Background Early detection of pupillary changes in patients with head injuries can alert the care team to increasing intracranial pressure. Previous research has shown inconsistencies in pupil measurement that are most likely due to the subjective nature of measuring pupils without the assistance of technology. Objectives To evaluate nurses’ abilities to assess pupil diameter accurately and detect unequal pupils. Methods In a 3-part study, the accuracy of critical care and neurosurgical nurses’ assessments of pupils was determined. The study included assessment of drawings of eyes with an iris and pupil, examination of photographs of human eyes, and bedside examination of patients with a head injury. Results Subjective assessments of pupil diameter and symmetry were not accurate. Across all phases of the study, pupil diameters were underestimated and the rate of error increased as pupil size increased. Nurses also failed to detect anisocoria and misidentified pupil reactivity. In addition, nearly all nurses relied on subjective estimation, even when tools were available. Conclusions Critical care and neurosurgical nurses underestimated pupil size, were unable to detect anisocoria, and incorrectly assessed pupil reactivity. Standardized use of pupil assessment tools such as a pupillometer is necessary to increase accuracy and consistency in pupil measurement and to potentially contribute to earlier detection of subtle changes in pupils. If pupillary changes are identified early, diagnostic and treatment intervention can be delivered in a more timely and effective manner.

Insertion of prehospital peripheral intravenous (PIV) catheters frequently occurs under suboptimal conditions. Timely replacement of prehospital PIV catheters may minimize the risk of inhospital catheter-related infections. Inconsistent recommendations exist concerning when prehospital PIV catheters should be replaced. The following study assessed compliance with hospital order sets for the discontinuation of prehospital PIV catheters in trauma patients and their associated complications. Results revealed 33.62% compliance with the trauma order set and 66.38% compliance with the hospital order set. Less than 1% of patients exhibited an associated complication. Guidelines for replacement of prehospital PIV catheters should focus less on time since insertion and more on patient factors.

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Electrocardiogram (ECG) false alarms are common in electrically-hostile peri-operative environments. Newer integrated monitoring, with sophisticated hardware and software, has the potential to minimise artefacts. However, monitoring issues continue to occur, with the potential for critical incidents and unnecessary and harmful interventions. We describe the root cause analysis of a series of apparent ECG flatline asystolic events that appeared in the operating room shortly after the introduction of new intra-operative monitoring systems. Clinical events and biomedical laboratory testing revealed complete loss of ECG signal with increasing resistance. The new ECG systems had incorporated both software and hardware changes to improve the fidelity of signal acquisition and display, but had become much more sensitive to impedance changes. After we alerted the manufacturer, they added software and hardware updates that resulted in resolution of all incidents of ECG loss-of-signal.

BackgroundHospice beds are a finite resource increasingly unable to support long-term admissions without specialist needs. However, it has been suggested that moving a patient may hasten death via “relocation syndrome.” Moves should be avoided where prognosis is less than 4 weeks.MethodsA retrospective observational study was carried out in a hospice. Computer-based records were analysed to calculate survival post-discharge over a three month period. Patient demographics, the length and purpose of admission, and preferred place of death (PPD) were recorded.Results63 patients were included. 44 died in the hospice and 19 were discharged. Of those who were discharged, 16% (n = 10) went home and 14% (n = 9) went to a care home. The median survival of those discharged home was 61.5 days compared to 12 days for those discharged to a care home.The PPD was met more often in those who died in the hospice. Those discharged to care homes were the most elderly; median age care home = 79, home = 72, hospice = 74.5 and had the longest admissions prior to transfer; median admission for care home discharge = 29 days, home = 13 days, hospice death = 9 days.DiscussionPrognostication is notoriously difficult. However, with the aim of a “good death,” it would have been preferable to avoid the discharges following which survival was short. The more rapid decline observed in those discharged to care homes may be anticipatable. Such individuals are likely frailer and more dependent. However, as patients who are thought to be unstable are not discharged, it is possible that this was influenced by ‘relocation syndrome’.Prolonged hospice admissions for patients discharged to care homes may signify particularly complex needs. In the current climate of difficulty accessing funding for care and placements, it may reflect a prolonged discharge planning process during which the window of opportunity for successful placement is lost. Further research is needed to explore this.