Ann-Charlotte Falk

Evaluation of documentation in potential abusive head injury of infants in a Paediatric Emergency Department

Aim: The aim is to evaluate medical record documentation regarding potential abusive head injury (AHI) in infants presenting to a Paediatric Emergency Department (ED) with certain primary complaints known to be associated with AHI.

Are the symptoms and severity of head injury predictive of clinical findings three months later

Aim: To describe symptoms and functional disabilities 3 mo after a minimal, mild or moderate head injury in children, and to analyse relationships between these and initial symptoms and management documented at the time of the injury. Methods: The sample consisted of all children (0–15 y) admitted to an emergency department during a 1‐mo period with a history of head injury. Data were collected from the medical records at the time of the injury, and questionnaires about symptoms/change and functional problems 3 mo after the injury. Results: Symptoms and functional problems were reported in 35% of the children 3 mo after a head injury. Documented altered consciousness (in children less than 5 y) and disorientation (in children 5 y of age or older) at the emergency department were correlated with changes in behaviour at 3 mo. The initial duration of unconsciousness was not predictive of subsequent behaviour. Conclusion: The difficulties in predicting outcomes in head‐injured children, especially younger ones, indicate the need for a follow‐up appointment in order to identify children with special needs. Further studies are needed regarding the early signs and symptoms in different age groups.

Barriers and opportunities in assessing calls to emergency medical communication centre - a qualitative study

IntroductionPrevious studies have described the difficulties and the complexity of assessing an emergency call, and assessment protocols intended to support the emergency medical dispatcher’s (EMD) assessment have been developed and evaluated in recent years. At present, the EMD identifies about 50-70 % of patients suffering from cardiac arrest, acute myocardial infarction or stroke. The previous research has primarily been focused on specific conditions, and it is still unclear whether there are any overall factors that may influence the assessment of the call to the emergency medical communication centre (EMCC).AimThe aim of the study was to identify overall factors influencing the registered nurses’ (RNs) assessment of calls to the EMCC.MethodA qualitative study design was used; a purposeful selection of calls to the EMCC was analysed by content analysis.ResultsOne hundred calls to the EMCC were analysed. Barriers and opportunities related to the RN or the caller were identified as the main factors influencing the RN’s assessment of calls to the EMCC. The opportunities appeared in the callers’ symptom description and the communication strategies used by the RN. The barriers appeared in callers’ descriptions of unclear symptoms, paradoxes and the RN’s lack of communication strategies during the call.ConclusionBarriers in assessing the call to the EMCC were associated with contradictory information, the absence of a primary problem, or the structure of the call. Opportunities were associated with a clear symptom description that was also repeated, and the RN’s use of different communication strategies such as closed loop communication.

Ambulance personnel's experience of pain management for patients with a suspected hip fracture: A qualitative study

Pain management is described to be insufficient for patients suffering from a hip fracture, and the management for this vulnerable group of patients may be challenging due to their medical history (multiple comorbidities) and polypharmacy. Previous research has mainly focused on fast tracks aiming to reduce time to surgery. But the research on how pain management is handled for these patients in the prehospital context has been sparse. Therefore, the purpose of this study was to describe the ambulance personnels experience of managing the pain of patients with a suspected hip fracture. A descriptive and qualitative design with Critical Incident Technique was used for collecting data. Moreover, a qualitative content analysis was used for analysing the collected data. Twenty-two participants communicated their experiences and 51 incidents were analysed. The main finding in the study was that the ambulance personnel, by using their clinical knowledge and by empowering the patients to participate in their own care, managed to individualize the pain relief for patients with a suspected hip fracture through a variety of interventions.

Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management

Abstract Background Pain is one of the most common symptoms treated in emergency department (ED). Pain may cause suffering and disability for the patient. Inadequate pain management may be associated with increased risk of complications such as sleep disturbance, delirium and depression. Previous studies conclude that pain management in ED is insufficient and inadequate. Yet, little is known about patients’ own experience regarding pain management in ED. Objective The aim of this study was to explore the satisfaction of pain management in patients having acute musculoskeletal injuries before and after implementation of mandatory documentation regarding pain assessment in the ED. Method An observational pre-post intervention study design was used. The study was conducted on patients having acute musculoskeletal injuries such as soft tissue injury, back pain or wrist/arm/leg/foot fractures in a 24-h adult (>15 years) ED at a public urban teaching hospital in Stockholm, Sweden. Data was collected by an interview based on a questionnaire. Results A total of 160 patients answered the questionnaire. In the pre- (n = 80) and post-intervention (n = 80) groups, 91/95% experienced pain in the ED. A significant difference (p < 0.003) was found during the post-intervention period, with more patients receiving analgesics compared to the pre-intervention group. A significant decline (p < 0.03) in patients’ own reported pain intensity at discharge was found between the groups. Patients’ reported satisfaction on pain management in the ED increased in the post-intervention group, but the difference was not statistically significantly. Conclusion Patients’ satisfaction with pain management increased, but not statistically significantly. However, both percentages of patients receiving analgesic drugs increased and pain intensity decrease at discharge were statistically significant after the intervention that made nurses obliged to register pain. Implication According to the findings of this study, mandatory pain documentation facilitates pain management in the ED, but there is still room for improvement. Additional actions are needed to improve patients’ satisfaction on pain management in the ED. Mandatory pain documentation in combination with person-centred care could be a way of improving patients’ satisfaction on pain management. Effective pain management is an important quality measure, and should be focused on in acute care in the ED. By routinely asking patients to report the pain intensity at discharge, the ED personnel can have direct feedback about the factual pain management. RNs may also be encouraged to use intravenous analgesics in higher extent when the patients have very severe pain.

Prehospital management of traumatic brain injury patients--a gender perspective.

BACKGROUND Studies show that there are differences between men and women when it comes to several aspects of health care. But the research on equal care in a prehospital setting for patients with severe traumatic brain injury (TBI) has been sparsely investigated. The aim of this study is to describe prehospital care from a gender perspective. METHOD This is a retrospective study of (n = 651) patients (>15 years) with severe TBI requiring intensive care at a University Hospital in Sweden during the years 2000-2010. Outcome was measured by survival and Glasgow Outcome Scale (GOS) scores at discharge. RESULT Our results show differences, though not significant, in the initial assessments and performed interventions between male and female TBI patients. Female patients received more assessments and performed interventions compared to men during prehospital care. Men received more interventions with I.V. fluid but significantly less airway interventions (endotracheal intubation) compared to female patients. More men were transported directly to neurosurgical specialist care as compared to females. No difference in outcome was found. CONCLUSION Our results show differences, however not significant in the assessments and performed interventions between gender, with female patients receiving more assessments and interventions compared to male patients during prehospital care. Future research should focus on gender differences in initial early signs of TBI to improve early identification.

The specificity of post-concussive symptoms in the pediatric population

The study compared patterns of reported symptoms between a mild head injury group and a group of children with abdominal complaints visiting an emergency department. Children (0—15 years) admitted to an emergency department during a three-month period with a history of head injury and a comparison group of children were included. Medical records at the time of injury were reviewed and follow-up questionnaires focused on presumed symptoms related to concussion at three months post-visit. The comparison group reported significantly more change in behaviour than the head injury group. However, for the older children, higher intensity of symptoms was reported by the comparison group compared to the head injury group. Initial differences in the amount and presence of symptoms between the two groups did not reflect the findings at three months; both groups reported symptoms or changes at three months after the event. Evaluating children aged under five, their symptoms and recovery patterns after a head injury is recommended.

Actions to improve documented pain assessment in adult patients with injury to the upper extremities at the Emergency Department – A cross-sectional study

BACKGROUND Pain is one of the most common symptoms in the Emergency Department (ED) and is the cause of more than half of the visits to the ED. Several attempts to improve pain management have been done by using, for example, standards/guidelines and education. To our knowledge no one has investigated if and how different actions over a longitudinal period affect the frequency of pain documentation in the ED. Therefore the aim of this study was to describe the frequency of documented pain assessments in the ED. METHOD A cross-sectional study during 2006-2012 was conducted. The care of patients with wrist/arm fractures or soft tissue injuries on upper extremities was evaluated. RESULT Despite various actions our result shows that mandatory pain assessment in the patients computerized medical record was the only successful intervention to improve the frequencies of documentation of pain assessment during care in the ED. During the study period, no documentation of reassessment of pain was found despite the fact that all patients received pain medication. CONCLUSION To succeed in increasing the frequency of documented pain assessment, mandatory pain rating is a successful action. However, the re-evaluation of documented pain assessment was nonexisting.

Educational Intervention to Improve Nursing Practice in the Critical Care Setting

A variety of educational interventions may have an impact on patient assessment and patient outcome. Studies have reported an inconsistency in the use of Neurological assessments performed by nurses, such as the Glasgow Coma Scale (GCS) in the acute care setting. The aim of this study is to evaluate the impact of an educational intervention for nurses on the number of performed neurological assessments over time. Intervention: A total of 60 health care staff was offered education on neurological assessment (GCS) of Pediatric Intensive Care Unit (PICU) at a level one-trauma center. Method: A quasi-experimental design to evaluate the change in the number of performed neurological assessments in children. The amount of GCS assessments was compared before and after the educational intervention. Findings: The educational intervention showed a significant increase in GCS assessments during the one and two-month periods after the intervention but with a decline at three months post-intervention.

The occurrence of pressure damage in the oral cavity caused by endotracheal tubes

The aim of this observational study was to investigate the occurrence of pressure damage caused by endotracheal tubes (ETT) when the tube is repositioned from one corner of the mouth to the other every third day. For the assessment of oral condition and the eventual damage caused by ETT, a modified version of the Oral Assessment Guide (OAG) was used. The oral condition was assessed once per day in all adult patients who were orally intubated with a tube for over 24 hours. Thirty-eight patients were included in the study. Most patients (n = 33, 86.8%) had no pressure damage. Five patients (13.2%) had pressure damage on the oral mucosa and lip caused by endotracheal tubes. The group with damage to the oral mucosa was treated with noradrenaline, had bleeding problems and clotting disorders and had significantly more intubated and study days. The assessment of the oral mucosa according to the OAG reflected the worsening oral condition in the group with pressure damage. Endotracheal tubes may need to be repositioned more often than every third day to avoid pressure damage in patients with a high risk of complications, and individually tailored care may need to be implemented.