Nurse Practitioner Mental Health Care in the Primary Context: A Californian Case Study

In America, mental health needs surpass the availability of specialized providers. This vulnerable population also has other obstacles for comprehensive care including gaps in medical coverage, stigma, economic barriers, and a geographical mal-distribution of qualified mental health professionals. A wide availability of primary care providers, including primary care and family nurse practitioners, are well-positioned to deliver integrated mental and physical health care. A case study from a Southern California Coachella Valley primary care clinic with integrated services is used to demonstrate the much-needed approach of care to address health disparities that face low-income immigrants, migrant workers, and others without access to specialized care centers and providers. It is argued that mental health care should be part of all holistic treatment provided by primary care and family nurse practitioners. This has implications for curricula and practice development.

Evaluation of a paediatric procedural sedation training and credentialing programme: sustainability of change

INTRODUCTION

An ongoing comprehensive paediatric procedural sedation (PPS) training and credentialing programme to improve patient safety was introduced into emergency departments (EDs) at a tertiary children's hospital (Royal Children's Hospital; RCH) and a suburban mixed ED (Sunshine Hospital; SH) in Melbourne, Australia. The study aimed to establish whether changes in practice had been sustained 3 years after implementation of the PPS programme.

METHOD

100 PPS episodes were identified at both hospitals (50 at each hospital) pre-implementation, 6 months and 3 years after implementation. This study retrospectively analysed 11 proxy markers of sedation safety by review of prospectively collected sedation records and medical records. Performance during the three time periods was compared using chi(2) testing.

RESULTS

Average age was 6 years and sedations were mainly for fracture reduction and laceration repair. Nitrous oxide and ketamine were the most commonly used agents. Midazolam use decreased over the study period. Six months after implementation at both hospitals relevant proxy markers of sedation safety were significantly improved over the pre-implementation level. Three years after implementation markers of sedation safety were still improved over pre-implementation levels. However, based on a minimum compliance with seven of 11 sedation safety markers both sites deteriorated; RCH from 96% to 80% (p=0.028) and SH from 68% to 32% (p=0.001).

CONCLUSION

Based on an analysis of proxy markers of sedation safety significant changes over pre-implementation sedation care were maintained 3 years after implementation of a PPS programme. Documentation of sedation safety markers decreased over the study period, more so at the community hospital. To maintain educational gains and system change in sedation safety requires ongoing resources.

Intranasal fentanyl and high-concentration inhaled nitrous oxide for procedural sedation: a prospective observational pilot study of adverse events and depth of sedation

OBJECTIVES

Nitrous oxide (N(2)O) is an attractive agent for pediatric procedural sedation and analgesia (PSA) with rapid onset and offset of sedation. However, it has limited analgesic efficacy. Intranasal fentanyl (INF) provides nonparenteral analgesia. There are currently no data on the combined use of N(2)O and INF for PSA in children. The authors set out to prospectively assess the depth of sedation and incidence of adverse events when N(2)O and INF are used in combination in pediatric patients.

METHODS

This was a prospective observational pilot study of combined N(2)O and INF for PSA at a tertiary children's hospital emergency department (ED). INF was administered at a precalculated dose of 1.5 μg/kg for preascertained weight ranges. N(2)O concentration, dose, timing of INF, adverse events, and sedation depth were recorded. Sedation depth was recorded using the University of Michigan Sedation Scale (UMSS).

RESULTS

A total of 41 patients, aged 1 to 14 years, received INF within 2 hours prior to N(2)O. N(2)O was administered at a maximal concentration of 70% in 40 patients, and at 50% in one patient. Most patients (80%) were minimally to moderately sedated (sedation score 1 or 2). Deep sedation (sedation score 3) was recorded in 14.6% of patients (95% confidence interval [CI] = 3.4% to 24.6%). No patients had serious adverse events; vomiting was recorded in 19.5% (95% CI = 7.4% to 31.6%). There were two patients (4.9%) who were deeply sedated and vomited during the procedure.

CONCLUSIONS

There were no serious adverse events identified in this pilot study of combined N(2)O and INF. However, there was an increased incidence of vomiting and deeper levels of sedation when compared to published data of single-agent use of N(2)O, which could lead to more serious adverse events. Further investigation is needed to establish the analgesic efficacy of combining N(2)O and INF and to clarify the safety profile before this combination can be recommended for PSA in children.

Paediatric arrhythmias in the emergency department

OBJECTIVE

Emergency department (ED) staff need to rapidly establish accurate diagnosis and management for children with arrhythmias. Limited data are available on the presenting features, epidemiology and management of arrhythmias encountered in the ED. The aim of this study was to characterise the incidence, presenting features, management and outcomes of arrhythmias at a large tertiary children's hospital ED.

PATIENTS AND METHODS

Retrospective review of medical records identified via the ED electronic database using ICD-10 codes for arrhythmias including cardiac arrests over a 6-year period (2002-2008). Patients <18 years were analysed using predefined criteria.

RESULTS

There were a total of 444 non-arrest arrhythmias with an incidence of 11.5:10 000 presentations. Median age of patients at presentation was 10.4 years; 45% were male. Supraventricular arrhythmias (SVTs) represented the largest subgroup (n=250, 56%). Conduction disorders (n=18), ventricular tachycardia (n=17) and atrial flutter/fibrillation (n=7) were rare. There were 19 cardiac arrests. Fifty-seven (13%) patients had underlying congenital heart disease. For ongoing SVT (n=135), vagal manoeuvres were used in 74%, and antiarrhythmic drugs in 64%. In five patients with SVT, drugs other than adenosine were used. Defibrillators were used only on 2 occasions for arrthymias and 6 times for cardiac arrests. 18 of 19 children in cardiac arrest died.

CONCLUSION

In this largest paediatric series outside the intensive care and postoperative setting, arrhythmias were uncommon, defibrillator use was very rare, and observed mortality was low.

A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol): the comparative rehydration in bronchiolitis study (CRIB)

BACKGROUND

Bronchiolitis is the most common reason for admission of infants to hospital in developed countries. Fluid replacement therapy is required in about 30% of children admitted with bronchiolitis. There are currently two techniques of fluid replacement therapy that are used with the same frequency-intravenous (IV) or nasogastric (NG).The evidence to determine the optimum route of hydration therapy for infants with bronchiolitis is inadequate. This randomised trial will be the first to provide good quality evidence of whether nasogastric rehydration (NGR) offers benefits over intravenous rehydration (IVR) using the clinically relevant continuous outcome measure of duration of hospital admission.

METHODS/DESIGN

A prospective randomised multi-centre trial in Australia and New Zealand where children between 2 and 12 months of age with bronchiolitis, needing non oral fluid replacement, are randomised to receive either intravenous (IV) or nasogastric (NG) rehydration.750 patients admitted to participating hospitals will be recruited, and will be followed daily during the admission and by telephone 1 week after discharge. Patients with chronic respiratory, cardiac, or neurological disease; choanal atresia; needing IV fluid resuscitation; needing an IV for other reasons, and those requiring CPAP or ventilation are excluded.The primary endpoint is duration of hospital admission. Secondary outcomes are complications, need for ICU admission, parental satisfaction, and an economic evaluation. Results will be analysed using t-test for continuous data, and chi squared for categorical data. Non parametric data will be log transformed.

DISCUSSION

This trial will define the role of NGR and IVR in bronchiolitis

TRIAL REGISTRATION

The trial is registered with the Australian and New Zealand Clinical Trials Registry--ACTRN12605000033640.