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1.
Maureane Hoffman Joshua N. Goldstein Jerrold H. Levy 《International journal of emergency medicine》2018,11(1):55
Background
Bleeding complications are a risk associated with all anticoagulants. Currently, the treatment options for the management of direct oral anticoagulant (DOAC)-associated bleeding are limited. Prothrombin complex concentrates (PCCs) have been proposed as a potential therapeutic option, and evidence regarding their use is increasing.Review
Many studies supporting PCC have used preclinical models and healthy volunteers; however, more recently, observational studies have further improved insight into current DOAC reversal strategies. Multiple clinical practice guidelines now specifically suggest use of PCCs for this indication. Specific reversal agents for Factor Xa inhibitors may become available in the near future, but data on their efficacy are still emerging.Conclusions
Ultimately, a multimodal approach may be the optimal strategy to restore haemostasis in patients presenting with DOAC-associated coagulopathy.2.
Gordon Mao Lauren King Sarah Young Richard Kaplan 《The Journal of emergency medicine》2017,52(5):731-737
Introduction
As increasing number of patients present to emergency departments with life threatening hemorrhages, particularly intracranial hemorrhage on anticoagulation physicians must be cognizant of the limitations of the available reversal options. Based upon the available literature, our institution formulated a reversal algorithm for patients with life-threatening bleeding on factor Xa inhibitors by administering factor eight inhibitor bypassing agent (FEIBA) 20 units/kg.Methods
A retrospective chart review was performed to include all patients who received FEIBA per institutional protocol. This case series excluded patients who received FEIBA for reversal of dabigatran. Pre and post FEIBA CT scans were compared for changes. Finally, patients were stratified by estimated mortality rates calculated based on pre-intervention characteristics via published risk models.Results
Thirteen patients were initially included in this study yet two patients were excluded because they were on dabigatran. Fifty-five percent of patients demonstrated stable ICH on CT scan after FEIBA administration while thirty-six percent showed worsening scans. Two patients developed thrombotic events after FEIBA administration.Discussion
FEIBA is a treatment option in patients on a TSOA with acute intracranial hemorrhage with evidence of at least partial pharmacologic reversal of their anticoagulation status. There does not appear to be any major risk of thromboembolic complications associated with FEIBA. Much larger study sizes will be necessary to establish statically significant clinical efficacy for FEIBA use in this patient population.Why Should an Emergency Physician Be Aware of This?
Emergency medicine physicians are first-line caretakers for patients with life threatening intracranial hemorrhages whether spontaneous or traumatic. FEIBA is a potentially safe option to reverse TSOA in this patient population. 相似文献3.
4.
Namkyung Jeong Kyung Su Kim Yoon Sun Jung Taegyun Kim So Mi Shin 《The American journal of emergency medicine》2019,37(2):277-280
Objectives
To determine the association between delayed (>24?h) endoscopy and hospital mortality in patients with upper gastrointestinal hemorrhage (UGIH).Methods
We retrospectively analyzed all adult patients with UGIH who underwent endoscopy in a single emergency room for 2?years. The primary exposure was defined as >24?h from the ED visit to the first endoscopy. The primary outcome was defined as all cause hospital mortality. Secondary outcomes were intensive care unit admission rate, ED length of stay, and hospital length of stay.Results
Among 1101 patients enrolled, 898 received endoscopy within 24?h (early group) and 203 received endoscopy after 24?h (delayed group). The hospital mortality of early and delayed group was 2.8% and 6.4%, respectively (unadjusted relative risk [RR] 2.30: 95% CI, 1.20–4.42, p?=?0.012). This was significant after adjusting covariates including AIMS65 and Glasgow-Blatchford score (adjusted RR 2.23: 95% CI, 1.18–4.20, p?=?0.013). Intensive care unit admission rate was not different between two groups. ED and hospital length of stay were significantly longer in delayed group.Conclusions
Endoscopy performed after 24?h was associated with increased hospital mortality in UGIH. Patients in the delayed group stayed longer in the ED and in the hospital. 相似文献5.
Sandra Cristina Pillon Kelly Graziani Giacchero Vedana Jessica Adrielle Teixeira Leonardo Afonso dos Santos Roberto Molina de Souza Alessandra Diehl Goolam Hussein Rassool Adriana Inocenti Miasso 《Archives of Psychiatric Nursing》2019,33(1):70-76
Aim
To investigate the prevalence of depressive symptoms, psychological problems, suicidal behaviour and their associations in substance users in treatment.Methods
A cross-sectional study, with 307 substance users in an out-patient treatment facility, was undertaken. Socio-demographic data, psychoactive substances used, depressive symptoms, and suicide information were obtained.Results
70% of participants were depressed; of those, 8.1% were either under the influence of drugs or in withdrawal. Suicidal ideation was found to be present in those who had anxiety, were nervous, had depressive symptoms, or were under drug influence or in withdrawal.Conclusion
It is important to identify potential suicidal risk factors and implement the management of these conditions in substance users. 相似文献6.
Brian W. Gilbert Joel B. Huffman Joe Slechta Christine Porter John M. Gallagher 《The American journal of emergency medicine》2019,37(2):294-297
Objective
The objective of this study was to evaluate a new multidisciplinary process in which intravenous alteplase (tPA) waste, used for acute ischemic stroke (AIS), was salvaged in an attempt to maximize cost effectiveness without impacting door-to-needle (DTN) administration times.Design
This was a retrospective cohort between May 2017 and February 2018. The primary endpoint evaluated for this study was the total tPA salvaged and total cost savings in U.S. dollars. Secondary endpoints evaluated included overall DTN time in minutes.Setting
Emergency department of a primary stroke center.Patients
A convenience sample of sequential adult (>18?years) patients who received tPA in the ED for AIS were included for analysis.Interventions
New stroke process which involved bedside mixing of tPA and salvaging of excess waste in the main central pharmacy.Measurements and main results
A total of 50 patients were included in the final analysis. There were 25 patients included in the new process and old process groups respectively. A total of 605?mg of alteplase was salvaged from 25 patients in the new process group which was associated with an estimated cost savings of over $120,000 annually. Patients in the new process group had statistically faster average (52?min vs. 60?min; p?=?0.01) and median (50?min vs. 58?min; p?=?0.03) DTN administration times.Conclusion
Preliminary data, in this pilot study, utilizing a multidisciplinary model for tPA administration led to significant cost savings of tPA and decreases in overall DTN administration times. 相似文献7.
Michelle Ng Jerrold Perrott Sarah Burgess 《The American journal of emergency medicine》2019,37(3):444-449
Introduction
Tranexamic acid (TXA) has been shown to decrease mortality in adult trauma patients with or at significant risk of hemorrhage when administered within 3?h of injury. The use and appropriateness of TXA in adult trauma patients presenting to Royal Columbian Hospital (RCH) was investigated.Methods
This retrospective chart review utilized the British Columbia Trauma Registry to identify 100 consecutive trauma patients that presented to the emergency department at RCH between April 2012 to June 2015 and met the following indications for TXA: systolic blood pressure <90?mm?Hg and/or heart rate >110?bpm and presentation within 8?h of injury. Primary outcomes included: percentage that met indications for TXA, received TXA according to the CRASH-2 protocol, received a pre-hospital dose, and received TXA ≤1, >1 to ≤3, or >3?h from injury.Results
During the given time period, 117 subjects (2.7%) met indications for TXA. 67 patients (57%) received TXA in any dose, with 10 subjects (8.5%) receiving TXA according to the CRASH-2 protocol. Of the 67 patients who received any TXA, 76% did so ≤3?h. 22 patients (19%) received TXA as a pre-hospital dose.Conclusions
<10% of adult trauma patients that met the indication for TXA received it according to the CRASH-2 protocol. Of those patients that received TXA, 76% did so within 3?h. Further inquiry to identify reasons trauma patients are not receiving TXA as well as quality improvement initiatives in trauma care are required.Level of evidence
IIIStudy type
Therapeutic 相似文献8.
Ingrid Llovera Kirsten Loscalzo Jia Gao Timmy Li Martina Brave Lance Becker Isabel Barata 《The American journal of emergency medicine》2019,37(3):486-488
Objective
We studied the impact four new urgent care centers (UCCs) had on a hospital emergency department (ED) in terms of overall census and proportion of low acuity diagnoses from 2009 to 2016. We hypothesized that low acuity medical problems frequently seen in UCCs would decrease in the ED population. Since Medicaid was not accepted at these UCCs, we also studied the Medicaid vs non-Medicaid discharged populations to see if there were some differences related to access to urgent care.Methods
We conducted a retrospective review of computerized billing data. We included all patients from 2009 to 2016 who were seen in the ED. We used the Cochran-Armitage Trend Test to examine trends over time.Results
As hypothesized, the proportion of ED patients with a diagnosis of pharyngitis decreased significantly over this time period from 1% to 0.6% (p?<?0.0001). The rate of bronchitis in the total ED population also decreased significantly (0.5% to 0.13%, p?<?0.0001).When we looked at the discharged patients with and without Medicaid, we found that significantly more Medicaid than non-Medicaid patients presented with pharyngitis to the ED with an increasing trend from 2009 to 2016: OR?=?2.33, p?<?0.0001. The overall census of the ED rose over the period 2009 to 2016 (80,478 to 85,278/year). Overall admission rates decreased significantly: 36.9% to 34.5% (p?<?0.0001).Conclusion
With the introduction of four new urgent care centers (UCCs) within 5?miles of the hospital, the ED diagnoses of pharyngitis and bronchitis, two of the most common diagnoses seen in UCCs, decreased significantly. Significantly more Medicaid discharged patients presented to the ED with pharyngitis than in the non-Medicaid discharged group, likely because Medicaid patients had no access to UCCs. 相似文献9.
Background
Schizophrenia is a chronic mental illness that affects the client, family, and community. Nurses are educated to use the nurse-patient relationship to provide health education and collaborative health decision-making. However, challenges abound for nurses and clients with schizophrenia to effectively utilize the relationship to reach these goals.Problem
There is a lack of evidence-based information to assist nurses to meet the challenges of building effective therapeutic relationships with clients for whom schizophrenia hinders health education and decision-making.Purpose
To examine current research findings on factors that influence therapeutic relationships in psychiatric treatment settings as an initial effort to provide empirically based guidance for psychiatric nurses who seek to better use the relationship to work with the client toward health-related goals.Method
This integrative review of the literature follows Whittemore and Knafl's (2015) method, analyzes 15 studies from multiple databases between the years 2006–2017, and assesses the rigor of each.Findings
Numerous methods are used to assess therapeutic relationships. Few studies included nurses. Provider perception of client symptoms can negatively affect provider assessment of quality of relationship; no such association was found on the part of clients. Providers and clients prioritize client needs differently, with providers influenced by treatment setting demands, but provider-training programs can have a beneficial effect on their relationships.Conclusion
Nurses and nurse educators can use the findings to guide assessment of how perceptions and priorities influence relationships. Findings also provide the foundation for further study of nurses' perceptions of therapeutic relationship, in progress, to yield more detailed information on what nurses and educators need to strengthen therapeutic relationships. 相似文献10.
Background
Leadership competency is required throughout nursing. Students have difficulty understanding leadership as integral to education and practice. A consistent framework for nursing leadership education, strong scholarship and an evidence base are limited.Purpose
To establish an integrated leadership development model for prelicensure nursing students that recognizes leadership as a fundamental skill for nursing practice and promotes development of nursing leadership education scholarship.Method
Summarizing definitions of nursing leadership, conceptualizing leadership development capacity through reviewing trends, and synthesizing existing leadership theories through directed content analysis.Discussion
Nine leadership skills form the organizing structure for the Nursing Leadership Development Model. Leadership identity development is supported via dimensions of knowing, doing, being and context.Conclusion
The Nursing Leadership Development Model is a conceptual map offering a structure to facilitate leadership development within prelicensure nursing students, promoting student ability to internalize leadership capacity and apply leadership skills upon entry to practice. 相似文献11.
12.
Josh Greenstein Devjani Das Josie Acuna Monica Kapoor Cara Brown Abbas Husain Brendan Lally Barry Hahn 《The American journal of emergency medicine》2019,37(2):313-316
Background
In the emergency department, rib fractures are a common finding in patients who sustain chest trauma. Rib fractures may be a sign of significant, underlying pathology, especially in the elderly patients where rib fractures are associated with significant morbidity and mortality. To date, no studies have evaluated the ability of ultrasound to detect rib fractures using cadaver models and subsequently use this model as a teaching tool.Objectives
The purpose of this study was to determine if it is possible to generate rib fractures on cadaver models which could be accurately identified using ultrasound.Methods
This was a cross-sectional study performed during one session at a cadaver lab. A single hemithorax from four adult cadavers were used as models. Single rib fractures on each of rib five through eight were created. Four subjects, blinded to the normal versus fractured ribs, were asked to identify the presence of a fracture on each rib.Results
A total of 8 of 16 potential ribs had fractured induced by study staff. Mean accuracy was 55% for all subjects. The overall sensitivity and specificity for detecting rib fractures was 50% (CI: 31.89–68.11) and 59.38% (CI: 35.69–73.55) respectively. The overall PPV and NPV was 55.17% and 54.29% respectively.Conclusions
In this pilot study, subjects were not able to detect induced rib fractures using ultrasound on cadaver models. The use of this model as a teaching tool in the detection of rib fractures requires further investigation. 相似文献13.
Mollie E. Aleshire Alexandra Dampier Leslie Woltenberg 《Journal of Professional Nursing》2019,35(1):37-43
Background
Nursing students' attitudes related to health care teams in the context of interprofessional education (IPE) and the impact of these attitudes on IPE and future practice are not fully understood.Purpose
The current study assesses baccalaureate nursing students' attitudes toward health care teams and evaluates if these attitudes have changed after completion of a nursing course focusing on health care systems from an interprofessional perspective.Method
A convenience sample of 116 undergraduate nursing students in a required interprofessionally-focused course was invited to participate. The Attitudes Toward Health Care Teams Scale Quality of Care subscale (ATHCT-QC) and Team Understanding Scale (TUS) were employed via a pretest-posttest design. Paired samples t-tests were conducted to compare mean scores.Results
Ninety-five respondents (81.8%) voluntarily participated at the beginning and conclusion of the course.Conclusions
There were no significant differences between pretest-posttest attitudes toward interprofessional health care teams. Nurse educators must create and evaluate innovative IPE interventions to enhance students' preparedness to be effective interprofessional health care team members. 相似文献14.
Nancy Hoffart Thomas P. McCoy Lynne P. Lewallen Shemeka Thorpe 《Journal of Professional Nursing》2019,35(2):93-100
Background
The New Careers in Nursing (NCIN) program provided scholarships and other supports to accelerated degree students at 130 nursing schools and collected data from the scholars at three time-points.Purpose
The NCIN database was analyzed to identify gender-based differences in scholars' profile characteristics, program experiences, and post-graduation outcomes.Method
An adaptation of Jeffreys's Nursing Universal Retention and Success Model guided the analysis. Gender differences were assessed after multiplicity adjustments for false positive rates.Results
Differences based on gender were found for profile characteristics, student affective factors, academic factors, professional integration factors, environmental factors, as well as academic, psychological and NCIN program outcomes. Results suggest that males were influenced by economic factors more than females when choosing nursing as a career. They had fewer concerns about financial aspects associated with being a student again yet secured employment sooner after graduation than female scholars. They did not view support services as important as did female students. They expressed confidence in their leadership competence more than their female counterparts.Conclusion
Efforts are needed to better understand and address the nuanced gender-based perceptions and needs of nursing students who are male. 相似文献15.
Introduction
Transgender and gender non-conforming (TGNC) people in the United States face disproportionate rates of mental health disorders, including suicidality, depression, anxiety, and substance use disorders than the general population. Patients' experiences utilizing mental healthcare is a determinant in their care-seeking behaviors and treatment success.Aim/question
The purpose of this integrative review is to better understand the firsthand mental healthcare experiences of TGNC persons.Method
The authors sought to locate recent English-language articles that described the mental healthcare experiences of TGNC persons. To do so, only articles that conducted data collection with a TGNC sample were considered for review.Results
Seven articles met criteria for review. Four themes emerged that depicted experiences of health promotion (welcoming environments, staff knowledge and response) and health prevention (enacted stigma, racial disparities and intersectional insensitivity).Discussion
Themes indicated that TGNC persons have mixed experiences (excellent to harmful/damaging) when receiving mental healthcare. There is room for healthcare provider growth in skills to increase TGNC cultural competency.Implications for practice
Mental healthcare providers and nurses would benefit from interventions to promote TGNC culturally competent care, including in-service training or continuing education for the current work force as well as incorporating TGNC content into pre-licensure educational curricula. 相似文献16.
Objectives
Diagnostic tests are widely used for patients with syncope in the emergency department (ED). This study aimed to determine the diagnostic yield of neuroimaging in patients with syncope without high-risk symptoms.Methods
Adult patients who presented to the ED with syncope in 2016 were screened retrospectively. Patients who suffered from mild head trauma due to syncope were also included. Patients with neurological examination findings (confusion, amnesia, focal neurological deficit, severe headache, dizziness, nausea and vomiting), patients on anticoagulants, patients with known intracranial malignancies and those whose loss of consciousness was attributed to reasons other than syncope were excluded from the study.Results
A total of 1114 patients were included in the study. The median age was 48?years (IQR?=?34–66?years) and 576 (51.7%) of the patients were male. The neuroimaging tests performed were cranial computerized tomography (CT) in 694 (62.3%) cases and magnetic resonance imaging (MRI) in 114 (10.2%) cases. Mild head trauma due to syncope was observed in 116 (10.4%) patients. None of the neuroimaging studies revealed any clinically significant findings.Conclusion
Neuroimaging is not beneficial in patients whose medical history and physical examination do not indicate neurogenic syncope, even if the patient has mild head trauma. 相似文献17.
Jong Wook Kim Jung Youn Kim Sun Tae Ahn Tae Yong Park Mi Mi Oh Du Geon Moon Hong Seok Park 《The American journal of emergency medicine》2019,37(1):45-47
Introduction
This study aimed to analyze the characteristics, etiology, and treatment of a series of patients with spontaneous perirenal hemorrhage (Wunderlich syndrome [WS]).Methods
We retrospectively reviewed the records of 26 patients hospitalized for WS in a tertiary urological center between 2011 and 2018. All patients were evaluated for perirenal hemorrhage observed on computed tomography (CT) in the emergency department. Clinical variables (age, underlying diseases, symptoms, shock, and hospitalization period), laboratory test results, and radiological and pathological results were reviewed.Results
The series included 28 events from 26 patients with a mean follow-up period of 20.2?±?18.0?months. Flank pain was most common symptoms (92%). Twelve patients (46%) had visible renal lesions and associated hematoma and 14 only showed perirenal hematoma. In six patients with shock (systolic blood pressure?<?90?mm?Hg), 2 underwent emergency angioembolization. Twelve patients (46%) underwent exploration and total nephrectomy. In the final diagnosis, 4 cases of renal cell carcinoma, 3 of angiomyolipoma, 4 of simple renal cyst, 2 of acquired cystic kidney disease, 4 of sarcoma or other malignancy, 4 of chronic pyelonephritis, and 5 of idiopathic WS were observed. Patient age was associated with prediction of renal cell carcinoma in the patients with WS.Conclusion
Renal masses are the main cause of WS, and CT is the diagnostic procedure of choice. Old age is a possible risk factor for renal cell carcinoma in etiology of WS. Surgical treatment is preferred in patients diagnosed with renal malignancy and in cases of hemodynamic instability. 相似文献18.
Background
Violence is a large concern for mental health professionals: 90% of physicians and nurses working in mental health areas have been subject to violence from patients. Approximately 80% of violent acts from patients are directed toward nurses.Objective
The purpose of this integrative literature review was to identify violence risk–assessment screening tools that could be used in acute care mental health settings.Design
The Stetler model of evidence-based practice guided the literature search, in which 8 violence risk–assessment tools were identified, 4 of which were used for further examination.Results
The Brøset Violence Checklist and Violence Risk Screening-10 provided the best assessment for violence in the acute care mental health setting.Conclusions
Using a violence risk assessment screening tool helps identify patients at risk for violence allowing for quick intervention to prevent violent episodes. 相似文献19.
20.
Jenna Garlock Leborah Lee Michaelia Cucci Lawrence A. Frazee Chanda Mullen 《The American journal of emergency medicine》2019,37(5):884-889
