Out-of-Hospital Intranasal Ketamine as an Adjunct to Fentanyl for the Treatment of Acute Traumatic Pain: A Randomized Clinical Trial.

STUDY OBJECTIVE: To evaluate if out-of-hospital administration of fentanyl and intranasal ketamine, compared to fentanyl alone, improves early pain control after injury. METHODS: We conducted an out-of-hospital randomized, placebo-controlled, blinded, parallel group clinical trial from October 2017 to December 2021. Participants were male, aged 18 to 65 years, receiving fentanyl to treat acute traumatic pain prior to hospital arrival, treated by an urban fire-based emergency medical services agency, and transported to the region's only adult Level I trauma center. Participants randomly received 50 mg intranasal ketamine or placebo. The primary outcome was the proportion with a minimum 2-point reduction in self-described pain on the verbal numerical rating scale 30 minutes after study drug administration assessed by 95% confidence interval overlap. Secondary outcomes were side effects, pain ratings, and additional pain medications through the first 3 hours of care. RESULTS: Among the 192 participants enrolled, 89 (46%) were White, (median age, 36 years; interquartile range, 27 to 53 years), with 103 receiving ketamine and 89 receiving placebo. There was no difference in the proportion experiencing improved pain 30 minutes after treatment (46/103 [44.7%] ketamine versus 32/89 [36.0%] placebo; difference in proportions, 8.7%; 95% confidence interval, -5.1% to 22.5%; P=.22) or at any time point through 3 hours. There was no difference in secondary outcomes or side effects. CONCLUSION: In our sample, we did not detect an analgesic benefit of adding 50 mg intranasal ketamine to fentanyl in out-of-hospital trauma patients.

Clostridium difficile infection and treatment in the pediatric inflammatory bowel disease population.

OBJECTIVE: Recent changes in the epidemiology of Clostridium difficile infection include an increase in the incidence of C difficile-associated disease (CDAD) and the identification of patients with inflammatory bowel disease (IBD) as a group at risk. In addition, the effectiveness of antimicrobial therapies has been questioned. Our aim was to estimate the incidence of CDAD in a pediatric IBD population and review treatment efficacy. PATIENTS AND METHODS: We identified patients ages 18 years or younger from our center's IBD database who tested positive for C difficile toxin A and/or B between August 1, 2007 and December 31, 2008. Demographic information and treatment details were recorded. Chi-square and Fisher exact tests were used to compare categorical variables and the Student t test was used for continuous variables. RESULTS: From 372 pediatric patients with IBD, we identified 29 patients who experienced a total of 40 cases of CDAD. The annualized incidence rate of CDAD was 7.2%. Initial treatment was successful in 17 cases (43%). Eventual success was documented with metronidazole in 15 cases (41%), with vancomycin in 16 cases (43%), and with other agents or a combination of agents in 6 cases (16%). Age, sex, and IBD type were not associated with initial treatment outcome or recurrence. The choice of initial antimicrobial treatment was not associated with treatment outcome. The type of IBD therapy medication was not associated with the likelihood of CDAD recurrence, although the use of anti-inflammatory therapy was positively associated with initial antimicrobial treatment success. CONCLUSIONS: CDAD occurred frequently in our cohort of pediatric patients with IBD. Antimicrobial treatment success was achieved equally with either metronidazole or vancomycin. Initial treatment failed more than half of the time, regardless of medication choice. Apparent lack of antimicrobial efficacy in resolving symptoms may reflect resistant C difficile infection or increased IBD severity in a subset of patients who are C difficile carriers. Awareness of the potential for a high incidence of CDAD and frequent failure rate of initial therapy is important in the management of children with IBD.

Computerized Provider Order Entry with Pager Notification Improves Efficiency in STAT Radiographic Studies and Respiratory Treatments.

BACKGROUND: The use of computerized provider order entry (CPOE) has been widely linked to improvements in patient safety. We hypothesized that electronic routing of CPOE-generated orders through individual pagers would improve the efficiency of STAT radiographic studies and respiratory treatments. METHODS: The study was conducted in two periods before and after implementing pager notification of STAT orders. In the Baseline Period, CPOE-generated STAT orders were communicated to radiology technicians or respiratory therapists through the use of printed orders, manual paging and/or telephone communication. The time to process the order and deliver a radiology result or respiratory treatment was tracked. In the Intervention Period CPOE-generated STAT orders were electronically routed to the radiology technician's or respiratory therapist's pager. During both time periods, clinicians completed user satisfaction surveys. RESULTS: Using pager notification, there was a significant reduction in radiology technician arrival time (16.8±2.1 vs 7.9±0.7 mins, p<0.001). Similarly there was a significant reduction in the cumulative time required to capture the radiographic image, image availability in the picture archiving and communication system (PACS) and the verbal report from the radiologist (p<0.05). The time required in obtaining a preliminary or final radiographic written report and the total cycle times were not significantly reduced. For STAT respiratory therapy orders there was a significant reduction in the mean time from ordering to administration of respiratory therapy treatments (124.7±14.1 vs 49.8±11.4 minutes, p<0.01). Radiologists, respiratory therapists and ordering clinicians reported improved satisfaction after implementation of pager notification. CONCLUSION: Computer-generated orders for STAT radiographic studies and respiratory treatments can be carried out significantly faster through the use of direct pager notification. The implementation of this process has resulted in improved care delivery and widespread clinician satisfaction.

Compliance after loop electrosurgical excision procedure or cold knife cone biopsy.

OBJECTIVE: To examine rates and predictors of compliance with follow-up recommendations in low-income women from a county hospital clinic undergoing loop electrosurgical excision procedure (LEEP) and cone knife cone biopsy. METHODS: A retrospective cohort study of 135 patients who underwent LEEP or cold knife cone biopsy was performed. Demographic data, results of cytology, colposcopy biopsy, excision specimen pathology, and indication for the LEEP or cold knife cone biopsy were collected. Compliance was determined by whether the patient adhered to the recommended follow-up within 1 year from the date of the procedure. Multivariable analysis was performed by using logistic regression. RESULTS: A total of 135 patients were included for analysis (81 LEEP and 54 cold knife cone cases). Type of procedure was significant in predicting compliance: 74.1% of cold knife cone patients were compliant compared with 43.2% of LEEP patients (adjusted relative risk 1.64, 95% confidence interval 1.30-1.87). There was a trend for older patients to be more compliant than younger patients in the univariable analyses but not in multivariable analysis. After adjusting for age, LEEP patients were still significantly less compliant than cold knife cone patients. Pathologic indication (severity of disease), race, payor source, and gravidity were not significant predictors of compliance and not included in the multivariable analysis. CONCLUSION: Compared with LEEP, cold knife cone patients were significantly more compliant with follow-up. Because LEEP is a less invasive in-office procedure, it may convey to patients the idea that their condition is less severe. LEVEL OF EVIDENCE: II.

Lessons from a successful implementation of a computerized provider order entry system.

OBJECTIVES: The electronic health record (EHR) can improve patient safety, care efficiency, cost effectiveness and regulatory compliance. Cincinnati Children's Hospital Medical Center (CCHMC) has successfully implemented an Integrating Clinical Information System (ICIS) that includes Computerized Provider Order Entry (CPOE). This review describes some of the unanticipated challenges and solutions identified during the implementation of ICIS. METHODS: Data for this paper was derived from user-generated feedback within the ICIS. Feedback reports were reviewed and placed into categories based on root cause of the issue. Recurring issues or problems which led to potential or actual patient injury are included. RESULTS: NINE DISTINCT CHALLENGES WERE IDENTIFIED: 1) Deterioration in communication; 2) Excessive system alerts to users; 3) Unrecognized discontinuation of medications; 4) Unintended loss of orders; 5) Loss of orders during implementation; 6) Amplification of errors; 7) Unintentional generation of patient care orders by system analysts; 8) Persistence of specific patient care order instructions; 9) Verbal orders entered under the incorrect clinician. CONCLUSIONS: Unanticipated challenges are expected when implementing EHRs. The implementation plan for any EHR should include methods to identify, evaluate and repair problems quickly. While continued challenges with this complex system are expected, we believe that the EHR will continue to facilitate improved patient care and safety. The lessons learned at CCHMC will permit other institutions to avoid some of these challenges and design robust processes to detect and respond to problems in a timely fashion to ensure implementation success.

Survey of attitudes regarding natural family planning in an urban Hispanic population.

METHODS: We performed a cross-sectional survey of 357 reproductive-aged women, mostly Hispanic (81.8%), presenting for ambulatory and hospital reproductive care in Phoenix, AZ, about their interest in natural family planning (NFP). Participants completed questionnaires, and responses were analyzed to determine predictors of interest in NFP. RESULTS: Sixty-one percent stated that they were likely or very likely to use NFP to avoid pregnancy, and 50% would use NFP to achieve pregnancy. Of factors studied, Hispanic ethnicity, lower level of acculturation, less education and recent use of condoms or withdrawal were independently associated with interest in using NFP to avoid pregnancy. Younger age and desire for future pregnancy were independently predictive of potential NFP use to achieve pregnancy. CONCLUSION: This study suggests that Hispanic women find NFP to be an appealing family planning alternative.