This was a randomized controlled, parallel group trial at Emergency Departments in England. The study compared the well known standard Valsalva maneuver to attempt conversion of SVT to sinus rhythm, to a modified Valsalva maneuver. The primary outcome was return to sinus rhythm at 1 minute after the chosen intervention. The standard maneuver required participants in a semi-recumbent position to perform the standardized strain to a pressure of 40 mmHg sustained for 15 seconds by forced expiration, and remain in that position for 60 seconds. In the modified maneuver, participants performed the standardized strain in the same semi-recumbent position but immediately after were laid flat and had their legs raised to 45 degrees for 15 seconds. They were then returned to the semi-recumbent position for the remaining 45 seconds prior to re-assessment of their rhythm. At the conclusion of the study, the results were that 17% of the participants assigned to the standard Valsalva achieved sinus rhythm, compared to 43% of participants who achieved sinus rhythm with the modified Valsalva. A major benefit of the modified Valsalva is that it can be easily taught to patients and appears to be more effective than the standard. Another benefit of discovering a more efficacious maneuver for conversion to sinus rhythm is that the effects of adenosine can be extremely unpleasant to patients, and this may decrease that rate at which it is administered. This can be easily implemented in our ED.
Even though there are many safety benefits of computerized provider order entry, there are still errors that can be made, such as ordering on the wrong patient. This study evaluated the short and long term effects of a computerized provider order entry based patient verification intervention to reduce wrong patient orders in 5 emergency departments. The goal of this study was to reduce wrong-patient orders. Prior to implementing the intervention, monthly measurements of wrong-patient ordering rates were obtained, and then compared to the rates after the implementation of the verification process. The intervention focused on providing some sore of visual cues about the patient to the provider, immediately prior to placing an order. A dialog box was displayed at the beginning of every ordering session, requiring providers to verify the patient for whom they were placing an order. The short term results were that wrong patient orders were reduced by 30% immediately after implementation of this dialog box intervention. The long term results showed that after 2 years, the rate of wrong patient orders remained 24.8% less than before intervention. One down-side of this type of intervention is the effect of alert fatigue on providers. However, the effect of alert fatigue on the response rate to alerts was analyzed and the slight decline in the effect of the patient verification module in the study was less severe and not statistically significant. Overall this was a though provoking study and in our discussion we agreed that spending an extra few seconds to verify a patient is worthwhile when compared to the potential risks of harming a patient with incorrect orders, and the time spend having to undo certain orders even if the mistake w
This was a retrospective cohort study of adults admitted with severe sepsis and septic shock to the MICU of a tertiary care academic hospital. The goal of the study was to determine the potential morbidity and mortality associated with fluid overload in those receiving adequate EGDT for both sepsis and septic shock on days 1 and 3, regardless of vasopressor use. Early fluid resuscitation through EGDT has been shown to decrease in hospital mortality and improve morbidity by decreased occurrence of organ dysfunction. However, there are adverse effects of fluid overload such as pulmonary edema and increased cardiac, that are detrimental to the patient. The study found that the clinical evidence of fluid overload was common and associated with increased medical interventions such as thoracentesis and diuretics, and increased hospital mortality. Interestingly, the study found that patients with fluid overload did not have a statistical difference in fluid administration. Additionally, BMIs were significantly higher in the fluid overload group, leading the reader to believe that those patients were at a higher risk of fluids overload in the first place. There were several limitations to the study, such as clinical evidence of overload being subjective, quality of documentation, and the retrospective nature of the study, which led to some gaps in the data. A major limitation was that the study was non-randomized. Since the study was not randomized, it is possible that certain patient factors may have been responsible for the development of fluid overload rather than the resuscitation approach. Since it is impossible to tell if the method of resuscitation caused the fluid overload or the patient's risk factors, we agreed in our discussion that we should not alter the way we resuscitate our patients at this time, but that we should be meticulously reassessing our patients for improvement v. deterioration and adjusting our therapies accordingly.