An Evaluation of the Efficacy of Selected Nonpharmacologic Pain Interventions in Infants

Infants subjected to painful stimuli respond with deleterious physiologic and metabolic effects, behavioral changes, and potentially long term effects on painful stimuli processing and response. There are few studies that address effective pain interventions for infants, particularly those interventions that staff nurses can implement independently. Interventions must be identified and their effectiveness must be validated for this vulnerable population. Pharmacologic management of pain may cause deleterious side effects and needs to be ordered by physicians or nurse practitioners. Nonpharmacologic methods to manage pain can usually be implemented by staff nurses independently. This study evaluated the efficacy of two nonpharmacologic pain management interventions, sucking and sucrose, and their ability to potentiate each other. This study is based on the Gate Control Theory of pain which posits that benign stimuli, such as sucking, send messages to the central nervous system that compete with painful stimuli to decrease the amount of pain perceived. Sucrose is thought to be mediated through opioid pathways. A sucrose coated pacifier may reduce pain via two pathways, thus being more effective than uni-modal techniques. A randomized, complete block, experimental design was used to evaluate the pain reduction efficacy of a: sucrose coated pacifier, oral sucrose solution, water moistened pacifier, and no intervention. Eighty-four neonates undergoing the painful procedure of heelstick were studied. Pain measures were duration of cry, vagal tone, and salivary cortisol. MANOVA revealed that the sucrose coated pacifier group cried significantly less than the water moistened pacifier and control groups. ANCOVA demonstrated significant covariation of birth weight with cortisol and procedure length with cry, neither covariate impacted treatment main effects. Repeated measures ANOVA revealed that the sucrose coated pacifier group demonstrated significantly lower vagal tone during heelstick than did the oral sucrose solution and no intervention groups. This significant difference persisted for 15 minutes post heelstick between the sucrose coated pacifier and no intervention groups. In summary, this study demonstrated the clinical efficacy of offering a sucrose coated pacifier to manage pain during heelstick in healthy neonates

Implementation of a Rapid Assessment Unit (Intake Team): Impact on Emergency Department Length of Stay

Implementation of a Rapid Assessment Unit (Intake Team): Impact on Emergency Department Length of Stay Richard S. MacKenzie, MD, David B. Burmeister, DO, Jennifer A. Brown, RN, Melissa Teitsworth, RN, BSN, Christopher J. Kita, MEd, Megan J. Dambach, DO, Shaheen Shamji, DO, Anita Kurt, PhD, RN , Susan Friend, Marna Greenberg, DO, MPH Acknowledge: Clare M. Lenhart, PhD, MPH Objective: Emergency Department (ED) crowding is an on-going formidable issue for many EDs. A Rapid Assessment Unit (RAU) is a potential solution. This process involves the use of a team approach to convert the current “series” type evaluation to a more “parallel” evaluation and treatment of patients. The RAU concept of evaluating and treating ED patients radically changes the current methods utilized in today’s standard emergency care area. The RAU concept offers a process in which the patient walks into the ED and is seen in a unit by an intake team composed of a nurse, registrar, and provider (physician assistant, nurse practitioner, or physician) that provides evaluation and emergent treatment. This removes the redundancy of a patient giving the same information several times before they are treated. Simultaneously, the team decides whether the patient would be better served by remaining seated or requires a recumbent position. This is referred to as allowing “vertical flow” versus the default “horizontal flow” where all patients recline on a stretcher whether they need it or not. Certainly, having construction that specifically supports these processes is an innovation as well (having an area where patients can be seated and remain “vertical”). The team structure itself is unique. The nurses and providers are not assigned geographically by room but rather are defined by their function. We set out to determine if the addition of the RAU process would decreases the LOS of the discharged ambulatory arrival patient. Methods: After IRB approval, this retrospective, pre- and post intervention, observational comparison study was conducted from August 2011-March 2012 at a suburban teaching hospital in central Pennsylvania with an annual ED census of approximately 54,000. The inclusion criteria were all ambulatory discharged patients. The exclusion criteria were all patients that arrived by ambulance and admitted patients. Data points captured included: time of arrival in triage , time in triage to ED entry, time of ED entry until seen by a provider, time from ED entry to discharge, total length of stay (LOS). The data were uploaded to Horizon Business Insight™ (HBI), a cumulative data manager and exported to an Microsoft excel file for analysis. Mann-Whitney U tests were used to demonstrate differences in Median LOS. All statistical tests were 2-sided; probability values \u3c0.05 were considered significant. Results: 11, 994 pre and 10814 post-RAU patients were included in analysis. Median LOS was shorter during the post-RAU period in each subcategory of LOS with the exception of the interval from being seen in the ER to discharge which is a result of provider seeing the patient earlier in the ED encounter. Results, Table 1. Conclusions: The RAU process decreases the LOS of the discharged ambulatory arrival patient and deserves further exploration as an innovative model in the ED that improves flow

Management of Benign Paroxysmal Positional Vertigo: A Randomized Control Trial

Management of Benign Paroxysmal Positional Vertigo: A Randomized Control Trial Regina R. Sacco, DPT, BA, BHSc, David B. Burmeister, DO, Valerie Rupp, RN, MSN, CRNP, Marna Rayl Greenberg, DO, MPH Background: Benign Paroxysmal Positional Vertigo (BPPV) is a common complaint of patients who seek care in the Emergency Department (ED). Objective: To compare the efficacy of vestibular rehabilitation (maneuver) vs. conventional therapy (medications) in ED patients with BPPV. In particular we sought to evaluate the improvement of vertigo in patients diagnosed with BPPV in the ED, assess their disposition time, and compare patient satisfaction between those patients who receive standard care vs. those who received vestibular rehabilitation. Methods: This was a prospective, single-blinded physician, randomized pilot study comparing two groups of patients who present to the ED with a diagnosis of BPPV at a Level 1 trauma center with an annual census of approximately 75,000. The first group received standard medications as per provider preference, to alleviate their symptoms, including treatments such as benzodiazepines, antihistamines, and antiemetics, while the second group received a canalith repositioning maneuver. In both groups, the research staff assessed for symptom resolution every 15 minutes for the first hour, then every 30 minutes up to two hours or until symptom resolution or physician re-assessment was complete using a visual analog scale; one measuring dizziness and another to measure nausea. Phone follow up assessing any repeat ED visits, satisfaction with their treatment, and the short form Dizziness Handicap Inventory Measure (DHI) was performed (a previously validated tool for measurement of nausea and dizziness on a severity scale.) Differences between the proportions by randomized treatment assignment were compared using a 2-tailed Fisher’s Exact test. Multinomial parameters such as patient satisfaction and the DHI were compared using a Wilcoxon Two-Sample test. Probability values Results: Twenty-six patients were randomized; 11 in the standard treatment arm, and 15 in the interventional arm. The age (mean +/-SD) of subjects randomized to receive maneuver and medication was 59+/-12.6 and 64+/-11.2 respectively; there was no significant difference in age between the 2 treatment arms (p=0.310). Two hours after treatment, the symptoms between the groups showed no difference in the measures of nausea (p=0.548) or dizziness (p=0.659). Both groups reported a high level of satisfaction, measured on a 0-10 scale. Satisfaction in subjects randomized to receive maneuver and medication was 9+/-1.5 and 9+/-1.0, respectively; there was no significant difference in satisfaction between the 2 arms (p=0.889). The length of stay during the ED visit did not differ between the treatment groups (p=0.873). None of the patients returned to an ED for similar symptoms. Conclusions: There is no difference in symptomatic resolution and patient satisfaction between standard medical care and canalith repositioning maneuver in this pilot study. Physicians should consider the canalith repositioning maneuver as their standard of care. Considering the potential cost savings, nursing time, and potential for adverse reactions to medications (even the limits on driving due to sedation) and complications from intravenous access, it seems that the maneuver has clear advantages for those so motivated to attempt it

An efficient shortest path routing algorithm in the data centre network DPillar.

DPillar has recently been proposed as a server-centric data centre network and is combinatorially related to the well-known wrapped butterfly network. We explain the relationship between DPillar and the wrapped butterfly network before proving a symmetry property of DPillar. We use this symmetry property to establish a single-path routing algorithm for DPillar that computes a shortest path and has time complexity O(klog(n))O(klog⁡(n)), where k parameterizes the dimension of DPillar and n the number of ports in its switches. Moreover, our algorithm is trivial to implement, being essentially a conditional clause of numeric tests, and improves significantly upon a routing algorithm earlier employed for DPillar. A secondary and important effect of our work is that it emphasises that data centre networks are amenable to a closer combinatorial scrutiny that can significantly improve their computational efficiency and performance

Patient Attitudes Regarding Consent for Emergency Department Computed Tomographies

INTRODUCTION: Little is known about patient attitudes towards informed consent for computed tomography (CT) in the emergency department (ED). We set out to determine ED patient attitudes about providing informed consent for CTs. METHODS: In this cross-sectional questionnaire-based survey study, we evaluated a convenience sample of patients\u27 attitudes about providing informed consent for having a CT at 2 institutional sites. Historically, at our institutional network, patients received a CT at approximately 25% of their ED visits. The survey consisted of 17 yes/no or multiple-choice questions. The primary outcome question was which type of informed consent do you feel is appropriate for a CT in the Emergency Department? RESULTS: We analyzed 300 survey responses, which represented a 90% return rate of surveys distributed. Seventy-seven percent thought they should give their consent prior to receiving a CT, and 95% were either comfortable or very comfortable with their physician making the decision regarding whether they needed a CT. Forty percent of the patients felt that a general consent was appropriate before receiving a CT in the ED, while 34% thought a verbal consent was appropriate and 15% percent thought a written consent was appropriate. Seventy-two percent of the ED patients didn\u27t expect to receive a CT during their ED visit and 30% of the ED patients had previously provided consent prior to receiving a CT. CONCLUSION: Most patients feel comfortable letting the doctor make the decision regarding the need for a CT. Most ED patients feel informed consent should occur before receiving a CT but only a minority feel the consent should be written and specific to the test