Urgent Patient Care Research Articles

Automated dispensing cabinets and nurse satisfaction.

Medication administration is a complex, demanding process that involves close patient contact, characterized by time constraints and frequent interruptions. Inextricably linked to nursing practice, medication administration often competes with other urgent patient care priorities.1 Medication admini

Diagnostic Accuracy of Point of Care Ultrasound in Determining Pulmonary Pathology by Acute Care Nurse Practitioners in Critically Ill Patients

SESSION TITLE: Rapid Session: Bedside Imaging SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 07:30 AM - 08:30 AM PURPOSE: Bedside ultrasonography (US) may facilitate rapid diagnosis of thoracic pathology in the Intensive Care Unit (ICU). The feasibility and accuracy of bedside thoracic US performed by acute care nurse practitioners (ACNP) in the ICU are unknown. We hypothesized that bedside thoracic US by ACNPs in the ICU would be feasible and have a high sensitivity and specificity for thoracic pathology visualized on CXR. METHODS: We conducted a prospective observational cohort study in a single medical ICU. Prior to study initiation, all 10 ACNPs staffing the ICU attended a focused, peer-led thoracic US training session, which included didactic instruction, hands-on practice of image acquisition, and image interpretation. During the study, each time a CXR was ordered by treating clinicians, ACNPs were asked to complete a bedside thoracic US prior to interpretation of the CXR. The ACNPs then documented in a secure online database the presence or absence of five key sonographic features in each of the four chest regions scanned. If an US was unable to be performed, the reason was documented. RESULTS: From July 2015- July 2016, 335 portable CXRs were ordered by treating clinicians. In 246 (73%) cases, a thoracic US was completed by the ACNP prior to interpretation of the CXR. In 89 (27%) cases, a thoracic US was not performed, most frequently due to inadequate ACNP time due to other urgent patient care needs. Among the 246 cases with US performed prior to CXR, the CXR identified parenchymal pathology in 141 (57.3%) cases, pleural effusion in 75 (30.6%) cases, and pneumothorax in 3 (1.2%) cases. For parenchymal abnormality on CXR, US demonstrated a sensitivity of 83.7% (95% CI 76.5-89.4%), specificity of 67.6% (95% CI 57.8-76.4%), positive predictive value of 77.6% (95% CI 72.3-82.2%), and negative predictive value of 75.5% (95% CI 67.5-82.1%) (kappa 0.52, P < 0.001). For pleural effusion on CXR, US demonstrated a sensitivity of 68.0% (95% CI 56.2-78.3%), specificity of 85.9% (95% CI 79.7-90.7%), positive predictive value of 68.0% (95% CI 58.7-76.1%), and negative predictive value of 85.9% (95% CI 81.3-89.5%) (kappa 0.54, P < 0.001). The negative predictive value of US for pneumothorax on CXR was 99.6%. The sensitivity and specificity of ultrasound for any pulmonary pathology was 87.7% (95% CI 82.2-92.0%) and 86.3% (95% CI 73.7-94.3%), respectively. The positive predictive value of ultrasound for pulmonary pathology was 96.1% (95% CI 92.5-98.0%). CONCLUSIONS: Bedside thoracic ultrasound demonstrated moderate sensitivity and specificity for pulmonary parenchymal abnormalities and pleural effusions compared to CXR. It demonstrated high sensitivity for pneumothorax and high positive predictive value for any pulmonary pathology. CLINICAL IMPLICATIONS: Bedside thoracic US performed by ACNPs can frequently be completed prior to CXR performance and shows moderate agreement with CXR findings. The primary limitation of bedside thoracic US by ACNPs compared to CXR may be the competing demands of other urgent patient care. DISCLOSURE: The following authors have nothing to disclose: Lisa Flemmons, Sarah Bloom, Todd Rice, Arthur Wheeler No Product/Research Disclosure Information

Analysis of emergency vascular surgery consults within a tertiary health care system

Patients with vascular disease often have multisystem atherosclerosis and multiple comorbidities requiring comprehensive interdisciplinary specialty care. Consultation is a critical component of a tertiary vascular surgery practice, but analysis of this service is under-reported in the literature. After-hours inpatient consultations and interhospital transfers are associated with urgent patient care. A retrospective analysis of vascular surgery consultations was carried out from January 1, 2013, to December 31, 2013. Consultations included inpatient services, the emergency department, surgical and medical intensive care unit, and interhospital transfers. Data analysis included number of consults, time of consultation (during hours, 0700-1859; after hours, 1900-0659), referring service, nature, and outcome of consultation. Consultations were then classified as urgent if vascular surgical intervention was required as an intraoperative consultation, within 24 hours, or during the same hospitalization. Patients without a same-hospital vascular surgical intervention were classified as nonurgent. During a 1-year period, 823 independent consult requests of 749 patients were analyzed. It was found that 57.8% of after-hours consults resulted in urgent patient care (P = .003); 29.7% of medicine, 33.3% of medical intensive care unit, 41.9% of trauma surgery, and 60% of emergency department after-hours consultations were urgent; 73% of surgery and 79.2% of interhospital after-hours consults required urgent vascular surgical intervention. Extremity ischemia, aortic disease, and iatrogenic consults accounted for 44.8%, 20.4%, and 11.1% of after-hours consults, with 57.9%, 56.4%, and 70% requiring urgent vascular surgical intervention, respectively. After-hours consultations are not always associated with an urgent vascular surgical intervention. Nonurgent after-hours consultations are requested more frequently from some services and may present an opportunity for education that could improve workflow of the vascular workforce.

Teaching Crucial Knowledge vs. Helping Out on the Unit.

When a clinical instructor must weigh the duty to educate against urgent patient care needs.

Supporting Air Versus Ground Vehicle Decisions for Interfacility Medical Transport Using Historical Data

Patients undergoing interfacility transfers are at potentially greater risk of adverse or critical events than those in hospital, and efficient transfers play a significant role in reducing mortality and morbidity. Medical dispatchers rely on accurate estimations of transfer time in determining the most appropriate method of transportation, often either a helicopter and/or land ambulance, in situations that are characterized by high time pressure and uncertainty. In this paper, we propose the design of a data-driven decision support tool to improve dispatcher transport mode decision making. We studied the dispatch process of the air and land medical transport system in Ontario, Canada through onsite observations and developed a tool which generates transfer time estimates based on historical data. We found that dispatchers have large estimation errors, and are biased toward higher degrees of underestimation for air transfers compared with land transfers. In contrast, the proposed tool produced estimates that had significantly less error than dispatcher estimates. The estimation error for the tool was on the average 21 min less: a practically significant difference in urgent patient care. Through onsite observations and the relevant literature, we also identified factors that may influence the collaboration between the dispatcher and the tool. This research is a first attempt to study how decisions are made for interfacility medical transfers and for evaluating the accuracy of human operator estimates of these transfer times. It is also the first to demonstrate a tool's utility in comparison to existing procedures for estimating transfer times.

Strategic design for pediatric neurosurgery missions across the Western Hemisphere

Background:With growing interest in global health, surgeons have created outreach missions to improve health care disparities in less developed countries. These efforts are mainly episodic with visiting surgeons performing the operations and minimal investment in local surgeon education. To create real and durable advancement in surgical services in disciplines that require urgent patient care, such as pediatric neurosurgery, improving the surgical armamentarium of the local surgeons must be the priority.Methods:We propose a strategic design for extending surgical education missions throughout the Western Hemisphere in order to transfer modern surgical skills to local neurosurgeons. A selection criteria and structure for targeted missions is a derivative of logistical and pedagogical lessons ascertained from previous missions by our teams in Peru and Ukraine.Results:Outreach programs should be applied to hospitals in capital cities to serve as a central referral center for maximal impact with fiscal efficiency. The host country should fulfill several criteria, including demonstration of geopolitical stability in combination with lack of modern neurosurgical care and equipment. The mission strategy is outlined as three to four 1-week visits with an initial site evaluation to establish a relationship with the hospital administration and host surgeons. Each visit should be characterized by collaboration between visiting and host surgeons on increasingly complex cases, with progressive transfer of skills over time.Conclusion:A strategic approach for surgical outreach missions should be built on collaboration and camaraderie between visiting and local neurosurgeons, with the mutual objective of cost-effective targeted renovation of their surgical equipment and skill repertoire.

Variation in patient management based on ECG interpretation by emergency medicine and internal medicine residents

This study was performed to determine the impact of electrocardiogram (ECG) interpretation on urgent patient care decisions by internal medicine (IM) and emergency medicine (EM) resident physicians. Six clinical scenarios and ECGs were given to 31 IM residents and 31 EM residents at a university medical center. Based on the ECG interpretation, the residents were asked to select the best patient management from a list of choices. IM and EM residents were equally likely to choose the correct management for complete heart block (90% IM v 97% EM, P = NS), and pulseless ventricular tachycardia (VT) (94% IM v 97% EM, P = NS). IM residents were less likely to choose the correct management for acute posterior wall myocardial infarction (MI) (26% IM v 74% EM, P < .0001) and unstable supraventricular tachycardia (SVT) (87% IM v 100% EM, P < .05). Residents in both programs were equally likely to misinterpret left ventricular hypertrophy (LVH) (23% IM and 16% EM, P = NS) and benign early repolarization (BER) (48% IM and 52% EM, P = NS) as acute myocardial ischemia when presented with a clinical history not suggestive of cardiac ischemia. IM and EM residents were equally likely to choose the correct management for complete heart block and pulseless VT. Compared with EM residents, IM residents were less likely to choose the correct management of posterior wall MI and unstable SVT. Both IM and EM residents were prone to misinterpreting LVH and BER as acute myocardial ischemia. Resident education in both specialties should focus on ECG interpretation skills to improve patient management decisions. (Am J Emerg Med 2002;20:188-195. Copyright 2002, Elsevier Science (USA). All rights reserved.)