Peripheral intravenous catheter practices in Australian and New Zealand neonatal units: A cross-sectional survey

Peripheral intravenous catheters (PIVCs) are important tools for the provision of treatment for unwell and premature neonates. This study aimed to explore current PIVC practices (i.e. insertion, product selection, complications and management priorities) within Australian and New Zealand neonatal units, to identify areas for innovation and practice change. The survey was distributed via Australian and New Zealand neonatal nursing associations, with 180 respondents (54% Australia; 46% New Zealand). Respondents reported an average of 2–3 insertion attempts were required per PIVC, with variability in cleansing agents, decontamination techniques, skin barrier films and PIVC dressing products used. The large majority of respondents reported seeing skin complications associated with PIVCs within their practice (94%). Infection prevention was the highest management priority, and skin complication prevention, the lowest priority. High quality research is necessary to inform neonatal PIVC insertion and management practices, to improve patient safety and treatment provision.     

Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support

Purpose

To describe the characteristics of patients who die in emergency departments and the decisions to withhold or withdraw life support.

Methods

We undertook a 4-month prospective survey in 174 emergency departments in France and Belgium to describe patients who died and the decisions to limit life-support therapies.

Results

Of 2,512 patients enrolled, 92 (3.7%) were excluded prior to analysis because of missing data; 1,196 were men and 1,224 were women (mean age 77.3 ± 15 years). Of patients, 1,970 (81.4%) had chronic underlying diseases, and 1,114 (46%) had a previous functional limitation. Principal acute presenting disorders were cardiovascular, neurological, and respiratory. Life-support therapy was initiated in 1,781 patients (73.6%). Palliative care was undertaken for 1,373 patients (56.7%). A decision to withhold or withdraw life-sustaining treatments was taken for 1,907 patients (78.8%) and mostly concerned patients over 80 years old, with underlying metastatic cancer or previous functional limitation. Decisions were discussed with family or relatives in 58.4% of cases. The decision was made by a single ED physician in 379 cases (19.9%), and by at least two ED physicians in 1,528 cases (80.1%).

Conclusions

Death occurring in emergency departments mainly concerned elderly patients with multiple chronic diseases and was frequently preceded by a decision to withdraw and/or withhold life-support therapies. Training of future ED physicians must be aimed at improving the level of care of dying patients, with particular emphasis on collegial decision-taking and institution of palliative care.     

The storage of tetanus vaccine in accident and emergency departments: a postal survey.

The aim of this study was to assess the quality of storage of tetanus vaccine in accident and emergency (A&E) departments and also of the awareness of Department of Health guidelines. A postal questionnaire was sent to 50 randomly selected major A&E departments in the British Isles, enquiring about awareness of Department of Health guidelines (Department of Health, 1990). Forty (80%) A&E departments responded. Only 14 were aware of the Department of Health guidelines and in only 18 was there a member of staff taking responsibility for vaccine storage. The study found that safe storage of vaccine, and therefore guarantee of efficacy, is not occurring in the majority of A&E departments. Unnoticed failure of refrigerators could be exposing patients to the risk of tetanus infection.     

The management of epistaxis in accident and emergency departments: a survey of current practice.

A short questionnaire on the subject of the management of epistaxis was sent to forty accident & emergency departments in two NHS regions. Thirty replies were received (response of 75%). It was found that all departments were involved in the initial management of epistaxis, but the extent of that involvement varied considerably. One of the most obvious factors contributing towards the degree of involvement was the liaison between the accident & emergency and the ENT departments. Three departments never referred patients to the ENT department for follow-up. Nine departments performed their own nasal cautery, but half of these did not use any form of local anaesthesia. Twenty-seven departments used various forms of nasal packing but, of these, two-thirds did not use any form of local anaesthesia. Twenty-three departments allowed patients to go home with a nasal pack in situ. The results of this survey are discussed and a guideline to the management of epistaxis in an accident & emergency setting is suggested.     

Nurse practitioners in major accident and emergency departments: a national survey.

Use of nurse practitioners in major accident and emergency (A&E) departments is rapidly increasing: currently they are used in 30% of such departments and this is expected to rise to 63% by the end of 1995. Most are trained by a formal programme in the employing hospital but 12% claim to have no formal training. The nurse practitioner could prescribe a limited range of drugs in 82% of major departments with 'official' nurse practitioners, but radiograph requesting was permitted in only 57% of such departments: of those not able to request radiographs, 95% blamed radiographers for preventing this.     

Chaperone policy in accident and emergency departments: a national survey

Background  Medico-legal societies and the General Medical Council have been urging a greater use of chaperones during intimate examinations. However, research into the use of chaperones has been limited only to general practice. The objectives of this national survey were to find out: (1) whether formal chaperone policy exists in accident and emergency (A&E) departments; (2) the frequency of chaperone use; and (3) clinical applications.
Methods  A simple questionnaire was submitted to the lead clinicians/clinical directors of 460 A&E departments in the UK. The departments were identified through the British Association of Accident and Emergency Medicine Directory. The completed questionnaires were either posted or faxed back to our department.
Results  In total, 270 of 460 forms were returned (58.7%), of which only 246 were useable. Although 81.71% of A&E lead clinicians/clinical directors believe that formal policies are needed, only 3.65% of the departments have a formal policy. The highest percentage of chaperone use was observed for male doctors examining female patients (91.46%), while the lowest percentage was observed for male doctors examining male patients (7.32%). Worryingly, 25.61% reported incidents of complaints regarding inappropriate examination by doctors.
Conclusion  We have demonstrated deficiencies in chaperone use and have identified specific factors that render A&E departments particularly vulnerable to allegations of inappropriate practice. We believe that policies should be designed and implemented focusing on the specific needs of A&E departments to counteract the rising numbers of medico-legal cases, thus safeguarding patient care and protecting the health providers.     

Long-acting inhaled beta 2-agonists in the management of asthma: recent advances and current recommendations

Salmeterol and formoterol belong to a new class of inhaled beta 2-agonists with a prolonged duration of action. At the time these agents were introduced, there was uncertainty regarding the safety of beta 2-agonist therapy in asthma and concern that they might lead to a deterioration in asthma control. Recent studies, in contrast, have demonstrated both their safety and therapeutic efficacy. The aims of this review are to highlight these new developments and to consider the place of these long-acting beta 2-agonists in asthma management strategies.     

What is new with the beta2-agonists: issues in the management of asthma

OBJECTIVE: To review the more recent literature addressing the issue of whether beta2-agonists can worsen asthma and/or increase the risk of severe exacerbations and death from asthma. DATA SOURCES: PubMed was searched (2001-December 2004), along with the Food and Drug Administration and Cochrane Library Web sites. In addition, the bibliographies of recent reviews of the subject were assessed. STUDY SELECTION AND DATA EXTRACTION: Randomized clinical trials, retrospective and prospective cohort studies, and meta-analyses published in the past 3 years were reviewed. Studies assessing the potential for beta2-agonists to worsen outcomes in asthma as well as long-term studies assessing asthma outcomes that included an arm with regular administration of short- or long-acting inhaled beta2-agonists (LABAs) were selected. Worsening asthma was defined as a decline in lung function, an increase in bronchial hyperresponsiveness, exacerbations, or death. Studies older than 3 years selected from the bibliographies of the primary articles that addressed background perspective were also included where appropriate. DATA SYNTHESIS: The studies fell into 3 primary categories with some overlap: those assessing toxicity of the S-enantiomer of albuterol, those evaluating the risk of specific genotypes regarding worsening asthma, and those assessing asthma outcomes with LABA therapy. CONCLUSIONS: The current data on the use of beta2-agonists continue to support the national and international guidelines for the treatment of asthma. That is, short-acting inhaled beta2-agonists should only be used as needed for symptoms and prevention of exercise-induced bronchospasm, and LABAs should only be used regularly as adjunctive therapy with inhaled corticosteroids in patients whose asthma is not controlled with low to medium doses of the inhaled corticosteroid.     

Hereditary angioedema: a survey of UK emergency departments and recommendations for management

Patients with hereditary angioedema may present to the emergency department (ED) with subcutaneous and submucosal swellings, the most important being the development of laryngeal oedema, which can rapidly obstruct the airways and cause death. The aim of this study was to establish whether local guidelines exist for the management of such patients and to determine where the C1 inhibitor concentrate (C1 INHC) was kept in the trusts. A questionnaire survey of the availability and use of C1 INHC was sent to 35 EDs across the UK with established immunology services within their trusts. A hundred percent response was received. Thirty-three trusts had a supply of the drug C1 INHC in varying quantities. Nineteen trusts had it in their ED. Only 17 departments had any guidance with regard to their use. There is a significant lack of guidance for C1 INHC use in the EDs surveyed. A guideline was developed as a result that can be used by EDs across Europe.     

A survey of sedation assessment and management in Australian and New Zealand paediatric intensive care patients requiring prolonged mechanical ventilation

INTRODUCTION: A retrospective analysis of sedation management for children receiving prolonged ventilation in one Australian paediatric intensive care unit (PICU) revealed no identifiable pattern in sedation management and an inadequacy in the sedation scoring system. Therefore, the investigators sought to explore the current practice of sedation in critically ill children in PICUs across Australia and New Zealand. METHOD: This study used a mail-out survey to audit sedation management within the eight dedicated Australian and New Zealand PICUs. Results: 100% of the units surveyed replied (n=8). There were a total of 6,133 admissions to 8 Australian and New Zealand PICUs, where 3036 (49.5%) required ventilation. Of these children, 888 (29.2%) required ventilation > or =72 hours. Only 4 units had written guidelines for sedation management. A combined sedation regime of benzodiazepines and opioids was employed in six units. Administration and titration of sedation agents was managed by nursing staff alone in six units. All units indicated that they aimed to achieve a 'moderate level' of sedation. Two units used designated assessment tools for sedation and withdrawal assessment. One unit utilised Bispectral Index (BIS) monitoring. CONCLUSION: There were similarities observed in the methods and types of sedation agents used within Australian and New Zealand PICUs. However, only half of the units had guidelines for sedation management, and most units did not use validated paediatric scales to assist staff in assessing patient sedation and pain levels. Therefore it is recommended that a standardised approach to sedation assessment and management of critically ill children requiring prolonged ventilation be developed and tested.