Lumbar Puncture.

Lumbar puncture (LP) is a procedural skill that is required for practice in the emergency care setting, most often for diagnostic purposes. Rarely, it can also be used therapeutically, to alleviate the pain of patients presenting to the emergency department with acute headache from idiopathic intracranial hypertension. In either case, LP constitutes an invasive procedure in which the subarachnoid space is entered in order to obtain a sample of cerebrospinal fluid from one of the most vulnerable areas of the human anatomy. It is essential for the emergency clinician to carefully weigh the risks and benefits of LP, to ensure informed consent when possible, and to proceed in a manner that ensures optimal patient safety and effectiveness. This article reviews current recommendations and considerations around performing LP, in addition to the process for performing the procedure.

CE: Assessing Back Pain in Patients Presenting to the ED.

ABSTRACT: Although back pain is common, most often benign, and generally resolves in a few days with self-care, nonspecific low back pain that does not resolve with self-care and prompts patients to seek treatment in an ED may result from a serious underlying pathology. In this article, the first in a series on clinical red flags-indicators that can be used in the clinical setting to screen for an elevated risk of severe underlying conditions-the author considers back pain manifestations that may signal the presence of a debilitating or even fatal disease process. Detecting such red flags and communicating their presence to the attending provider can facilitate appropriate diagnosis and management.

Regulatory Challenges to Emergency Medicine Procedural Sedation.

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.

Implementation and Evaluation of Tactical Combat Casualty Care for Army Aviators.

INTRODUCTION: The importance of developing military strategies to decrease preventable death by mitigating hemorrhage and reducing time between the point of injury and surgical intervention on the battlefield is highlighted in previous studies. Successful implementation of Tactical Combat Casualty Care (TCCC) throughout elements of the USA and allied militaries begins to address this need. However, TCCC implementation is neither even nor complete in the larger, conventional force. Army Aviators are at risk for preventable death as they do not receive prehospital care training and are challenged to render prehospital care in the austere environment of helicopter operations. Army aviators are at risk for preventable death due to the challenges to render prehospital care in the austere environment of helicopter operations. Helicopters often fly at low altitudes, engage in direct action in support of ground troops, operate at a great distance from medical facilities, typically do not have medical personnel onboard, and can have long wait times for medical evacuation services due to the far forward nature of helicopter operations. MATERIALS AND METHODS: This is a quality improvement pre-post-intervention design study evaluating the implementation of a combat casualty care training program for Army aviators using well-established evidence-based guidelines for providing care to casualties on the battlefield. The evaluation consisted of participants' self-perceived confidence in providing care to a casualty and change in knowledge level in combat casualty care in a pre/post-intervention design. Clinical skills of tourniquet application, nasopharyngeal airway placement, and needle chest decompression were assessed on a pass/fail grading standard. RESULTS: A total of 18 participants completed the pre- and post-education surveys. A paired t-test showed a statistically significant increase in total composite scores from pre (M = 24.67, SD = 5.06) to post-education self-efficacy (M = 37.94, SD = 2.10), t (17) = -11.29, p < 0.001. A paired t-test revealed a significant increase in exam scores from pre (M = 70.22, SD = 9.43) to post (M = 87.78, SD = 7.19), t (17) = -7.31, p < 0.001. There was no pre-intervention skills assessment, however, all participants (n = 18, 100%) passed the tourniquet application, needle chest compression, and insertion of nasopharyngeal airway. CONCLUSION: TCCC for Army Aviators is easily implemented, demonstrates an increase in knowledge and confidence in providing prehospital care, and provides effective scenario-based training of necessary psychomotor skills needed to reduce preventable death on the battlefield. TCCC for Army Aviators effectively takes the TCCC for All Combatants curriculum and modifies it to address the unique considerations in treating wounded aviators and passengers, both in flight and after crashes. This project demonstrates on a small scale how TCCC can be tailored to specific military jobs in order to successfully meet the intent of the upcoming All Service Member TCCC course mandated in DoD 1322.24. Beyond Army aviation, this program is easily modifiable for aviators throughout the military and civilian sector.

Implementation and Evaluation of a First-Responder Bleeding-Control Training Program in a Rural Police Department.

BACKGROUND: In the prehospital environment, nonmedical first responders are often the first to arrive on the scene of a traumatic event and must be prepared to provide initial care at the point of injury. In civilian communities, these nonmedical first responders often include law enforcement officers. Hemorrhage is a major cause of death in trauma, and many of these deaths occur in the prehospital environment; therefore, prehospital training efforts should be directed accordingly toward bleeding control. METHODS: A bleeding control training program was implemented and evaluated in a rural police department in Pinehurst, North Carolina, from February to April 2017. A repeated measures observational study was conducted to evaluate the training program. Measured were self-efficacy (pre- and post-test), knowledge (pretest, post-test 1 [immediate], post-test 2 [at 4 weeks]), and limb-tourniquet application time (classroom, simulation exercise). RESULTS: The study population was composed of 28 police officers (92.9% male) whose median age was 37 (interquartile range, 22-55) years. Mean self-efficacy scores, equating to user confidence and the decision to intervene, increased from pre- to post-training (34.54 [standard deviation (SD) 4.16] versus 35.62 [SD 4.17]; p = .042). In addition, mean knowledge test scores increased from pre- to immediately post-training (75.00 [SD 16.94] versus 85.83 [SD 11.00]; p = .006), as well as from preto 4 weeks post-training (75.00 [SD 16.94] versus 84.17 [SD 11.77]; p = .018). Lower limb-tourniquet application times were more rapid in the classroom than during the simulation exercise (23.06 seconds [SD 7.68] versus 31.91 seconds [SD 9.81]; p = .005). CONCLUSION: First-responder bleeding-control programs should be initiated and integrated at the local level throughout the Nation. Implementation and sustainment of such programs in police departments can save lives and enhance existing law enforcement efforts to protect and serve communities.

Chest Pain: If It Is Not the Heart, What Is It?

Noncardiac chest pain is an angina-type discomfort without indication of ischemia. Diagnosis can be difficult because of its heterogeneous nature. Classification varies by specialty; gastroenterology uses the terminology gastroesophageal reflux disease related versus non-gastroesophageal reflux disease related. Other disciplines recognize noncardiac chest pain etiologies as having gastrointestinal, musculoskeletal, psychiatric, or pulmonary/other as underlying etiologies. Diagnostics yield a specific cause for effective treatment, which is aimed at the underlying etiology, but it is not always possible. Some patients with noncardiac chest pain have comorbidities and ongoing pain that lead to decreased quality of life and continued health care use.

The Experience of Advanced Practice Nurses in US Emergency Care Settings.

INTRODUCTION: Little information has been published regarding the actual practice, training, and validation of basic skills and competencies needed by the advanced practice registered nurse (APRN) in the emergency care setting. The purpose of this study was to (1) identify skills being performed by APRNs practicing in emergency care settings (2); explore types of training; and (3) describe competency validation. Additionally, we explored frequency of skill use and facilitators and barriers to performing a skill to the full extent of training and education. METHODS: An exploratory mixed-methods study was performed incorporating a self-report survey and focus group interviews. RESULTS: The educational path to advanced practice nursing in emergency care settings is not standardized. Few programs incorporate or address the need for APRNs to receive acute care training across the life span, which is the hallmark of emergency nursing practice. Similarly, training is reported as fragmented, and validation of skills for both nurse practitioners and clinical nurse specialists can vary. APRN practice autonomy is affected by the presence of other providers (specifically physicians), institutional culture, and state boards of nursing that regulate practice. DISCUSSION: Integrated educational and orientation programs are needed that address high-acuity patients across the life span. Additionally, a more nuanced approach to assessing APRN capabilities as a combination of hard (clinical emergency) and soft (communication and organizational) skills may be an appropriate framework within which to examine the advanced practice role. Future research should continue to evaluate training, competency assessment, and outcomes for APRNs in the emergency care setting.

Measuring Fatigue in Triage: A Pilot Study.

: Given the critical nature of triage in facilitating emergency department (ED) functions, an understanding of the factors that impact triage nurses' ability to accurately assign triage scores and the ways in which these factors may affect various patient outcomes is extremely important; yet, there exists a paucity of such research in the literature. To further develop this knowledge base, an investigation of triage nurse fatigue and the role it may play in the ability to accurately assign triage scores was developed. The purpose of this pilot study was to determine how the length of a triage shift affects perceived fatigue levels among triage nurses. This pilot study was conducted using a prospective, descriptive cohort design with 28 registered nurses at a university-affiliated community hospital in the southeastern United States. Fatigue data were collected every 2 hr while the subject was in triage over the course of eighteen 24-hr periods between November 2015 and April 2016. Fatigue was measured using a self-reported fatigue questionnaire that included 2 validated fatigue scales: Karolinska Sleepiness Scale and Samn-Perelli Seven-Point Fatigue Scale. Data were analyzed using SPSS and Microsoft Excel. Results indicate a strong correlation between the amount of time spent in triage and fatigue scores, with average fatigue scores increasing by 64.4%-75.2% over the course of a 12-hr shift. Findings suggest that there was a positive correlation between the length of a triage shift and perceived fatigue levels among triage nurses in the ED. The biggest percent increase in fatigue scores is between hours 4 and 8. Further studies are needed to determine optimal triage shift length as well as the effect of nursing fatigue on triage accuracy.

Exploring the Management of Death: Emergency Nurses' Perceptions of Challenges and Facilitators in the Provision of End-of-Life Care in the Emergency Department.

INTRODUCTION: The importance of end-of-life (EOL) care for dying patients and their families is well described; however, little research has been performed in emergency settings. The purpose of this study was to explore emergency nurses' perceptions of challenges and facilitators in the care of patients at the EOL. METHODS: A mixed-methods design using survey data (N = 1,879) and focus group data (N = 17). Data were collected on questions regarding care of the EOL patient in the emergency department, specifically nurses' perceptions of the care of these patients; educational content needs; barriers to safe and effective care; and the availability of resources. RESULTS: High scores on the quantitative survey showed a high mean level of consistently positive attitudes and beliefs toward caring for dying patients and their families and loved ones (131.26 ± 10.88). Analysis of the focus group transcripts uncovered 9 themes, reflecting concerns around comfort and challenges with EOL care, appropriate training for nurses, and the availability of resources to provide this type of care in the emergency setting. Also noted was dissonance between the nature of emergency care and the nature of EOL care. DISCUSSION: Emergency nurses are comfortable providing EOL care in the emergency setting but note that challenges to providing good care include lack of space, time, and staff. Other challenges involve the mismatch between the goals of emergency care and those of EOL care, as well as the emotional burden of caring for the dying, especially when the appropriate resources are lacking.

Bundling the death and dying learning experience for prelicensure nursing students.

One of the greatest challenges in nursing education lies in linking classroom content to the clinical environment. Simulation is now an established method for allowing students to practice the skills and techniques discussed in didactic nursing education and to allow this to occur in a safe, controlled environment before moving into the real world of clinical practice. Multidimensional learning bundles, such as the End-of-Life Nursing Education Consortium curriculum, provide an opportunity to link theoretical content with practice, yet time constraints may limit implementation of the full curriculum. A compacted learning bundle with a didactic component, unfolding case study, and video-recorded family conference to prepare students for a simulation on care of the dying patient is being used in 1 accelerated bachelor of science in nursing program to address students' learning needs.