Supplemental thiamine for the treatment of acute heart failure syndrome: a randomized controlled trial.

BACKGROUND: The purpose of this pilot study was to determine if a definitive clinical trial of thiamine supplementation was warranted in patients with acute heart failure. We hypothesized that thiamine, when added to standard of care, would improve dyspnea (primary outcome) in hospitalized patients with acute heart failure. Peak expiratory flow rate, type B natriuretic peptide, free fatty acids, glucose, hospital length of stay, as well as 30-day rehospitalization and mortality were pre-planned secondary outcome measures. METHODS: This was a blinded experimental study at two urban academic hospitals. Consecutive patients admitted from the Emergency Department with a primary diagnosis of acute heart failure were recruited over 2 years. Patients on a daily dietary supplement were excluded. Randomization was stratified by type B natriuretic peptide and diabetes medication categories. Subjects received study drug (100 mg thiamine or placebo) in the evening of their first and second day. Outcome measures were obtained 8 h after study drug infusion. Dyspnea was measured on a 100-mm visual analog scale sitting up on oxygen, sitting up off oxygen, and lying supine off oxygen with 0 indicating no dyspnea. Data were analyzed using mixed-models as well as linear, negative binomial and logistic regression models to assess the impact of group on outcome measures. RESULTS: Of 130 subjects randomized, 118 had evaluable data (55 in the control and 63 in the treatment groups), 89% in both groups were adjudicated to have primarily AHF. Thiamine values increased significantly in the treatment group and were unchanged in the control group. One patient had thiamine deficiency. Only dyspnea measured sitting upright on oxygen differed significantly by group over time. No change was found for the other measures of dyspnea and all of the secondary measures. CONCLUSIONS: In mild-moderate acute heart failure patients without thiamine deficiency, a standard dosing regimen of thiamine did not improve dyspnea, biomarkers, or other clinical parameters. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00680706 , May 20, 2008 (retrospectively registered).

A comparison of patient and nurse expectations regarding nursing care in the emergency department.

INTRODUCTION: Patient satisfaction, an important measurable outcome, allows nurses to assess what can be improved in nursing practice. The purpose of this study is to compare expectations of patients and nurses using 3 nursing care attributes: 1) friendliness, courtesy, and respectfulness; 2) comfort measures; and 3) degree of information sharing. METHODS: This is an Institutional Review Board-exempt survey of paired patients' and nurses' perceptions of nursing care in a 50-bed emergency department of a level 1 trauma center. The survey consists of questions that addressed 3 performance attributes of nursing care. The respondent circled their responses in a Likert scale of 5 choices from 1: "way below expectation" to 5: "way above expectation." An open-ended comment section followed each question; the last survey item asked for recommendations on how to make nursing care extraordinary. RESULTS: Nineteen males and 30 female patients, ages 18-89 participated. Of the nurse participants, 20% had <5 years ED experience, 22% had 5-10 years, and 52% had >10 years. The patients rated the care they received consistently higher than nurses. The difference in the average patient ratings vs. the average nurse's rating was significant. (P = < 0.002, paired T test and Sign test). Patient ratings were also consistently higher when patients either knew their nurse's name or were able to identify them by sight. The higher average rating was significant in all 3 attributes (P = 0.02, Wilcoxon Rank-sum test). DISCUSSION: The unexpected highly positive patient rating did not identify specific areas for practice improvement; it did provide positive feedback for excellent care, reinforcing good nursing practice.

Near-infrared spectroscopy assessment of tissue saturation of oxygen in torsed and healthy testes.

OBJECTIVES: The objective was to assess whether testicular torsion is associated with low testicular tissue saturation of oxygen (StO2 ) as measured by transscrotal near-infrared spectroscopy (NIRS) and to compare the differences in NIRS values between testicles of the same patient, both in patients with testicular torsion and in healthy controls. METHODS: This was an observational study of healthy controls and patients with surgically confirmed testicular torsion who were recruited from males under 30 years of age presenting to the emergency department (ED). The hypothesis was that the difference in NIRS values for the control's two testicles would be zero, and that the difference between the torsed and healthy testicles on an individual patient would not be zero. Based on animal data, the study was powered to detect an absolute difference of StO2 of 47%. RESULTS: The mean StO2 for the left control patients' testicles was 73.6% (95% confidence interval [CI] = 68.0% to 79.1%) and the mean StO2 for the right controls' testicles for controls was 73.6% (95% CI = 66.9% to 80.4%; n = 17). The absolute difference in NIRS StO2 for left minus right for each individual was 3.5% (95% CI = 1.8% to 5.4%), which was significantly different (p = 0.0007), and refuted the hypothesis that there was no significant difference in StO2 between left and right testes in healthy patients. In the testicular torsion group, the torsed side had a mean StO2 of 82.8% (95% CI = 68.7% to 96.9%), and the contralateral nontorsed testes had a mean of 85.8% (95% CI = 72.3% to 99.3%). The mean StO2 difference, nontorsed minus torsed was 3.0% (range = -1% to 9%, 95% CI = -2% to 8%; p = 0.174), refuting the hypothesis that torsed testes would demonstrate significantly lower values for StO2 . CONCLUSIONS: While pilot animal investigations support a potential role for transscrotal NIRS for the detection of testicular torsion, this first clinical translation of animal findings reveals that the investigated, transcutaneous, reflectance geometry NIRS device failed to demonstrate symmetric oxygenation of left and right testes in healthy controls and also failed to demonstrate depressed tissue saturation of oxygen values in patients with confirmed testicular torsion. While limited by a small sample size, other problems such as inability to calibrate depth of measurement of StO2 may have led to falsely elevated readings in patients with torsion.

A "back to basics" approach to reduce ED medication errors.

INTRODUCTION: Medication error is the most frequently reported error in the emergency department. Nationally, 36% of medication errors occur in the administration phase. The purpose of this study is to reduce medication administration errors in the emergency department by reinforcing basic medication administration procedures. METHODS: This study examined a 3-month educational intervention using a nonrandomized, single group comparing pre-post outcome variables. The educational intervention, titled "Preventing Medication and IV Administration Errors," described current medication errors in the emergency department, and recommended practices for reducing medication administration errors. Of 127 nurses, 75% participated. Three measures used pre- and post-intervention were: a) knowledge of medication administration procedures assessed by tests; b) behaviors reflecting recommended medication practices assessed by surveys; and c) medication administration errors, identified via chart review and voluntary error reports. RESULTS: In the post-test, 91% achieved perfect scores vs. 69% on the pre-test (P =. 0001). In the post-survey, the proportion responding that they follow recommended practice "all" or "most" of the time increased in 8 of the 10 survey questions, but the changes did not reach statistical significance (P = .98). Reviews of charts (299 pre-test and 295 post-test) revealed little change in total medication errors: 25% vs. 24% (P = .78). Voluntarily reported medication errors dropped from 1.28 to .99 errors/1000 patients. DISCUSSION: This educational intervention successfully improved knowledge of recommended medication administration practices. However, improved knowledge did not translate to a significant change in practice. More research is needed to identify interventions that can modify behavior in clinical settings.

Assessing validity by comparing transition and static measures of dyspnea in patients with acute decompensated heart failure.

This study assessed the convergent validity of 2 dyspnea measures, the transition measure and the change measure, by comparing them with each other in patients admitted to the hospital with acute decompensated heart failure. Static measures of dyspnea were obtained at baseline (pre-static measure) and at time 1 hour and 4 hour (post-static measures). The change measure was calculated as the difference between the pre-static and post-static measures. Transition measures were obtained at time 1 hour and 4 hour. Visual analog scales and Likert scales were used. Both physicians and patients measured the dyspnea independently. A total of 112 patients had complete data sets at time 0 and 1 hour and 86 patients had complete data sets at all 3 time points. Correlations were calculated between the transition measures and static measures (pre-static, post-static, and change measure). Bland-Altman plots were generated and the mean difference and limits of agreement between the transition measures and the change measures were calculated. In general, short-term dyspnea assessment using transition measures and serial static measures can not be used to validate each other in this population of patients being admitted with acute decompensated heart failure.

Physician vs patient assessment of dyspnea during acute decompensated heart failure.

This study assessed agreement between physician and patient self-reported measures of dyspnea severity during acute decompensated heart failure (ADHF). Both the physician and patient measured the change in dyspnea severity over 1 hour using 2 methods: (1) the difference of two static dyspnea measures (STATIC) and (2) a single transitional measure (TRANS). Likert scales and visual analog scales (VASs) were used. Data on 112 patients were analyzed. The mean difference between physician and patient VAS scores was 1 mm (limits of agreement: -54 to 56 mm) using the STATIC data. For TRANS data, the mean difference was 5 mm (limits of agreement: -75 to 86 mm). For the Likert scales, the weighted kappa was 0.13 and 0.23 for STATIC and TRANS data, respectively. The wide limits of agreement restrict our ability to substitute physician assessment for patient self-assessment of dyspnea in patients with ADHF.

Pulse oximetry using a disposable finger sensor placed on the forehead in hypoxic patients.

BACKGROUND: Disposable pulse oximetry sensors designed for the finger are sometimes placed on the forehead. Although finger sensors have not been designed to accurately measure arterial oxygen saturation when placed on other body parts, they are used on the forehead when an oximetry waveform cannot be obtained from the finger. OBJECTIVES: The purpose of this prospective observational study was to measure the agreement between disposable transmittal sensors placed on the finger and the same sensors placed on the forehead. METHODS: We used a convenience sample of hypoxic emergency department patients. Patients were attached to three oximeters: 1) a non-disposable finger sensor (reference); 2) a disposable finger sensor placed on the finger; and 3) a disposable finger sensor placed on the forehead. Data were analyzed using the Bland-Altman method. A difference of 5% was considered clinically significant. RESULTS: Twenty-five patients were approached, and 20 were enrolled. Eleven of the patients had an absolute difference between the disposable finger sensor placed on the finger compared to the forehead > or = 5%. CONCLUSION: Pulse oximetry measurements taken on the forehead using a disposable finger sensor were inaccurate in over half of the subjects. Therefore, disposable finger oximetry sensors should not be placed on the forehead.

Emergency department patients who stay more than 6 hours contribute to crowding.

BACKGROUND: Admitted and discharged patients with prolonged emergency department (ED) stays may contribute to crowding by utilizing beds and staff time that would otherwise be used for new patients. OBJECTIVES: To describe patients who stay > 6 h in the ED and determine their association with measures of crowding. METHODS: This was a retrospective, observational study carried out over 1 year at a single, urban, academic ED. RESULTS: Of the 96,562 patients seen, 16,017 (17%) stayed > 6 h (51% admitted). When there was at least one patient staying > 6 h, 60% of the time there was at least one additional patient in the waiting room who could not be placed in an ED bed because none was open. The walk-out rate was 0.34 patients/hour when there were no patients staying in the ED > 6 h, vs. 0.77 patients/hour walking out when there were patients staying > 6 h in the ED (p < 0.001). When the ED contained more than 3 patients staying > 6 h, a trend was noted between increasing numbers of patients staying in the ED > 6 h and the percentage of time the ED was on ambulance diversion (p = 0.011). CONCLUSION: In our ED, having both admitted and discharged patients staying > 6 h is associated with crowding.

Blood glucose measurement in patients with suspected diabetic ketoacidosis: a comparison of Abbott MediSense PCx point-of-care meter values to reference laboratory values.

INTRODUCTION: The purpose of this study is to compare blood glucose levels measured by a point of care (POC) device to laboratory measurement using the same sample venous blood from patients with suspected diabetic ketoacidosis (DKA). METHODS: A descriptive correlational design was used for this IRB-approved quality assurance project. The study site was the 50-bed BMC emergency department (ED) which has an annual census of over 100,000 patient visits. The convenience sample consisted of 54 blood samples from suspected DKA patients with orders for hourly blood draws for glucose measurement. Spearman correlations of the glucose POC values, reference lab values, and differences between the two, were evaluated. A chi-square test was used to evaluate the association between the acidosis status and FDA acceptability of POC values. RESULTS: Patient age range was 10-86 years; 63% were females; 46% had a final diagnosis of DKA. POC values underestimated glucose levels 93% of the time. There was a high correlation between the lab value and the magnitude of the difference, (lab minus POC value) indicating that the higher the true glucose value, the greater the difference between the lab and the POC value. A chi-square test showed no overall association between acidosis and FDA-acceptability. DISCUSSION: The POC values underestimated lab reported glucose levels in 50 of 54 cases even with the use of same venous sample sent to the lab, which make it highly unreliable for use in monitoring suspected DKA patients.

Testing a classification model for emergency department errors.

AIM: This paper presents an evaluation of the Eindhoven Classification Model for categorizing healthcare errors. BACKGROUND: The ability to decrease healthcare errors will depend on an understanding of the types and patterns of error that occur in various settings. Research addressing the systematic classification of error is in its infancy. METHODS: The sample for this study was two existing sets of healthcare error reports obtained from the emergency department of a regional trauma center. Study data were collected in the summer of 2001 and 2002. The errors in these reports were categorized using a coding tool based on the Eindhoven Classification Model. In addition to testing for inter-rater reliability, the classification model was also evaluated for the number of unclassifiable errors and of categories never selected by the raters (not useful to the error classification model). RESULTS: Our findings of poor inter-rater reliability, large numbers of unclassifiable errors and categories not selected, suggest that the Eindhoven Classification Model, in its current form, cannot be applied to categorizing healthcare errors in an emergency department setting. CONCLUSIONS: Further study is needed to develop and test error categorization models for use in emergency departments and other healthcare settings.

Strategies used by nurses to recover medical errors in an academic emergency department setting.

PURPOSE: The purpose of this study was to gain insight into how nurses recover medical errors in the emergency department (ED) setting. METHODS: The research method was of exploratory descriptive design with qualitative analysis. Subjects who signed the informed consent participated in one of four focus groups centering on nurse's role in recovering errors. Questions were asked during the focus groups to elicit information regarding nurse's role in the three phases of error recovery, namely, identifying, interrupting, and correcting the error. RESULTS: Five themes emerged to describe methods used by nurses to identify errors in the ED setting. These themes included: surveillance, anticipation, double checking, awareness of the "big picture," and experiential "knowing." Five themes emerged as methods used to interrupt errors: patient advocacy, offer of assistance, clarification, verbal interruption, and creation of delay. The themes for correcting an error were assembling the team and involving leadership. CONCLUSION: The results of this study provide preliminary evidence of the strategies used by ED nurses in the recovery of medical error. Further research is needed to generalize these findings to other ED settings. Knowledge of effective recovery strategies can ultimately be used to develop interventions for reducing medical error and improving patient safety.

A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users.

INTRODUCTION: Emergency department (ED) overcrowding has been a significant problem for the last 10 years. Several studies have shown that a relatively small number of ED patients are responsible for a disproportionate amount of ED visits. This study aims to describe the frequent users of our emergency department. METHODS: This was an institutional review board-approved descriptive study performed by a retrospective review of electronic records. This pilot describes and compares patients who had 12 or more ED visits during the study year with those who visited less. RESULTS: The 234 patients who met criteria for high-frequency use (HFU) of the emergency department were responsible for a total of 4633 visits. Sex, race, and age distribution of HFU patients were similar to those of general ED patients. Eighty-four percent of HF users have insurance and 93% have primary care providers. A relatively small percentage of HFU visits, 4%, were mental health-related visits and 3% were alcohol- and drug-related visits. The HFU visits are socially connected: 93% have their own homes; 94% have relatives or friends; 73% have a religious affiliation. Pain or pain-related conditions are the most common diagnoses. These patients are also frequent users of ambulatory care services. CONCLUSION: The similarities between our HFU and the general ED population are more numerous than their differences. The HFU patients of our emergency department are different in terms of age, employment status, and type of insurance. IMPLICATIONS FOR NURSES: A detailed description of local HFU may help to inform planning and better meet ED patients' needs. As one of many results of this study, the ED chairman met with the Hematology-Oncology team and reviewed the protocol for ED management of sickle cell crisis. The meeting resulted in a revised protocol, including an immediate change in their pain medication from meperidine to either morphine or hydromorphone.

Errors in a busy emergency department.

STUDY OBJECTIVE: We describe errors occurring in a busy ED. METHODS: This is a prospective, observational study of reported errors at an academic emergency department (ED) with 100000 annual visits. Trained personnel interviewed all ED staff with direct patient contact, during and at the end of every shift, by using standardized data sheets. RESULTS: One thousand nine hundred thirty-five ED patients registered during the 7-day study period in the summer of 2001. Four hundred error reports were generated, identifying 346 nonduplicative errors (18 per 100 registered patients; 95% confidence interval [CI] 15.9 to 20.0). Forty percent of errors were reported by nurses, 25% by providers, 19% by clerical staff, 13% by technicians and orderlies, and 3% multiple reporters. Errors reported for every 100 hours worked were similar for all groups (5.5; 95% CI 5.2 to 5.9). Errors were categorized as 22% diagnostic studies, 16% administrative procedures, 16% pharmacotherapy, 13% documentation, 12% communication, 11% environmental, and 9% other. Patients involved in errors were more likely to be older (P <.0001) and more likely to have higher visit level intensity (P <.0001) than registered ED patients. Ninety-eight percent of errors did not have a significant adverse outcome. Seven errors (0.36 per 100 registered patients; 95% CI 0.14 to 0.72) were associated with an adverse outcome. CONCLUSION: Reported errors occurred in almost every aspect of emergency care. Ninety-eight percent of errors in the ED do not result in adverse outcomes. System changes need to be implemented to reduce ED errors.

How reliable are pain scores? A pilot study of 20 healthy volunteers.

INTRODUCTION: Pain scales such as the 100-MM Visual Analog Scale and the 10-point Numeric Rating Scale are used to describe pain intensity. The Visual Analog Scale and the Numeric Rating Scale provide accurate descriptors for a patient's perceived level of pain. But how accurate or reliable is a patient's perception of pain? METHODS: To test the relationship between the intensity of the pain stimulus and pain perception, we devised an experiment using a convenience sample of 20 healthy adult volunteers. A cutaneous nerve stimulator delivered a series of shocks of increasing intensity to the individual via a pediatric EKG electrode. The participants indicated their threshold for "intolerable pain." With use of this same level of stimulus in subsequent shocks, the participants, blinded to the amount of stimulus, were then asked to rate each shock as either "the same," "a little less," or "a little more" than the baseline stimulus. They then recorded their VAS score for each stimulus. RESULTS: "Intolerable pain" varied widely between 8 mm to 73 mm; likewise, the level of stimulus that produced this pain ranged from 4 to 9. Once a person's threshold of "intolerable pain" had been reached, 49% of the subsequent shocks were perceived as different, even though the stimulus was exactly the same. DISCUSSION: This experiment showed that (1) given the same intensity of pain stimulus, different persons have different perceptions of pain; and (2) the same intensity of pain stimulus, given to the same person repeatedly, does not result in the same self-report of pain intensity.

Evaluation of an educational video for cardiac patients.

Prehospital delay is a major problem in the management of patients with acute cardiac ischemia. The authors created a patient teaching program consisting of an educational video and written instructions designed to reduce prehospital delays in patients with chest pain. Patients who received standard discharge instructions served as the control group, whereas those who received the new patient teaching in addition to standard discharge instructions served as the intervention group. Of the 500 enrolled, 19% were rehospitalized within 1 year. Analysis of rehospitalizations showed no significant difference between the two groups on the three outcome variables: percentage who presented within thefirst hour of pain, use of ambulance, and time from anginal onset to emergency department arrival. In a comparison of the index hospitalization to the rehospitalization, there was a significant increase in the use of ambulances for the intervention group, p = .03, but not for the control group.