Subhypnotic Intravenous Ketamine Improves Patient Satisfaction With Burn Wound Care: A Quality Improvement Project.

Despite advancements in pain management for burn injuries, analgesia often fails to meet our patients' needs. We hypothesized that low doses of intravenous (IV) ketamine as an adjunct to our current protocol would be safe, improving both nurse and patient satisfaction with analgesia during hydrotherapy. Burn patients admitted who underwent hydrotherapy from June 1, 2021, to June 30, 2023 were surveyed. Ketamine was administered with the standard opioid-midazolam regimen. Demographics, oral morphine equivalents, midazolam, ketamine doses and time of administration, and adverse events were collected. Patient and nurse satisfaction scores were collected. The ketamine and no-ketamine groups were compared. P < .05 was considered significant. Eighty-five hydrotherapies were surveyed, 47 without ketamine, and 38 with ketamine. Demographics, comorbidities, %TBSA, and hospital length of stay were not different. The median amount of ketamine given was 0.79 mg/kg [0.59-1.06]. Patients who received ketamine were more likely to receive midazolam (100% vs 61.7%; P < .001), and both oral and IV opioids (94.7% vs 68.1%; P = .002) prior to hydrotherapy and less likely to receive rescue opioids or midazolam during hydrotherapy. Two patients in the ketamine group had hypertension (defined as SBP > 180) that did not require treatment. Nurses tended to be more satisfied with patient pain control when ketamine was used (10 [8-10] vs 9 [7-10], P = .072). Patient satisfaction was higher in the ketamine group (10 [8.8-10] vs 9 [7-10], P = .006). Utilizing subhypnotic dose of IV ketamine for hydrotherapy is safe and associated with increased patient satisfaction.

Optimizing burn wound procedural pain control, efficiency, and satisfaction through integrated nurse and physician education.

Herein, we report the results of a quality improvement project (QI). Following a review of the burn unit practices, a nursing-led, physician supported educational intervention regarding optimal timing, dosage, and indication for medications used during hydrotherapy, including midazolam and opioids, was implemented. We hypothesized that such intervention would support improvement in both nurse and patient satisfaction with pain control management. Patients undergoing hydrotherapy were surveyed. Demographics, opioid dose prescribed (oral morphine equivalents), midazolam use, timing of administration, and adverse events were collected. Patient pain scores (1-10) before and after hydrotherapy and patient and nurse satisfaction scores (1-10) after hydrotherapy were collected. The pre- and post-education populations were compared. P < 0.05 was considered significant. Post-education, administration of opioids (59.1% v. 0%, p < 0.001) and midazolam (59.1% vs. 10.4%; p < 0.001) prior to hydrotherapy significantly improved, leading to fewer patients requiring rescue opioids during hydrotherapy (25% vs. 74%, p < 0.001). Hydrotherapy duration significantly decreased post-education (19 [13.3-30] min vs. 32 [18-43] min, p = 0.003). Nurses' ratings of their patient's pain control (9 [7.3-10] vs. 7.5 [6-9], p = 0.004) and ease of procedure (10 [9,10] vs. 9 [7.8-10], p = 0.037) significantly improved. Patients' pain management satisfaction rating did not change, but the number of subjects rating their pain management as excellent tended to increase (36.4% vs. 20%, p = 0.077). Nursing led, physician supported, education can improve medication administration prior to and during hydrotherapy, increasing the ease of the procedure as well as staff satisfaction.

Quality Improvement of Pediatric Airway Emergency Carts: Standardization, Streamlining, and Simulation.

Objective Pediatric airway emergencies are amongst the most tenuous scenarios faced by on-call providers, requiring quick access to the appropriate equipment and a timely response. In the present study, we report on the testing and improvement of pediatric airway carts at our institution. The primary objective was to optimize our pediatric airway emergency carts to improve response times. Secondarily, we aimed to implement a training scenario to improve providers' familiarity and confidence in attaining and assembling equipment. Methods Surveys of airway cart configuration at our hospital and others were used to identify differences. Volunteer otolaryngology physicians were tasked with responding to a mock scenario using an existing cart or one modified based on the survey. Outcomes included (1) time to arrival of the provider with the appropriate equipment, (2) time from arrival to complete assembly of equipment, and (3) time for re-assembly of the equipment. Results The survey revealed differences in cart equipment and location. The inclusion of a flexible bronchoscope and a video tower, as well as the placement of the carts directly within the ICU, resulted in improved time to arrival by an average of 181 seconds, and improved equipment assembly time by an average of 85 seconds. Discussion Standardization of pediatric airway equipment on the cart and location near critically ill patients improved response efficiency. Simulation led to improved confidence and reduced reaction time among providers at all levels of experience. Conclusion The present study provides an example for the optimization of airway carts, which can be adapted by healthcare systems to their local milieu.

Data on the clinical, analytical, and laboratory factors associated with negative anion gaps at an academic medical center.

The anion gap is a calculated parameter derived from the difference between the major plasma cations and anions in serum/plasma or whole blood, with a widely used simple equation utilizing concentrations of sodium, chloride, and bicarbonate. While there is extensive literature on the clinical significance and causes of elevated anion gaps, there is comparatively less data on low anion gaps. Occasionally, anion gap calculations result in a negative number (-1 or less). From the published literature, causes of these 'negative anion gaps' include laboratory error, specimen contamination or interference, hypoalbuminemia, extreme hyperkalemia, bromism, and paraproteins from multiple myeloma or similar pathologic processes. The data in this article present results from retrospective review of clinical chemistry and blood gas analysis testing at an academic medical center. The data include electrolyte concentrations and anion gap values derived from a total of 2,948,574 specimens (2,841,863 serum/plasma specimens analyzed on Roche Diagnostics clinical chemistry analyzers, 93,987 whole blood specimens analyzed on Radiometer blood gas analyzers, and 12,724 whole blood specimens on point-of-care chemistry devices) from 371,925 unique patients, clinical area where testing was ordered (for serum/plasma samples), sex, and age. For serum/plasma specimens with a negative anion gap, the data additionally include information from detailed chart review of possible factors and disease conditions contributing to the negative anion gap, pattern of electrolyte abnormalities, presence or absence of hypoalbuminemia, and corrected anion gap (if hypoalbuminemia is present).

Impact of Interfacing Near Point of Care Clinical Chemistry and Hematology Analyzers at Urgent Care Clinics at an Academic Health System.

BACKGROUND: Point-of-care (POC) testing equipment is commonly utilized in outpatient clinics. Our institution recently interfaced POC chemistry and hematology devices at two outpatient clinics via middleware software to the central electronic health record (EHR), facilitating a comparison of manual transcription versus automatic reporting via interface. This allowed for estimation of serious/obvious error rates and manual time savings. Additional goals were to develop autoverification rules and analyze broad trends of results in response to common clinician complaints on the POC testing. MATERIAL AND METHODS: Data were obtained from two satellite clinic sites providing both primary and urgent care within an academic health system. Interface of devices was accomplished via Instrument Manager middleware software and occurred approximately halfway through the 38 month retrospective timeframe. Laboratory results for three testing POC chemistry and hematology panels were extracted with EHR tools. RESULTS: Nearly 100,000 lab values were analyzed and revealed that the rate of laboratory values outside reference range was essentially unchanged before and after interface of POC testing devices (2.0-2.1%). Serious/obvious errors, while rare overall, declined significantly, with none recorded after the interface with autoverified results and only three related to manual edits of results that failed autoverification. Fewer duplicated test results were identified after the interface, most notably with the hematology testing. Anion gap values of less than zero were observed more frequently in POC device tests when compared to central laboratory tests and are attributed to a higher proportion of Cl values greater than 110 mEq/L and CO2 values greater than 30 mEq/L with POC results. Time savings of eliminating manual data entry were calculated to be 21.6 employee hours per month. CONCLUSIONS: In a switch from manual entry to automatic interface for POC chemistry and hematology, the most notable changes were reduction of serious/obvious errors and duplicate results. Significant time employee time savings highlight an additional benefit of instrument interfacing. Lastly, a difference between POC and central laboratory instruments is a higher rate of high Cl and CO2 values relative to the central laboratory.

Update on the Practice of Splinting During Acute Burn Admission From the ACT Study.

Burn scar contracture (BSC) is a common pathological outcome following burn injuries, leading to limitations in range of motion (ROM) of affected joints and impairment in function. Despite a paucity of research addressing its efficacy, static splinting of affected joints is a common preventative practice. A survey of therapists performed 25 years ago showed a widely divergent practice of splinting during the acute burn injury. We undertook this study to determine the current practice of splinting during the index admission for burn injuries. This is a review of a subset of patients enrolled in the Burn Patient Acuity Demographics, Scar Contractures and Rehabilitation Treatment Related to Patient Outcome Study (ACT) database. ACT was an observational multicenter study conducted from 2010 to 2013. The most commonly splinted joints (elbow, wrist, knee, and ankle) and their seven motions were included. Variables included patients' demographics, burn variables, rehabilitation treatment, and hospital course details. Univariate and multivariate analysis of factors related to splinting was performed. P < .05 was significant. Thirty percent of the study population (75 patients) underwent splinting during their hospitalization. Splinting was associated with larger burns and increased injury severity on the patient level and increased involvement with burns requiring grafting in the associated cutaneous functional unit (CFU) on the joint level. The requirement for skin grafting in both analyses remained independently related to splinting, with requirement for grafting in the associated CFU increasing the odds of splinting six times (OR = 6.0, 95% CI = 3.8-9.3, P < .001). On average, splinting was initiated about a third into the hospital length of stay (LOS, 35 ± 21% of LOS) and splints were worn for 50% (50 ± 26%) of the LOS. Joints were splinted for an average 15.1 ± 4.8 hours a day. The wrist was most frequently splinted joint being splinted with one third of wrists splinted (30.7%) while the knee was the least frequently splinted joint with 8.2% splinted. However, when splinted, the knee was splinted the most hours per day (17.6 ± 4.8 hours) and the ankle the least (14.4 ± 4.6 hours). Almost one third had splinting continued to discharge (20, 27%). The current practice of splinting, especially the initiation, hours of wear and duration of splinting following acute burn injury remains variable. Splinting is independently related to grafting, grafting in the joint CFU, larger CFU involvement and is more likely to occur around the time of surgery. A future study looking at splinting application and its outcomes is warranted.