Feasibility of adolescent contraceptive care in the pediatric emergency department: A pilot randomized controlled trial.

BACKGROUND: This study assessed feasibility constructs of adolescent contraceptive care in the pediatric emergency department (PED), including contraception initiation. METHODS: We conducted a randomized trial in two PEDs with pregnancy-capable adolescents aged 15-18 years who were assigned to enhanced usual care (usual) or same-day initiation (same day). All received counseling and clinic referral, but same-day participants could also receive contraception in the PED. We trained PED clinicians in counseling and prescribing. Adolescents and clinicians rated feasibility using five Likert-type items (1 = strongly disagree to 5 = strongly agree) after the session. We assessed PED medication initiation and appropriateness via medical record review and contraception use and side effects at 30 days via adolescent survey. To further explore feasibility, we conducted clinician interviews at study completion; these were audio-recorded, transcribed, and analyzed. We hypothesized contraceptive care would be feasible (defined as average score ≥ 4 across five survey items). RESULTS: We enrolled 37 adolescents (12 in usual and 25 in same-day), mean age was 16.6 years, 73% were Black, and 19% were Hispanic. We trained 27 clinicians. Average feasibility scores were 4.6 ± 0.4 (adolescents) and 4.1 ± 0.8 (clinicians). Eleven (44%) same-day participants initiated contraception in the PED. One adolescent with migraines initially received estrogen-containing pills; this was corrected after discharge. At 30 days, same-day participants were more likely to report contraception use (78% vs. 13%; p = 0.007). One adolescent reported bloating as a side effect. Clinicians enjoyed delivering contraceptive care, found study resource materials useful, and identified staffing shortages as a barrier to care delivery. CONCLUSIONS: We are among the first to report on PED-based adolescent contraception initiation to prevent unintended pregnancy. Adolescents and clinicians reported that contraceptive care was feasible. Initiation was common and medications were largely appropriate and tolerated. Future efforts should explore integrating contraceptive care into routine PED care.

Contraception Initiation in the Emergency Department: Adolescent Perspectives.

PURPOSE: The purpose of this study was to identify factors affecting contraceptive intention and behavior among adolescent females in the pediatric Emergency Department. METHODS: We conducted a qualitative interview study nested within a larger prospective cohort study examining adolescent contraceptive counseling for females ages 15-18 years at-risk of unintended pregnancy presenting to the pediatric Emergency Department. Interviews were conducted in a subset of participants. The ecologically expanded Theory of Planned Behavior, expert opinion, and literature review informed the interview guide. Interviews were recorded, transcribed, coded and monitored for thematic saturation. RESULTS: Twenty-eight interviews were analyzed. Mean age was 17.1 years. Themes were mapped to ecologically expanded Theory of Planned Behavior constructs. Within health system influences, prior contraceptive experiences and patient-clinician interactions were described. Within community influences, contraceptive education, knowledge and misinformation, teen pregnancy norms, and social media impacts were described. Within attitudes influences, side-effect and safety concerns, contraceptive motivations and teen pregnancy beliefs were described. Within subjective norm influences, peer and family impacts were described. Within perceived behavioral control, Emergency Department (ED) counseling intervention impacts were described. DISCUSSION: We identified factors affecting contraceptive initiation/behavior among an ED adolescent population that otherwise may not have received contraceptive education in similar detail as provided by study clinicians. Adolescents' prior contraceptive and clinician interactions, limited access to contraceptive education, knowledge and misinformation, and side-effect and safety concerns affected initiation. Peer/family sharing and social media were leading contraceptive information sources. Future studies should incorporate insights into adolescent ED intervention design to make optimal use of resources while maximizing potential benefit.

Neurogenic Shock: A Case Report.

BACKGROUND: Neurogenic shock is a life-threatening emergency associated with spinal cord injuries. Early cervical spine immobilization to reduce the risk of neurogenic shock is imperative. In addition, early recognition and treatment of neurogenic shock are essential to prevent hypoperfusion-related injuries and death. CASE PRESENTATION: This case outlines a 65-year-old male who experienced a cervical spine fracture after a motorcycle crash. The patient received stabilizing treatment by a flight crew consisting of both a registered nurse and paramedic. After assessment and stabilization, he was diagnosed as having neurogenic shock. Despite invasive treatment and resuscitation efforts, the patient succumbed to his injuries. CONCLUSION: It is important for emergency nurses to quickly identify the risk factors for cervical spine injuries and maintain cervical spine immobilization to minimize the risk of neurogenic shock.

Expanding Contraceptive Access for Teens-Leveraging the Pediatric Emergency Department.

PURPOSE: Adolescents have limited access to sexual healthcare services, and the emergency department (ED) may be the only place some will seek care. We implemented an ED-based contraception counseling intervention to assess intervention feasibility, and adolescent intention to initiate contraception, contraception initiation, and follow-up visit completion. METHODS: This prospective cohort study trained advanced practice providers in the EDs of two pediatric urban academic medical centers to deliver brief contraception counseling. A convenience sample of patients enrolled from 2019 to 2021 included females aged 15-18 not pregnant/desiring pregnancy and/or using hormonal contraception/an intrauterine device. Participants completed surveys to assess demographics and intention to initiate contraception (yes/no). Sessions were audiotaped and reviewed for fidelity. We ascertained contraception initiation and follow-up visit completion via medical record review and participant survey at 8 weeks. RESULTS: Twenty-seven advanced practice providers were trained, and 96 adolescents were counseled/responded to surveys (mean age 16.7 years; 19% non-Hispanic White, 56% non-Hispanic Black; 18% Hispanic). Mean counseling duration was 12 minutes and >90% of reviewed sessions maintained fidelity to content/style. Most participants (61%) reported intention to initiate contraception, and these participants were older and more likely to report prior contraceptive use, compared to those without intention. One-third (33%) initiated contraception in the ED or after the follow-up visit. DISCUSSION: Contraceptive counseling was feasible to integrate in the ED visit. Intention to initiate contraception was common and many adolescents initiated contraception. Future work should increase the pool of trained providers and supports for same-day contraception initiation for those desiring in this novel setting.

Paramedic To Provider Consultation Challenges in the Emergency Department in Kazakhstan: An Online Survey.

Objective: Consultation is an important and necessary aspect of patient care in the emergency department. We prospectively examined difficulties during the consultation process between paramedics and providers in emergency departments in Kazakhstan. Methods: The paramedics were interviewed using various platforms and face-to-face meetings. Questionnaires were administered to paramedics to gather feedback on the current consultation process. In our survey, 202 paramedics of ambulance from the cities of Semey, Pavlodar, and Ust-Kamenogorsk, located in the North and East of Kazakhstan took part. Results: Serious barriers to effective consultation were identified during consultations with cardiologists, pediatricians, and traumatologists. Weekends, as well as nighttime, are associated with more consultation difficulties. The most common problems for paramedics are non-attendance of the consultant, refusal of hospitalization by the consultant, and referral to other specialists and departments. More than 40% of the respondents noted the desire to share responsibility for the patient with medical consultants, which indicates uncertainty in their own knowledge due to the limited work experience of the majority of respondents. Conclusion: Barriers that arise during the consultation process of patients with emergency conditions can lead to unfavorable outcomes. Strategies to address these barriers are needed to improve the quality of patient care. This review aims to understand and evaluate the issues that arise during the consultation process.

Contraceptive counseling for adolescents in the emergency department: A novel curriculum for nurse practitioners and physician assistants.

ABSTRACT: Many adolescents use the emergency department (ED) as their primary source of health care. As a result, the ED serves as a unique opportunity to reach adolescents. Although many adolescent visits to the ED are related to reproductive health, ED providers report barriers to providing this care, including lack of training. Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in the provision of consistent care to adolescents in the ED. The purpose of this study was to create a curriculum to train NPs and PAs at two pediatric institutions to provide patient-centered contraceptive counseling to adolescents in the pediatric ED regardless of their chief complaint. To do this, we created a four-part webinar followed by an in-person training session. Participants completed training and then conducted counseling sessions with adolescents in the ED. Counseling sessions were recorded and reviewed for fidelity to delineated counseling principles, and data from post-counseling surveys were collected. 27 NPs and PAs completed the training and conducted 99 counseling sessions. Nearly all sessions incorporated essential content and communication principles such as shared decision making (90%) and teach-back methods (75%). All NPs and PAs who participated reported satisfaction and subjective improvement in knowledge and competence from the training. This curriculum offers a novel and feasible approach to train NPs and PAs to deliver patient-centered contraception counseling to adolescents in the ED setting, and it can serve as a model for how to educate different providers to incorporate reproductive health education into the busy ED visit.

Ovarian Hyperstimulation Syndrome: A Case Report.

BACKGROUND: Ovarian hyperstimulation syndrome is a rare, life-threatening obstetric emergency. Early recognition and prompt treatment of ovarian hyperstimulation syndrome are essential owing to the risk of long-term complications associated with this condition. CASE PRESENTATION: A 30-year-old female presented to the emergency department with a chief complaint of abdominal pain. After assessment and diagnostic testing, she was diagnosed as having ovarian hyperstimulation syndrome. The patient was admitted for 24-hour observation. The patient was discharged home with instructions to follow up with an outpatient reproductive medicine clinic. One month after her visit to the emergency department, the patient has not had any complications related to the diagnosis. CONCLUSION: This manuscript outlines the case of a patient presenting to the emergency department with ovarian hyperstimulation syndrome that was promptly recognized and treated. It is important for emergency nurses to quickly identify the risk factors and clinical presentation of ovarian hyperstimulation syndrome to decrease the risk of long-term complications.

Acute Heart Failure.

Heart failure impacts millions of Americans and has an approximate 5-year mortality rate of 50%-55%. Decompensation of this disease state could result in a patient's initial presentation and diagnosis or may reflect a worsening of a chronic condition that is being managed but needs optimization. Secondary to this, it is important for members of the health care team in the emergency department to recognize the presentation of this disease and manage the patient's signs and symptoms appropriately. Patients may be normotensive upon presentation or hemodynamically unstable. Those who are normotensive are often managed with loop diuretics and possibly low-dose vasodilators, whereas those who are hemodynamically unstable require more aggressive, focused care. It is important to note that some patients may present with respiratory failure and with no known history of heart failure. In these cases, a rapid and accurate diagnosis is critical. This article briefly summarizes the common acute clinical presentations of heart failure and the therapies considered first line for treatment based on the primary literature.

COVID-19 and New Onset IgA Vasculitis: A Systematic Review of Case Reports.

INTRODUCTION: Immunoglobulin A vasculitis is historically more commonly found in children after certain viral infections such as Epstein-Barr, varicella virus, and parvovirus B19. COVID-19 has not been formally established in literature as a trigger for immunoglobulin A vasculitis. However, a main pathogenetic mechanism of COVID-19 is vascular damage, which makes it likely that vasculitis associated with COVID-19 (ie, COVID-19-mediated immunoglobulin A vasculitis) could be biologically plausible, with serious implications, especially for adults. The purpose of this review is to assist emergency nurses in gaining knowledge on the pathophysiology, symptoms, and treatment of COVID-19-mediated immunoglobulin A vasculitis. METHODS: A systematic search for case reports of COVID-19-associated immunoglobulin A vasculitis was conducted in the PubMed and Scopus electronic databases. The search terms used were COVID-19, coronavirus 2019, SARS COVID-19, and IgA vasculitis, case reports. The following were the inclusion criteria: publication dates between December 1, 2019, and December 1, 2021; full-text article, clinical case studies, and letters to the editor available electronically in English. The following were exclusion criteria: a summary of reports and newspaper publications. RESULTS: Only 13 clinical cases met the inclusion criteria. The median age of patients described in the case reports were 38.1 years. Of them, 3 children were less than 5 years old. Twelve patients were male. In 7 of 13 cases of immunoglobulin A vasculitis, renal involvement was found. DISCUSSION: The analysis of published clinical cases showed that COVID-19-associated immunoglobulin A vasculitis affected mostly adults and was characterized by a more severe course because of renal involvement. COVID-19 may be a possible trigger for immunoglobulin A-related disorders. More research is needed to better understand the relationship between immunoglobulin A vasculitis and COVID-19.

External Jugular Vein Peripheral Intravenous Catheters: An Emergency Nurse's Guide.

Insertion of a peripheral intravenous catheter into the external jugular vein is regularly performed in emergency departments to treat patients with difficult intravenous access. Although emergency nurses are experienced in inserting peripheral intravenous catheters, there is an inconsistent practice and a lack of education and training regarding the insertion of catheters in the external jugular vein. This manuscript provides a practical guide for emergency nurses to care for patients who require an external jugular peripheral intravenous catheter. Key information found in this manuscript includes indications for external jugular intravenous access, the nurse's role in performing external jugular peripheral intravenous catheters, and clinical considerations when caring for patients with an external jugular peripheral intravenous catheter.

The E3 ubiquitin ligase component, Cereblon, is an evolutionarily conserved regulator of Wnt signaling.

Immunomodulatory drugs (IMiDs) are important for the treatment of multiple myeloma and myelodysplastic syndrome. Binding of IMiDs to Cereblon (CRBN), the substrate receptor of the CRL4CRBN E3 ubiquitin ligase, induces cancer cell death by targeting key neo-substrates for degradation. Despite this clinical significance, the physiological regulation of CRBN remains largely unknown. Herein we demonstrate that Wnt, the extracellular ligand of an essential signal transduction pathway, promotes the CRBN-dependent degradation of a subset of proteins. These substrates include Casein kinase 1α (CK1α), a negative regulator of Wnt signaling that functions as a key component of the ß-Catenin destruction complex. Wnt stimulation induces the interaction of CRBN with CK1α and its resultant ubiquitination, and in contrast with previous reports does so in the absence of an IMiD. Mechanistically, the destruction complex is critical in maintaining CK1α stability in the absence of Wnt, and in recruiting CRBN to target CK1α for degradation in response to Wnt. CRBN is required for physiological Wnt signaling, as modulation of CRBN in zebrafish and Drosophila yields Wnt-driven phenotypes. These studies demonstrate an IMiD-independent, Wnt-driven mechanism of CRBN regulation and provide a means of controlling Wnt pathway activity by CRBN, with relevance for development and disease.

Cesarean Scar Ectopic Pregnancy: A Case Report.

BACKGROUND: A cesarean scar pregnancy is a rare, life-threatening obstetric emergency. Early recognition and prompt treatment of cesarean scar pregnancy is essential because of the risk for long-term reproductive complications associated with this condition. CASE PRESENTATION: A 33-year-old gravida 6 para 5 female presented to the emergency department with pain to the suprapubic area. Following assessment and diagnostic testing, she was diagnosed with a cesarean scar pregnancy. The patient was admitted to the women's services department where she received a multidose regimen of methotrexate. The patient was discharged home, and no further surgical interventions were necessary. Two months after her visit to the emergency department, the patient has not had any complications related to the cesarean scar pregnancy. CONCLUSION: This manuscript outlines the case of a patient presenting to the emergency department with a cesarean scar pregnancy that was promptly recognized and treated. It is important for emergency nurses to quickly recognize the risk factors and clinical presentation of a cesarean scar pregnancy to reduce maternal morbidity and mortality.

Brief Motivational Intervention to Improve Adolescent Sexual Health Service Uptake: A Pilot Randomized Controlled Trial in the Emergency Department.

OBJECTIVE: To test the hypothesis that our motivational sexual health intervention (SexHealth) would increase health service uptake when compared with control. STUDY DESIGN: In a randomized controlled trial at a pediatric emergency department, sexually active adolescents received either the SexHealth intervention or printed materials (control). SexHealth, delivered by a health educator, was a tablet-based, interactive intervention that included motivational techniques to promote sexual health, condom skills training, and tailored service recommendations. We assessed feasibility (eg, intervention completion, recommendations discussed, intervention duration), acceptability (ie, proportion enrolled and rating intervention as satisfactory), and efficacy; secondary outcomes were sexual and care-seeking behaviors at 6 months. The efficacy outcome was completion of ≥1 service at the index visit (ie, counseling, condoms, emergency contraception for immediate or future use, pregnancy/sexually transmitted infection/HIV testing, sexually transmitted infection treatment, and clinic referral). RESULTS: We enrolled 91 participants (intervention = 44; control = 47). The intervention demonstrated high feasibility: 98% completed the intervention; 98% of recommendations were discussed; duration was 24.6 minutes, and acceptability: 87% of eligible adolescents enrolled and 93% rated the intervention as fairly to very satisfactory. Compared with controls, intervention participants were more likely to complete ≥1 service (98% vs 70%, P < .001) including HIV testing (33% vs 6%, P = .02) and emergency contraception (80% vs 0%, P = .01). There were no meaningful differences between arms in behaviors at follow-up. CONCLUSIONS: SexHealth was feasible to implement, acceptable to youth, and resulted in increased uptake of health services during the emergency department visit. Additional strategies may be needed to extend intervention effects over time. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; NCT03341975.

Transcutaneous Pacing: An Emergency Nurse's Guide.

Transcutaneous pacing is commonly performed in emergency departments to treat patients with cardiac dysrhythmias. Although emergency nurses are required to complete a standardized course that reviews components of transcutaneous pacing, such as Advanced Cardiac Life Support, performing transcutaneous pacing on patients may be done infrequently in some facilities and can lead to anxiety and fear for bedside emergency nurses, especially novice emergency nurses and nurses who infrequently care for patients requiring external pacing. This manuscript provides a practical guide for emergency nurses to care for patients who require transcutaneous pacing. Key information found in this manuscript includes indications for transcutaneous pacing, the nurse's role when performing transcutaneous pacing, and transcutaneous pacing troubleshooting information.

Building a Contextually-Relevant Understanding of Resilience among African American Youth Exposed to Community Violence.

Studies consistently demonstrate that African American youth experience disproportionate levels of community violence, which is associated with negative health and well-being outcomes among these youth. The frequency and severity of community violence exposure is a unique challenge for these youth and requires tailored approaches to promote resilience after community violence exposure. However, limited research exists that operationalizes resilience after community violence based on the unique context and lived experience of African American youth. Developing a more contextually relevant understanding of resilience is critical to reducing health inequities experienced by African American youth and promoting their well-being. Five focus groups were conducted with 39 African American adolescents (ages 13-18) exposed to community violence. Participants also completed a brief survey that included questions on demographics, adverse childhood experiences, social capital, and resilience. Focus-group transcripts were independently coded by two members of the research team and analyzed using an inductive approach. Youth highlighted key indicators of resilience including the ability to persevere, self-regulate, and change to adapt/improve. Youth also described family, peer, and cultural contexts that impact how resilience is produced and manifested, highlighting trust, perceived burdensomeness, self-determination, connectedness, and mental health stigma as key factors within these contexts. Results of this qualitative study support the development of health promotion programs for African American youth exposed to community violence that address unique risks and build on existing protective factors within family, peer, and cultural contexts.

The therapeutic efficacy of adjunct therapeutic plasma exchange for septic shock with multiple organ failure: a single-center experience.

BACKGROUND: Sepsis remains a common condition with high mortality when multiple organ failure develops. The evidence for therapeutic plasma exchange (TPE) in this setting is promising but inconclusive. Our study aims to evaluate the efficacy of adjunct TPE for septic shock with multiple organ failure compared to standard therapy alone. METHODS: A retrospective, observational chart review was performed, evaluating outcomes of patients with catecholamine-resistant septic shock and multiple organ failure in intensive care units at a tertiary care hospital in Winston-Salem, NC, from August 2015 to March 2019. Adult patients with catecholamine-resistant septic shock (≥ 2 vasopressors) and evidence of multiple organ failure were included. Patients who received adjunct TPE were identified and compared to patients who received standard care alone. A propensity score using age, gender, chronic co-morbidities (HTN, DM, CKD, COPD), APACHE II score, SOFA score, lactate level, and number of vasopressors was used to match patients, resulting in 40 patients in each arm. RESULTS: The mean baseline APACHE II and SOFA scores were 32.5 and 14.3 in TPE patients versus 32.7 and 13.8 in control patients, respectively. The 28-day mortality rate was 40% in the TPE group versus 65% in the standard care group (p = 0.043). Improvements in baseline SOFA scores at 48 h were greater in the TPE group compared to standard care alone (p = 0.001), and patients receiving adjunct TPE had a more favorable fluid balance at 48 h (p = 0.01). Patients receiving adjunct TPE had longer ICU and hospital lengths of stay (p = 0.003 and p = 0.006, respectively). CONCLUSIONS: Our retrospective, observational study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct TPE compared to standard care alone. Hemodynamics, organ dysfunction, and fluid balance all improved with adjunct TPE, while lengths of stay were increased in survivors. The study design does not allow for a generalized statement of support for TPE in all cases of sepsis with multiple organ failure but offers valuable information for a prospective, randomized clinical trial.

The Implementation of a Cultural Change Toolkit to Reduce Nursing Burnout and Mitigate Nurse Turnover in the Emergency Department.

PROBLEM: Nursing burnout and high levels of nursing turnover contribute to negative work environments, diminished patient care, and increased health care costs. There is a gap in literature regarding cost-effective, easily implemented interventions to address burnout and turnover. The purpose of this project was to determine if the implementation of evidence-based interventions would improve the perception of the practice environment, decrease the levels of nursing burnout, and decrease the voluntary nurse turnover rate in the emergency department. METHODS: The Cultural Change Toolkit was developed based on current recommendations in literature and implemented within an emergency department in southeast Texas. The toolkit included specific interventions related to meaningful recognition, shared decision making, and increased leadership involvement and support. Nursing burnout and anticipated turnover were measured using the Anticipated Turnover Scale and the Oldenburg Burnout Inventory both before and after implementation of the project. Participants (n = 30) included nursing staff employed in the emergency department. RESULTS: There was a reduction in both the anticipated turnover (mean anticipated turnover score, preimplementattion = 3.133, postimplementation = 2.989) and burnout scores among nursing staff (mean burnout score, preimplementation = 4.808, postimplementation = 4.463). The reduction in overall burnout scores were statistically significant following a paired t-test analysis (P = 0.004). There were no resignations among nursing staff throughout the project period. DISCUSSION: Nursing burnout and turnover are frequently discussed topics. The results support the use of cost-effective interventions outlined in the Cultural Change Toolkit to address nursing turnover and burnout.