DiversityNursing Blog

3 Ways to Select ICU Kids for Seizure Monitoring

Posted by Erica Bettencourt

Wed, Dec 10, 2014 @ 01:54 PM

By John Gever

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Not all children with severe brain injuries need to be monitored for subclinical seizures, researchers said here, which means that resources can be focused on those at the highest risk.

Victims of abuse, those younger than 2, and those with bleeding within the brain rather than only in the epidural compartment are the pediatric ICU patients most likely to show significant seizure activity that should be detected and treated, said Rajsekar Rajaraman, MD, of the University of California Los Angeles (UCLA).

A separate study by many of the same investigators also found that, in a broader range of pediatric brain injury cases, risk of seizures could be predicted with "fair-to-good" accuracy on the basis of clinical characteristics that would be recorded routinely at admission.

Both studies were reported at the American Epilepsy Society's annual meeting here.

A senior author on both studies, Nicholas Abend, MD, of Children's Hospital of Philadelphia, said at an AES press briefing that identifying and treating seizures is important in the pediatric ICU. When seizures are extremely frequent or long-lasting -- and these can easily go without detection in hospitalized children who are unconscious or lethargic -- they significantly increase the likelihood of poor short- and long-term outcomes.

Such seizures can only be detected via continuous EEG monitoring, Abend explained, which also requires interpretation from trained electroneurologists.

Another investigator in the studies, UCLA's Jason Lerner, MD, noted that children may appear to be napping peacefully while actually undergoing continuous seizures.

Although it would be desirable to perform intense monitoring on all pediatric cases involving head trauma, that is not feasible at most centers, Abend said. He said the field could benefit from risk-stratification models that would allow the care team to track only those patients at the highest risk for damaging subclinical seizures.

Such models, he added, could be tailored to meet the needs of individual centers on the basis of their patient mix, staffing, and other factors.

In a platform session at AES, Rajaraman described one approach to developing such a model. He and colleagues collected data on 135 consecutive pediatric patients (ranging in age from infant to late adolescent) with traumatic brain injury who were treated in ICUs at UCLA and at Children's Hospital of Colorado in Denver. These children had continuous EEG monitoring for detecting subclinical seizures.

They found that all such seizures occurred in children younger than 2 and in those with intradural bleeding, and that the vast majority also involved abusive head trauma. Rajaraman and colleagues then sought to validate these associations in a separate cohort of 44 pediatric ICU patients with head injuries treated at Children's Hospital of Philadelphia. The same patterns were seen.

Across both cohorts, 81% of those with subclinical seizures were determined to have been victims of abusive head trauma, whereas the prevalence of such trauma in all the patients was 25%. Abend said it was uncertain why abusive trauma should be such a strong predictor of these seizures, but speculated that "shaken baby syndrome" -- the most common form of abuse of infants and toddlers -- may produce fundamentally different injuries in the brain compared with falls and car accidents.

Also, such abuse is often chronic, such that the episode that brings a child to the hospital is only the latest in a series of abusive incidents.

The other study, led by Abend, was aimed at producing a predictive model yielding a risk index score that pediatric centers could use to identify critically ill children who could benefit the most from continuous EEG monitoring. It was based on clinical information to which the attending neurologist would have ready access: age, seizure etiology, presence of clinical seizures prior to beginning continuous EEG, initial EEG background category, and interictal discharge category.

Data to design the model were drawn from a database of 336 patients from 11 centers, and then tested against a separate validation dataset of 222 patients treated at Children's Hospital of Philadelphia.

Normalized scores in the model could range from 0 to 1.0, and Abend and colleagues examined the sensitivity and specificity of various cutoffs. When set at 0.10 in the validation cohort, sensitivity was 86% but sensitivity was only 58% -- the high sensitivity meant that 43% of patients would be identified as candidates for continuous monitoring. At the other end, a cutoff of 0.45 reversed the sensitivity and specificity percentages to 19% and 97%, respectively, such that only 5% of patients would be assigned to monitoring.

Abend said the beauty of this approach is that an individual center could choose its own optimal cutoff depending on the resources it has available to monitor multiple patients at one time. A well-equipped and staffed ICU could thus opt for high sensitivity whereas one with more limited resources could be more restrictive.

Source: www.medpagetoday.com

Topics: Children's Hospital, ICU kids, seizure, monitoring, EEG, nursing, health, healthcare, nurse, children, medical, patients, physicians, hospitals

ER Visits on the Rise, Study Reports

Posted by Erica Bettencourt

Wed, Nov 26, 2014 @ 11:49 AM

By Robert Preidt

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The number of emergency department visits in the United States rose from about 130 million in 2010 to a record 136 million in 2011, according to the U.S. Centers for Disease Control and Prevention.

The findings also showed that fewer people were going to ERs with non-urgent medical needs: 96 percent of patients were identified as needing medical care within two hours of arriving at the ER. In 2010, that number was 92 percent, according to the research.

Sixty percent of patients arrived at the ER after normal business hours (after 5 p.m. on weekdays). One-third of visits were for patients on either end of the age spectrum -- younger than 15 or older than 65, the researchers found.

Almost 30 percent of visits were for injuries. The highest injury rates were among patients 75 and older, the study noted.

"The report also finds that there are large numbers of admitted patients who wait long times for inpatient beds," Dr. Michael Gerardi, president of the American College of Emergency Physicians (ACEP), said in an ACEP news release.

"Nearly two-thirds of patients waited two or more hours for beds in 2011, and nearly three-quarters of hospitals continued to board patients, even when the emergency department was critically overloaded. Hospitals must move admitted patients out of the emergency department faster to make room for the increasing number of people coming," he said.

It's believed that there will be about 140 million ER visits in 2014, according to the ACEP.

"The growth in patient demand aligns with what emergency physicians have been seeing and predicting: demand is going to increase," Gerardi said.

"Given that our nation's population is aging, and emergency departments have a critical role as the front line of responding to disasters and infectious disease outbreaks in America, such as what we saw with Ebola, we need to prepare for increased numbers of patients," he added.

Despite increasing use of ERs, most hospitals had not expanded their ERs as of 2011 and had no plans to expand them in the following two years, according to Gerardi.

"Emergency departments are essential to every community and must have adequate resources," he said. "They continue to be under severe stress and face soaring demands, despite the efficiency of caring for more than 136 million of the sickest patients each year using only 4 percent of the nation's health care dollar. This report is more evidence that we are going to need more resources, not less, in the future."

Source: www.nlm.nih.gov

Topics: ER, emergency room, studies, health, healthcare, nurses, health care, medical, physicians, hospitals

Mentoring project aims to increase minorities in medicine

Posted by Alycia Sullivan

Fri, Jun 14, 2013 @ 11:00 AM

By KEVIN B. O’REILLY

A Web-based mentoring service launched in August 2012 has attracted 400 active users in its effort to help underrepresented minorities pursue careers in medicine.

The project, DiverseMedicine Inc., allows users to request a personal mentor to answer questions through the website’s instant messaging or video chat functions. High school, college and medical students also use discussion forums to cover topics such as admissions testing and residency applications.

The need for the service is great, say organizers of the project, which is open to all students online (link). Seven percent of medical school faculty are black, Hispanic or Native American, says the Assn. of American Medical Colleges. The share of medical students from underrepresented minority groups is about 15%, a figure that has not budged much since 2001.

Closing the gap

Courtesy|unlim|free|mug|photo|100x150|“One of the main reasons why there are so few minorities in the field of medicine is because of the mentoring gap. If nobody’s there to tell you how to get into medical school, you’re not going to get in,” said Dale O. Okorodudu, MD, the project’s founder and a senior resident at Duke University School of Medicine’s internal medicine residency program in Durham, N.C. Too many students do not get advice about postbaccalaureate premedical programs or health-related master’s degrees that can aid their chances of medical school admission, said Cedric Bright, MD. He sits on the project’s board of directors and is assistant dean of admissions at the University of North Carolina School of Medicine.

“This online component … provides a venue for folks to realize that there are role models out there that they don’t see that often,” Dr. Bright said. The American Medical Association is working to develop a LinkedIn-style mentoring site for medical students and residents to connect with practicing physicians.

Source: amednews

Topics: minorities, DiverseMedicine Inc, medical careers, physicians

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