Creation of a registered nurse-administered nitrous oxide sedation program for radiology and beyond

Children undergoing urethral catheterization for urologic imaging under existing sedation practices were identified as an underserved patient population. Using a multidisciplinary approach, a registered nurse (RN)-administered nitrous oxide sedation program was developed to meet the needs of these children. Program development required delineation of RN scope of practice, evaluation of equipment, formulation of an educational program, and compliance with occupational safety standards. The program was implemented in 2004 using standard "dental" nitrous oxide equipment coupled with distraction and imagery to enhance the efficacy of the sedation experience. Initial assessment via telephone questionnaire indicated fewer adverse effects and more rapid return to baseline than oral midazolam, the sedative previously used for these procedures. Ongoing evaluation continues to confirm patient and environmental safety. The nitrous oxide program has expanded to provide sedation for additional tests in radiology as well as in other hospital departments. By implementing an RN-administered nitrous oxide program, children's access to this sedative/analgesic agent is increased.

Delay in seeking emergency care

OBJECTIVE

To determine whether patient clinical and socioeconomic characteristics predict patient delay in coming to the emergency department (ED).

METHODS

Adult ED patients at five urban teaching hospitals were surveyed regarding self-reported delay in coming to the ED. Delay was measured by self-perception as well as by the number of days ill and unable to work. Patient socioeconomic and clinical characteristics were obtained by survey questionnaire and chart review. Cross-sectional analysis within a prospective study of 4,094 consecutive patients was performed using a subset of 1,920 patients (84% eligible rate) to whom questionnaires were administered.

RESULTS

Overall, 32% of the patients completing the survey reported delay in seeking ED care. Of these patients reporting delay, 71% thought their problem would go away or was not serious. Patients who were older, had higher acuity, or were frequent ED users reported less delay in coming to the ED, while patients without a regular physician or who were African American reported more delay. Perception of increased number of days ill prior to visiting the ED was reported by frequent ED users and those with worse baseline physical function, while patients who had higher acuity reported fewer days ill prior to coming to the ED.

CONCLUSIONS

A patient's decision to delay coming to the ED often reflects a belief that his or her illness is either self-limited or not serious. The decision to delay correlates with patient characteristics and access to a regular physician. The correlates of delay in seeking ED care may depend on the delay measure used. Better understanding of patients at risk for delaying care may influence interventions to reduce delay.

Localization of natriuretic peptide-activated guanylate cyclase mRNAs in the rat brain

Physiological actions of atrial natriuretic peptide (ANP) and C-type natriuretic peptide (CNP) are elaborated by membrane-bound natriuretic peptide receptors (NPRs). These receptors possess intracellular guanylate cyclase domains that mobilize cyclic guanosine monophosphate upon binding of peptide. Two distinct NPR subtypes have been described in brain: the NPR-A selectively binds ANP, whereas NPR-B exhibits high affinity for CNP. To define further the potential domains of ANP and CNP action in brain, the present study used in situ hybridization histochemistry to map NPR-A and NPR-B mRNA-expressing cell populations. Significant levels of neuronal NPR-A mRNA expression were observed only in the mitral cell layer of the olfactory bulb, medial habenula, subfornical organ, and area postrema. Expression of NPR-A mRNA was observed in forebrain white matter tracts, suggesting synthesis in glial cells. In contrast, NPR-B mRNA was widely expressed throughout the neuraxis. In the telencephalon, signal was abundant throughout limbic cortex and neocortex, olfactory bulb, hippocampus, and amygdala. Intense NPR-B mRNA hybridization was observed in preoptic-hypothalamic neuroendocrine circuits and in motor nuclei of cranial nerves. Intermediate expression of NPR-B mRNA was observed in brainstem nuclei controlling autonomic function. Labeling for NPR-B but not NPR-A mRNA was observed in pituicytes in the neural lobe of the pituitary and in scattered cells of the anterior pituitary. These results suggest that CNP is the primary biologically active natriuretic peptide in brain. In contrast with NPR-B, NPR-A appears to be expressed largely in restricted cell populations containing high levels of ANP and in circumventricular organs. These data implicate the NPR-A in autoregulation of ANP neurons and central registration of cardiac ANP release.