Vitamin-C and thiamine have powerful experimental treatment effects suppressing mortality in critical care: implications for preventing patient deterioration in sepsis

Dr Simon Black

Background: Early antibiotics and appropriate fluid resuscitation have increased survival of patients with sepsis; however, mortality remains around 25%. Recently remote ischemic conditioning (RIC) was demonstrated to prevent sepsis-associated mortality. The biology of conditioning includes regulating mitochondrial function and preventing metabolic collapse associated with sepsis. Vitamin-C and thiamine mimic RIC and limits mitochondrial failure. Aim: The purpose of this study was to describe the effect-size of vitamin-C and thiamine in suppressing mortality amongst patients in critical care with presumed sepsis. Method: A systematic-like review was undertaken to identify controlled trials investigating the treatment effect of vitamin-C or thiamine on mortality in critical care. Results: Nine studies were identified that investigated the impact of vitamin-C on 3166 patients in comparison to 2900 control patients all with presumed sepsis. A significant treatment effect of vitamin-C was observed: Hedge’s g=0.339 (95% CI 0.071-0.607) p=0.013, Tau²=0.118. Seven studies of the effect of thiamine on 300 patients compared with 287 control patients all with presumed sepsis were identified. A significant treatment effect of thiamine was observed: Hedge’s g = 0.549 (95% CI 0.091-1.003 p=0.019, Tau² = 0.238. Discussion: Treatment effects of vitamin-C and thiamine for suppressing sepsis-related mortality were relatively homogeneous and large. Numbers Need to Treat (NNT) translated from the treatment effects was 5.279 for Vitamin-C and 3.321 for thiamine. Within an ongoing investigational paradigm, vitamin-C and thiamine could be considered potential adjunctive treatments for sepsis capable of reducing sepsis mortality. Pharmacologic induction of conditioning may become an important tool for maintaining patient safety.

Point of View Telemedicine at Point of Care

Study Objectives: Increasingly in recent foreign conflicts and disaster zones, forward deployed healthcare providers strive to communicate with their physician and specialist extra-theater counterparts with the aim of providing improved patient care and outcomes. So far, these efforts have been limited to email consultation, with the exception of specialized teams with limited video capability. Several organizations have attempted to provide real-time video audio interaction in an attempt to extend the capabilities of modern medicine to rural settings and various natural disasters. So far these efforts have required expensive, large pieces of equipment and technological expertise. We aimed to show that ultra-portable live-streamed point of view video consultation had a significant impact on simulated patient outcomes and is feasible with current technology.

Methods: We utilized a double-blinded randomized crossover design. Each tester was evaluated on various patient outcomes to include: time to identification of life threats, time to critical interventions, triage categories, and time to evacuation decision.

Results: Results showed there was a significant decrease in the time to evacuation for patients with video feed (p=0.009) Otherwise the data showed no significant difference in the addition of video as opposed to sole two way radio in terms of the number of interventions, time to interventions, or operator or teleconsultant confidence in care or procedures performed. Subjects did not perform significantly more interventions in the second iteration indicating no training effect.

Conclusion: It is possible that given the teleconsultant was able to visualize the injuries and vitals, evacuation was impressed upon the operator as the priority, without sacrificing life-saving interventions. This study demonstrated the feasibility and ease of a highly portable (weight less than 3 lbs. in total) and economical (total cost <$500) rugged telemedicine platform with live video and two way radio capabilities.

Dr Lane Thaut

Dr. Lane Thaut is a chief resident of the Emergency Medicine Residency at the San Antonio Military Medical Center located in San Antonio, Texas. SAMMC serves as one of two Level I trauma centers for the city of San Antonio and the surrounding areas, extending to the US-Mexico border.  The emergency department treats over 80,000 patients annually. Lane is a Captain in the United States Air Force. He attended Rocky Vista University in Parker, Colorado for medical school and he is a distinguished graduate of the United States Air Force Academy. He is originally from Colorado, USA and enjoys skiing, surfing, and many other outdoor activities in his free time.

Health Literacy of Young Adults [18-25 years old] from the Perspective of Emergency Department Presentations

Mr Ed Davis

-Background-
Research demonstrates the complexity of measuring and understanding health literacy (HL) with young adult [YA] health literacy in particular being little understood. However research does highlight low HL is tied to increased capital expenditure and over utilisation of health services; specifically, front line services such as the Emergency Department.

-Objective-
To improve the health literacy responsiveness of the Emergency Department for young adults through:

Assessing the health literacy of young adults that present to a regional Emergency Department [ED] through the novel use of a contemporary health literacy assessment tool; and
Assessing the HL knowledge and skills of staff within the Emergency Department.

-Methods-
33 young adults that presented to a regional ED consented to participate in HL data collection by 15 volunteer staff using the Conversational Health Assessment Tool [CHAT]. Confidence levels of the volunteer staff in their understanding of HL were measured pre and post study.

-Key results-
Young adults access and utilise a wide range of resources that support and inform health decision making. They are confident to apply their understanding of health to actively manage their own health. A diverse range of barriers to health do exist; evidence of these barriers is demonstrated through 48% of young adults reporting long standing illness or disability and within this group 30% indicated depression or anxiety as the illness.
Staff were noted to feel confident about HL concepts pre and post study.

Accuracy of the EMMA Capnometer. Can a small portable capnometer be used to transport the critically ill?

Purpose: End-tidal carbon dioxide (ETCO2) monitoring is an essential component of procedural sedation, anaesthesia and transport of critically ill patients. However, no ETCO2 monitoring devices have been previously validated for use on humans in the hyperbaric chamber. We identified the EMMA(TM) capnometer, a small hand-held device, as being useful and safe in the hyperbaric chamber. Previous studies comparing the EMMA capnometer to reference devices showed a consistent small negative bias. We undertook to determine whether the EMMA capnometer could be reliably used at 1.0 ATA and under standard hyperbaric conditions.

Study design: This was a two-stage observational study using ten healthy, spontaneously-breathing participants. In Stage 1, simultaneous ETCO2 measurements were recorded from the EMMA capnometer and the reference capnograph, the Dräger® Infinity M540. In Stage 2, participants were pressurised in the hyperbaric chamber and EMMA capnometer measurements were recorded. In both stages, sampling was repeated for air and 100% oxygen gas, and ± heat-moisture-exchanger.

Results: Bland-Altman Plots performed on Stage 1 data showed the EMMA capnometer produced a consistent bias of +1.2 mmHg. The ETCO2 trend was stable for each pressure studied. Repeated measures ANOVA on Stage 2 data showed the ETCO2 measurements increased with pressure and also when breathing air.

Conclusion: The EMMA capnometer may be reasonably used in place of the Dräger Infinity M540 at 1.0 ATA. In hyperbaric conditions, it produces useful ETCO2 trends. However, further study is required to determine exactly why ETCO2 increased with pressure.

Accuracy and use of modified early warning system (MEWS) charts

Aleksandra Trajkovska1, Munawar Farooq2, Drew Richardson3

1 Medical Student, ANU Medical School, Canberra Hospital and Health Services, ACT. u4406563@anu.edu.au
2 Staff Specialist and Clinical Lecturer in Emergency Medicine, Canberra Hospital and Health Services, ACT. munawar.farooq@act.gov.au
3 Professor, ANU Medical School, Canberra Hospital and Health Services, ACT. drew.richardson@act.gov.au

Objective: Track and trigger systems are a recognised adjunct in hospital patient care. This study aimed to assess the utility of the general observation modified early warning score (MEWS) chart in a busy emergency department (ED) setting as part of a larger investigation.

Method: Retrospective cohort clinical audit of all adult general observations (MEWS) charts in ED of a mixed tertiary hospital over 4 weeks. Data extracted included recorded parameters required to calculate MEWS.  The primary research question was the proportion of accurately completed forms and the secondary question was the documentation of response to abnormality.

Results: Of 5901 ED presentations, the medical records system identified 2482 MEWS charts of which 347 (14%) were missing or blank. Of the 2135 MEWS charts, 1597 (74.8% [95% CI 72.9-76.6]) contained a maths error; 1108 (51.9% [49.8-54.0]) had one or more missing parameters; and 782 (36.6% [34.6-38.7]) did not have initial/target blood pressure recorded. 536 (25.1% [23.3-27.0] were correctly completed. 443 of all charts had a single MEWS ≥ 2, of which chart review showed 428 (96.6% [94.5-97.3]) were identified as abnormal by nurses with 114 (25.7% [21.9-30.0]) having recorded ‘doctor noted’ in the nursing notes; only 25 (5.6% [3.9-8.2]) of these had evidence of recognition by medical staff.

Conclusions: This study suggests serious deficiencies in both completion of charts and documentation of response to abnormal parameters. A greater understanding of clinically deteriorating ED patients is needed to inform an evidence-based approach to recognition of, and response to clinical deterioration.

Evaluation of an evidence-informed emergency nursing assessment framework using full immersion simulation

Belinda Munroe1,2, Kate Curtis1-3, Margaret Murphy 1,4, Luke Strachan5, Julie Considine6, Jennifer Hardy1, Mark Wilson7, Kate Ruperto8, Judith Fethney1 &Thomas Buckley1 

1 Sydney Nursing School, University of Sydney
2 Emergency Department, The Wollongong Hospital
3 Trauma Service, St George Hospital
4 Emergency Department, Westmead Hospital
5 Emergency Department, Blacktown Hospital
6 Deakin University, Geelong, School of Nursing and Midwifery / Eastern Health, Box Hill
7 Emergency Department, Shellharbour Hospital
8 Emergency Services, Illawarra Shoalhaven Local Health District

Introduction: The negative effect poor clinical assessment has on patient outcomes requires strategies to improve patient assessment in the Emergency Department. This study evaluates the impact of HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) 1 (Figure 1), an evidence-informed emergency nursing assessment framework, on the clinical performance of emergency nurses and identifies factors influencing the future successful implementation of HIRAID into clinical practice.

Methods: The performance of 38 early career emergency nurses was evaluated conducting an initial assessment of a simulated emergency patient, before and after undertaking education in HIRAID. Participants also completed surveys, interviews and focus groups. Qualitative and quantitative data were analysed separately prior to being integrated.

Results: The quality of history taking, recognition and reporting of critical indicators and reassessments performed, improved from pre to post intervention. Non-technical skills (communication, decision-making, task management and situational awareness) were also enhanced. Anxiety levels decreased (p<0.01) and self-efficacy in assessment performance increased (p<0.01). The majority of nurses reported high satisfaction with the usefulness of HIRAID. A range of potential factors were identified to influence uptake of HIRAID in clinical practice.

Discussion: Implementation of HIRAID has the potential to improve nursing assessment and the quality of patient care.

References:

  1. Munroe B, Curtis K, Margerat M, Strachan L, Buckley T. HIRAID: An evidence-informed emergency nursing assessment framework. Australasian Emergency Nurses Journal. 2015;18(2):83-97.

Effectiveness of nurses plastering and splinting in the Emergency Department: A systematic review of current evidence

Leahanna Stevens1, Susie Thompson2, Emma Stoddart3, Nerolie Bost4, Amy N.B. Johnston5

1 Nurse Practitioner, Mersey Community Hospital Emergency Department, Torquay Road, Latrobe, TAS, 7307 leahanna.stevens@ths.tas.gov.au
2 Nurse practitioner, Emergency Department, Logan Hospital, Cnr Loganlea and Armstrong Roads, Meadowbrook, QLD 4131, susanne.thompson@health.qld.gov.au
3 Nurse practitioner, Emergency Care, Gold Coast Hospital and Health Service, D Block, LG096 1 Hospital Boulevard, QLD 4215, emma.stoddart@health.qld.gov.au
4 Nurse Researcher, Emergency Department, Gold Coast Hospital and Health Service, D Block, LG096 1 Hospital Boulevard, QLD 4215, nerolie.bost@health.qld.gov.au
5 Research Fellow, Gold Coast Hospital and Health Service and Menzies Health Institute Queensland, Griffith University Gold Coast campus QLD 4222, a.johnston@griffith.edu.au

Aim: The aim of this systematic integrative review was to explore the effectiveness of nurses plastering and splinting in Emergency Departments (EDs). The focus was patient and staff satisfaction, cost and time-effectiveness of the procedures with nurses performing the task and overall clinical impacts.  The review was undertaken to provide evidence to guide the development of a model of nursing care incorporating plastering and splinting.

Methods: This systematic review is part of a larger study that has ethical approval. Following PRISMA guidelines, a multistage search process was undertaken using search terms: ED/s, Emergency department/s, Emergency room/s, ER/s OR A&E coupled with (AND) plastering, splinting, plasters, splints, fast track, fracture care, sprain, strain (AND) nurses; an open date range and databases such as CINAHL and Pubmed. Literature that described plaster or splinting application and/or care processes was excluded. Data extraction and review of quality assessment was undertaken. Full-text analysis was undertaken for 11 papers.

Results:  No papers were found that focused specifically on outcomes from nurses applying plasters or splints. However three studies indicated that plastering, as part of a suite of advanced nursing skills, had positive outcomes on patients and patient flow by reducing waiting times to treatment and decreasing ‘Did Not Wait’ rates.

Conclusions/Recommendations: There is limited evidence to guide protocol development for the role of nurses in plastering and splinting. Further research is recommended to evaluate the impact of ED nurses plastering and splinting on patient satisfaction and health care costs.

Conference Committee

Dr Brian Doyle
Australasian College for Emergency Medicine (ACEM)

Bess Swinton & Ryan Posselt
Paramedics Australasia (PA)

Michael Browne
College of Emergency Nursing Australasia (CENA)

Important Dates

Early Bird - June 2018
Conference - 10 - 12 August 2018

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