Transfusion-Associated Adverse Events: A Case Report of Nurse Hemovigilance and Recognition of Respiratory Distress.

Although blood transfusions are considered a potentially life-saving therapy, noninfectious and infectious adverse events can lead to significant morbidities and even mortality. Vital signs and visual observation of patients during blood transfusions are thoroughly taught in nursing school. Updated terms of hemovigilance and transfusion-associated adverse events ( TAAEs ) are presented through this case study. A patient with factor V deficiency, which requires chronic plasma transfusions, experienced 2 types of TAAEs, anaphylaxis and transfusion-associated circulatory overload. The patient's history and TAAEs are presented and discussed to provide evidence for the importance of vigilant bedside surveillance. Early identification of TAAEs may prevent unnecessary morbidity and/or mortality. The primary nursing functions and responsibilities are presented with algorithmic supplementation to facilitate better understanding of best practice. Ongoing assessment of hemovigilance practices is indicated to ascertain which monitoring tools can lead to optimal patient care.

Implementation of an in situ qualitative debriefing tool for resuscitations.

AIM: Multiple guidelines recommend debriefing of resuscitations to improve clinical performance. We implemented a novel standardized debriefing program using a Debriefing In Situ Conversation after Emergent Resuscitation Now (DISCERN) tool. METHODS: Following the development of the evidence-based DISCERN tool, we conducted an observational study of all resuscitations (intubation, CPR, and/or defibrillation) at a pediatric emergency department (ED) over one year. Resuscitation interventions, patient survival, and physician team leader characteristics were analyzed as predictors for debriefing. Each debriefing's participants, time duration, and content were recorded. Thematic content of debriefings was categorized by framework approach into Team Emergency Assessment Measure (TEAM) elements. RESULTS: There were 241 resuscitations and 63 (26%) debriefings. A higher proportion of debriefings occurred after CPR (p<0.001) or ED death (p<0.001). Debriefing participants always included an attending and nurse; the median number of staff roles present was six. Median intervals (from resuscitation end to start of debriefing) & debriefing durations were 33 (IQR 15, 67) and 10 min (IQR 5, 12), respectively. Common TEAM themes included co-operation/coordination (30%), communication (22%), and situational awareness (15%). Stated reasons for not debriefing included: unnecessary (78%), time constraints (19%), or other reasons (3%). CONCLUSIONS: Debriefings with the DISCERN tool usually involved higher acuity resuscitations, involved most of the indicated personnel, and lasted less than 10 min. Future studies are needed to evaluate the tool for adaptation to other settings and potential impacts on education, quality improvement programming, and staff emotional well-being.

Test characteristics of an automated age- and temperature-adjusted tachycardia alert in pediatric septic shock.

OBJECTIVES: This study aimed to create and analyze the performance of an automated triage tool alerting triage nursing staff and physicians to an abnormal heart rate consistent with septic shock in a pediatric emergency department. METHODS: A computerized best-practice alert (BPA) triage system corrected heart rate for temperature (5 beats per minute for each 1°F above 100°F or 9.6-10 beats per minute for each 1°C > 36°C) and alarmed on tachycardia. If patients appeared ill and/or had medical comorbidities predisposing them to sepsis, a "shock protocol" was activated. Sensitivity was calculated for patients clinically diagnosed with shock during the study period. RESULTS: During the study period (February to August 2010), the BPA was triggered in 4552 (11.5%) of 39,697 visits. Mean age was 5.4 years (range, 18 days to 18 years); 53% were female. The tool was 81% sensitive in identifying the 210 patients with shock. Missed patients were more likely to be previously healthy (odds ratio, 2.7; 95% confidence interval, 1.2-6.2), younger (5.7 vs 8.7 years, P = 0.004), and less likely to have a malignancy (odds ratio, 0.38; 95% confidence interval, 0.2-0.8). The tool was 89% specific; positive and negative predictive values were 4% and 99.9%, respectively. CONCLUSIONS: The BPA-automated sensitive triage tool, based solely on initial temperature and heart rate, led to the identification of most children with septic shock, even before clinical acumen and laboratory values were incorporated into the diagnostic algorithm.

Implementation of goal-directed therapy for children with suspected sepsis in the emergency department.

BACKGROUND: Suboptimal care for children with septic shock includes delayed recognition and inadequate fluid resuscitation. OBJECTIVE: To describe the implementation of an emergency department (ED) protocol for the recognition of septic shock and facilitate adherence to national treatment guidelines. PATIENTS AND METHODS: Root-cause analyses and morbidity and mortality conferences identified system problems with sepsis recognition and management. A group of ED and critical care physicians met to identify barriers and create solutions. RESULTS: To facilitate sepsis recognition, a computerized triage system alarmed on abnormal vital signs, and then toxic-appearing children or children at high risk for invasive infection were placed in a resuscitation room. To facilitate timely delivery of interventions, additional nursing, respiratory therapy, and pharmacy personnel were recruited. Fluids were administered via syringe delivery; standardized laboratory studies and antibiotics were ordered and prioritized. Frequent vital-sign measurements and interventions were documented on a graphical flow sheet to facilitate interpretation of physiologic response to therapy. After protocol initiation, there were 191 encounters in 167 patients with suspected sepsis. When compared with children seen before the protocol, time from triage to first bolus decreased from a median of 56 to 22 minutes (P < .001) and triage to first antibiotics decreased from a median of 130 to 38 minutes (P < .001). CONCLUSIONS: The protocol resulted in earlier recognition of suspected sepsis and substantial reductions in both time to receipt of time-sensitive interventions and a decrement in treatment variation.