Accident and Emergency - Essay Example

Appraise a Piece of Research that may be Suitable for Implementation in your Work Area of Practice (Accident and Emergency). Detail How It Could Be Implemented. Introduction: The term emergency management traditionally refers to care given to patients with urgent and critical needs. The philosophy of emergency management has broadened to include the concept that an emergency is whatever the patient or the family considers it to be. Large numbers of people seek emergency care for serious life-threatening cardiac conditions, such as myocardial infarction, acute heart failure, pulmonary edema, and cardiac dysrhythmias. Apart from these, the Accident and Emergency Department also caters services of emergency management of trauma (Subbe et al., 2006, 841-845). Usually the management is given under the guidance of a physician or an emergency nurse practitioner. The emergency nurse has had specialized education, training, and experience in assessing and identifying patients' problems in crisis situations. Along with that, the nurse prioritises, monitors, and provides continuous assessment of the acutely ill or injured patients. The role does not end there. She has also the role to support and attend to families, to supervise allied health personnel, and to teach the patients and families in a care environment that is time-limited and highly pressured. Nursing interventions are usually accomplished in collaboration with or under the direction of a qualified physician or nurse practitioner. The strengths of nursing and medicine are complementary in an emergency situation. Appropriate nursing and medical interventions are anticipated based on assessment data and current evidence for appropriate measures (Brook and Crouch, 2004, 211-216). The emergency health care staff members work as a team in performing the highly technical care for patients in an emergency situation, where taking an important decision matters, and research evidence can serve as a guide to make confident decision (Gerrish and Lacey, 2006, 3-15). Although published in the British Journal of Anaesthesia, in this work, the author is going to appraise the piece of research titled, "Identifying the sick: can biochemical measurements be used to aid decision making on presentation to the accident and emergency department", authored by Hucker et al. in the year 2005 (Hucker et al., 2005, 735-741). The intent of this piece of appraisal is to find out through a critical review, whether the findings from this piece of research can be implemented in our area of practice, to examine where the findings from this research would serve as enough evidence to change and improve practice (Gerrish and Lacey, 2006, 16-30). The Nursing process in the Accident and Emergency provides a logical framework for problem solving in this environment. Patients in the A and E have a wide variety of actual or potential problems, and their condition may change constantly (Lattimer et al., 2004, 685-691). Therefore, nursing assessment must be continuous, and nursing diagnoses change with the patients' condition. Although a patient may have several diagnoses at a given time, the focus is on the most life-threatening ones; often, both independent and interdependent nursing interventions are required (Sakr et al., 2003, 158-163). Therefore, it becomes pertinent to find out quickly which condition demands immediate care, so the patient may benefit from early and aggressive medical and nursing interventions, and the outcome of the condition is improved. The authors establish their point from references from already existent researches with evidence that early goal directed interventions in the A and E before admission to the Intensive Care Unit would significantly improve survival (Department of Health, 2005). The challenge to the A and E nurses are those of providing holistic care in the context of a fast-paced, technology-driven environment in which serious illness and death are confronted on a daily basis. Emergency nurses spend many hours learning to classify different illnesses and injuries to ensure that patients most in need of care do not wait to receive it. Protocols may be followed to initiate laboratory or x-ray studies from initial encounter while the patient might wait for a bed in the A and E if indicated. The laboratory investigations are important in the sense that a quick and accurate detection of the pathophysiologic process needs to be detected before it becomes irreversible due to progression of the pathology, and it can be intervened at the earliest by different measures such as fluid resuscitation, correction of acid-base balance, pressor support, arrest of haemorrhage, respiratory support, or a multitude of other nursing interventions (Leman et al., 2004, 452-456). The authors arrive at the problem in a step-wise manner, explaining the issues, so the reader does not have problems in understanding the issues that really are hindrances to care in the A and E (Gerrish and Lacey, 2006, 17-20). Nurses in the A and E collect crucial initial data: vital signs and history, neurologic assessment findings, and diagnostic data if necessary. The conventional protocol, however, considers physiologic markers such as heart and respiratory rates, urine output, and other markers that may prove to be misleading in many clinical situations that present in the A and E. In such conditions, these markers are less reliable since they change late in the course of the illness. In contrast, in the ICU setting, there are many potential markers of physiological deterioration that may predict the course of the illness. Of them, laboratory tests that indicate acidosis are pH, standard base excess, and lactate are very simple and easy to execute, yet they have significant diagnostic and prognostic importance. Although these tests are nonspecific as to identify the aetiology of the acidaemia, these are at least very viable options to recognize acidaemia, and if the cause is tissue hypoxia, simple measures like oxygen administration may be instituted that may alter the prognosis. The authors suggest a new method for biochemical delineation of the pathology in the form of determination of base excess and acid-base status. This protocol is dependent on three markers, namely, PCO2, string ion difference, and total concentration of nonvolatile weak acids. Although fruitful in the ICU setting, these have not been used in the A and E, and the authors hypothesize that use of these tests against the conventional markers of acid-base status may prove to be useful in diagnosing derangements early on the course and would improve outcome. To this end, the authors aimed to study whether routine clinical measurements such as heart rate, blood pressure, percentage oxygen saturation, level of consciousness, ventilator frequency and/or these markers of metabolic abnormalities such as serum lactate, SBE, anion gap, and string anion gap are useful in early identification of high risk patients in the A and E Department. The authors describes clear inclusion and exclusion criteria, avoided all possible bias, chose location of this prospective observational study over a period of 6 months in a busy A and E Department of a general hospital (Cecil, Thompson, and Parahoo., 2006, 395-402). All the patients who had chances of diagnosed or intervened earlier were excluded including those referred by the GP, since the majority of the GP referrals were admitted via an emergency assessment unit. From the literature review, the authors had established the methodology, and the details of the methodology appears to be succinct and clear to the reader in that on presentation to the A and E, venous blood was drawn and then analyzed with a blood gas analyzer (Parahoo 2006, 21-32). The authors did not fail to mention the details of equipments, since if any one wished to replicate the data by repeating the tests, they can perform it. Errors from analysis were prevented by daily calibration and standardization. During the second period of the study, in addition to the venous blood analysis, the clinical variables mentioned earlier were recorded by the admitting nurse with the case notes of the expired patients were analyzed to ensure accuracy of the reporting (Polit & Beck, 2005, 17-41). The followup for determination of hospital survival and length of stay were done, and all therapeutic management in the A and E were at the attending physician's discretion, thereby eliminating observer bias. Appropriate statistical analysis was performed after statistical manipulation of the data to conform to a symmetrical distribution, and the data were tabulated in the article. To assess the relationship between state of consciousness at the presentation and survival and to identify which quantitative variables were related to survival, the authors performed appropriate statistical tests on the data, and they found that age was an important factor for survival. Therefore, the authors rightly modeled the survival with logistic regression analysis on each prognostic variable in combination with age. After an initial investigation, length of stay of the survivors were grouped into 1 day and >1 day, and the authors assessed further which of the quantitative variables were related to the categorical variables (Watson and Thompson, 2006, 330-341). The total number of patients included in the study was 2221, and venous blood samplings were done in 1424 patients, 58% of the total sample size. Of the patients, whose data were available, 91% survived. The authors present the results in an organized manner, so the reader is able to understand the implications of these numbers clearly and can identify the categories of these numbers easily. The data has been presented in a nutshell in a table (Hucker et al., 2005, 735-741). The findings from this study are that all variables demonstrated statistically significant differences between survivors and nonsurvivors. Greater percentage of conscious patients survived. The prognostic ability of each variable increased with inclusion of age of the patient. The variables that showed a significant difference for length of stay were Na+, Ca2+, Cl-, albumin, urea, creatinine, AG adjusted, SIG effective, SIG, age, temperature, SaO2, ventilator frequency and heart rate. The final finding is very significant in that conventional clinical measurement upon presentation to the A and E could not clearly predict hospital mortality or hospital stay in conformity with previous studies (Newman, Thompson, and Roberts, 2006, 4-7). This also indicates that recent comprehensive critical care guideline recommendation of MEWS would fail to provide any early warning since the variables that are used to predict such warning are neither validated, nor studied, specially when viewed against the findings of this study. Therefore, it could be concluded that the clinical data in isolation of the biochemical data do have no practical significance. Despite different limitations in this study and existence of very many clinical scenario in any given patient presenting in the A and E, the authors have taken all measures to increase the internal and external validity of the study including avoidance of bias, and thus the findings have considerable generalizability. The limitations of this study are many, and some are actually unavoidable. This study aimed to study the metabolic state of a patient on presentation to the A and E, and assessment of the metabolic state is difficult. In the clinical setting, usually arterial blood gas analysis is performed, but in this study, the authors uses venous blood analysis keeping in mind that the nurses would be initiating the process, where venipuncture is a feasible safe option, in case the findings are implemented in practice. The authors, however, provide enough evidence that there is not much of a significant difference between arterial and venous blood when pH is the criteria. Limited resources could have affected the adequate capture of data in the busy A and E setting. Excepting the extremes of ranges, all other data had very high probability of being accurate. Although all attempts were done on the part of the authors to prevent study of the treated patients, there is always a chance that some patients might have received treatments from outside sources, and that could have influenced the findings in both the categories (Gerrish and Lacey, 2006, 71-89). The outcome variables might have been influenced by the type of care that the patients receive once admitted, and there was a possibility that appropriate inpatient management would create a systemic bias of change in mortality and length of the hospital stay. However, due to the large sample size, this effect would have been minimized. Therefore, even though this is an observational study showing combination of venous blood values and clinical parameters will assist the A and E nurse with a triage tool, the results of the study can be investigated further with stratification by the cause of metabolic derangement and can well be implemented in practice. This would need funding since these tests would cause extra cost per patient triaged in the A and E Department. This funding should be available since this improves the quality and outcome of care. The number of patients benefited out of this evidence being used to change practice could save a lot of money thereby justifying implementation of the research findings even though there are cost and funds involved (Gerrish and Lacey, 2006, 90-106). Early and aggressive medical intervention can be indicated by early detection of metabolic abnormalities in A and E triage by the A and E nurses, and this has been demonstrated to be providing survival advantage when these markers were used in association with conventional assessment parameters to assist in the identification of these patients. Furthermore, these parameters can be used to guide A and E resuscitation process on presentation and detection in the A and E before the patients were admitted to the A and E inpatient or Intensive Care Unit. The current provision for level I and level II facilities that would be required to manage these patients are highly inadequate, and this indicates a major source implication for the National Health Service. If in the level I, there would be provisions for metabolic resuscitations beds in the A and E to employ these tests and to initiate early resuscitations based on these studies, it could be cost effective and would be able to reduce mortality (Department of Health 2005). If this indicates a change is practice, the hospital authority or NHS may create provisions for these tests and the beds that were suggested, and the A and E nursing care team must be a part of it. To begin with the findings of the research would need to be presented to the authority to convince them about the benefits of such a change. After appraising the study, many other nurses who face critically ill patients on a daily basis during their duties, must be creating enough reflecting ripples, as this author is experiencing. There would be some who will have to come forward with the zeal to implement the evidence provided by this study, and some leader among these nurses would emerge who could lead the process. From this study, it is very much apparent that the A and E nurses have enough expertise to carry this out in practice, since the intervention is very easy to apply. All they have to do is to assess the patient carefully and record the data, which they are already doing. Along with this, they will have to perform a venipuncture and submit the blood for testing. The testing would be done in an automated analyzer, and when the reports would be coming depending on the data, under guidance of A and E physician, they can initiate the process of early resuscitation as long as the patient is not transferred to the appropriate department for acute management (Burns and Grove, 2006, 20-27). While implementing the evidence a risk assessment is necessary. Since the intervention designed is a preventive measure, this is obviously not going to increase the risks for the patient. Moreover the conventional assessment is also being done along with, so the risks are not increasing in the baseline. The predictive validity has already been discussed in the executive summary, and deployment of this change would not worsen the situation beyond the existing condition. The rationale of these tests are purely biochemical, and they build upon existing and established knowledge, thus carrying out these tests do not pose any risk. This implementation is not an intervention to influence outcome, therefore, free of risk, and the nursing researches can take the lead to investigate further whether a newer method of intervention can result out of this change in practice (Clifford., Clark, and Clark, 2004, 60-81). The stakeholders would be the fellow nurses, A and E physician, laboratory technicians, hospital authority, RCN, NHS authorities, patient, and the patient's family. The rule of engagement, actually is very simple. For others, explanation of the findings from this research and invitation of open discussion and criticism, for the A and E physician demonstrating the significance in practice, for the laboratory technician request, for the family and the patient, educating then on the need of this and explaining them the significance of this (Green & Thorogood, 2004, 51-76). Nursing research can call on no separate identifiable budgets at national or local levels within the structure of NHS financing. The main financing would happen through DOH directly managed projects. DOH should commission such process. Proposals must fall on the current priorities from DOH. Along with that, the proposal must be written in such a way that, the Ministers get an objective information on ways of improving organization, administration, and operation. After the funding, the NHS authority would be contacted with a plan to change. Theoretical and practical training of the nurses would be arranged. A laboratory dedicated to such tests manned by a dedicated laboratory technician would need to be arranged. Institutional directives must reach all the departments including A and E physician. A protocol and guideline would be created that would include details of the steps that would be necessary. Appropriate modification in the consent form would be done, and once everything is in place, the change would be in practice (Cormack, D, 2000, 43-50). The process would be audited and evaluated by noting the records of admission, laboratory tests, and the records of the nurses in terms of conventional data. These patients will be monitored about their progress and outcome during their stay in the hospital. Regular audit of the A and E care as to how the protocol and guidelines are followed will be done. Calibration of the auto analyzer would be done on a regular basis. These data will be evaluated and compared (Crookes and Davies, 2004, 63-87). The financial benefits are immense. In the long run, it would improve care and will be of economic benefit by allowing the patient to have metabolic resuscitation at entry, thereby increasing diagnostic accuracy and preventing complications that would need more resources to manage successfully these cases. It would also ensure better healthcare on the face of limitation of resources. Early management would cause speedy recovery, and the patient will need to spend less time in the hospital preventing complications of prolonged stay. Last but not the least, the A and E nurses would get more job satisfaction thereby increasing their involvement. Reference Brook, S. and Crouch, R., (2004). Doctors and nurses in emergency care: where are the boundaries now Trauma; 6: 211 - 216. Burns, N; Grove, SK (2006). Understanding Nursing Research, 4th edition. Saunders. Cecil, R., Thompson, K., and Parahoo, K., (2006). The research assessment exercise in nursing: learning from the past, looking to the future.J Clin Nurs; 15(4): 395-402. Clifford, C., Clark, JE., and Clark, J., (2004). Getting Research Into Practice. Elsevier Health Sciences. 60-81. Cormack, D, (2000). The Research Process in Nursing. Blackwell Publishing. London. 43-50. Crookes, P. and Davies, S., (2004). Research Into Practice: Essential Skills for Reading and Applying Research. Baillire Tindall, 63-87. 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