Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study.

BACKGROUND: Clinicians often encounter agitated patients, and current treatment options include benzodiazepines and antipsychotics. Ketamine rapidly induces dissociation, maintains cardiovascular stability, spontaneous respirations, and airway reflexes. There are no prospective, randomized studies comparing ketamine to other agents in the initial management of acute agitation in the Emergency Department (ED). OBJECTIVE: Determine the efficacy and safety of ketamine compared to parenteral haloperidol plus lorazepam for initial control of acute agitation. METHODS: This study was a prospective, single-institution, randomized, open-label, real world, standard of care pilot study. Adult patients with combative agitation were randomized to ketamine (4 mg/kg IM or 1 mg/kg IV) or haloperidol/lorazepam (haloperidol 5-10 mg IM or IV + lorazepam 1-2 mg IM or IV). The primary outcome was sedation within 5 min, and secondary outcomes included sedation within 15 min, time to sedation, and safety. RESULTS: Ninety three patients were enrolled from January 15, 2018 to October 10, 2018. Significantly more patients who received ketamine compared to haloperidol/lorazepam were sedated within 5 min (22% vs 0%, p = 0.001) and 15 min (66% vs 7%, p < 0.001). The median time to sedation in patients who received ketamine compared to haloperidol/lorazepam was 15 vs 36 min respectively (p < 0.001). Patients who received ketamine experienced a significant, but transient tachycardia (p = 0.01) and hypertension (p = 0.01). CONCLUSION: In patients with combative agitation, ketamine was significantly more effective than haloperidol/lorazepam for initial control of acute agitation, and was not associated with any significant adverse effects.

Preceptors' experiences of using a competence assessment tool to assess undergraduate nursing students.

The purpose of this study was to explore Irish preceptors' experience of using a competence tool to assess undergraduate nursing students' clinical competence. This study used a mixed methods design. This study was conducted in two phases, the qualitative phase involved six focus group interviews to ascertain preceptors' experiences of using an assessment tool to assess clinical competence. The quantitative phase involved a descriptive survey measuring preceptors (N = 843) attitudes linked with the use of the assessment tool. The key themes that emerged from qualitative analysis were challenges of using the assessment tool, recognising competence and valuing adult learners. The challenges of using the tool included negotiating complex language and time constraints in completing assessments. Recognising competence revealed the use of intuition and subjectivity. While valuing adult learners acknowledged the reciprocal learning process between the preceptor and the learner. These findings reveal the inherent skills of preceptors to intuitively and subjectively recognise competence. The quantitative findings revealed merits and challenges for the preceptors using the assessment tool. In particular the complexity of the language was highlighted as an issue. A key recommendation from this research is the need to revise the assessment tool to support objective and subjective measurement of competence.