Journal Reviews: Myocardial infarction; acute pain in children; assaults against nurses
May 1, 2002
Journal Reviews
Gibler WB, Armstrong PW, Ohman EM, et al. Persistence of delays in presentation and treatment for patients with acute myocardial infarction: The GUSTO-I and GUSTO-III experience. Ann Emerg Med 2002; 39:123-130.
According to this study, there are four groups at high risk for delays in arrival and treatment for acute myocardial infarction: the elderly, women, diabetics, and minorities. The study looked at delays of 27,849 patients in two large trials of fibrinolytic therapy: Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I), and Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-III). The study found that the groups not only arrived to the hospital later, they also received treatment later. Patients with higher levels of occupation, professional occupations, and private health insurance arrived to the hospital sooner and received treatment more quickly.
The researchers recommend the following:
- education of all patients with increased risk for the development of atherosclerosis and myocardial infarction, with special efforts for those at high risk for delays;
- targeting of individual patients instead of relying on mass-media education;
- further education of health care providers on atypical symptoms associated with acute myocardial infarction in elderly patients with diabetes, because this presentation can delay diagnosis and treatment.
Bulloch B, Tenenbein M. Assessment of clinically significant changes in acute pain in children. Acad Emerg Med 2002; 9:199-202.
EDs should assess whether the method of pain control in children actually gives a clinically significant improvement, says this study from Children’s Hospital in Winnepeg, Manitoba, Canada. The researchers asked 121 children presenting to a pediatric ED with acute pain to rate current pain severity using two standardized pain scales:
- the Color Analogue Scale (CAS), a 10-cm scale that is shaded from white (indicating no pain) to red (indicating the worst pain) with a numerical scale on the reverse side;
- the Faces Pain Scale (FPS), a seven-point scale that uses a line of faces to indicate varying amounts of pain.
After every pain control intervention, the child was asked to rate the pain again. Of a total of 153 pain comparisons made, only three children complained that their pain got worse. In 20 comparisons, children said it was the same, 60 comparisons reported the pain was a little less, and 71 comparisons reported the pain as much less. This process was repeated until the child was discharged form the ED or had a score of zero. The researchers conclude that the following are criteria to use to assess whether a child’s pain has been managed:
- For a child to state that pain is "a little bit better," a decrease of 2 cm on the CAS or one face on the FPS is required.
- For a child to state that pain is "much better," a decrease on the CAS of 4 cm and on the FPS of two faces is required.
"The assessment and treatment of pain in children are an important component of pediatric practice, whether in the practitioner’s office or in the emergency department," the researchers assert. "This study provides health care professionals and clinical investigators the information necessary to assess whether their method of pain control in children is clinically relevant."
May DD, Grubs LM. The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. J Emerg Nurs 2002; 28:11-17.
According to this study from Florida State University in Tallahassee, nurses experience abuse and assaults from family members and visitors just as often as they do from patients. Of 86 respondents to a survey given to ED, intensive care unit, and floor nurses, ED nurses reported the highest rates of these incidents. All the ED nurses surveyed reported being verbally assaulted, and 82.1% reported being physically assaulted, within the past year.
Here are key findings:
- The most common perpetrators of assault were patients with substance abuse, patients with cognitive dysfunction, and individuals who were angry because of the patient’s condition.
- The most common causes of assault by family members and visitors who were angered about hospital policies, the patient’s condition, wait times, and the health care system in general.
- Half of the assault or abuse incidences were never reported in writing.
Nurses reported the following interventions as helpful in prevention of future incidents:
- specially trained security staff for high-risk situations;
- training in aggression-reduction techniques and self-defense;
- use of metal detectors at the ED entrance;
- flagging charts of patients who have exhibited violent behavior.
The study also found that many nurses believed that reporting the incident would be time-consuming and not result in any action by managers. "Nurses do not seem to believe it is necessary to report assault or abuse if there is no evidence of physical injury, as if proof of assault is needed to justify reporting the incident," wrote the researchers.
They recommend the following:
- educating nurses about assault and abuse, including techniques for self-defense, definitions of assault, and aggression-defusion training;
- having clear policies and procedures for assault and abuse against hospital employees;
- making incident reports mandatory for any incidents of abuse or assault, regardless of whether there is evidence of physical injury;
- developing employee assistance programs to provide immediate assistance to employees after an assault or abuse incident.
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