Peds Part I

I read a great blog (510 Medic) about the importance of taking vital signs in pediatric patients. The author cites great research on how often vital signs are not taken, especially blood pressure which puts our patients at risk if we are unable to properly assess and measure vital sign data. This issue cannot be underscored and is applicable to all providers in the emergency services - both pre-hospital and in the hospital. I often get asked about pediatric assessments (including vital signs) from nurses and paramedics alike. My answer is always the same...what does the child look like and do the vital signs match the rest of the clinical picture?

For instance, some years ago I had an ED nurse tell me that an infant had a respiratory rate of 8 - 10 and was in no distress. Apparently I had an alarmed look on my face as she questioned my concern. I asked, "what does the child look like - color, skin temp, capillary refill, respiratory effort, etc.?" She proceeded to tell me the child was comfortably sitting in the mother's lap, skin very warm, flushed cheeks, but taking Pediatlyte from a bottle. Obviously I reassessed the child including vital signs and found that the respiratory rate was in fact almost triple the original rate and the heart rate was quite tachycardic due to fever.

It is important that we synthesize all the patient data and evaluate what we are hearing or seeing. Does it make sense with the clinical picture?

Thanks to 510 Medic for addressing a topic near and dear to my heart! Stay tuned for Part II with a discussing breaking down the numbers and correlating to the pediatric assessment.

Celebrate Clinical Nurse Specialists!

2nd Annual National CNS Week September 1st - 7th

Clinical Nurse Specialist Facts from NACNS:

• Hildegard Peplau, RN, Ed.D. (9/1/1909 – 3/17/1999), is the founding mother of the CNS role. Rutgers University School of Nursing is the birthplace of the CNS role.
• Dr. Peplau was a nursing theorist who published a landmark work in 1952 titled, "Interpersonal Relations in Nursing." She emphasized the nurse-client relationship as the foundation for nursing practice, and the important partnership model that focused on shared experience through observation, description, formulation, interpretation, validation and intervention. This theory was considered "revolutionary", since at that time clients or patients typically were passively receiving treatment and nurses were merely acting out doctor’s orders. In 1956, Dr. Peplau established the first nursing Master’s Degree program with a focus exclusively on clinical practice. Graduates of this program were called "clinical specialists."
• Health systems across the nation are commemorating this recognition week. Plans include community activities and public lectures, receptions honoring Clinical Nurse Specialists, wellness fairs, community outreach, and fundraisers promoting the spirit of nursing, such as organized walks or golf outings which in turn support underserved communities or particular health concerns.
• An estimated 72,521 Clinical Nurse Specialists practice in the U.S. They are licensed registered nurses who hold masters or doctorate degrees in nursing.
• CNSs are expert clinicians in a specialized area of nursing practice. The specialty may be identified in terms of a population (i.e. Pediatrics), a setting (ie. Emergency Dept.), a disease or medical subspecialty (i.e. Diabetes), type of care (ie. Psychiatric), or type of problem (i.e. Pain).
• CNS practice improves the healthcare environment and outcomes by influencing: direct care of patients/clients, nursing standards and personnel, and care delivery systems. In other words, as leaders CNSs drive innovation in their environments from care at the bedside to system-wide improvements.
• Examples of outcomes of CNS practice: reduced medical complications in hospitalized patients, reduced hospital costs and length of stays, improved pain management practices, increased patient satisfaction with nursing care, reduced frequency of emergency room visits.

More proof that STEMI Systems work

A recent news article showcased the coordination of care between EMS and a hospital in Vancouver for patients having an MI: En-route diagnoses save heart attack victims’ lives. It is unfortunate that despite increasing global evidence that pre-hospital diagnosis is an integral piece of improving patient outcomes with STEMI, there are still barriers and turf wars that prevent the same. So how do we change this?

Putting a sacred cow to pasture - cervical and spinal immobilization

The American Emergency Physicians News recently published a piece on the use of spinal immobilization and cervical collars. Despite evidence against the use and very little evidence that using immobilization techniques and equipment protects the patient from further injury this practice continues to put patients at risk for injury. There is increasingly more literature that discusses the harms associated with inappropriate cervical and spinal immobilization, which is defined as either incorrectly applied devices or inappropriately placed on patients without signs/symptoms of injury. This practice has been under scrutiny since the 1980s yet both pre-hospital and emergency departments use this practice routinely despite valid and recent evidence recommending otherwise. Disclaimer: this is not to say that there are not situations that spinal and/or cervical immobilization is not appropriate or necessary; and there is literature that supports this practice.

Further contributing to increased morbidity is prolonged immobilization once in the emergency department. Delays in being evaluated by an emergency department physician or nurse practitioner leave the patient lying immobilized for a prolonged period of time increasing the risk for extension injuries, skin complications, airway complications, elimination issues and emotional distress. Many nurses are not trained or competencied to adequately care for a patient with cervical collars and/or spinal immobilization let alone application and removal; this is often the case in non-trauma centers or in an academic institution with medical residents. Nurses often lose track of how long their patients are immobilized and a substantial delay occurs before being evaluated and removed from such devices. Once in the emergency department, nurses must advocate for their patients and treat immobilization as a priority of care.

Both paramedics and nurses must be familiar with evidence-based practices and know both the risks and benefits of the care they provide. Performing a skill on the basis of “that’s how we’ve always done it” is dangerous business for the patients we care for and it is incumbent upon us to ensure the care we provide is rooted in evidence and not just another scared cow.

The return of communicable diseases

There was a story today in the NYT Health section regarding people contracting Dengue fever in the Florida Keys. In recent weeks, there has been much discussion of the alarming rate in which Pertussis (Whooping Cough) has spread in California and other parts of the country. This is concerning for me and should be for all healthcare providers in all settings (prehospital, emergency departments, outpatient clinics, acute care/inpatient, etc). Many communicable diseases have previously been eradicated with vaccinations and have not been an issue for decades. Unfortunately, many of us would be unable to recognize many of these diseases; especially those such as dengue fever with vague, nondescript sympotomolgy.

So what does this all mean? The resurgence of communicable diseases requires education for all healthcare providers that may potentially come in contact with infected individuals. Ensuring vaccination to diseases such as pertussis and measles is also important to protect your own health. Both of these efforts are especially important for both EMS and emergency department staff (paramedics, EMTs, nurses, physicians, NPs, CNSs, patient care techs, etc) that have first contact with patients.

Education is perhaps the single most important step we can take for both ourselves and our patients.

1. Know what, if any communicable diseases have been reported in your geographic area or region. The CDC, WHO and local health departments have free information for both healthcare providers and the laypublic.
2. Many state health departments send memos to hospitals and EMS systems to alert providers the status of various diseases in the region. These memos are a great resource, providing information on symptoms, transmission, incubation period, disease course and priorities for treatment.
3. Look for teachable moments: Encourage high-risk populations to vaccinate their children and themselves, use cough-etiquette and perform good hand-hygiene.
4. Educate your colleagues: share the information you recieve and promote personal safety practices such as hand-hygiene.

Taking a proactive rather than reactive approach may help to reduce the incidence of these deadly diseases.

Lateral violence among nurses

There is a great discussion at allnurses.com regarding the age-old issue of "nurses eating their young". It is amazing to me that for all the compassion nurses have for patients and being ranked as the most ethical profession, nurses have no reservations turning on each other. Disclaimer: Not all nurses are guilty of this behavior; but not all nurses will intervene or stop one nurse from harassing another either. And lately it seems that there is a renewed emphasis on lateral violence and healthy work environments by many nursing organizations which aim to raise awareness and empower nurses to not tolerate such behavior (a great effort and much needed topic for discussion). But I have to ask will this ritual ever end?

Tall Stan - Part 1

The new AACN theme introduced Tall Stan - this is my Stan sporting palm tree scrubs!

Stand Tall means to recognize the unique and indispensable role nurses play. Recognize it, understand it, articulate it, own it, accept responsibility for it, and celebrate it.
Stand Tall — be proud of what you do.
Stand Tall — speak up.
Stand Tall — together we can do more.
Stand Tall — own the outcomes of your work.
Stand Tall — enjoy what you do.

-AACN

Stan working on evidence-based practices!