Prevalence of risk for sleep apnea among hospitalized patients who survived a medical emergency team activation.

STUDY OBJECTIVES: Sleep-disordered breathing (SDB) is a common disorder that causes people to stop breathing in their sleep, and obstructive sleep apnea (OSA) is the most common form of SDB in the general population. Because OSA is often undiagnosed and undermanaged, it has been associated with adverse events and morbidity in hospitalized patients. The purpose of the study was to evaluate prevalence of OSA risk in a population of patients who survived a medical emergency team (MET) activation during hospitalization. METHODS: This prospective study was conducted at a hospital in the Midwest in 2014. Patients who survived a MET activation and consented to participate were administered the STOP-Bang questionnaire and asked other health and lifestyle questions. Review of the medical record was conducted to ascertain patient characteristics, comorbidities, and medications. Differences were assessed using Kruskal-Wallis one-way analysis of variance and the chi-square test. RESULTS: Of 148 study patients, median age was 68 years (interquartile range: 55-78) and 15% were morbidly obese (body mass index ≥ 40 kg/m²). Fifty percent of patients (n = 74) were found to be at high risk for OSA, yet only 38% (n = 28) of those patients received a previous diagnosis of OSA. Variables available in the medical record were highly correlated with the overall STOP-Bang score (r =. 75, P < .001). CONCLUSIONS: Half of patients who survived a MET activation during hospitalization screened at high risk for OSA. Standardized screening for risk of sleep apnea, as well as a truncated risk score generated by variables in the medical record, could guide clinical decision making in this at-risk population.

Underestimation of Pupil Size by Critical Care and Neurosurgical Nurses.

BACKGROUND: Early detection of pupillary changes in patients with head injuries can alert the care team to increasing intracranial pressure. Previous research has shown inconsistencies in pupil measurement that are most likely due to the subjective nature of measuring pupils without the assistance of technology. OBJECTIVES: To evaluate nurses' abilities to assess pupil diameter accurately and detect unequal pupils. METHODS: In a 3-part study, the accuracy of critical care and neurosurgical nurses' assessments of pupils was determined. The study included assessment of drawings of eyes with an iris and pupil, examination of photographs of human eyes, and bedside examination of patients with a head injury. RESULTS: Subjective assessments of pupil diameter and symmetry were not accurate. Across all phases of the study, pupil diameters were underestimated and the rate of error increased as pupil size increased. Nurses also failed to detect anisocoria and misidentified pupil reactivity. In addition, nearly all nurses relied on subjective estimation, even when tools were available. CONCLUSIONS: Critical care and neurosurgical nurses underestimated pupil size, were unable to detect anisocoria, and incorrectly assessed pupil reactivity. Standardized use of pupil assessment tools such as a pupillometer is necessary to increase accuracy and consistency in pupil measurement and to potentially contribute to earlier detection of subtle changes in pupils. If pupillary changes are identified early, diagnostic and treatment intervention can be delivered in a more timely and effective manner.

Is pain really undertreated? Challenges of addressing pain in trauma patients during prehospital transport and trauma resuscitation.

BACKGROUND: Prior research has documented the inadequacy of pain management for trauma patients in the emergency department (ED), with rates of pain assessment and opioid administration averaging about 50%. Such rates, however, may be misleading and do not adequately capture the complexity of pain management practices in a trauma population. The goal of the study was to determine if pain was undertreated at the study hospital or if patient acuity explained the timing and occurrence of pain treatment in the prehospital setting and the ED. METHODS: A retrospective study was performed at a Level 1 adult trauma centre in the Midwest. The trauma registry was used to identify patients who received a trauma activation during the study period (June-November 2012; N=313). Using the first set of patient vitals and ISS, patients were grouped into three categories: physiologically stable with low injury severity (n=132); physiologically stable with moderate to severe injury (n=122); and physiologically unstable with severe injury (n=56). Differences were assessed with Kruskal-Wallis and chi-square tests. RESULTS: Patients who were physiologically unstable were the least likely to receive a standardised pain assessment and the least likely to receive an opioid in the ED. Patients who were physiologically stable at entry to the ED but sustained a severe injury were the most likely to receive an opioid. Time to first pain assessment and time to first opioid did not differ by patient acuity. CONCLUSIONS: Results confirm that patient acuity greatly affects the ability to effectively and appropriately manage pain in the initial hours after injury. This study contributes to the literature by noting areas for improvement but also in explaining why delaying pain treatment may be appropriate in certain patient populations.