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written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date.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.

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.

Improving comfort and throughput for patients undergoing fractionated laser ablation of symptomatic burn scars.

INTRODUCTION: Utilization of fractionated ablation with a carbon dioxide (CO2) laser has shown to be efficacious in the management of symptomatic burn scars. Although effective, this procedure is painful and burn patients traditionally evidence low pain tolerance. For this reason intravenous anesthesia is used during these procedures. However, operative anesthetics and intravenous opioids are associated with patient discomfort postoperatively and prolonged recovery times. The American Society of Anesthesiologists' (ASA) Task Force on Acute Pain Management for the perioperative setting recommends the use of multimodal anesthesia, including the use of regional blockade with a local anesthetic. A quality improvement project was implemented to incorporate this practice and evaluate outcomes. The main goal of this project was to improve patient comfort as evidenced by improved pain scores with a decreased requirement for intravenous opioids post-procedure. The secondary goal of this project was to improve patient throughput in the setting of an outpatient surgical facility as evidenced by decreased time in the facility. METHODS: A historic cohort of 36 cases was compared to 36 cases managed under the ASA guidelines for multimodal anesthesia utilizing a topical local anesthetic. Statistical analysis included a t-test for continuous variables while chi square was utilized to analysis dichotomous variables. RESULTS: Intravenous narcotic utilization and mean pain scores in the recovery phase of care were significantly reduced as a result of adoption of the ASA recommendations. Throughput time increased by 36 minutes; notably in the preoperative phase, while patient movement through the procedural phase was significantly decreased as was procedure to discharge times. CONCLUSIONS: Implementing the use of a topical anesthetic as a component of multimodal anesthesia for patients undergoing fractionated laser ablation of symptomatic burn scars can significantly decrease patient pain and the need for intravenous opioids during the recovery phase of care. Increased overall throughput times were noted primarily in the preoperative period, while procedure to discharge times decreased. As operative and recovery phases represent higher operational costs, decreased time in these areas represent potential cost savings for the facility.

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.

Evaluation of the effect of the modified early warning system on the nurse-led activation of the rapid response system.

The modified early warning system (MEWS) is a scoring rubric used to detect the earliest signs of a change in a patient's condition. This mixed-methods study used pre- and postintervention data to describe the impact of the MEWS on the frequency of rapid response system activations and cardiopulmonary arrests among patients admitted to medical-surgical units. Focus groups of nursing staff provided insight into the factors that influence how nurses use the MEWS at the bedside as a framework to identify, intervene, and manage patients in need of an advanced level of care.

Preparing quality improvement, research, and evidence-based practice manuscripts.

Understanding how to organize a manuscript reporting quality improvement (QI), research, and evidence-based practice (EBP) initiatives is important to provide essential information for readers to evaluate the findings for possible use in their own settings and replicate studies. Using guidelines for reporting QI, research studies, and EBP initiatives will help ensure authors submitting manuscripts to peer-reviewed publications report essential information and communicate it clearly to readers. This framework also guides the design and implementation of a project to ensure the information needed for a manuscript is collected and recorded for use in dissemination when the project is completed. Providing this specific information may also affect the likelihood of the manuscript being accepted for publication.

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.

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.