Can We Stop (Predict) The Drop? – April No Falls Month

For many Australian hospitals, April is ‘No Falls Month’. This month we have a full-scale education attack against one of the most prevalent forms of in hospital patient harm – the fall. In the consistent form of Injectable Orange we have a not so hidden curriculum – critical appraisal and evidence based practice. There is a wealth of information relating to best practice in preventing falls and harm from falls, however there is little to guide the accurate prediction of future falls for geriatric patients presenting to the Emergency Department. This is of importance, because not every person presenting with a fall is admitted to hospital and as such, the potential to reliable screen and intervene or refer to supporting services is a primary and preventative health priority.

As part of our education this month, I would encourage the enthusiastic ED nurse to read the following article. While reading the article, take the next step and cast a critical eye at the quality of the systematic review. Here is the CASP tool to help with this appraisal. Once you have formed your own opinion have a listen to the podcast below. We’d love to hear your thoughts and also any great initiatives you are using to help prevent falls and harm from falls in your ED or wards, leave a comment below!

Remember this all counts toward your nursing continuing professional development. Pro-tip on organising and capturing your CPD activities: keep a portfolio. Quite simply, document your intended personal learning objective; identify a high quality resource that addresses this (article, workshop, conference); document a reflection on your achieved personal learning outcome. For a comprehensive overview of a Nursing Professional Portfolio head to this guide from the ACN. My newly discovered resource for keeping track of CPD portfolio is this great app from Ausmed Education.


The Article

Carpenter, C. R., Avidan, M. S., Wildes, T., Stark, S., Fowler, S. A., & Lo, A. X. (2014). Predicting Geriatric Falls Following an Episode of Emergency Department Care: A Systematic Review. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 21(10), 1069–1082. http://doi.org/10.1111/acem.12488


The Podcast

For the uninitiated, The Skeptics’ Guide to Emergency Medicine (The SGEM) is a weekly podcast hosted by the brilliant Dr Ken Milne, Canadian Emergency and Family Medicine Physician. Ken pitches a clinical case and then reviews a recent or ‘Hot of the Press’ article that may potentially answer the question. Ken will invite a guest skeptic to help appraise the ‘game changer’ quality of the article and for select episodes will discuss with a principal author of the publication. The SGEM uses the Best Evidence in Emergency Medicine (BEEM) appraisal tools to form the structure of the conversation and also to subversively teach us a reliable and reproducible format for our own critical appraisal.

In this episode Ken discusses the above article with it’s primary Author Dr Chris Carpenter addressing the following case and question.

Case: 84yo woman (Mrs. C) who lives independently and alone in her own home presents to the emergency department via ambulance with a standing level fall. She was bending over to pick up a letter that had dropped off her desk, lost her balance and hurt her left, non-dominant arm. After the fall she was afraid to stand and could not reach her telephone so she laid on the floor calling for help until a neighbor heard her and called 911. She notes infrequent falls at home with no prior injurious falls. Her past medical history includes hypertension and a remote history of breast cancer, but she does not take anti-platelet or anticoagulant medications. An appropriate physical exam is performed and reveals an isolated left shoulder injury. The x-ray of her left shoulder is negative for any fracture. She is diagnosed with a minor contusion and provided with some acetaminophen. The daughter-in law arrives to take her home, but asks if Mrs. C is at risk for further falls in the future.

Question: Can healthcare personnel accurately identify subsets of geriatric adults at increased risk of falls or injurious falls in the months following an episode of emergency department care?

SGEM#89: Preventing Falling to Pieces

ED Nurses Vent and Haemodynamics Workshop

This post captures some of the resources discussed in the ED Nurses Vent and Haemodynamic Monitoring workshop at Redcliffe Hospital. These resources are high quality FOAM and can help with expanding upon the learning and piqued curiosity from the workshop. Happy self-directed learning.

Pro-tip on organising and capturing your CPD activities: Keep a portfolio. Quite simply, document your intended personal learning objective; identify a high quality resource that addresses this (article, workshop, conference); document a reflection on your achieved personal learning outcome. For a comprehensive overview of a Nursing Professional Portfolio head to this guide from the ACN. My newly discovered resource for keeping track of CPD portfolio is this great app from Ausmed Education.


Arterial lines, central lines and haemodynamic monitoring

Quick snapshot on Arterial lines – http://lifeinthefastlane.com/ccc/arterial-line/

Literally the whole chapter on Haemodynamic Monitoring, an amazing resource – http://www.derangedphysiology.com/main/core-topics-intensive-care/haemodynamic-monitoring

arterial pressure waveform

Image from Deranged Physiology


Acute Respiratory Failure

Medscape emedicine overview of Respiratory Failure – http://emedicine.medscape.com/article/167981-overview

British Thoracic Society Guidelines for a host of diseases, diagnoses and therapies in ARF – https://www.brit-thoracic.org.uk/standards-of-care/guidelines/


Non-Invasive Ventilation

NIV Clinical Practice Guidelines – http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/239740/ACI14_Man_NIV_1-2.pdf

Q&A format NIV for the criitcally ill patient from LITFL – http://lifeinthefastlane.com/non-invasive-ventilation/

LIFTL Critical Care Compendium NIV – http://lifeinthefastlane.com/ccc/non-invasive-ventilation-niv/

Great 5 minute overview of NIV


Rapid Sequence Induction/Intubation

RSI Checklist Podcast and host of resources – https://emcrit.org/podcasts/intubation-checklist-2-0/

The Vortex Approach : a unique and systematic approach to safe emergency airway management – http://vortexapproach.org/

Nice overview of indications for RSI

RSI Dump Sheet adapted from KI Docs


Post-Intubation Care

The go-to package for post-intubation, EMCrit – https://emcrit.org/podcasts/post-intubation-package/


Mechanical Ventilation

For those that want EVERYTHING, here is the chapter from Deranged Physiology – http://www.derangedphysiology.com/main/core-topics-intensive-care/mechanical-ventilation-0

Don’t forget the importance of alarm settings – CritIQ video

A huge suite of brilliant videos from Respiratory Review – The Principles of Mechanical Ventilation

A short lecture on basic ventilator settings using the Hamilton T1 – https://www.youtube.com/watch?v=XOt4nMrJgww

Hamilton T1 online settings simulator – https://www.hamilton-medical.com/.static/HAMILTON-T1/start.html


The Crashing Ventilated Patient

This is a brilliant lecture with some good mental models and mnemonics for assessing and treating the patient who crashes post-intubation

Take the Resilience Challenge

There are many pressures in healthcare, all of which have an impact on people who work on the front lines. Resilience Challenge, a new interactive videogame, aims to raise awareness about these pressures.

http://game.resiliencecentre.org.uk/

In the early 2000’s, Safer Healthcare Now and other initiatives were launched to improve the 10% error rate in hospitals worldwide. After over a decade of research, and billions of dollars of funding, the error rate remains unchanged. So what went wrong? There are several perspectives on why patient safety hasn’t improved. These include a) we didn’t understand safety as a culture, not just individual errors b) we need to strengthen what goes right, not just eliminate what goes wrong, and c) we need better engagement between researchers and clinicians to makes sure that researchers are asking the right questions and clinicians are implementing the results.

Resilience Challenge is one way that researchers at in the Centre for Applied Resilience in Healthcare (CARe) at King’s College London are addressing these questions. We are studying how we foster organisational resilience in order to improve patient safety and support clinicians to provide high quality care. Organisational resilience is the ability of a system to adapt safely to pressures in healthcare. The Resilience Challenge videogame supports nurses, doctors, and healthcare professionals to explore this concept, and understand what it means in practice. Organisational resilience is not about individuals coping with poor working conditions; it’s about creating better environments in hospitals so that people can give great care.

The videogame is based on guiding a patient’s journey through the hospital safely. It combines comic book style visuals with accurate medical imagery to create an experience that is both familiar and imaginative. We want to engage with people from a broad range of backgrounds including healthcare students, professionals, and the public to understand the pressures healthcare providers face at work, and how organisations can support clinicians and safe decision-making. 

The Resilience Challenge is part of CARe’s wider work to inform policy about healthcare safety. The game is designed to raise awareness of the pressures on healthcare professionals and to start conversations about what can be done at an organisational level to support successful decision-making. CARe’s goal is to make healthcare systems work safely for everyone involved.

The Resilience Challenge was created through a collaboration between King’s College London’s Centre for Applied Resilience in Healthcare (CARe) and Karman Interactive, brokered and supported by the Cultural Institute at King’s.

Play the game, and please complete the survey at the end to support CARe’s research.

Learn more about our work here: http://resiliencecentre.org.uk/