm which differentiates treatments based on simply stable vs unstable and narrow vs wide complex this diagram covers the large range of diagnoses associated with tachydysrhythmias and offers suggestions for each.

There's a great re-post from CoreEM on emDocs discussing ocular trauma. Jeffret Cruz and Anad Swaminathan discuss presentation, workup, and treatments for some of the typical ocular injuries that will present to the ED: globe rupture, hyphema, retrobulbar hematoma, retinal detachment, corneal abrasion. This is a quick review, the take home message for nurses is to maintain a high degree of suspicion for all ocular injuries.

This months Emergency Medicine News published a special report on the Glasgow Coma Scale by Gina Shaw. This report focuses on the shortcomings of the GCS scale: its complicated scoring system, poor inter-rater reliability, and limited prognostic value. Shaw acknowledges that the GCS has flaws, but describes how poor utilization of the tool "gestalt scoring", poor communication "GCS = 9" (what are the subset scores), and poor understanding of what the tools is designed for (it has poor predictive power) have generated criticism. The GCS has it's flaws; but it's a universal standard, it's useful for tracking changes, and it's likely here to stay. This is a good reminder to use the tool to the best of its ability, and to take the time to score patients accurately and deliberately.

I reviewed a 2014 article this week on FOANed Reviews that discussed evidence based approaches for de-implementing non-evidence based practices. The article discussed strategies for the discontinuation of practices that are known to be ineffective, practices that are lacking direct evidence, and novel medical practices. The article unfortunately fails to clearly link evidence to their suggested strategies and the strategies are lacking concrete action points; however I think the research is still well worth a read. The topic is certainly interesting, and the case studies offer an insight into how prevalent non-evidence based practice is.

De-Implementation Review

A 2014 review by Vinay Prasad and John Ioannidis in the Journal of Implementation Science reviewed strategies for de-implementing unproven or harmful medical procedures. The authors conducted a review of the available evidence to determine the best approach for removing practices that are not supported by science. They identified and made recommendations for three categories of healthcare practice that may need de-implementation: Practices that are known to be ineffective, practice without evidence proving effectiveness, and novel medical practices that are undergoing validation.

New evidence that suggests current practice is ineffective frequently comes under attack in one of several ways. Proponents of current practice will publish contradictory editorials, critique the evidence using subgroup analysis to achieve different results, or will conducting opposing studies with modified designs of weaker methodology. The problem with this process Prasad and Ioannidis argue is that weaker evidence and contradictory editorials are creating the false appearance that the established practice is still under debate, this creates delays to de-implementation allowing the practice to remain entrenched. The authors discuss the example of gown and glove controls as prevention for MRSA/VRE transmission to illustrate their point. The evidence for these control measures comes from a non-experimental before-after design study, that hasn't been reproduced. The intervention has failed to change colonization rates in subsequent cluster randomized trials; but the results from the weaker initial study have become entrenched in practice. Clinicians in this example have gone from accepting weak evidence, to being ambivalent about contradictory evidence, to continuing the use of an unsupported intervention until it has been not only been proven ineffective, but proven harmful. The authors highlight that in these instances de-implementation should begin with high quality evidence and progress until contradictory evidence comes from studies that are, at the very least, of equivalent rigor, and preferably of higher quality.

Unproven medical practices, or practices where we have no evidence to support our action are another area where de-implementation can be difficult. The authors discuss a Cochrane review that determined that the "existing evidence base was unable to support or refute 49% of interventions, and [that] 48% of American College of Cardiology recommendations are supported by expert opinion only". They suggest that a lack of evidence is pervasive and that much of clinical practice is unsupported by evidence. The key to de-implementation in these instances the authors suggest is through systematic testing of existing standard practice, with preference being given to testing practices that are common, that have optional approaches, have high costs, and have the weakest level of evidence.

The final recommendation for de-implementation suggests using preventative measures to ensure that the novel approaches that are being validated don't become entrenched. Prasad and Ioannidis use the example of experimental intracranial arterial stents to illustrate their point. In this instance a single uncontrolled study was used to gain FDA approval to use stents for arterial stenosis. Funding was approved by the Centers for Medicare & Medicaid Services (CMS), but only for RCT; there was fierce pressure from industry to open up the use of the stents, but CMS refused to pay for a liberalized use of the procedure. The result was after 6 years the only RCT on the procedure proved the practice almost tripled 30 day mortality, the CMS move likely saved thousands of lives. In this instance the authors argue the move prevented the need to pursue extensive de-implementation, and they recommend a similar strategy be used with all new treatments.


This review offers some guidance on how to categorize practices that need to be discontinued, Prasad and Ioannidis offer some general approaches to de-implementation, unfortunately however they don't offer any concrete strategies for how to implement these approaches. The review failed to discuss the selection criteria or review methodology for practices requiring change, how they determined their categories of practices that need discontinuation, or to directly link evidence to what the best approaches for de-implementation are. It was also somewhat lacking in the area of specific recommendations for how to action their general recommendations. From a nursing perspective this article doesn't provide concrete steps for de-implementing practices; but it does offer some global considerations for evaluating clinical practice, it suggests some metrics by which to evaluate practice, and has uses clinically relevant case studies, the discussion about isolation precautions alone makes this worth reading.

http://www.ncbi.nlm.nih.gov/pubmed/24398253

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.