A comparative study of two nebulizers in the emergency department: breath-actuated nebulizer and handheld nebulizer.

INTRODUCTION: The breath-actuated nebulizer (BAN) and the handheld nebulizer (HHN) are 2 nebulizers used in the ED of Cooper University Hospital. The purpose of this study was to compare the nebulizers to identify which device resulted in a resolution of symptoms with fewer treatments. The primary hypothesis was that adult ED patients with a chief complaint of wheezing and dyspnea who were given nebulized treatments via the BAN would require less nebulizer treatments than those patients given nebulized treatments via HHN. In addition, the secondary purposes of the study was to determine if the BAN would have significantly higher peak expiratory flow measurements, lower Modified Borg Score, overall decreased respiratory rate, and lower heart rates compared to subjects receiving nebulized treatments via HHN. METHODS: A single-site, prospective, randomized, comparative design study was conducted in the ED between March 2010 and February 2011. Fifty-four subjects presenting with dyspnea and wheezing and an Emergency Severity Index of 3 or 4 were enrolled and randomly assigned to 1 of 2 groups (BAN or HHN). Subjects were administered 1 to 3 nebulizer treatments (#1 ipratropium bromide and albuterol sulfate, #2 ipratropium bromide and albuterol sulfate, #3 albuterol sulfate), which was consistent with the ED Advanced Nursing Guideline for Wheezing. Nebulizer treatments were discontinued if a patient's dyspnea or wheezing resolved. IRB approval was obtained prior to study commencement. RESULTS: There was no significant difference found between the HHN and BAN in respect to number of treatments, respiratory rate, peak flow measurements, and Modified Borg scores in the 54 subjects. There was a difference of 7 points in pulse rate between the pre- and post-second BAN treatment (n = 51, P = 0.01). Subjects in the BAN group who completed all 3 treatments (n = 18) had a total treatment time that was on average of 10 minutes longer than those in the HHN group. CONCLUSIONS: This study demonstrated no clinical difference between the BAN and HHN in terms of respiratory rate, peak flow, perception of dyspnea, and number of treatments. It is possible that the longer treatment times account for the elevated pulse rate. The data suggests that the higher cost and the longer treatment time do not justify the use of the BAN in this setting. We recommend that these devices be tested with a larger sample size to further test the differences between these 2 devices.

Differences in automated and manual blood pressure measurement in hospitalized psychiatric patients.

Few studies have been conducted recently with noncritically ill patients evaluating commonly used automated blood pressure (BP) devices. The purpose of this study was to compare BP values obtained using a manual sphygmomanometer versus an oscillometric automated electronic BP device on an acute care psychiatry unit. A method-comparison design was used, and data were analyzed using the Bland-Altman method. Outliers were removed, resulting in 39 participants for analyses of systolic readings and 41 participants for diastolic readings. Paired t tests revealed a significant difference in manual versus automatic systolic BP readings (p < 0.05). Automated readings averaged 3.9 points higher. No significant differences in diastolic readings (p = 0.72) were found. Care must be taken in using automated or manual BP readings to make important clinical decisions. Based on these findings, a protocol was instituted in an acute care psychiatry unit indicating that BP must be measured manually for patients with medication-hold parameters for BP.

Hemolysis of coagulation specimens: a comparative study of intravenous draw methods.

INTRODUCTION: Hemolysis of blood samples creates significant delays in the treatment and disposition of patients in the emergency department. The purpose of this study was to compare the hemolysis rates of coagulation blood samples obtained during insertion of an intravenous (IV) catheter without (group 1) or with (group 2) extension tubing connected to the IV catheter hub. A secondary purpose of this study was to determine whether the investigators could predict whether a coagulation sample was hemolyzed based on visual observation during the specimen withdrawal process. METHODS: A prospective, 2-group randomized comparative design was used to determine which method of blood collection for coagulation specimens provided the lowest hemolysis rate. This study was conducted in an urban level I emergency department averaging 58,000 visits per year. The sample consisted of 121 adult ED patients randomly assigned to 1 of the 2 groups. Data collectors were trained in the 2 methods of coagulation sample collection and followed a strict protocol. The clinical laboratory used a standardized color-coded scale to determine hemolysis. RESULTS: Pearson χ(2) analysis was used to test for differences between all nominal variables. The level of significance for all tests was P < .05. There was no significant difference in hemolysis rates between the groups by use of χ(2) analysis (P = .84). Nurses were significantly more likely to predict that a sample was hemolyzed when it was not and to think that it was not hemolyzed when in fact it was (P < .001). DISCUSSION: High hemolysis rates occurred equally when coagulation blood samples were drawn via a peripheral IV catheter either at the hub or through extension tubing. Emergency nurse investigators could not accurately predict by visualization whether a coagulation sample was hemolyzed at the time of blood withdrawal. Venipuncture as the preferred method of blood draw is an industry recommendation. This method has been shown in prior experimental studies to reduce hemolysis rates to less than 4%. Therefore, if hemolysis rates are a concern, one should consider obtaining blood whenever possible through a venipuncture rather than through an IV catheter. Replication studies are needed to determine whether the findings of this study can be generalized to the larger population.