Use of intranasal diamorphine spray for acute pain in children

From the Emergency Medicine Journal:

A novel multipatient intranasal diamorphine spray for use in acute pain in children: pharmacovigilance data from an observational study

Objectives To establish the safety of an intranasal diamorphine (IND) spray in children.

Design An open-label, single-dose pharmacovigilance trial.

Setting Emergency departments in eight UK hospitals.

Participants Children aged 2–16 years with a fracture or other trauma.

Outcome measures Adverse events (AE) specifically related to nasal irritation, respiratory and central nervous system depression.

Results 226 patients received 0.1 mg/kg IND. No serious or severe AEs occurred. The incidence of treatment-emergent AEs (TEAEs) was 26.5% (95% CI 20.9% to 32.8%), 93% being mild. 89% were related to treatment, all being known effects of the drug or route of administration except for three events in two patients. 20.4% (95% CI 15.3% to 26.2%) patients reported nasal irritation, all mild except one moderate and one ‘unknown’ severity. No respiratory depression was reported. Three AEs related to reduced Glasgow Coma Score (GCS) occurred, all mild.

Conclusions There were no safety concerns raised during the conduct of the study. In addition to expected side effects, IND can cause mild nasal irritation in a proportion of patients.

Agonal respirations reported to dispatchers complicates telephone-based CPR instruction efforts

From the Emergency Medicine Journal:

Abnormal breathing of sudden cardiac arrest victims described by laypersons and its association with emergency medical service dispatcher-assisted cardiopulmonary resuscitation instruction

Background Current guidelines for cardiopulmonary resuscitation (CPR) emphasise that emergency medical service (EMS) dispatchers should identify sudden cardiac arrest (CA) with abnormal breathing and assist lay rescuers performing CPR. However, lay rescuers description of abnormal breathing may be inconsistent, and it is unclear how EMS dispatchers provide instruction for CPR based on the breathing status of the CA victims described by laypersons.

Methods and results To investigate the incidence of abnormal breathing and the association between the EMS dispatcher-assisted CPR instruction and layperson CPR, we retrospectively analysed 283 witnessed CA cases whose information regarding breathing status of CA victims was available from population-based prospective cohort data. In 169 cases (59.7%), laypersons described that the CA victims were breathing in various ways, and that the victims were ‘not breathing’ in 114 cases (40.3%). Victims described as breathing in various ways were provided EMS dispatch-instruction for CPR less frequently than victims described as ‘not breathing’ (27.8% (47/169) vs 84.2% (96/114); p<0.001). Multivariate logistic regression showed that EMS dispatch-instruction for CPR was associated significantly with layperson CPR (adjusted OR, 11.0; 95% CI, 5.72 to 21.2).

Conclusions This population-based study indicates that 60% of CA victims showed agonal respiration, which was described as breathing in various ways at the time of EMS call. Although EMS dispatch-instruction was associated significantly with an increase in layperson CPR, abnormal breathing was associated with a much lower rate of CPR instruction and, in turn, was related to a much lower rate of bystander CPR.

What an Emergency Department Report Card Tells Us

From MedPage Today:

The press release promised that a new report would answer the question: “Are your state’s emergency rooms making the grade?”

But while an American College of Emergency Physicians (ACEP) report card out today said the nation’s emergency care environment has worsened since their effort in 2009, it doesn’t really answer that specific question.

America’s Emergency Care Environment: A State-by-State Report Card

From ACEP (press release):

Emergency physicians today sounded a warning that the continuing failure of state and national policies is endangering emergency patients, citing as proof a worse grade of D+ in the latest edition of a state-by-state report card on support for emergency care (Report Card). The Report Card forecasts an expanding role for emergency departments under Obamacare and describes the harmful effects of the competing pressures of shrinking resources and increasing demands. The Report Card measures conditions and policies under which emergency care is being delivered, not the quality of care provided by hospitals and emergency providers.

“Congress and President Obama must make it a national priority to strengthen the emergency medical care system,” said Dr. Alex Rosenau, president of the American College of Emergency Physicians (ACEP). “There were more than 130 million emergency visits in 2010, or 247 visits per minute. People are in need, but conditions in our nation have deteriorated since the 2009 Report Card due to lack of policymaker action at the state and national levels. With so much changing in health care, emergency care has never been more important to our communities. This Report Card is a call to action.”

In 2009, the last time ACEP’s Report Card was issued, America earned an overall grade of C-. According to Dr. Rosenau, the lower grade in 2014 also reflects a misguided focus on cutting resources for emergency departments because of the popular but misguided view that emergency care is expensive, despite being less than 5 percent of overall health care costs. 

America’s Emergency Care Environment: A State-by-State Report Card” — has 136 measures in five categories:

  • Access to Emergency Care (30 percent of the grade): the nation received a D-
  • Quality and Patient Safety (20 percent): the nation received a C
  • Medical Liability Environment (20 percent): the nation received a C-
  • Public Health and Injury Prevention (15 percent): the nation received a C
  • Disaster Preparedness (15 percent): the nation received a C- 

The District of Columbia ranked first in the nation with a B-, surpassing Massachusetts, which held the top spot in the 2009 Report Card. Wyoming ranked dead last, receiving an F overall.

  • The top ranked states were the District of Columbia (1st, B-), Massachusetts (2nd, B-), 
    Maine (3rd, B-), Nebraska (4th, B-) and Colorado (5th , C+). 
  • The bottom ranked states were Wyoming (51st, F), Arkansas (50th, D-), New Mexico (49th, D), Montana (48th, D) and Kentucky (47th, D).

According to Dr. Jon Mark Hirshon, chair of the task force that directed development of the Report Card, the national grade for Access to Emergency Care has not improved since 2009.

“America’s grade for Access to Emergency Care was a near-failing D- because of declines in nearly every measure,” said Dr. Hirshon. “It reflects that hospitals are not getting the necessary support in order to provide effective and efficient emergency care. There were 19 more hospital closures in 2011, and psychiatric care beds and hospital inpatients beds have fallen significantly, despite increasing demand. People are increasingly reliant on emergency care, and primary care physicians are advising their patients to go to the emergency department after hours to receive complex diagnostic workups and to facilitate admissions for acutely ill patients.” 

The Report Card includes national recommendations, and ACEP is asking Congress to take actions, such as the following:

  • Fund the Workforce Commission, as called for by the Affordable Care Act (ACA), to investigate shortages of physicians, nurses and other health care professionals.
  • Pass the “Health Care Safety Net Enhancement Act of 2013,” H.R. 36 introduced by Rep. Charlie Dent (R-PA) and the companion legislation S. 961, introduced by Senator Roy Blunt (R-MO). This legislation would provide limited liability protections to (emergency and on-call) physicians who perform the services mandated by the federal EMTALA law, which requires emergency patients be screened, diagnosed and treated, regardless of their insurance status or ability to pay. 
  • Fund pilot programs, provided for in the ACA, to design, implement and evaluate innovative models of regionalized, comprehensive and accountable emergency care and trauma systems. 
  • Support and fund the mission of the Emergency Care Coordination Center at H.H.S. to create an emergency care system that is patient- and community-centered, integrated into the broader health care system, high quality and prepared to respond in times of public health emergencies.
  • Withhold federal funds to states that do not support key safety legislation, such as motorcycle helmet laws and .08 blood alcohol content laws.
  • Fund graduate medical education programs that support emergency care, especially those related to addressing physician shortages in disadvantaged and rural areas.
  • Support efforts to fund emergency care research by the new Office of Emergency Care Research under the National Institutes of Health. 
  • Hold a hearing to examine whether additional strains are occurring in the emergency department safety net as a consequence of the Affordable Care Act.

According to the Report Card, states continued to struggle with many issues, including health care workforce shortages, limited hospital capacity to meet the needs of patients, long emergency department wait times and increasing financial barriers to care. Twenty-one states received F’s in the Access to Emergency Care category. In the Quality and Patient Safety category, ten states received F’s. Ten states received an F for their Medical Liability Environment. Ten states received F’s in Public Health and Injury Prevention. 

Thirteen states received F’s in the Disaster Preparedness category: Delaware, Hawaii, Idaho, Illinois, Indiana, Maine, Montana, South Carolina, Utah, Vermont, Washington State, Wisconsin and Wyoming.

“Everyone hopes that their communities would perform as well as Boston did after the Marathon bombing, yet nearly half the states received either D’s or F’s for Disaster Preparedness, which is alarming,” said Dr. Rosenau. “While there has been increased state and federal focus on disaster preparedness, there is great variability among states in terms of planning and response capacity.”

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.

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