Is it safe to discharge a heart failure patient?
About one-third of heart failure patients are discharged from the ED home, and some of these patients are at risk for dying shortly after their ED visit, says a new study.1
"The mortality rate of patients with heart failure who are discharged from the ED is not small," says Douglas S. Lee, MD, PhD, FRCP(C), the study's lead author and assistant professor of medicine at the University of Toronto, Ontario. "Acute heart failure should be viewed as a very serious condition with significant potential for death."
Among 50,816 heart failure patients treated at 180 EDs in Ontario from April 2004 to March 2007, 16,094 were discharged. Of this group, 4% died within 30 days, and 1.3% died within one week.
Patients who arrived by ambulance, those who had more prior heart failure admissions, and those who spent longer duration of time in the ED were more likely to die within seven days of being discharged from the ED. Also, older patients, men, and those with valvular, peripheral vascular, or respiratory disease were more likely to die.
"This study highlights the need for clinical tools to help us to decide which heart failure patients could be safe to discharge from the ED," says Lee.
- Lee DS, Schull MJ, Alter DA, et al. Early deaths in heart failure patients discharged from the emergency department: A population-based analysis. Circ: Heart Failure2010; 3:228-235.
For more information on heart failure patients in the ED, contact:
- Douglas S. Lee, MD, PhD, Assistant Professor of Medicine, University of Toronto, Ontario. Phone: (416) 480-6100 ext. 3018. E-mail: firstname.lastname@example.org.
Staff should be prepared for car crash victims
Most aren't treated at trauma centers
About two-thirds (63%) of the 3.5 million motor vehicle crash victims treated in emergency departments in 2006 were not treated in trauma centers, says a new analysis from the Agency for Healthcare Research and Quality.
The patients' injuries included sprains (44%), superficial injuries such as scrapes (35%), open wounds (10%), fractures (15%), head injuries (5%), and internal injuries of the thorax, abdomen, and pelvis (3%).
'Trauma has no boundaries," says Shelley L. Sides, RN, MSN, trauma coordinator at Eastern Maine Medical Center in Bangor. "Any nurse in any ER can be faced with a critical trauma patient. The initial care the trauma patient receives is important to overall morbidity and mortality."
To improve care of motor vehicle crash victims:
Use multiple confirmatory techniques to verify advanced airway placement, including end tidal carbon dioxide monitoring.
Steven Glow, MSN, FNP, RN, associate clinical professor at Montana State University College of Nursing in Missoula, says, "Evidence suggests that non-visualized airways take less time and are more likely to be placed correctly."
Glow recommends monitoring end tidal carbon dioxide levels in intubated patients to detect and modify hypo or hyperventilation. "Recently intubated patients are often hyperventilated, causing undesirable acid/base shifts and decreasing survival," he says.
Make sure the patient's circulation is being accurately monitored.
Laura Aagesen, RN, BSN, MBA, trauma coordinator at Northwest Community Hospital in Arlington Heights, IL, says, "This reduces the risk of hemorrhage, which is the main cause of post-injury death."
Consider the medications your patient is taking.
Warfarin, clopidogrel, and acute aspirin therapy put patients at a higher risk for hemorrhage, says Aagesen. "A patient with a history of radiation therapy for breast cancer having a fall will be at a much higher risk for fractures than a patient without any comorbidity," she adds.
In addition, antihypertensive medications such as beta and calcium channel blockers can interfere with normal compensatory mechanisms, which decreases the ability of the patient to mount a tachycardic or vasoconstrictive response, says Glow. "As a result, early signs of shock may not be recognized, and these patients can decompensate more quickly."
If you suspect a cervical injury, patients require a cervical spine collar and must remain in a supine position.
Aagesen says, "Log rolling techniques should be used when transferring the patient from the cart to any other surface. Allowing a patient to ambulate or sit in a wheelchair with a cervical collar is a dangerous practice."
Assess the patient's breathing for the presence and effectiveness of respirations.
Assess for rate and pattern, accessory muscle usage, chest excursion, chest symmetry, skin color, and lung sounds. "All trauma patients should receive supplemental oxygen to ensure tissue oxygenation," adds Sides.
The patient with a compromised respiratory status might require assisted respirations with eventual intubation. "Be familiar with supplies and medications used for rapid sequence intubation," says Sides. "Patients should always receive sedation with a paralytic, as paralyzing agents do not offer any sedative effects."
Undress patients to identify external injuries that might assist in the identification of underlying internal injuries.
You might find other wounds, including stab wounds, gunshot exit, or entry wounds. Unresponsive patients or patients with other distracting injuries may not be reliable in telling you where their injuries are," says Aagesen.
Removing clothing also could help prevent further injury for a patient involved in a motor vehicle crash. Aagesen says, "Your patient could potentially lay in pieces of glass throughout your entire assessment, causing discomfort and potential injury to the skin and underlying tissues."
For more information on improving care of trauma patients involved in motor vehicle crashes in the ED, contact:
Trauma patient stable? Don't assume a thing
Never be complacent
Although a 76-year-old motor vehicle crash victim was stable in the field, the ED nurse noted hypotension when the patient arrived. The patient quickly was bolused with fluids, and her blood pressure stabilized after 30 minutes. She underwent several CT scans, which revealed multiple injuries.
"The patient continued to stay alert and talking with staff, when suddenly she became unresponsive and went into cardiopulmonary arrest," says Laura Aagesen, RN, BSN, MBA, trauma coordinator at Northwest Community Hospital in Arlington Heights, IL.
The consequences of hypotension in trauma rely on the patient's physiologic reserves and if there are any underlying illnesses or disorders, explains Aagesen. In this particular case, an early sign of a problem came when the patient started answering questions in a confusing way.
"This change in mental status was an early sign of decompensating," says Aagesen. "Due to the comorbidities and severity of the injuries, the patient was not able to recover."
'Chaotic, code type situation'
If you rely on initial normal vital signs or fail to perform frequent reassessments of your patient, these decisions could result in a "chaotic, code type situation," warns Aagesen. A patient coming in by EMS might have given the appearance of being stable in the field and rapidly decompensate after arrival to the ED. "A simple head injury to a geriatric patient who presents talking to you on arrival to the ED can turn into an unresponsive patient with a herniating subdural hematoma within minutes," says Aagesen.
Look at your patient's color, skin temperature, and moisture, and assess heart rate, blood pressure, and urine output to ensure your patient's hydration status, says Aagesen.
Never take the word of others over your own full head-to-toe assessment. EMS workers recently told ED nurses that they knew a motor vehicle crash victim and he was always acutely anxious. "On arrival to the ED, the patient's behavior developed into combativeness," says Aagesen. "After further work-up, it was discovered the patient had a ruptured diaphragm and was hypoxic. This was the cause for the increased anxiety."
"Once a patient in a high-risk group such as the geriatric population starts to decompensate, they do not have the physiologic reserves that a younger adult would have to bounce back," says Aagesen.
By the time you notice your patient's decreasing blood pressure, it might be too late. "Once hypotension begins, your trauma patient is already in Class Three shock," says Aagesen. "Look for more subtle signs such as anxiety and cool, moist skin as earlier indicators."
Do this if C-spine injury is possible
Until a cervical spine injury is ruled out, use manual in-line stabilization throughout all assessments and interventions.
"Cervical collar application should be completed on these patients as soon as possible, to maintain inline immobilization of the spine until it can be cleared clinically and/or radiographically," says Shelley L. Sides, RN, MSN, trauma coordinator at Eastern Maine Medical Center in Bangor. "Don't forget to assess the posterior aspect of the patient."
If patients can be safely removed from a long spine board, do so. "This can prevent any risk of tissue ischemia related to increase tissue interface pressures with the board," says Sides. "Many patients can be kept safely on the ER stretcher without the application of the long spine board until movement of the patient is indicated."
Patients should be taken off the backboard within 15 minutes of their arrival, but this can be overlooked in a busy ED, warns Laura Hochwalt, RN, BSN, a charge nurse and chair of the trauma committee at Grady Memorial Hospital in Atlanta. "It allows you to do an assessment of the spine and get orders for appropriate imaging," says Hochwalt. "If the patient is on a backboard too long, it can cause pressure points and potentially cause skin breakdown, more so for the elderly population."
When patients arrive on backboards at Hochwalt's ED that are stable and do not need to go into the trauma bay, she alerts a couple of ED physicians. "We meet the patient at the board and take them off the backboard before I place them in a room," says Hochwalt.
Ensure patency of patient's IV lines
Check all intravenous (IV) lines for patency upon the patient's arrival to your ED and every time something is given intravenously, says Shelley L. Sides, RN, MSN, trauma coordinator at Eastern Maine Medical Center in Bangor. This step can be done simply by flushing the line with normal saline and observing for any signs of infiltration into surrounding tissues.
"If your line starts to flush harder, or the patient experiences pain or redness, you may want to consider an alternative site," says Sides. "The wrong time to notice that an IV is no longer patent is when you need it immediately."
Assess capillary refill for trauma
Capillary refill is an excellent predictor of circulatory compromise, especially in the pediatric population, says Shelley L. Sides, RN, MSN, trauma coordinator at Eastern Maine Medical Center in Bangor. Remember these three things:
"A hypothermic patient may have prolonged capillary refill which may improve after re-warming," says Sides. "When assessing capillary refill, the upper extremities should be used and should be held higher than level of the heart."