Utilizing compassion and collaboration to reduce violence in healthcare settings.

Violence in healthcare settings is a global problem and violent acts are more likely to occur in emergency departments (EDs). Significant barriers to reporting workplace violence persist among healthcare workers. This, and lack of shared definitions and metrics, increase the difficulty of assessing its prevalence, understanding its causes, and comparing the impact of interventions to reduce its frequency. While risk factors for violence in EDs have been articulated, less is known about how the perspectives of patients and accompanying persons, and their interactions with ED staff may contribute to violence.We discuss the nature and social context of ED violence and some approaches used to address this problem in the U.S. We argue that perpetrators of violence as well as healthcare staff who experience ED violence suffer when it occurs. While securing safety is paramount, compassionate practices to address this suffering and the social context from which it emerges should be developed and provided for all involved. Collaboration among stakeholders, including patients and family members, may lead to effective approaches to address this problem.

Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.

OBJECTIVES: The objective was to compare the effectiveness of intravenous (IV) procainamide and amiodarone for the termination of spontaneous stable sustained ventricular tachycardia (VT). METHODS: A historical cohort study of consecutive adult patients with stable sustained VT treated with IV amiodarone or procainamide was performed at four urban hospitals. Patients were identified for enrollment by admissions for VT and treatment with the study agents in the emergency department (ED) from 1993 to 2008. The primary measured outcome was VT termination within 20 minutes of onset of study medicine infusion. A secondary effectiveness outcome was the ultimate need for electrical therapy to terminate the VT episode. Major adverse effects were tabulated, and blood pressure responses to medication infusions were compared. RESULTS: There were 97 infusions of amiodarone or procainamide in 90 patients with VT, but the primary outcome was unknown after 14 infusions due to administration of another antidysrhythmic during the 20-minute observation period. The rates of VT termination were 25% (13/53) and 30% (9/30) for amiodarone and procainamide, respectively. The adjusted odds of termination with procainamide compared to amiodarone was 1.2 (95% confidence interval [CI]=0.4 to 3.9). Ultimately, 35/66 amiodarone patients (53%, 95% CI=40 to 65%) and 13/31 procainamide patients (42%, 95% CI=25 to 61%) required electrical therapy for VT termination. Hypotension led to cessation of medicine infusion or immediate direct current cardioversion (DCCV) in 4/66 (6%, 95% CI=2 to 15%) and 6/31 (19%, 95% CI=7 to 37%) patients who received amiodarone and procainamide, respectively. CONCLUSIONS: Procainamide was not more effective than amiodarone for the termination of sustained VT, but the ability to detect a significant difference was limited by the study design and potential confounding. As used in practice, both agents were relatively ineffective and associated with clinically important proportions of patients with decreased blood pressure.

Adenosine for wide-complex tachycardia: efficacy and safety.

OBJECTIVES: : To determine whether adenosine is useful and safe as a diagnostic and therapeutic agent for patients with undifferentiated wide QRS complex tachycardia. The etiology of sustained monomorphic wide QRS complex tachycardia is often uncertain acutely. DESIGN: : A retrospective observational study. SETTING: : Treatment associated with emergency visits at nine urban hospitals. PATIENTS: : Consecutive patients treated with adenosine for regular wide QRS complex tachycardia between 1991 and 2006. INTERVENTIONS: : Treatment with adenosine infusion. MEASUREMENTS AND MAIN RESULTS: : Measured outcomes included rhythm response to adenosine, if any, and all adverse effects. A positive response was defined as an observed change in rhythm including temporary atrioventricular conduction block or tachycardia termination. A primary adverse event was defined as emergent electrical or medical therapy instituted in response to an adverse adenosine effect. A rhythm diagnosis was made in each case. The characteristics of adenosine administration as a test for a supraventricular as opposed to ventricular tachycardia were determined, and the adverse event rates were calculated. A total of 197 patients were included: 104 (90%) of 116 (95% confidence interval, 83%-95%) and two (2%) of 81 (95% confidence interval, 0.3%-9%) supraventricular tachycardia and ventricular tachycardia patients demonstrated a response to adenosine, respectively. The odds of supraventricular tachycardia increased by a factor of 36 (95% confidence interval, 9-143) after a positive response to adenosine. The odds of ventricular tachycardia increased by a factor of 9 (95% confidence interval, 6-16) when there was no response to adenosine. The rate of primary adverse events for patients with supraventricular tachycardia and ventricular tachycardia was 0 (0%) of 116 (95% confidence interval, 0%-3%) and 0 (0%) of 81 (95% confidence interval, 0%-4%), respectively. CONCLUSIONS: : Adenosine is useful and safe as a diagnostic and therapeutic agent for patients with regular wide QRS complex tachycardia.

Amiodarone is poorly effective for the acute termination of ventricular tachycardia.

STUDY OBJECTIVE: It is hypothesized that intravenous (IV) amiodarone is poorly effective for the acute termination of sustained monomorphic ventricular tachycardia because of the relatively slow onset of its Vaughn-Williams class III effect to prolong myocardial depolarization and the refractory period. This study is designed to determine the effectiveness and safety of IV amiodarone for the termination of sustained monomorphic ventricular tachycardia. METHODS: A retrospective case series was collected at 4 urban university-affiliated hospitals from September 1996 to April 2005 after institutional review board approval with waiver of informed consent. Emergency department (ED) patients treated with IV amiodarone for ventricular tachycardia were identified by ED treatment and hospital pharmacy billing records, International Classification of Diseases, Ninth Revision discharge codes, and ECG characteristics. All consecutive patients who received at least 150 mg amiodarone in 15 minutes or less for spontaneous sustained monomorphic ventricular tachycardia were eligible for inclusion. Sustained monomorphic ventricular tachycardia was defined as a tachycardia with uninterrupted duration or rapid recurrence despite automatic internal cardiac defibrillator therapy for at least 5 minutes before amiodarone treatment, monomorphic morphology, rate greater than 120 beats/min, QRS duration greater than 120 ms, and subsequently determined to be ventricular tachycardia by ECG criteria (eg, atrioventricular dissociation), implanted device interrogation, or formal electrophysiology study. Measured outcomes included sustained termination of ventricular tachycardia within 20 minutes of initiation of amiodarone infusion and any documented adverse effects. Rates of successful termination and adverse effects and their 95% confidence intervals (CIs) were calculated. The presence or average values of potentially confounding predictors in patients with and without ventricular tachycardia termination after amiodarone were also calculated and compared. RESULTS: Thirty-three patients were identified and included. Five patients received electrical therapy within 20 minutes of initiation of amiodarone infusion, and the response to amiodarone was unknown. Twenty-seven of the remaining 28 patients received 150 mg amiodarone, and the rate of successful ventricular tachycardia termination was 8 of 28, 29% (95% CI 13 to 49). Two of 33 patients, 6% (95% CI 1 to 20), required direct current cardioversion for presyncope or hypotension temporally associated with amiodarone treatment. CONCLUSION: IV amiodarone, as currently administered, is relatively safe but ineffective for the acute termination of sustained ventricular tachycardia.