Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use.

BACKGROUND: Fascia iliaca compartment block (FICB) has become a keystone technique for acute pain management in patients with hip and proximal femur fractures. OBJECTIVES: To demonstrate that administering FICB preoperatively to patients with hip or proximal femur fractures in the emergency department (ED) is likely to reduce opioid use and related complications, and to decrease hospital length of stay (LOS). METHODS: An unblinded study of adult patients with hip and proximal femur fractures who consented to receive an FICB with 30 cc of bupivacaine with epinephrine administered in the ED. We compared this group with a contemporaneous group of controls who only received systemic opioids. Over the course of approximately 6 months, main outcome measured between the two groups was amount of morphine equivalents given from block administration until 8 h after. We also compared complications such as delirium, constipation, and bleeding rates (oozing from injection site or hematoma formation). RESULTS: A total of 166 patients with hip and proximal femur fractures from August 12, 2018 to April 25, 2021; 81 received FICB plus systemic opioids, and 85 received only systemic opioids. Among the FICB group, morphine equivalents were reduced by 0.6 mg/h with no significant difference in LOS. A statistically significant difference in opioid-related adverse outcomes was found between the anticoagulated group vs. the no anticoagulation group. CONCLUSIONS: FICB is a safe and effective preoperative technique for initial pain management in patients with hip and proximal femur fractures, as it can also be used with additional systemic opioids. FICB administration may reduce systemic opioid use preoperatively, thus reducing opioid-related adverse effects with no significant impact on hospital LOS.

Retrospective Evaluation of Return Rates in Pediatric Patients Treated With Inhaled Racemic Epinephrine for Croup.

OBJECTIVES: To determine if the length of observation (< 2 hours vs ≥ 2 hours) following treatment of croup with inhaled racemic epinephrine in the emergency department (ED) is associated with return rates (within 48 hours after treatment) in pediatric patients. METHODS: We conducted a retrospective review of patients' medical records from February 2010 through June 2018 for pediatric patients (male and female, ≤ 12 years of age) diagnosed with croup in the ED, treated with racemic epinephrine, and discharged from the ED. RESULTS: We evaluated patients observed for less than 1 hour, 1 to 2 hours, and greater than 2 hours to determine difference in return rates within 48 hours. For patients with mild croup symptoms, 2% observed for less than 1 hour returned; 5% observed for 1 to 2 hours returned, and 3% observed for greater than 2 hours returned. Of the patients with moderate croup symptoms, 29% observed for less than 1 hour returned, 20% observed for 1 to 2 hours returned, and 20% observed for greater than 2 hours returned. A majority who returned for follow-up were not retreated with racemic epinephrine. CONCLUSION: Based on our study results, we can conclude that observing patients following treatment of croup with inhaled racemic epinephrine in the ED for less than 2 hours did not increase their risk of deterioration or need to return. Our data did not show that a longer observation time resulted in lower return rates within 48 hours.

Supraglottic airway device placement by respiratory therapists.

OBJECTIVE: Respiratory Therapists (RTs) are some of the first staff to arrive at in-hospital incidents where cardiopulmonary resuscitation (CPR) is needed, yet at some facilities, their ability to intubate is limited by hospital scope of practice. During the intubation process, CPR is often interrupted which could potentially increase the likelihood of adverse patient outcomes. Training RTs to secure the airway using non-intubation methods may reduce or eliminate time for CPR interruptions and allow for earlier continuous/uninterrupted chest compressions. DESIGN: A pilot study was developed to assess the effectiveness of a new policy for RT scope of practice. METHODS: RTs were trained for supraglottic airway device placement prior to procedure initiation. After each device insertion event, RTs completed a written survey. Time between cardiac arrest and device insertion, number of insertion attempts, ease of placement, technical specifications of the device, complications, and survival were compiled and compared between supraglottic airway device and endotracheal tube (ETT) placement. RESULTS: Procedural information from 23 patients who received a supraglottic airway device during the trial was compared to retrospective data of CPR events requiring intubation from the previous year. Time between initiation of cardiac arrest and advanced airway placement decreased significantly (p < 0.0001) when RTs placed the supraglottic airway device (4.7 min) versus ETT at CPR events the previous year (8.6 min). Device-associated complications were minimal and patient mortality was the same regardless of device. CONCLUSION: We propose that more RTs should be trained to insert supraglottic airway devices during inpatient CPR events.

Finding the key to a better code: code team restructure to improve performance and outcomes.

Code teams respond to acute life threatening changes in a patient's status 24 hours a day, 7 days a week. If any variable, whether a medical skill or non-medical quality, is lacking, the effectiveness of a code team's resuscitation could be hindered. To improve the overall performance of our hospital's code team, we implemented an evidence-based quality improvement restructuring plan. The code team restructure, which occurred over a 3-month period, included a defined number of code team participants, clear identification of team members and their primary responsibilities and position relative to the patient, and initiation of team training events and surprise mock codes (simulations). Team member assessments of the restructured code team and its performance were collected through self-administered electronic questionnaires. Time-to-defibrillation, defined as the time the code was called until the start of defibrillation, was measured for each code using actual time recordings from code summary sheets. Significant improvements in team member confidence in the skills specific to their role and clarity in their role's position were identified. Smaller improvements were seen in team leadership and reduction in the amount of extra talking and noise during a code. The average time-to-defibrillation during real codes decreased each year since the code team restructure. This type of code team restructure resulted in improvements in several areas that impact the functioning of the team, as well as decreased the average time-to-defibrillation, making it beneficial to many, including the team members, medical institution, and patients.