ED Push - September 2016 First Issue

Nurse-Driven Protocols Reduce Lengths of Stay for Some ED Patients

EDMONTON, ALBERTA – If your emergency department is looking for a way to shorten length of stay for certain common conditions, the answers might be all around you. Literally.

A new Canadian study published in Annals of Emergency Medicine suggests that protocols permitting nurses to administer specific types of ED treatment can significantly shorten length of stay (LOS) for patients with fever, chest pain, hip fractures, and vaginal bleeding during pregnancy.

“For certain patients, nurse-driven protocols can dramatically decrease the amount of time they spend in the emergency department,” explained lead author Matthew Douma, RN, BSN, clinical nurse educator at Royal Alexandra Hospital in Edmonton, Alberta. “Emergency department crowding is a common and complicated problem, so anything we can do to get our patients treated and discharged is to the good. It helps everyone in the ER by reducing crowding.”

The Joint Commission mandates that any nurse-driven protocols must be written so that there is no doubt as to the requirements needed to implement them and should take nationally recognized and evidence-based guidelines into account.

In this case, evaluation of the six nurse-initiated protocols occurred in a busy, crowded, inner-city ED. Researchers measured them against primary outcomes, including time to diagnostic test, time to treatment, time to consultation, or ED length of stay.

Results indicate that the nurse-driven protocols decreased the median time to administer acetaminophen to ED patients with pain or fever by more than three hours. In addition, those types of protocols decreased average time by 79 minutes for troponin testing of patients with chest pain suspected to be heart attack, while average LOS was reduced by almost four hours for patients presenting with fractured hips and with vaginal bleeding.

“Given the long waits many emergency patients endure prior to treatment of pain, the acetaminophen protocol was a quick win,” Douma pointed out in an American College of Emergency Physicians press release. “That said, nurse-driven protocols are not an ideal solution, but a stop-gap measure to deal with the enormous problem of long wait times in emergency departments especially for patients with complex problems. Emergency department crowding will continue to require broad and creative strategies to ensure timely care to our patients."

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New Guidance on Managing Pediatric Mental Health Emergencies

PROVIDENCE, RI – The rates of children and adolescents presenting to the emergency department with mental health and behavioral emergencies has soared, with as many as 70% of ED patients screening positive for at least one mental health disorder,and 45% potentially having a mental health problem resulting in impaired psychosocial functioning.

That’s according to information provided by the American Academy of Pediatrics (AAP), which recently released a set of new clinical reports to assist ED clinicians and others in caring for children and adolescents with acute mental health and behavioral problems. The two reports, Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part 1: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies and Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms, along with executive summaries, are due to be published in the September issue of Pediatrics.

Lead author Thomas H.Chun, MD, MPH, of Brown University noted that an especially worrisome trend is the rise in “boarding” of psychiatric patients in the ED and inpatient pediatric units for extended stays of days or even weeks. He pointed out in an online AAP article that the practice, while not well-researched, appears to be a problem because of the lack of mental health services in those settings.

The reports were written from the perspective of ED clinicians and are designed to help guide them in caring for children and adolescents during an acute crisis, Chun said.

Part I focuses on patients presenting to the ED with a chief complaint involving mental health problems. It includes information on medical clearance of pediatric psychiatric patients, suicidal ideation and suicide attempts, involuntary hospitalization, as well as coordination of care with the medical home. Among the issues discussed is restraint of agitated patients, including a comparison of verbal, chemical, and physical restraint methods.

In Part II, the authors discuss challenging patients with primarily medical or indeterminate presentations in which an underlying mental health condition remains unclear or is a complicating factor. Other topics covered in the report include:

• somatic symptom and related disorders;
• adverse effects to psychiatric medications (including antipsychotics, neuroleptic malignant syndrome, and serotonin syndrome); and
• children with special needs in the ED (including autism spectrum and developmental disorders).

Because mental health conditions frequently go unrecognized by clinicians, the second part of the report also includes information about rapid mental health screening tools, including screens for depression, anxiety, post-traumatic stress, and substance abuse.

Chun noted that vague somatic complaints such as headache, gastrointestinal tract distress, back pain, or concern for a sexually transmitted infection, among others, can mask underlying mental health conditions.

The reports were developed by the pediatric emergency medicine committees of the AAP and the American College of Emergency Physicians (ACEP).

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Care Improved by Information on Patients Most Likely to Develop Sepsis

ATLANTA – Which patients are most likely to develop sepsis?

Knowing the answer to that question could aid in prevention, early recognition, and more effective treatment strategies, according to a new study published in the Morbidity & Mortality Weekly Report, which details patient demographics, risk factors, and infections leading to sepsis.

To better describe characteristics of patients with sepsis, researchers from the national Centers for Disease Control and Prevention and co-authors conducted a retrospective chart review in four New York hospitals, reviewing random samples of medical records from adult and pediatric patients with administrative codes for severe sepsis or septic shock. Overall, medical records of 246 adults and 79 children up to age 17 were reviewed.

Results indicate that 72% of patients had healthcare involvement during the 30 days before sepsis admission or a selected chronic condition requiring frequent medical care. The most common infection leading to sepsis was pneumonia, with Escherichia coli in adults, Klebsiella spp. in children 1 year of age or older, and Enterococcus spp. in infants younger than 1 year of age being the most common pathogens isolated from blood cultures. No pathogen was isolated for 33% of the patients, according to the report.

A fourth of the patients died, including 26% of adults and 22% of infants and children, study authors report.

The median age of adult patients with sepsis was 69 years and 52% were male, according to the study, which found that the median length of hospital stay was nine days. Most patients, 97%, had at least one comorbidity, most commonly diabetes mellitus, 35%; cardiovascular disease (including coronary artery disease, peripheral vascular disease, or congestive heart failure), 32%; chronic kidney disease, 23%; and chronic obstructive pulmonary disease, 23%.

After pneumonia, which was identified in 35% of sepsis patients, urinary tract infections 25%; gastrointestinal infections, 11%, and skin/soft tissue infections, 11%, were most likely to be the precipitating infections, according to the results.

The majority of cases among adults, 58%, were identified as healthcare-associated, with 18% of those hospital-onset and 42% classified as community-associated, without healthcare factors. Acute care hospitalization or nursing home stays of two or more days in the preceding 30 days were the most common experiences leading to development of sepsis, the study notes.

Another issue, according to the researchers, is that only 44% of sepsis patients had received pneumococcal vaccination in the preceding year and 35% had received a flu shot.

For pediatric patients, at least one comorbidity was present for 78% of sepsis patients, with congenital heart disease being the most common condition for infants, affecting 23% of patients, and cognitive deficits or cerebral palsy being most common for children, 38%.

Children who developed sepsis were most likely to have respiratory infections, 29%, followed by gastrointestinal infections, 24%, according to the results.

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EDs Miss Opportunity to Get Treatment for Potential Diabetes Patients

TEL AVIV, ISRAEL – Emergency departments might be missing an opportunity to help patients with diabetes receive treatment.

A study published in the International Journal of Clinical Practice sought to assess the prevalence of hyperglycemia in patients presenting to an ED with no known history of diabetes, and to evaluate how often the medical staff recommended those patients follow up with outpatient care.

To do that, Tel Aviv University researchers and colleagues from Israel and the United States performed a cross-sectional study, examining the medical records of adult patients referred to an ED between Nov. 1, 2011, and Jan. 31, 2012. Included were patients with random blood glucose of 140 mg/dL or higher and no known history of diabetes.

Discharge documents were examined for the presence of instructions to conduct further follow-up.

During the time period, 16,784 patients presented to the ED, and 2.4% without known diabetes were determined to be hyperglycemic. Of those, 346 patients had blood glucose levels 140 mg/dL or greater, with 56 patients having blood glucose levels above 200 mg/dL.

Yet, according to the results, only 35 of the 402 included patient files (8.7%) contained instructions for further investigation. No statistically significant differences were discovered in terms of age, sex, or blood glucose levels between those who received a letter for further follow-up compared with those who did not.

“Over 2% of patients who presented to the [ED] were hyperglycemic, without a prior diagnosis of diabetes,” study authors conclude. “A small percent was recommended to have outpatient follow-up. This represents a missed opportunity for earlier diagnosis of diabetes and emphasized the need for raising medical staff awareness concerning abnormal blood glucose and its implication.”

A retrospective review published earlier this year, which used U.S. data, found that hospitals in general are missing an opportunity for early diabetes detection among inpatients because of underuse of glycated hemoglobin testing.

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