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  • High Pitfalls in ED

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    Nadya Wiratami Nurrakhmawati
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    This document discusses several high risk pitfalls in the emergency department. It summarizes that ED overcrowding can increase patient risks and negatively impact outcomes. It recommends ensuring proper triage and monitoring of waiting patients. For endotracheal tube placement, it emphasizes using multiple verification methods like end-tidal CO2 monitoring and advises against relying solely on clinical assessment. It also recommends being prepared to perform intraosseous access for vascular access in critical patients if IV access is delayed or not possible. Finally, it stresses using maximal barrier precautions like sterile gowns and drapes when performing invasive procedures to prevent catheter-related infections.

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    This document discusses several high risk pitfalls in the emergency department. It summarizes that ED overcrowding can increase patient risks and negatively impact outcomes. It recommends ensuring proper triage and monitoring of waiting patients. For endotracheal tube placement, it emphasizes using multiple verification methods like end-tidal CO2 monitoring and advises against relying solely on clinical assessment. It also recommends being prepared to perform intraosseous access for vascular access in critical patients if IV access is delayed or not possible. Finally, it stresses using maximal barrier precautions like sterile gowns and drapes when performing invasive procedures to prevent catheter-related infections.

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    58 views34 pages

    High Pitfalls in ED

    Uploaded by

    Nadya Wiratami Nurrakhmawati
    This document discusses several high risk pitfalls in the emergency department. It summarizes that ED overcrowding can increase patient risks and negatively impact outcomes. It recommends ensuring proper triage and monitoring of waiting patients. For endotracheal tube placement, it emphasizes using multiple verification methods like end-tidal CO2 monitoring and advises against relying solely on clinical assessment. It also recommends being prepared to perform intraosseous access for vascular access in critical patients if IV access is delayed or not possible. Finally, it stresses using maximal barrier precautions like sterile gowns and drapes when performing invasive procedures to prevent catheter-related infections.

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    of 34

    High Risk Pitfalls in ED

    dr Jollis, SpEM

    1. ED OVER CROWDING

    Multiple factors contributing


    Patient hospital bed shortages
    Insufficient availability of ED examination bed
    Shortages in RN staff
    Increasing medical acuity
    Increasing patient volume

    There may be increased risks of harm to


    patients resulting from impaired
    communication and diminished access to care
    Possible increases in morbidity and mortality

    ED overcrowding patients leaving ED


    without fully evaluated or at least screened
    20 years ago, never heard patients call 911
    when they were already in ED waiting room
    Reports of patients suffering significant injury
    secondary to delay of care-or worse dying in
    ED waiting room

    The manner in which ED handle wait times


    and patient's who leave without being seen
    can impact liability, patient safety, and
    hospital finances

    ANY patients who come to ED requesting


    examination or treatment for medical
    condition must be screen medically for
    emergency (TRIAGE)
    If emergency, the patient must be stabilized or
    transfer to another hospital

    Once triage completed, having policy and


    procedure that can ensure continued
    monitoring of patients who are waiting

    Every 2 hours (many hospital used)


    Triage and re-triage must be reliable
    Vital sign should be reevaluated

    Was the triage assessment appropiate based


    on chief complaint and vital sign?
    Did the wait time exceed standards (national?)
    for that triage level?
    Were re-assessments performed on a regular
    basis?

    2. Endotracheal tube placement

    Verification of correct ETT placement after


    intubation is critical to prevent hypoxia and
    gastric insufflation
    How?
    Auscultate epigastrium
    Auscultate lateral lung fields

    Don't rely on clinical examination alone to


    confirm correct ETT placement
    Why?
    Clinical examination is hepful, but IMPERFECT
    Air flow into oesophagus can produce similar
    sound quality that flow through trachea
    Mainstem intubation not compared to
    opposite side may caused intubator to assume
    esophangeal intubation

    Even experienced intubators can be misled


    Fog in ETT?
    Over reliance on pulse oximetry?

    Best Way?
    Most common and most reliable method is
    Qualitative End Tidal CO2 (ETCO2) capnometry
    Producing color change in the presence of
    exhaled CO2
    Purple-tan-yellow
    Must persists beyond six breaths through ETT

    Quantitative or waveform capnography even


    better
    Most reliable, but one limitation: cardiac
    arrest

    Esophangeal detector device (EDD)


    Used by many EMS agencies
    Very effective

    Recent studies: role of ultrasonography in


    verifying ETT placement
    Requires real time use of ultrasound probe
    placed over the neck during intubation

    All these methods show varying sensitivities


    and specificities
    Using at least two modalities for any given
    intubation will decread likelihood of
    unrecognized esophangeal intubation
    No method should be used alone
    ETCO2 capnography should be used whenever
    possible

    3. IV ACCESS

    Obtaining rapid vascular access in critical ill


    patient is a key step in resus
    Vascular collapse often occurs
    Inability to secure iv peripheral line major
    challenge for resus team
    Chaotic first moments of resus central line?
    Even in most skilled hands, still need minutes
    during a time when seconds count

    Be familiar with Intraosseous


    Access
    Not a new method
    Effective route medications and fluids
    Radionucleotide shown IO deliver fluids as
    rapidly as IV
    Indication: need emergency vascular access
    when conventional methods fail

    ACLS-ATLS-PALS recommend IO as alternative


    means of vascular access when IV delayed or
    not feasible
    AHA: IO under 6 yo who have had 2 failed IV
    attempts or where >2 min have elapsed at
    attempting IV access
    Eastern Associations of Surgeons of Trauma:
    IO in adults trauma when IV access failed 2
    attempts or unobtainable

    Contraindication: Fracture of bone near access


    site
    Complications (RARE): fluid extravasation,
    osteomyelitis

    What can go through IO needle?


    Any standard IV fluids
    Blood products
    All drugs administered IV
    10 ml/min by gravity until 41 ml/min by
    pressurized bags

    4. PROCEDURE

    Do not be Lazy..
    Use maximal Barrier Protection
    when performing invasive
    procedures
    Catheter related bloodstream infections
    (CRBSIs)

    CRBSIs high financial costs and significant


    health consequences. Prevention is critical
    Infections rate from IV peripheral catheters:
    0,5 per 1.000 IVD-days (0,1%)
    Arterial catheters: 0,4%
    CV catheters: 4,4%

    Confirmation CRBSI needs standardized techniques to


    determine colonization of catheters and isolation
    same organism from bloodstream
    Most obvious intervention that prevent CRBSI
    maximal barrier precautions:
    Sterile gloves
    Long-sleeved sterile gown
    Mask and Cap
    Large sterile sheet drape when insert CVC

    5 evidence-base procedure
    (NEJM, 2007)

    Maximal barrier techniques


    Hand washing
    Use chlorhexidine for skin preparation
    Avoiding femoral site if possible
    Removal unnecessary catheters

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