Advanced Emergency Nursing Blog from AENJ

The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.

Monday, November 27, 2017

ILCOR goes Annual! AHA gives focused recommendations​.​​

The International Liaison Committee on Resuscitation (ILCOR) has for some years been meeting and agreeing upon resuscitation practices every five years; in addition to which there is the necessary slack time before and after each meeting to produce and disseminate the newly appropriate course materials.

On November 6th, 2017, it was announced in the journal Circulation of the American Heart Association, that ILCOR is converting to an annual cycle to minimize delay in effectuating change in recommendations and practices. New evidence will be reviewed, graded as to quality, recommendations proposed, and new research areas for the coming cycle prioritized. This year has five BLS changes for adults, and one for children.

The following quotes from the ILCOR and AHA documents, under fair-use doctrine, will help summarize for you the changes. Only trivial formatting changes are made, and links are provided. More complete discussion of the review process, levels of evidence, comparisons, and the values with which they were interpreted are within the original papers. AHA statements are labeled with" [AHA]".

We can now expect more frequent and closer cycling and knowledge translation from the laboratory workbench or studies of cases and outcomes to our own practice.

 

DISPATCH-ASSISTED COMPRESSION-ONLY CPR COMPARED WITH DISPATCH-ASSISTED CONVENTIONAL CPR (ADULTS): CONSENSUS ON SCIENCE.

Treatment Recommendation: "We recommend that dispatchers provide chest compression-only CPR instructions to callers for adults with suspected out-of-hospital cardiac arrest (OHCA) (strong recommendation, low quality evidence)."

Knowledge Gaps:

1.     What is the optimal instruction sequence for coaching callers in dispatch-assisted CPR?
2.     What are the identifying key words used by callers that are associated with cardiac arrest?
3.     What is the impact of dispatch-assisted CPR instructions on cardiac arrests from noncardiac causes such as drowning, trauma, or asphyxia in adult and pediatric patients?

 

[AHA] "2017 Summary of Evidence

No new studies were reviewed for this topic."

[AHA] "2017 Recommendation—Updated

1.     We recommend that when dispatchers' instructions are needed, dispatchers should provide chest compression–only CPR instructions to callers for adults with suspected OHCA (Class I; Level of Evidence C-LD)."
 

BYSTANDER COMPRESSION-ONLY CPR COMPARED WITH BYSTANDER CPR USING COMPRESSIONS AND VENTILATIONS (ADULTS): CONSENSUS ON SCIENCE.

Treatment Recommendations:
"We continue to recommend that bystanders perform chest compressions for all patients in cardiac arrest (good practice statement). In the 2015 CoSTR, this was cited as a strong recommendation but based on very low-quality evidence.19,20

We suggest that bystanders who are trained, able, and willing to give rescue breaths and chest compressions do so for all adult patients in cardiac arrest (weak recommendation, very-low-quality evidence)."

Knowledge Gaps:

1.     The effect of delayed ventilation versus 30:2 high-quality CPR.
2.     The impact of continuous chest compressions on outcomes for cardiac arrests from noncardiac causes such as drowning, trauma, or asphyxia in adult and pediatric patients.
3.     The ability of bystanders to perform correct mouth-to-mouth ventilations.

 

[AHA] "2017 Recommendations—Updated

1. For adults in OHCA, untrained lay rescuers should provide chest compression–only CPR with or without dispatcher assistance (Class I; Level of Evidence C-LD).

2. For lay rescuers trained in chest compression–only CPR, we recommend they provide chest compression–only CPR for adults in OHCA (Class I; Level of Evidence C-LD).

3. For lay rescuers trained in CPR using chest compressions and ventilation (rescue breaths), it is reasonable to provide ventilation (rescue breaths) in addition to chest compressions for the adult in OHCA (Class IIa; Level of Evidence C-LD)."

 

EMS-DELIVERED CPR: CONSENSUS ON SCIENCE.

Treatment Recommendations:

"We recommend that EMS providers perform CPR with 30 compressions to 2 ventilations or continuous chest compressions with PPV delivered without pausing chest compressions until a tracheal tube or supraglottic device has been placed (strong recommendation, high-quality evidence).

We suggest that when EMS systems have adopted minimally interrupted cardiac resuscitation, this strategy is a reasonable alternative to conventional CPR for witnessed shockable OHCA (weak recommendation, very-low-quality evidence)."

 

Knowledge Gaps:
"Several knowledge gaps were identified in the review of this topic. A more comprehensive list has been posted on the ILCOR website.10 The BLS Task Force ranked the knowledge gaps in priority order, and the top 3 follow:

1. What is the effect of delayed ventilation versus 30:2 high-quality CPR?

2. Which elements of the bundled care (compressions, ventilations, delayed defibrillation) are most important?

3. How effective is passive oxygen insufflation (applying a flow of oxygen via a face mask or a supraglottic airway but without PPV)?"

 

[AHA] "2017 Recommendations—Updated

1. We recommend that before placement of an advanced airway (supraglottic airway or tracheal tube), EMS providers perform CPR with cycles of 30 compressions and 2 breaths (Class IIa; Level of Evidence B-R). As an alternative, it is reasonable for EMS providers to perform CPR in cycles of 30 compressions with 2 breaths without interrupting chest compressions to give breaths (Class IIa; Level of Evidence B-R). It may be reasonable for EMS providers to use a rate of 10 breaths per minute (1 breath every 6 seconds) to provide asynchronous ventilation during continuous chest compressions before placement of an advanced airway (Class IIb; Level of Evidence C-LD).

2. These updated recommendations do not preclude the 2015 recommendation that a reasonable alternative for EMS systems that have adopted bundles of care is the initial use of minimally interrupted chest compressions (ie, delayed ventilation) for witnessed shockable OHCA (Class IIb; Level of Evidence C-LD)."

 

IN-HOSPITAL CPR: CONSENSUS ON SCIENCE

Treatment Recommendation:

"Whenever tracheal intubation or a supraglottic airway is achieved during in-hospital CPR, we suggest that providers perform continuous compressions with PPV delivered without pausing chest compressions (weak recommendation, very-low-quality evidence)."

Knowledge Gaps:

"Several knowledge gaps were identified in the review of this topic. A more comprehensive list has been posted on the ILCOR website.10 The BLS Task Force ranked the knowledge gaps in priority order, and the top 3 are as follows:

1. No prospective study of in-hospital CPR compares delivery of ventilations during continuous manual chest compressions with ventilations delivered during pauses in manual chest compressions.

2. What is the effect of delayed ventilation versus 30:2 high-quality CPR?

3. What is the optimal method for ensuring a patent airway?"

 

[AHA] "CPR FOR CARDIAC ARREST"

 

[AHA] "2017 Summary of Evidence

No new studies were reviewed for this topic.

[AHA] 2017 Recommendations—Updated

1.     Whenever an advanced airway (tracheal tube or supraglottic device) is inserted during CPR, it may be reasonable for providers to perform continuous compressions with positive­pressure ventilation delivered without pausing chest compressions (Class IIb; Level of Evidence C-LD). It may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed (Class IIb; Level of Evidence C-LD)."
 

CHEST CV RATIO (ADULTS): CONSENSUS ON SCIENCE

Treatment Recommendation:

"We suggest a CV ratio of 30:2 compared with any other CV ratio in patients with cardiac arrest (weak recommendation, very-low-quality evidence)."

 

Knowledge Gaps:

"Several knowledge gaps were identified in the review of this topic. A more comprehensive list has been posted on the ILCOR website.10 The BLS Task Force ranked the knowledge gaps in priority order, and the top 3 follow:

1. The possible benefit of higher CV ratios (more compressions per ventilations).

2. The ability of CPR providers to deliver 2 effective ventilations during the short pause in chest compressions during CPR.

3. Is there a ratio-dependent critical volume of air movement required to maintain effectiveness?"

 

[AHA] "2017 Summary of Evidence

No new studies were reviewed for this topic.

[AHA] 2017 Recommendation—Updated

1. It is reasonable for rescuers trained in CPR using chest compressions and ventilation (rescue breaths) to provide a compression­to­ventilation ratio of 30:2 for adults in cardiac arrest (Class IIa; Level of Evidence C-LD)."

 

BYSTANDER CPR FOR PEDIATRIC OHCA: CONSENSUS ON SCIENCE

Treatment Recommendations:

"We suggest that bystanders provide CPR with ventilation for infants and children <18 years of age with OHCA (weak recommendation, very-low-quality evidence).

We continue to recommend that if bystanders cannot provide rescue breaths as part of CPR for infants and children <18 years of age with OHCA, they should at least provide chest compressions (good practice statement). In the 2015 CoSTR, this was cited as a strong recommendation but based on very-low-quality evidence. 21,22"

 

[AHA PEDIATRIC]

[AHA PEDIATRIC] COMPONENTS OF HIGH-QUALITY CPR: CHEST COMPRESSION-ONLY CPR

[AHA PEDIATRIC] 2017 Summary of Evidence.

Omitted for brevity, please see original document.

 

"2017 Recommendations—Updated

1. CPR using chest compressions with rescue breaths should be provided for infants and children in cardiac arrest (Class I; Level of Evidence B-NR). Based on a growing evidence base since the 2015 guidelines update publication, this recommendation reinforces the 2015 guideline.

2. If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children (Class I; Level of Evidence B-NR).

We weighed the survival benefits of CPR using chest compressions with rescue breaths against the convenience of aligning with the adult recommendation for chest compression–only CPR and concluded that the incremental benefit of rescue breaths justified a different recommendation."

 

ADDITIONAL SCIENCE PUBLISHED SINCE THE SYSTEMATIC REVIEW WAS COMPLETED

Knowledge Gaps:

"In order of priority, the top knowledge gaps for this topic are as follows:

1. More high-quality studies are needed to compare compression-only CPR and CPR with ventilation for infants and children with OHCA.

2. Data are needed from other resuscitation registries that will enable comparison of the role of ventilation with CPR because this varies worldwide, largely on the basis of differences in local resuscitation council guidelines. This should also include subgroup analysis of different patient ages (eg, infancy, 1–8 years, >8 years) and causes of cardiac arrest.

3. Can telephone dispatchers coach bystanders to provide effective rescue breaths/CPR with ventilation for infants and children?"

 

Olasveengen, T. M., de Caen, A. R., Mancini, M. E., Maconochie, I. K., Aickin, R., Atkins, D. L., ... & Chung, S. P. (2017). 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary. Circulation, CIR-0000000000000541.
DOI: https://doi.org/10.1161/CIR.0000000000000541. Circulation. 017;CIR.0000000000000541. Originally published November 6, 2017.  PDF:

 

Kleinman, M. E., Goldberger, Z. D., Rea, T., Swor, R. A., Bobrow, B. J., Brennan, E. E., ... & Travers, A. H. (2017). 2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, CIR-0000000000000539.
DOI:  https://doi.org/10.1161/CIR.0000000000000539. Circulation. 2017;CIR.0000000000000539. Originally published November 6, 2017. PDF.

 

Atkins, D. L., de Caen, A. R., Berger, S., Samson, R. A., Schexnayder, S. M., Joyner, B. L., ... & Meaney, P. A. (2017). 2017 American Heart Association Focused Update on Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, CIR-0000000000000540.
DOI: https://doi.org/10.1161/CIR.0000000000000540. Circulation. 2017; CIR.0000000000000540. Originally published November 6, 2017. PDF.

 

                             Sincerely,
 
                                      Tom Trimble, RN
 
                                                 All opinions are solely those of the author.
                                                 Readers must verify validity to their own practice.​


Sunday, October 8, 2017

Emergency Nursing Week 2017

 

 

Throughout human existence, a need for 'emergency nursing' has always existed. Whether provided by fellow warriors or caregivers in the family grouping, care for wounds and illness was an ad hoc thing. With increasing size and complexity of society and the injuries appertaining thereto, the advancement of medical arts and organization to increase the potential of recovery, emergency nursing no longer can be done by anybody's mom or an army's camp-follower. Nor can any generally trained nurse deal with the spectrum of emergency care without specialized education and training. 

There are other specialties in nursing, which indicate preparation for a limited spectrum of care or discipline, and its own emergencies. However, what is unique in Emergency Nurses, is the ability to confront, decisively and actively, any emergency, regardless of medical specialty; to do so instantly, and without initial direction. They are focused in time and criticality of all fields. No other specialty 'takes on all comers' with undifferentiated problems in this way. 

Just as nurses in the emergency department were at times the only long-service employees and provided guidance to inexperienced physician-trainees, the specialty has now evolved to include advanced practice roles as Licensed Independent Practitioners able to render diagnosis and treatment through the entire episode of care. 

I can recall when a major metropolitan hospital had an unattended "First Aid Room" to which one's personal physician or a resident might be called should one come to the hospital with a problem. Or another, at which the ambulance crew would have to call the hospital's telephone operator to send someone to unlock the door at night. Or municipal "Emergency Hospitals" (free treatment rooms with a doctor and nurse, attached to an ambulance station) that also locked the doors at night. 

Clearly, the numbers of patients, varieties of problems, severity of injury or illness, and expectation of immediate expert care regardless of availability of a personal physician have increased like an avalanche since the years following World War II. Indeed, wars have set the example for emergency medical services and specialized care that are now adapted to civilian life and the needs just mentioned. 

The Emergency Nurses Association has, with the 'can do' spirit of its founders and members, developed and supported the mission and growth of emergency nursing. I am proud of what we do, and what ENA does and who it represents. 

Emergency Nursing Week and Emergency Nursing Day honor and celebrate these nurses, their work, their transformation and development of the specialty, "for being resourceful and masterful in their work." 

 

 

Trimble, Tom, RN. (1997) The Emergency Nursing FAQ and Emergency Nursing World ! FAQ. Emergency Nursing World ! [http://ENW.org] © 1997 Tom Trimble, RN. 

Schriver, J. A., Talmadge, R., Chuong, R. and Hedges, J. R. (July 2003), Emergency Nursing: Historical, Current, and Future Roles. Academic Emergency Medicine, 10: 798–804. doi:10.1197/aemj.10.7.798 [PDF] 

Schriver, J. A., Talmadge, R., Chuong, R., & Hedges, J. R. (October 2003). Emergency nursing: historical, current, and future roles. Journal of Emergency Nursing, 29(5), 431-439. [PDF] 

Fadale, J. M. (2000). As we celebrate: reflections on Anita Dorr and early ENA days. Journal of Emergency Nursing, 26(1), 31-34. [PDF] 

Jezierski, M. (1996). Anita Dorr: her legacy to ENA. Journal of Emergency Nursing, 22(3), 258-260. [PDF] 

Kelleher, J. (2000). A conversation with ENA co-founder, Judy Kelleher, RN, MSN, CEN. Interview by Iris C Frank. Journal of emergency nursing: JEN: official publication of the Emergency Department Nurses Association, 26(1), 35. [PDF] 

Emergency Nurses Association. (No Author) (2017) Emergency Nurses Week.

 

                      Sincerely,
 
                      Tom Trimble, RN
 
                      All opinions are solely those of the author.
                      Readers must verify validity to their own practice.

 


Friday, September 8, 2017

The Nexus of Violence, Law Enforcement, and Nursing

 

            Just recently, Nurses ─who are often at risk for violence, (but whose perpetrators often "get away with it", have apparently endured frightening violence apparently through the neglect or arrogance of Law Enforcement Officers themselves. Of course, it will be said that these are exceptional cases and hardly representative. Yet, it must be noted that Nurses are compelled to be in the middle.

            Both occupations, it must be said, are creatures of law whose licensed/appointed employment is created, regulated, and disciplined by operation of law; and those with high professional tenets swear an oath to perform at awesome ethical levels. Those who fail at this may be censured, discharged, and never trusted again, --as these are occupations of public trust.

            Information released recently about earlier events have achieved prominence. In the Illinois case, jail guards responsible for their inmate in a hospital were seemingly inattentive and derelict in their duties, resulting in the prisoner getting loose, stealing the deputy's gun, taking hostages, beatting and raping one nurse until the ordeal was ended by SWAT shooting him and wounding the nurse.

            In the latter case, at University of Utah Hospital, Nurse Alex Wubbels has gained fame, and Salt Lake City Police have gained notoriety for her calm and careful refusal to permit a blood test of an unconscious patient as legal and administrative agreements had not been met. There was no warrant, the patient was not under arrest, and he was unable to give consent. In what appeared to be arrogant frustration, the detective abruptly placed Ms Wubbels under arrest, handcuffing her, forcibly removed her from the hospital to the police car, despite her complaints of innocence, pain, and of the wrongdoing by the officers.

            The City Mayor and Chief of Police hastened to make an apology, but the public rightly feel that the police conduct was outrageous. Unfortunately, most public media used a brief video clip that focuses on the scuffle's excited phase, rather than the preceding portion showing a calm and reasoned refusal noting the agreement between police and the hospital. Seeing that, the abuse of authority is, in my opinion, so egregious that the city should just write the check: "How much do you want?" The conduct was wrong-headed and inappropriate (IMO). The may have been metabolizing, but he was certainly not going anywhere. Time Out: a phone call; calling higher-ups; would have been so much more reasonable …

            These events should not have occurred. The nurses came to work, that day, to nurse: which they did; but showed that heroism rises within, even when confronted with evil and abusive behaviors befalling them.

            Generally, there are cooperative and understanding relationships between law enforcement and nursing. We face similar problems, and treat the same patients. The agencies involved in these episodes owe a great deal of internal work as well as apologies.

 

                               Sincerely,
 
                                     Tom Trimble, RN
 
                                     All opinions are solely those of the author.
                                     Readers must verify validity to their own practice.


 

Susan Sarkauskas. "Attorney: Delnor nurse was tortured, raped during hostage situation." www.DailyHerald.com. Updated: 5/25/2017 4:52 PM.

Marcia Frellick. "Nurse Arrested After Protecting Patient From Blood Draw."  Medscaoe. September 01, 2017.

Utah Nurse Arrested After Refusing to Allow Cop Take Blood From Unconscious Patient. YouTube. "Storyful News." 09/01/2017.

Mayor, Police /chief RESPOND TO COP ARRESTING NURSE! YouTube. September 2, 2017.

Utah nurse arrested Alex Wubbels responds to apology from Chief of Police, Salt Lake- Jeff Payne. YouTube. September 1, 2017.

 


Thursday, July 27, 2017

Finding Positive Aspects in Negative Experiences​

Everyone In healthcare has a fund of "war stories" or past cases; one's own or those of others, that are useful with a selected audience of coworkers or trusted friends for discussion or to point a precept. Informally, this can be a useful way of sharing lore or vicarious learning. Generally, these tend to show a favorable light or heroic cast to the tale. There are a few which meet an acceptable level of 'bizarre' that can add spice. 

Some stories we may not enjoy telling and don't share, or may be uncomfortable to recall. These may be where all possible efforts were insufficient to overcome the adversity; those which we find personally affecting; those where there was some inaccuracy of diagnosis or treatment; those which may not reflect credibly upon the care or participants. Such cases do not necessarily require personal involvement to be memorable. 

"Lessons Learned," as the military call it, can come from negative experiences as from positive experiences. Indeed, were it not so, there would be little use for 'Morbidity & Mortality' conferences. To encourage this, these conferences are confidential and usually protected from the legal "discovery" process. 

"How not to do it" is as vital an informative process as is the celebration of successes. "I'd like to know more about that"; "I don't want to be surprised by that"; or "There must be a better way of treating that" are, in my opinion, useful provocations of study that can lead to an expertise. 

We owe it to ourselves, our patients, our coworkers, and to science at large, to learn from each experience, to test and evaluate possible solutions, so that the highest quality care can evolve.  

                   

Sincerely,
 
Tom Trimble, RN
 
All opinions are solely those of the author.
Readers must verify validity to their own practice.​

 

AHRQ; Agency for Healthcare Research and Quality. Patient Safety Network. U.S. Department of Health and Human Services. [No author] "Culture of Safety". Patient Safety Primer. Last Updated: June 2017. PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. 

AHRQ; Agency for Healthcare Research and Quality. Patient Safety Network. U.S. Department of Health and Human Services. WebM&M Cases & Commentaries[Ongoing series; each article has own authorship, date.] PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel.




Saturday, June 24, 2017

What are you doing for the rest of your Life?

 

            This is the time of year that is usually inter-term or long vacation for educational institutions. You could be out enjoying the weather and friends, working extra for that special holiday, or making the most of family time.

            ─It's a good time to take stock of your 'Life Plans.' If you decide to make changes, it's a great time to investigate data, brochures, institutions, obtain financing, get transcripts and make applications, … Oh, no, I don't want to go back to school just yet! I've had so much of it!

            What do you want your future to be? Do you want improved opportunities? Control over what you do: Respect from your colleagues? Freedom to schedule work life as you wish? Do you want to make more money? Even, some fame? Do you wish your opinion to be sought at high, even highest, levels?

            Look at those people who are doing some of what you want to do. Unless they're independently wealthy (and probably not a nurse), I'll bet that they have higher degrees and more certifications or additional studies, than you do. So, this might just be the time to decide what you want to do, and how to get there. While these achievements won't guarantee your wildest dreams, they make it a lot easier to show that you have the knowledge and abilities to show you'll be able to do the work at the level you want.

            If not now, when? Though there may be some "adventures" in meshing your new plans with the realities of your life, when will it ever be better? Will you be as young and resilient? Will you have as much energy to match your motivation? Will you be better able to flex your work and earnings as needed? With delay comes only more difficulty with less flexibility.

            If you aspire to succeed in academia, writing and publishing, higher levels of advanced practice, administration, or leading an enterprise, you may need to increase and diversify the letters after your name. Good Luck! May your dreams become plans that succeed!

           

                               Sincerely,
 
                                     Tom Trimble, RN
 
                                      All opinions are solely those of the author.
                                      Readers must verify validity to their own practice.