Obstacle course runs: review of acquired injuries and illnesses at a series of Canadian events (RACE)

Hawley, A. et al. Emergency Medicine Journal. Published Online: 15 September 2016

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Background: The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on emergency medical services (EMS) and local EDs. Literature concerning the safety of these events is minimal and mostly consists of media reports. We sought to characterise the injury and illness profile of OCRs and the level of medical care required.

Methods: This study analysed OCR events occurring in eight locations across Canada from May to August 2015 (total 45 285 participants). Data were extracted from event medical charts of patients presenting to the onsite medical team, including injury or illness type, onsite treatment and disposition.

Results: There were 557 race participants treated at eight OCR events (1.2% of all participants). There were 609 medical complaints in total. Three quarters of injuries were musculoskeletal in nature. Eighty-nine per cent returned to the event with no need for further medical care. The majority of treatments were completed with first aid and basic medical equipment. Eleven patients (2% of patients) required transfer to hospital by EMS for presentations including fracture, dislocation, head injury, chest pain, fall from height, and abdominal pain.

Conclusions: We found that 1.2% of race participants presented to onsite medical services. The majority of complaints were minor and musculoskeletal in nature. Only 2% of those treated were transferred to hospital through EMS. This is consistent with other types of mass gathering events.

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Clinical Practice: Using a Best Evidence Sepsis Scoring Tool to Identify and Manage Pediatric Patients With Severe Sepsis in the Emergency Department

Calhoun, C. et al. (2016) Journal of Pediatric Nursing. 31(5) pp. 560-561

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Severe sepsis and septic shock are leading causes of pediatric morbidity and mortality, resulting in prolonged hospitalization and increased healthcare costs. 1,2 Delays in recognition of sepsis, vascular access, and administration of fluids and antibiotics are major barriers within pediatric emergency departments (ED). 3,4 Severe sepsis is defined as symptoms suspicious of infection plus signs of organ dysfunction or tissue hypoperfusion. 5 A sepsis trigger tool at triage can identify vital sign abnormalities of severe sepsis, alert ED resources, and rapidly begin the sepsis protocol. 3 Annually, almost 100,000 pediatric patients present to the ED with signs of severe sepsis. 6.

Using the concept of “PIRO” (predisposition, infection, response, and organ dysfunction), the sepsis tool was adapted to identify pediatric patients at risk for sepsis with signs of infection, age-related abnormal vital signs, and signs of organ dysfunction.

With 5 or greater score (maximum score of 16), a “sepsis alert” was paged. A multidisciplinary team was mobilized: ED nurse, ED paramedic, physician, respiratory therapist, and child life specialist. Using a nurse-initiated pathway, patient was placed on cardiac apnea monitor, pulse oximeter, and oxygen, vital sign monitoring was begun, intravenous (IV) line insertion with lab work was obtained, and weight-based IV fluid bolus was initiated with antibiotics anticipated. Sepsis scores were repeated after interventions or with status changes. An ED sepsis committee was formed to audit charts and educate staff on the sepsis tool.

From January 2014 through April 2015, median times for triage-to-IV fluid bolus improved from 65 to 51 min and triage-to-antibiotic times improved from 137 to 80 min.

With early recognition and treatment of sepsis, ED experienced improved patient mortality rates, shorter hospital stays, and decreased hospital costs. The successes of multidisciplinary interventions, effective communication, increased awareness, and staff compliance have led to decreases in triage-to-bolus and triage-to-antibiotic times. The tool was accurate in identifying severe sepsis; the admission rate for positive sepsis alerts was 60%.

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Severe community-acquired pneumonia: timely management measures in the first 24 hours

Phua, J. et al. Critical Care. Published online: 28 August 2016

Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.

In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.

These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).

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While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.

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Personal Protective Equipment Guidelines for Health Care Facility Staff

The American College of Emergency Physicians (2016). Annals of Emergency Medicine 68(3). pp. 406-407

The American College of Emergency Physicians (ACEP) believes a critical component of emergency preparedness is for health care facility staff to use personal protective equipment (PPE) that is appropriate to protect themselves, patients, and others from chemical, biological, and radiologic elements Decisions about what type of PPE to use and when it should be used should be made only after thorough analysis of all available information. Guidance should then be appropriately reassessed and modified to ensure consistency with evolving information.

Hospitals have standard precautions for blood-borne and respiratory pathogens, but these may not necessarily protect against every hazardous exposure. At present, there is little available evidence to help determine the level of PPE needed for health care facility staff in every situation.

Essential protective measures depend heavily on the location of the decontamination area, the role of the health care facility in the community response to hazardous material incidents, and the hazard vulnerability analysis. Critical priorities include ensuring the safety of the health care facility staff, ensuring continuity of health care facility operations up to and including a possible determination for appropriately controlled hospital access, and providing initial triage and treatment for contaminated or exposed or potentially contaminated patients arriving at the health care facility and seeking treatment.

Key elements in the selection process for appropriate PPE levels and decontamination facilities include the following:

  • Forming strategic partnerships with response agencies, professional associations, accrediting bodies, governmental agencies, and others

  • Performing a hospital hazard vulnerability analysis consistent with community threats

  • Determining initial and ongoing training requirements and equipment needs appropriate to the PPE level required at a facility, meeting at least current essential standards as determined by the Centers for Disease Control and Prevention, and with consideration to other federal regulating and credentialing agencies, such as the National Institute of Occupational Safety and Health and the Occupational Safety and Health Administration, and other response agency partnerships

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Surface cleaning effectiveness in a walk-in emergency care unit: Influence of a multifaceted intervention

Frota, P.O. et al. American Journal of Infection Control. Published online: 24 August 2016

Highlights

  • The interventions immediately improved the effectiveness of cleaning.
  • These improvements disappeared after four months of interventions.
  • Microfiber cloths did not impact any increase in cleaning effectiveness.
  • Continuous education and feedback on cleaning practices appear to be warranted.
  • This policy should be adapted to the particularities of each health care setting.

Abstract

Background: Cleaning of surfaces is essential in reducing environmental bioburdens and health care-associated infection in emergency units. However, there are few or no studies investigating cleaning surfaces in these scenarios. Our goal was to determine the influence of a multifaceted intervention on the effectiveness of routine cleaning of surfaces in a walk-in emergency care unit.

Methods: This prospective, before-and-after interventional study was conducted in 4 phases: phase I (situational diagnosis), phase II (implementation of interventions—feedback on results, standardization of cleaning procedures, and training of nursing staff), phase III (determination of the immediate influence of interventions), and phase IV (determination of the late influence of interventions). The surfaces were sampled before and after cleaning by visual inspection, adenosine triphosphate bioluminescence assay, and microbiologic culture.

Results: We sampled 240 surfaces from 4 rooms. When evaluated by visual inspection and adenosine triphosphate bioluminescence, there was a progressive reduction of surfaces found to be inadequate in phases I-IV (P < .001), as well as in culture phases I-III. However, phase IV showed higher percentages of failure by culture than phase I (P = .004).

Conclusions: The interventions improved the effectiveness of cleaning. However, this effect was not maintained after 2 months.

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Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study

Goldhaber-Fiebert, S. et al. Anesthesia & Analgesia. 123(3) pp. 641–649

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Background: Emergency manuals (EMs), context-relevant sets of cognitive aids or crisis checklists, have been used in high-hazard industries for decades, although this is a nascent field in health care. In the fall of 2012, Stanford clinically implemented EMs, including hanging physical copies in all Stanford operating rooms (ORs) and training OR clinicians on the use of, and rationale for, EMs. Although simulation studies have shown the effectiveness of EMs and similar tools when used by OR teams during crises, there are little data on clinical implementations and uses. In a subset of clinical users (ie, anesthesia residents), the objectives of this pilot study were to (1) assess perspectives on local OR safety culture regarding cognitive aid use before and after a systematic clinical implementation of EMs, although in the context of long-standing resident simulation trainings; and (2) to describe early clinical uses of EMs during critical events.

Methods: Surveys collecting both quantitative and qualitative data were used to assess clinical adoption of EMs in the OR. A pre-implementation survey was e-mailed to Stanford anesthesia residents in mid-2011, followed by a post-implementation survey to a new cohort of residents in early 2014. The post-implementation survey included pre-implementation survey questions for exploratory comparison and additional questions for mixed-methods descriptive analyses regarding EM implementation, training, and clinical use during critical events since implementation.

Results: Response rates were similar for the pre- and post-implementation surveys, 52% and 57%, respectively. Comparing post- versus pre-implementation surveys in this pilot study, more residents: agreed or strongly agreed “the culture in the ORs where I work supports consulting a cognitive aid when appropriate” (73.8%, n = 31 vs 52.9%, n = 18, P = .0017) and chose more types of anesthesia professionals that “should use cognitive aids in some way,” including fully trained anesthesiologists (z = −2.151, P = .0315). Fifteen months after clinical implementation of EMs, 19 respondents (45%) had used an EM during an actual critical event and 15 (78.9% of these) agreed or strongly agreed “the EM helped the team deliver better care to the patient” during that event, with the rest neutral. We present qualitative data for 16 of the 19 EM clinical use reports from free-text responses within the following domains: (1) triggering EM use, (2) reader role, (3) diagnosis and treatment, (4) patient care impact, and (5) barriers to EM use.

Conclusions: Since Stanford’s clinical implementation of EMs in 2012, many residents’ self-report successful use of EMs during clinical critical events. Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use. Larger, mixed-methods studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.

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A joint report between the RCN and the Royal College of Emergency Medicine (RCEM) makes recommendations for meeting increased demand.

RCN & RCEM. The Medicine Needed for the Emergency Care Service. Published online: 18 August 2016

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Image source: RCEM/RCN

The Royal College of Emergency Medicine and the Royal College of Nursing today launch their report: The Medicine needed for the Emergency Care Service.

The pressure on the Emergency Care Service continues unabated and the service is at a crisis point. Growth in patient numbers is outpacing growth in the workforce and so the system has insufficient emergency physicians and emergency nurses. Crowded and chaotic departments are dangerous for patients and demoralising for staff.

A crisis summit was held between the Royal College of Emergency Medicine and the Royal College of Nursing to work together to develop some key recommendations to tackle the situation facing emergency medicine. These recommendations comprise ‘the medicine’ needed for emergency care:

  1. Education and Training: there needs to be (i) a commitment for both educational funding and provision of training time and (ii) an effective and realistic workforce planning strategy.
  2. The A&E hub: A&E should become a hub not a department. Within this hub the emergency department would be one, albeit key component.
  3. A new culture needs to accompany the Five year Forward View: the wider hospital system and the professionals working within it need to collaborate more deeply to support their patients.

Read the full report here