Pediatric emergency department triage-based pain guideline utilizing intranasal fentanyl: Effect of implementation.

BACKGROUND: Pain management guidelines in the emergency department (ED) may reduce time to analgesia administration (TTA). Intranasal fentanyl (INF) is a safe and effective alternative to intravenous opiates. The effect of an ED pain management guideline providing standing orders for nurse-initiated administration of intranasal fentanyl (INF) is not known. The objective of this study was to determine the impact of a pediatric ED triage-based pain protocol utilizing intranasal fentanyl (INF) on time to analgesia administration (TTA) and patient and parent satisfaction. METHODS: This was a prospective study of patients 3-17 years with an isolated orthopedic injury presenting to a pediatric ED before and after instituting a triage-based pain guideline allowing for administration of INF by triage nurses. Our primary outcome was median TTA and secondary outcomes included the proportion of patients who received INF for pain, had unnecessary IV placement, and patient and parent satisfaction. RESULTS: We enrolled 132 patients; 72 pre-guideline, 60 post-guideline. Demographics were similar between groups. Median TTA was not different between groups (34.5 min vs. 33 min, p = .7). Utilization of INF increased from 41% pre-guideline to 60% post-guideline (p = .01) and unnecessary IV placement decreased from 24% to 0% (p = .002). Patients and parents preferred the IN route for analgesia administration. CONCLUSION: A triage-based pain protocol utilizing INF did not reduce TTA, but did result in increased INF use, decreased unnecessary IV placement, and was preferred by patients and parents to IV medication. INF is a viable analgesia alternative for children with isolated extremity injuries.

Does the emergency medical treatment and labor act affect emergency department use?

BACKGROUND: Emergency departments (EDs) face increasing patient volumes and economic pressures. These problems have been attributed to the Emergency Medical Treatment and Labor Act (EMTALA). STUDY OBJECTIVE: To determine whether modifying EMTALA might reduce ED use. METHODS: We surveyed ED patients to assess their knowledge of hospitals' obligations to treat all patients regardless of insurance and to determine whether knowledge is associated with ED use. RESULTS: Among 4136 study subjects, 72% reported awareness of the law. Sixty-one percent of subjects were moderate ED users (≥ 1 additional ED visit in 12 months). Moderate users more often knew the law (74% vs. 70%, p=0.005). Multivariate regression showed that factors associated with moderate use were: awareness of EMTALA (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.24-1.67), adult patient (OR 1.94; 95% CI 1.69-2.22), and government insurance (OR 2.67; 95% CI 2.30-3.08) or uninsured (OR 1.72; 95% CI 1.42-2.08). Only 8% of subjects were high-frequency users (≥5 visits). High-frequency users were more often aware of EMTALA (78% vs. 72%, p=0.02). Covariates associated with high frequency were EMTALA awareness (OR 1.69; 95% CI 1.28-2.24), adult patient (OR 2.59; 95% CI 2.00-3.36), and government insurance (OR 3.73; 95% CI 2.76-5.06) or uninsured (OR 3.77; 95% CI 2.65-5.35). CONCLUSION: Many patients know that the law requires hospitals to provide care. This knowledge is associated with more frequent ED use. EMTALA changes might reduce ED use, but broader policy implications should be considered.

Early recognition and treatment of shock in the pediatric patient.

Pediatric cardiopulmonary arrest is frequently a terminal event of an unrecognized progressive shock state. This article describes predisposing factors and classifications of shock as they relate to pediatric patients. It assists the experienced pediatric nurse as well as the nurse who is less experienced in caring for children in identifying early shock in this population and provides practical advice on the assessment of children. In addition, management and intervention techniques are addressed.

An emergency department septic shock protocol and care guideline for children initiated at triage.

BACKGROUND: Unrecognized and undertreated septic shock increases morbidity and mortality. Septic shock in children is defined as sepsis and cardiovascular organ dysfunction, not necessarily with hypotension. OBJECTIVE: Cases of unrecognized and undertreated septic shock in our emergency department (ED) were reviewed with a focus on (1) increased recognition at triage and (2) more aggressive treatment once recognized. We hypothesized that septic shock protocol and care guideline would expedite identification of septic shock, increase compliance with recommended therapy, and improve outcomes. METHODS: We developed an ED septic shock protocol and care guideline to improve recognition beginning at triage and evaluated all eligible ED patients from January 2005 to December 2009. RESULTS: We identified 345 pediatric ED patients (49% male, median age: 5.6 years), and 297 (86.1%) met septic shock criteria at triage. One hundred ninety-six (56.8%) had ≥ 1 chronic complex condition. Hypotension was present in 34% (n = 120); the most common findings were tachycardia (n = 251 [73%]) and skin-color changes (n = 269 [78%]). The median hospital length of stay declined over the study period (median: 181-140 hours; P < .05); there was no change in mortality rate, which averaged 6.3% (22 of 345). The greatest gains in care included more complete recording of triage vital signs, timely fluid resuscitation and antibiotic administration, and serum lactate determination. CONCLUSIONS: Implementation of an ED septic shock protocol and care guideline improved compliance in delivery of rapid, aggressive fluid resuscitation and early antibiotic and oxygen administration and was associated with decreased length of stay.

Ethnomedicine in healthcare systems of the world: a Semester at Sea pilot survey in 11 countries.

BACKGROUND: An understanding and appreciation for the varied healthcare systems in use throughout the world are increasingly vital for medical personnel as patient populations are now composed of ethnically diverse people with wide-ranging belief systems. OBJECTIVE: While not a statistically valid survey, this pilot study gives a global overview of healthcare differences around the world. DESIGN: A pilot study of 459 individuals from 11 different countries around the world was administered by 33 students in the upper division course, People, Pathology, and World Medicine from Semester at Sea, Fall 2007, to ascertain trends in healthcare therapies. Open-ended surveys were conducted in English, through an interpreter, or in the native language. RESULTS: Western hospital use ranked highly for all countries, while ethnomedical therapies were utilized to a lesser degree. Among the findings, mainland China exhibited the greatest overall percentage of ethnomedical therapies, while the island of Hong Kong, the largest use of Western hospitals. CONCLUSIONS: The figures and trends from the surveys suggest the importance of understanding diverse cultural healthcare beliefs when treating individuals of different ethnic backgrounds. The study also revealed the increasingly complex and multisystem-based medical treatments being used internationally.