Phlebitis in field-started IVs: Margaret Belcher. University of Louisville Hospital, 530 S. Jackson, Louisville, KY 40292

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    variation in temperature across the rates. Little variation in Tsoln occurred during data collection (mean + SD = 21.14 + 0.796 ~ C).

    Conclusion: The Level i fluid warmer with the D-60HL tubing and the Hot Line warmer with L-70 tubing provided fluid at greater than 37 ~ C at flow rates tested in this study.

    7. Reliability of Clinical Assessments by Emergency Nurses and Physi- ciaus in the Evaluation of Dehydration in Children. Kathleen A. Murphy, Marc Gorelick. Chi ldren's Hospital of Philadelphia, 34th & Civic Center Blvd., Philadelphia, PA 19104.

    Purpose: Dehydration result ing from gastroenterit is or other acute il lnesses is a common problem in pediatric emergency care. Accurate diagnosis, based on clinical signs and symptoms, is essential to make proper triage and t reatment decisions. Although these findings are somewhat subjec- tive, there are no existing data examining the consistency of assessments by different observers. The purpose of this study was to determine the interobserver reliability between experienced emergency personnel in their clinical evalua- tion of the signs of dehydrat ion in children.

    Design/setting: A cross-sectional concordance study was con- ducted at an urban, tertiary care pediatric emergency department.

    Sample: A convenience sample included 71 children age 2 weeks to 6 years seen in the emergency department with a chief complaint of vomiting, diarrhea, or poor oral fluid in- take. Excluded were children with coexisting serious illness, or those treated at another health care facility.

    Methodology: Study personnel included pediatric emergency nurses and physic ians with a min imum of 4 years of pedi- atric experience. Prior to therapy, each subject was inde- pendent ly evaluated by two study observers (nurse/nurse, or nurse/physician) who completed a checklist of nine signs and symptoms based on the World Health Organization cri- teria: general appearance; respiratory patterns; radial pulse; sunken fontanelle; skin turgor; sunken eyes; absence of tears; humidity of mucous membranes; urine output; and capillary refill measurement according to a standardized protocol. Measures of reliability were determined, including the kappa statist ic and the proportion of positive and neg- ative agreement.

    Result: Kappa, represent ing overall agreement corrected for chance, varied from 0.27 to 0.76 for the 10 clinical findings. Two of the findings, abnormal respiratory patterns and skin turgor, had unacceptably low kappas of less than 0.35. Kappa was very similar when nurse/nurse pairs and nurse/ physic ian pairs were analyzed separately. For all findings, specific agreement was greater than overall agreement: proportion of positive agreement ranged from 0.33 to 0.89, while proportion of negative agreement ranged from 0.85 to 0.95.

    Conr There is some variability in the assessment signs of dehydrat ion even by exper ienced observers; however, the level of agreement is acceptable for the most commonly elicited findings. Both nurses and physicians show a simi- lar degree of consistency. Nursing assessments of children at risk for dehydrat ion should emphasize those clinical find- ings with acceptable interobserver reliability.

    8. Parentally Abducted Children: Cues to Suspected Diagnosis. Heidi A. Hodges, Margaret Auld Bruya. PO Box 1295, Spokane, WA 99210.

    Purpose: In 1988, more than 350,000 children were abducted. Numbers of abducted children reported to missing chil- dren's organizations are increasing each year. Abducted children are difficult to locate. Abducted children are likely to be treated in emergency settings. This study explored the knowledge, ability to diagnose, and wil l ingness to report parentally abducted children by emergency health services (EHS) professionals.

    Design and setting: A randomized stratif ied geographic sam- piing method selected nine states with in three regions of the United States for this exploratory, descript ive study. South- east states were Alabama, Kentucky, and Tennessee. North- west states were Minnesota, North Dakota, and Wyoming. Southwest states were Colorado, New Mexico, and Okla- homa.

    Sample: Subjects from selected states were randomly se- lected from state lists purchased from the Emergency Nurses Association, the American College of Emergency Physicians, nurse practit ioner associations, and the Amer- ican Academy of Physician Assistants. Subjects had less than 1 to more than 20 years of experience in health care. Registered nurses comprised 67%, physic ians 23%, nurse practit ioners 7%, physician assistants 1%, and LPNs 0.01%. Most of the subjects were parents and 7% reported prior ex- perience with child abduction.

    Methodology: Surveys were mailed to 298 EHS professionals. Each subject received the Knowledge of Parental Abduct ion scale, Hodges Abducted Child Cue scale, Clinical Scenarios, and demographic questionnaire. A follow-up postcard was mailed to all subjects.

    Result: One hundred thirteen instruments were returned (38%). EHS professionals' knowledge correlated highly (r= 0.76, p < 0.01) with child abduct ion experts and corre- lated significantly with diagnosis (r = 0.31, p = 0.001). Sce- narios depict ing abducted children were correctly identified 66% of the time. E ighteen of 25 cues were valued to diag- nose child abduction. Subjects report ing experience with abducted children provided diagnostic cues. Intention to report was less than diagnosis. Uncertainty and belief the child was not endangered were the most frequently reported reasons for intent ion not to report.

    Conclusion: EHS professionals can correctly identify paren- tally abducted children given s imulated scenarios. Cues valued by subjects without experience with child abduct ion are closely al igned with diagnostic cues provided by sub- jects with experience. These cues may be useful in recog- nit ion of parentally abducted children within the emergency setting. In clinical scenarios, intent ion to report was less than recognition. Research is needed to validate diagnostic cues valued by EHS professionals and to p3aborate upon reasons for intent ion not to report.

    9. Phlebitis in Field.Started IVs, Margaret Belcher. University of Louisville Hospital, 530 S. Jackson, Louisville, KY 40292.

    Purpose: The purpose of this study was to determine the in- c idence of phlebitis associated with intravenous lines (IVs)

    380 Volume 21, Number 5

  • started in the field by paramedics and registered nurses. In the field was defined as any IV started outside the physical confines of a health care setting or in the emergency department, that was not dressed with a clear occlusive dressing and labeled with the date, time, gauge, and initialed. Due to an increased incidence of phlebitis reported at one urban medical center, a policy was written to support the practice of pulling and restarting every field-started IV when the patient was admitted to an inpatient unit. This study was done in response to that policy.

    Methods: Between July 1991 and April 1992 all patients admitted to the hospital on randomly selected days via the emergency department with field-started IVs had their IV sites observed daily for 3 consecutive days for signs and symptoms of phlebitis. Phlebitis for the purpose of this study was defined as a 5 mm diameter of erythema at the venipuncture site, red streaks extending I cm upward from the IV site, or purulent drainage from the venipuncture area,

    Results: One hundred forty-one (N = 141) IV sites were observed; 101 were started by RNs in the emergency department and 40 by paramedics prior to the patients' ar- rival at the emergency department. Nine IV sites became phlebitic; two were identified on day 1, five on day 2, and two on day 3. Seven of the phlebitic sites were started with #18 angiocatheters and two with #16 angiocatheters. The phlebitic sites included three in the hand, three in the fore- arm, two in the antecubital area, and one in the wrist. Five of the nine phlebitic sites were started by RNs, the remain- ing four were initiated by paramedics. Overall, the phlebitic rate was 0.06% (9 of 141). Insertion site, angiocatheter size, dressing and labeling of the site, and whether the site was started by an RN or paramedic did not influence phlebitis.

    Conclusion: The results of this study did not support the cur- rent policy of discontinuing field-started IVs. Maintaining IVs initiated in the emergency department or prehospital care setting decreases health care costs by eliminating un- necessary nursing time and IV setup costs. This study is significant to emergency nursing; it demonstrates that although IVs are started on unstable critically ill patients, the technique is safe and complications minimal.

    10. The Almshouse Revisited: Heavy Users of Emergency Services. Ruth E. Malone. University of California, San Francisco School of Nursing N319X, San Francisco, CA 94143-0602.

    Purpose: A small subgroup of ED patients is responsible for a disproportionate amount of ED visits and costs. This sub- group, heavy users of ED services, is identified as a medi- cally and socially vulnerable population. Interventions aimed at reducing this group's use of ED services have not proven effective, for reasons which remain unclear. The broad ob- jective of this study was to improve understanding of the phenomenon of heavy ED use. The primary aims were to: describe the context in which heavy ED use occurs and ex- plore the meanings of such use to patients who are heavy ED users; uncover the dimensions of the "problem" by ex- amining it from several perspectives, and explicate the findings within a policy perspective. The study was grounded in Heideggerian interpretive phenomenology.

    Desigr~ Interpretive ethnography utilizing multiple data points.


    Setting: Two inner-city trauma center, teaching hospital emergency departments in separate cities.

    Sample: Patients identified by nurses as frequent visitors were interviewed by the researcher. Forty-six patients par- ticipated in taped unstructured interviews. Approximately 50 to 60 nurses and other hospital staff participated in taped, informal, break-room discussions of their experiences with frequent ED visitors. Other staff and patients were observed during fieldwork. Medical records of a subsample of the pa- tient sample were also reviewed.

    Methodology: Transcribed interviews, observational notes, and medical records data were treated as text analogues for interpretive analysis. Data analysis used the interrelated processes of thematic analysis, analysis of exemplars, and search for paradigm cases. Second-level analysis examined findings from the data and compared them for "fit" with policy assumptions.

    Results: Patients identified as heavy ED users shared two commonalities: They all had social or medical problems not readily "fixable" by standard medical treatment, and their problems raised issues of legitimacy and helplessness for both providers and patients. Many of these patients are viewed as "hopeless cases," yet some "former" heavy ED users were found to be making significant contributions. Is- sues of legitimacy, recognition, vulnerability, possibility for change, and community were common themes in the dis- course of both patients and providers.

    Conclusions: Deficit-focused views of these patients leave out their commonality with ourselves, the meaningful context within which their behaviors make sense, their values, fears, and concerns, and their contributions. Breakdowns of fam- ily and community and the changes within health care mean that caregivers in "safety net" settings such as the emer- gency department are asked to assume greater burdens. In- stitutional and social policies based on narrowly focused medical-economic models of care render more basic needs invisible and contribute to the medicalization of social problems and the objectification of patients.

    11. ST Monitoring and the Early Diagnosis of Myocardial lschemia/In- farction in the Low-Risk Chest Pain Patient. Anthony J. Joseph, Jill Hertzendorf, Susan C. Finefrock,* Mary Ann Zanetos. Riv- erside Methodist Hospitals, 3535 Olentan~] River Road, Columbus, OH 43214.

    Objectives: To show that use of continuous 12-1ead ST mon- itoring (STM) in low-risk chest pain patients decreases time to diagnosis of ischemia/infarction and has predictive value for stress testing.

    Methods: Randomized, prospective trial in which 281 consec- utive patients with a chief complaint of chest pain and meet- ing elic~bility requirements were assigned to either the chest pain protocol (CPK/CK-MB and EKG at 0, 6, and 12 hours after arrival) or that, plus continuous ST monitoring.

    Subjects: 30 years or older, no heart disease, had at least one major or two minor risk factors (AHA). Subjects had stress thallium testing after 12 hours if not contraindicated and were followed up in 30 days.

    Setting: Community hospital emergency department with 65,000 visits/year.

    October 1995 381


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