Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

Follow Dr. Clay Smith at @spoonfedEM, and sign up for email updates here.

#1: You Glued the Eye Shut – What Now?

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If you accidentally glue someone’s eye shut, soaking the eye in dexamethasone, neomycin, polymyxin B eyedrops for two hours was most effective at loosening histoacryl tissue adhesive.

Why does this matter?
If you’ve used tissue adhesive, you know it can flow where you don’t want it to go. A worst case is if it glues the eyelid shut. Personally, I don’t use it near the eye. But if this happens, what should you do?

Inadvertent tissue adhesive tarsorrhaphy…really? Just say you glued the eye shut…
These authors reviewed the literature and then trialed 24 compounds on glued pigskin to see which was most effective at removing histoacryl tissue adhesive. Soaking (vs rubbing) a wound in dexamethasone, neomycin, polymyxin B eyedrops was most effective at opening wound edges at two hours. This is called Polydexa in Singapore; Maxitrol in the U.S. All other compounds, such as petroleum jelly, KY jelly, artificial tears, and other antibiotic drops failed.

Inadvertent tissue adhesive tarsorrhaphy of the eyelid: a review and exploratory trial of removal methods of Histoacryl. Emerg Med J. 2020 Apr;37(4):212-216. doi: 10.1136/emermed-2019-209177. Epub 2020 Jan 9.

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#2: Ten Ways to Improve Physician-Nurse Communication

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Successful communication between emergency physicians and nurses requires strategies to improve knowledge sharing, streamlining plan of care, acknowledging patient status changes, and awareness of team dynamics.

Why does this matter?
Communication in the ED is vital for safe and effective care, but it can also be challenging to implement. This research conducted focus groups and performed a concept-mapping analysis among emergency physicians and nurses to identify shared information needs, communication strategies and barriers, and factors affecting successful communication. These were distilled into 10 best practices.

10 commandments of physician – nurse communication:

  1. Communicate diagnostic assessment, plan of care and disposition plan to other team members as early as possible. Update the team of any changes to the plan.

  2. Communicate pending tasks in the patient’s care as well as information regarding changes or holdups to tasks or orders.

  3. Communicate details regarding proactive diagnostic testing and therapeutic interventions (e.g. placing IV and drawing bloodwork prior the physician evaluation in patients with abdominal pain, obtaining urine HCG in women of childbearing age).

  4. Don’t assume everyone has a shared understanding: recognize that you might have unique access to information and make sure that it is shared in a timely manner.

  5. Notify providers of any critical or unexpected changes in vital signs or patient status. Did the patient develop new tachycardia, fever, or hypotension? Is the patient more somnolent or getting more agitated?

  6. Do not assume electronic orders substitute for verbal communication.

  7. Use asynchronous communication for lower priority items to aid in prioritization (e.g. leaving a note for a physician requesting they sign-off on non-urgent orders).

  8. Adapt communication strategies based on team members’ experience level and existing relationships. For example, a new nurse may need extra time and guidance while orienting.

  9. Adapt communication strategies to the physical layout of the ED, especially in those facilities where nurses and physicians may have workstations out of sight from one another or where it is not obvious which staff members are on different care teams.

  10. Use strategies that exploit provider experience level regardless of role hierarchy. Perhaps we all remember being a fresh resident physician (finally a doctor!) and realizing that we knew very little compared to the seasoned charge nurse.

Ten Best Practices for Improving Emergency Medicine Provider-Nurse Communication. J Emerg Med. 2020 Mar 4. pii: S0736-4679(19)30939-4. doi: 10.1016/j.jemermed.2019.10.035. [Epub ahead of print]

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#3: PEN-FAST – Penicillin Allergy Risk Tool

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Using the PEN-FAST rule, patients with low-risk penicillin allergies can be identified without need for formal allergy testing.

Why does this matter?
Many patients self-report penicillin allergies, but most are not truly penicillin allergic. This unnecessarily eliminates this drug class, leaving less effective, broader spectrum alternatives. But formal testing is both resource and labor-intensive. This study derives and validates a clinical decision rule to risk stratify patients claiming to have penicillin allergies based on historical features and to identify those who may safely use this family of drugs without need for confirmatory allergy testing.

Life in the PEN-FAST lane
To develop the decision rule, 622 patients reporting a penicillin allergy prospectively underwent allergy testing via skin prick, intradermal, or patch testing and/or oral challenge. The clinical variables associated with positive penicillin allergy test results were distilled into a mnemonic, PEN-FAST.

  • For patients reporting a PENicillin allergy:

  • Five years or less since reaction (2 points)

  • Anaphylaxis or angioedema OR

  • Severe cutaneous adverse reaction (2 points)

  • Treatment required for reaction (1 point)

0 points = Very low risk of positive penicillin allergy test <1%
1-2 points = Low risk of positive penicillin allergy test 5%
3 points = Moderate risk of positive penicillin allergy test 20%
4 points = High risk of positive penicillin allergy test 50%

In the low risk group (scores <3), which comprised 74% of the cohort, only 17 of 460 patients had a positive test result (3.7%). The negative predictive value was 96.3%. External validation of the PEN-FAST decision aid remained clinically relevant in a retrospective cohort of 945 patients from 3 centers in Sydney and Perth, Australia and Nashville, TN. This study supports identifying patients with low risk for true penicillin allergy and safe use of this drug class, perhaps through an observed oral challenge in a primary care setting.

Development and Validation of a Penicillin Allergy Clinical Decision Rule.  JAMA Intern Med. 2020 Mar 16. doi: 10.1001/jamainternmed.2020.0403. [Epub ahead of print]

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