Current trends in the acute treatment of ischemic stroke: analysis from the Paul Coverdell National Acute Stroke Program.

BACKGROUND: The intra-arterial treatment (IAT) of acute ischemic stroke (AIS) is now evidence-based and given the highest level of recommendation among eligible patients. Using a multi-state stroke registry, we studied the trend in IAT among patients with AIS over 11 years and its impact on the utilization of intravenous thrombolysis (IVT) within the same 11 years. METHODS: Using data from the Paul Coverdell National Acute Stroke Program (PCNASP), we studied trends in IVT and IAT for patients with AIS between 2008 and 2018. Trends over time were examined for rates of IVT only, IAT only, or a combination of IVT and IAT (IVT+IAT). Favorable outcome was defined as discharge to home. RESULTS: During the study period there were 595 677 patients (mean age 70.4 years, 50.4% women) from 646 participating hospitals with a clinical diagnosis of AIS in the PCNASP. Trends for IVT only, IAT only, and IVT+IAT all significantly increased over time (P<0.001). Total use of IVT and IAT increased from 7% in 2008 to 19.1% in 2018. The rate of patients discharged to home increased significantly over time among all treatment groups (P<0.001). CONCLUSION: In our large registry-based analysis, we observed a significant increase in the use of IAT for the treatment of AIS, with continued increases in the use of IVT. Concurrently, the percent of patients with favorable outcomes continued to increase.

Evaluation and management of elevated blood pressures in hospitalized children.

Elevated blood pressures (BP) are common among hospitalized children and, if not recognized and treated promptly, can lead to potentially significant consequences. Even though we have normative BP data and well-developed guidelines for the diagnosis and management of hypertension (HTN) in the ambulatory setting, our understanding of elevated BPs and their relationship to HTN in hospitalized children is limited. Several issues have hampered our ability to diagnose and manage HTN in the inpatient setting including the common presence of physiologic conditions, which are associated with transient BP elevations (i.e., pain or anxiety), non-standard approaches to BP measurement, a lack of clarity regarding appropriate diagnostic and therapeutic thresholds, and marginal outcome data. The purpose of this review is to highlight the issues and challenges surrounding BP monitoring, assessment of elevated BPs, and the diagnosis of HTN in hospitalized children. Extrapolating from currently available clinical practice guidelines and utilizing the best data available, we aim to provide guidelines regarding evaluation and treatment of elevated BP in hospitalized children.

The Intranasal Route as an Alternative Method of Medication Administration.

Intranasal drug administration is a less invasive method of drug delivery that is easily accessible for adult and pediatric patients. Medications administered by the intranasal route have efficacy comparable to intravenous administration and typically have superior efficacy to subcutaneous or intramuscular routes. The intranasal route is beneficial in emergent situations when the intravenous route is not available. The intranasal route is safe and effective in various indications, and therapeutic systemic concentrations of medication can be attained via this route. As the evidence for and comfort with intranasal administration continue to grow, guidance on correct technique, medications, and dosing is vital for appropriate use. This article reviews the process and practices of appropriate intranasal medication administration.

Ultrasound-guided intravenous catheter survival impacted by amount of catheter residing in the vein.

OBJECTIVE: Ultrasound (US)-guided peripheral IVs have a high failure rate. We explore the relationship between the quantity of catheter residing within the vein and the functionality of the catheter over time. METHODS: This was a prospective, observational single-site study. Adult ED patients with US-guided IVs had the catheter visualised under ultrasound post-placement. IV placement time and catheter length residing in the vein was obtained. Exclusions included catheter not visualised, patient discharged from ED unless IV failed, <24 hour hospitalisation unless IV failed or patient self-removed IV.Inpatient follow-up occurred within 24, 48 and 72 hours from the IV placement time. Catheter functionality was noted. If the catheter failed, the time and reason for failure was documented. RESULTS: 113 patients were enrolled; 27 were excluded. Of the 86 study subjects, 29 (33.7%) patients' IVs failed and 57 (66.3%) remained functional. Median time to IV failure was 15.6 hours. 100% of IVs failed when <30% of the catheter was in the vein; 32.4% of IVs failed when 30%-64% of the catheter was in the vein; no IVs failed when ≥65% of the catheter was in the vein (p<0.0002). The HR was 0.71 (95% CI 0.60 to 0.83), and for every 5% increase of catheter in vein, the hazard of the IV failing decreases by 29% (p<0.0001). CONCLUSION: The quantity of catheter residing in the vein is a key predictor of long-term functionality of US-guided IVs and is strongly associated with the hazard of failure within 72 hours. Catheter failure is high when <30% of the catheter resided in the vein. Optimum catheter survival occurs when ≥65% of the catheter is placed in the vein.

Teacher-made models: the answer for medical skills training in developing countries?

BACKGROUND: The advantages of using simulators in skills training are generally recognized, but simulators are often too expensive for medical schools in developing countries. Cheaper locally-made models (or part-task trainers) could be the answer, especially when teachers are involved in design and production (teacher-made models, TM). METHODS: We evaluated the effectiveness of a TM in training and assessing intravenous injection skills in comparison to an available commercial model (CM) in a randomized, blind, pretest-posttest study with 144 undergraduate nursing students. All students were assessed on both the TM and the CM in the pre-test and post-test. After the post-test the students were also assessed while performing the skill on real patients. RESULTS: Differences in the mean scores pre- and post-test were marked in all groups. Training with TM or CM improved student scores substantially but there was no significant difference in mean scores whether students had practiced on TM or CM. Students who practiced on TM performed better on communication with the patient than did students who practiced on CM. Decreasing the ratio of students per TM model helped to increase practice opportunities but did not improve student's mean scores. The result of the assessment on both the TM and the CM had a low correlation with the results of the assessment on real persons. CONCLUSIONS: The TM appears to be an effective alternative to CM for training students on basic IV skills, as students showed similar increases in performance scores after training on models that cost considerably less than commercially available models. These models could be produced using locally available materials in most countries, including those with limited resources to invest in medical education and skills laboratories.

An audit of basic practical skills acquisition of final year medical students in a Nigerian medical school.

BACKGROUND/OBJECTIVE: Young medical graduates undertaking their housemanship are naturally expected to demonstrate reasonable competence in basic practical skills. Failure to do this may not only be a source of anxiety to the doctor but also potentially dangerous to the patient. The objective was to assess the level of exposure of final year medical students of a Nigerian medical school to basic practical skills. MATERIALS AND METHODS: This is a descriptive cross-sectional study. Structured questionnaires were distributed to a set (all) of 86 final year medical students of the University of Port Harcourt immediately after their last lecture in their final posting in medicine and surgery. The questionnaires listed some selected basic practical skills (e.g. phlebotomy, male urethral catheter insertion, etc.) that house officers are expected to be competent in. The students were asked to anonymously fill them and return same before leaving the lecture hall. RESULTS: Of the 86 students, 84 completed and returned the questionnaires, giving a 97.7% response rate. No student had performed an arterial puncture for an arterial blood sample. Seventy-six students (90.5%) had not inserted a naso-gastric tube. Only 14 (16.7%) students had successfully inserted more than 10 intravenous canulae. A significant number, 38 (45.2%), had never inserted a urinary catheter (for male patients) nor had any experience with bag/mask skills. Majority, 59 (70.2%) had had some experience with intravenous antibiotics administration. Forty-one (48.7%) students had had 6 or more successful attempts at venous blood sampling. CONCLUSION: The exposure level of final year medical students to basic practical skills was low.

Improved practices for safe administration of intravenous bolus morphine in a pediatric setting.

Postoperative pain control is a clinical imperative, for which morphine is a preferred opioid. However, interpatient variability and drug accumulation with repeated doses, as well as medication errors, may result in respiratory arrest with this medication. Early detection of respiratory depression is essential for safe use of morphine, following both initial and repeated doses. A multidisciplinary team contributed to development of an intravenous (IV) bolus morphine monitoring guideline that reflects current knowledge of morphine pharmacokinetics. Monitoring over a 22-week period in a postsurgical unit was then assessed via record review. A total of 270 postsurgical patients received a first dose of IV bolus morphine, with 784 subsequent doses also administered. Complete monitoring (heart rate, respiratory rate, blood pressure, sedation score, oxygen saturation, and pain score) after the morphine bolus was documented at baseline and 10 and 20 minutes for 34%, 30%, and 23%, respectively, of the patients; partial monitoring (respiratory rate and oxygen saturation) was documented for an additional 22%, 15%, and 9% of patients; 43% of subsequent morphine doses were followed with complete monitoring, and an additional 30% with at least partial monitoring. Adherence to the monitoring procedure fluctuated over the study period with no consistent upward or downward trend. A small number of children exhibited a reduced respiratory rate potentially indicating respiratory depression, but no child required antidote or respiratory support. Despite suboptimal guideline adherence, potential signs of respiratory depression were detected that might otherwise have gone unnoticed. This validates the improved guideline and suggests that some incidents may have remained undetected. Front-line staff must be involved to optimize change, champion the initiative, and promote patient safety.

Towards IV drug standardization in critical care.

Local infusion practice within critical care has evolved over time, and one example of this is the wide variation in concentrations of drug infusions within critical care. While there are many similarities between critical care units, there are also many differences. Often drug infusions are used outside their product licence and, because of the diversity in practice, manufacturers are unlikely to license multiple preparations of even the most commonly used infusions. Critical care nurses spend many hours every day preparing and administering intravenous infusions. Much time could be saved if the infusions were available as a ready-to-use solution. This would also reduce the risk of errors that occur during the preparation and administration of medication infusions. This article describes a national project to achieve consensus on the strengths of drug infusions used within UK critical care units. Having agreed on standard solutions, it is hoped that manufacturers will seek licences for commonly used infusions and work towards mass production of these products. Off the shelf, ready-to-use infusions of commonly used medications could become a reality.

The quest to eliminate intrathecal vincristine errors: a 40-year journey.

BACKGROUND: Intrathecal administration of vincristine is a rare event but catastrophic for the patient, family and clinical team involved. Analysis of this source of harm shows it to be a classic systems error which has proved intractable for nearly 40 years. Failure to learn from history, communicate safety solutions nationally and internationally, create safety agencies which effectively and reliably prevent adverse events, conduct investigations and enquiries which fully reveals how to mitigate system error, develop robust physical design solutions to prevent harm to patients, make effective solutions universal and preparing for the unexpected are all major challenges. CONCLUSIONS: The elimination of rare yet catastrophic errors like this remains one of the tests of whether we can make healthcare safer. In this paper, we discuss why effective learning has been so slow and illustrate lessons for other fields of patient safety.

Patient identification errors are common in a simulated setting.

STUDY OBJECTIVE: We evaluate the frequency and accuracy of health care workers verifying patient identity before performing common tasks. METHODS: The study included prospective, simulated patient scenarios with an eye-tracking device that showed where the health care workers looked. Simulations involved nurses administering an intravenous medication, technicians labeling a blood specimen, and clerks applying an identity band. Participants were asked to perform their assigned task on 3 simulated patients, and the third patient had a different date of birth and medical record number than the identity information on the artifact label specific to the health care workers' task. Health care workers were unaware that the focus of the study was patient identity. RESULTS: Sixty-one emergency health care workers participated--28 nurses, 16 technicians, and 17 emergency service associates--in 183 patient scenarios. Sixty-one percent of health care workers (37/61) caught the identity error (61% nurses, 94% technicians, 29% emergency service associates). Thirty-nine percent of health care workers (24/61) performed their assigned task on the wrong patient (39% nurses, 6% technicians, 71% emergency service associates). Eye-tracking data were available for 73% of the patient scenarios (133/183). Seventy-four percent of health care workers (74/100) failed to match the patient to the identity band (87% nurses, 49% technicians). Twenty-seven percent of health care workers (36/133) failed to match the artifact to the patient or the identity band before performing their task (33% nurses, 9% technicians, 33% emergency service associates). Fifteen percent (5/33) of health care workers who completed the steps to verify patient identity on the patient with the identification error still failed to recognize the error. CONCLUSION: Wide variation exists among health care workers verifying patient identity before performing everyday tasks. Education, process changes, and technology are needed to improve the frequency and accuracy of patient identification.

Therapy of acute basilar artery occlusion: intraarterial thrombolysis alone vs bridging therapy.

BACKGROUND AND PURPOSE: While intravenous recombinant tissue plasminogen activator (rt-PA) has been approved for acute stroke therapy within 3 hours, the optimum management of basilar artery occlusion (BAO) is still a matter of debate. We compared intraarterial thrombolysis with the combined bridging approach of intravenous abciximab and intraarterial thrombolysis with rt-PA (bridging therapy) in an observational, longitudinal, monocenter study. METHODS: Between 1998 and 2006, information for 106 patients with acute BAO were prospectively entered into a local database. Patients eligible for treatment received either intraarterial thrombolysis with rt-PA alone (intraarterial thrombolysis) or were treated with intravenous abciximab and intraarterial rt-PA (bridging therapy). Outcome parameters were recanalization of the basilar artery according to Trial in Myocardial Infarction criteria, survival, and reduction of severe disability and death at 3 months. Logistic regression was used to identify independent predictors for recanalization, survival, and clinical outcome. RESULTS: Of a total of 106 patients with confirmed BAO, 87 patients underwent subsequent angiography. Among those, 75 patients were identified who received the full treatment protocol. Patients in the bridging group had a better recanalization rate (83.7% vs 62.5%; P=0.03), a higher survival rate (58.1% vs 25%; P=0.01), and a better chance for an outcome with no or only mild to moderate disability (modified Rankin Scale score, 0-3; 34.9% vs 12.5%; P=0.02). Symptomatic intracerebral hemorrhage rates were comparable in both groups (14% in the bridging group vs 18.8%; P=0.41). Independent predictors for recanalization were age (OR, 0.95; 95% CI, 0.91-0.99), atrial fibrillation (OR, 6.53; 95% CI, 1.14-37.49), and bridging therapy (OR, 3.37; 95% CI, 1.02 to 11.18). Independent prognostic factors for outcome were Glasgow coma scale score at presentation (OR, 1.24; 95% CI, 1.03-1.45) and the combination of bridging therapy with successful recanalization (OR, 3.744; 95% CI, 1.04-13.43). CONCLUSIONS: Bridging therapy for acute BAO with intravenous abciximab and intraarterial rt-PA appears to be safe and yields higher recanalization and improved survival rates, as well as an overall improved chance for a better outcome.