In this model of opioid overdose cardiac arrest, brain tissue hypoxia is common and treatable. Further work will elucidate best strategies and impact of titrated care on functional outcomes.
In the setting of acute traumatic brain injury (TBI), an abnormal pupil assessment may suggest a worsening intracranial lesion. Early detection of pupillary changes may expedite emergent care to improve outcomes. Automated, handheld pupillometers have been commercially available for 20 years, and several studies suggest that their use may facilitate early recognition of worsening injury and intracranial hypertension. The use of pupillometry as a bedside tool in the routine care of patients with severe TBI (Glasgow Coma Scale score ≤ 8) has not been described. We performed a quality improvement project to implement routine use of quantitative pupillometry in our neurotrauma intensive care unit. Nursing staff were trained on device use and the project's aims in a 30-minute in-service session. Nurses caring for severe TBI patients completed standard pupil assessments using (a) a flashlight and (b) a pupillometer to quantify pupil size and reactivity (Neurological Pupil index) every hour. Abnormal results were reported to on-call providers. We administered surveys to evaluate knowledge, practical use of the pupillometer data, and satisfaction with the device every 3 months. Data were available for 22 nurses at 4 separate time points. Staff were positive about their ability to use and understand the device (µ = 8.7 and 9.1, respectively, on a 10-point scale) and reported that it added value to patient care and critical decision-making. Use of automated pupillometry is acceptable to nursing staff in a neurotrauma intensive care unit, and staff believed that pupillometry results enhanced clinical decision-making.
Future nurses, both entry level and advanced practice, are pivotal to the nation’s disaster response. They are critical frontline, acute, primary, and public health workers in the United States and internationally. To respond well, they must be taught how to prepare and intervene appropriately. This preparation is multidimensional and includes not only concrete knowledge but mental, emotional, and ethical preparation for the realities of working and providing care while affected by chaos. Training should be experiential and reflective and expose students to the interprofessional nature of disaster planning and response. New nurses, as they enter practice, as the COVID-19 pandemic has demonstrated, may also take on the role of a frontline disaster responder. The ability to effectively respond and access available resources to care for patients is required. Schools of nursing and nursing faculty increasingly will be required to include disaster preparedness as an integral part of the nursing curriculum.
Although, historically, shock associated with traumatic injury has been evaluated through knowledge of the 4 recognized shock patterns--cardiogenic, obstructive, distributive, and hypovolemic--many trauma practitioners view traumatic shock as a unique fifth shock pattern. Although secondary to a systemic inflammatory response syndrome triggered by endogenous danger signals, traumatic shock represents a unique pathological condition that begins with multiple, usually blunt, trauma and may conclude with multiple organ dysfunction syndrome and death. While varying mechanisms of injury may lead to different presentations of shock and cardiovascular decompensation, a unifying theme of traumatic shock is an overwhelming inflammatory response driven by proinflammatory cytokines, and the downstream results of this cytokine storm including, but not limited to, acute respiratory distress syndrome, coagulopathy, sepsis, and multiple organ dysfunction syndrome. Treatment is primarily supportive; however, research into novel therapeutics for traumatic shock is ongoing and promises some direction for future care.
Background: Cardiac arrests are often preceded by several hours of physiological deterioration that may go undetected.Local Problem: Cardiac arrests frequently occurred on medical-surgical units without prior rapid response team intervention. Methods: A pre/postintervention design was used to evaluate a protocol to guide the use of the Modified Early Warning Score (MEWS) by medical-surgical nurses to escalate the care of deteriorating adult patients. Interventions: Following staff education, the MEWS protocol was implemented across 8 medical-surgical units.Results: There was a significant increase in patients experiencing a rapid response prior to a cardiac arrest after implementing the MEWS protocol (P < .0001). Conclusion: Implementing a consistent review of MEWS values allows medical-surgical nurses to initiate assistance from a rapid response team that may prevent an inpatient cardiac arrest.
BackgroundThe addition of Advanced Practice Providers (APPs) such as Nurse Practitioners or Physician Assistants as hospital-based service providers has been shown to increase efficiency of care, provide for better continuity of care across the inpatient and outpatient settings, and facilitate interdisciplinary collaboration. As healthcare systems attempt to not only increase access to care but also improve quality, the addition of APPs is becoming an option to meet division-specific goals. To decrease readmissions and increase access to care for patients discharged on intravenous (IV) antibiotics and in the Outpatient Parenteral Antibiotic Therapy (OPAT) Program, the Division of Infectious Diseases at UPMC Presbyterian hired two APPs in early 2017. Our aim was to compare readmission and follow-up rates from the time before expansion of the program with APPs to after expansion.MethodsWe completed a retrospective study of all OPAT patients seen by any Infectious Diseases (ID) provider (MD or APP) n the period from January to May 2017 (prior to APP outpatient clinics with OPAT patients) and in the period from January to February 2018. The total number of patients seen by an ID provider and the 30-day readmission rates were collected and evaluated. A comparison of proportions was done with a two-tailed z-test for the percentage of readmissions prior to program expansion compared with the percentage of readmissions after program expansion.ResultsFollowing the expansion of the OPAT program with the addition of two APPs in 2017, there was a decrease, from 14.7% to 9.6%, in 30-day readmissions for all patients who were seen for follow-up (P = 0.0461, 95% CI 0.0672–9.3164). The percentage of patients who were seen for follow-up increased after expansion of the program from 29.5% to 39.3% (P = 0.0051, 95% CI 2.8714–16.9153).ConclusionExpansion of the OPAT program within the Division of Infectious Diseases at UPMC with the addition of two APPs has significantly increased access to care and significantly decreased 30-day readmissions when the patient was seen for follow-up by an ID provider (MD or APP).Disclosures All authors: No reported disclosures.
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