- Email: [email protected]
16
Research Forum Abstracts markedly, decreasing from 281 to 190 (p ⬍ .001) despite an increase in ED census of 10.2%. Conclusion: The institution of a protocol which incorporates bridging orders and a dedicated admitting nurse significantly improves ED TAT times and measures of patient satisfaction.
16
was noted to be potentially protective, but the significance of this is uncertain. Subsequent validation of this predictive model is needed. Predictive model for intubation in patients with ADHF*
Hospital Crowding Affects the Timeliness of Pneumonia Care
Andrus P, Oyama J, Dickson J, Hoxhaj S/Mount Sinai School of Medicine, New York, NY
Study Objectives: To determine the factors affecting time to delivery of antibiotics in adult patients with pneumonia. Methods: We performed a retrospective review of Emergency Department (ED) records for all patients aged 18 and older admitted with an ED diagnosis of pneumonia during the first six months of 2005, at the inception of an institution wide effort to comply with the Centers for Medicare and Medicaid Services (CMS) core measures. The study was performed at a single, urban, academically affiliated, tertiary medical center. Patient data gathered included: age, sex, source and mode of arrival, date and time of arrival, date and time of antibiotic delivery, ED length of stay (LOS), hospital occupancy for day of arrival, and ED census for day of arrival. We used the Emergency Severity Index (ESI) as a surrogate for severity of illness. The data collected was compiled in a Microsoft Excel database for analysis. LOS and age were broken down into quartiles for statistical purposes. Statistical significance was determined by using Chi-Square testing. Results: During our study period, 343 patients were admitted with an ED diagnosis of pneumonia. Patients with shorter LOS were more likely to receive antibiotics within four hours of triage (Q1 88%, Q4 57%, p ⬍ 0.001). Patients transported by EMS were more likely to receive antibiotics within four hours (EMS 76% vs. Ambulatory 67%, p ⬍ 0.05). Older patients were more likely to receive antibiotics within four hours (Q1 81%, Q4 62%, P ⬍ 0.025). Patients with the greatest illness severity at triage were more likely to receive antibiotics within four hours (ESI 1⫽88%, ESI 2⫽78%, ESI 3⫽65%, ESI 4⫽57%, P ⬍ 0.01). Conclusion: As measured in our study, the patient length of stay is significantly associated with a delay to delivery of antibiotics thus indicating that crowding has some impact on the timeliness of pneumonia care. Patients who are older and those who have a greater initial severity of illness are significantly more likely to receive antibiotics within the CMS four-hour window. To improve the timeliness of pneumonia care, emergency departments should focus their performance improvement efforts on walk-in, non-elder patients with lower acuity of illness at presentation. More validated measures of crowding are needed to better delineate the effects of crowding on the timeliness and quality of care.
17
Endotracheal Intubation in Patients Being Treated for Acute Decompensated Heart Failure: A Predictive Model
Levy PD, Wech R, Zalenski R/Wayne State University, Detroit, MI
Study Objective: To develop a predictive model for endotracheal intubation (ETI) in a cohort of patients with acutely decompensated heart (ADHF). Methods: This study was a retrospective analysis of institutional data compiled as part of a larger, national registry. Included were patients admitted to one of four hospital study sites within the Detroit Medical Center with a primary diagnosis of ADHF. Patients were dichotomized into those who did and did not require ETI. Using forward and backward step-wise logistic regression, a predictive model was developed to determine the probability of need for ETI. Demographics, prior medial histories, and presenting characteristics were considered as potential predictors. Hemodynamic variables also included in the model development process and were summated using the shock index (multiplied by 10 for scale). Results: A total of 1289 patients were included in the analysis. ETI was required in 56 (4.34%) patients. After controlling for potential interactions, 5 variables were identified as independent predictors of ETI and were included in the final model (see table). Anemia, which appeared to be protective, was retained as a 6th variable. Conclusions: Advanced age, increased serum creatinine, elevated shock index, a history of coronary artery disease and a primary symptom of dyspnea at rest are were identified as significant risk factors for ETI in patients with ADHF. Anemia
S6 Annals of Emergency Medicine
18
The Preferred Modifications and Relative Success Rates After First Attempt at Intubation Among Emergency Physicians
Shah K, Hazan A, Lipsky A, Newman D, Wiener D/St. Luke’s-Roosevelt Hospital, New York, NY; Harbor UCLA, Los Angeles, CA
Study Objectives: We sought to determine the preferred modifications chosen by emergency medicine residents and attendings after a missed first attempt intubation, and the relative success rates after each of these maneuvers. Methods: Between July, 2004 and March, 2006 we conducted a prospective, observational study of emergency medicine resident and attending intubation practices at two affiliated, urban hospitals with a 3-year EM residency program and an annual emergency department census of 150,000. The study population included all adult patients on whom intubation was attempted. Every laryngoscopist completed a data form immediately following laryngoscopy recording patient characteristics, factors that might make intubation more difficult, and maneuvers used if the first attempt was unsuccessful. Physicians reported all difficulty factors and modification maneuvers. Consecutiveness of the sample was monitored by trained research associates working in the ED approximately 18 hours per day. In addition to reporting descriptive statistics, we fit a logistic regression model to determine odds of success after a failed first attempt while controlling for training level, difficulty factors, and parallel maneuvers. Results: 439 physicians performed laryngoscopy with 274 (62%) successful and 165 unsuccessful (38%) first-attempt laryngoscopies. Among unsuccessful attempts, 67 (41%) were ‘Easy,’ 72 (44%) were ‘Restricted,’ and 26 (16%) were ‘Difficult’ based on the modified Cormack-Lehane Classification. The intubating physicians consisted of 29 PGY (post-graduate year) I (18%), 82 PGY II (50%), 34 PGY III (21%), and 20 attendings (12%). The most commonly reported reasons for unsuccessful initial attempt were inability to visualize the cords (n⫽98; 59%), short, thick neck (n⫽56; 34%), cervical spine immobilization (n⫽19; 12%), and difficulty anticipated by the “3-3-2” rule (n⫽19; 12%). The most common maneuvers used after initial unsuccessful attempt were changing the operator (n⫽77; 47%), changing the laryngoscope blade (n⫽42; 25%), choosing a smaller endotracheal tube size (n⫽31; 19%); and repositioning the patient (n⫽18; 11%). When controlling for significant predictors of difficulty and simultaneous maneuvers, we found that changing the laryngoscope blade was associated with a 3.2-fold increase in the odds of success (95% CI: 1.5-7.1; p⫽0.003), and using a smaller endotracheal tube was associated with a 2.6-fold increase in the odds of success (95% CI: 1.0-6.5; p⫽0.04). Conclusion: Although the most common maneuvers after initial missed intubation were changing the operator and the laryngoscope blade, when controlling for predictors of difficulty and simultaneous maneuvers, the maneuvers which resulted in significantly increased chances of success were changing the blade and selecting a smaller endotracheal tube. In our ED training cohort, emergency airway management was also noted to be associated with a high rate of failed first attempt intubation and laryngeal view restriction.
19
Pediatric Digital Intubation: Should Every Clinician Have This Technique in Their Bag of Airway Tricks?
Snyder S, Gibbons R, Hersey S, White S, Hays S, McKinney J, Han J, Storrow A/ Vanderbilt University Medical Center, Nashville, TN
Study Objectives: Digital or “finger” intubation is a technique for endotracheal tube placement which predates direct laryngoscopy. For some patients in which direct laryngoscopy is difficult or impossible, digital intubation may be a useful alternative technique for endotracheal tube placement; however, this has never been studied. In
Volume , . : October
16
was noted to be potentially protective, but the significance of this is uncertain. Subsequent validation of this predictive model is needed. Predictive model for intubation in patients with ADHF*
Hospital Crowding Affects the Timeliness of Pneumonia Care
Andrus P, Oyama J, Dickson J, Hoxhaj S/Mount Sinai School of Medicine, New York, NY
Study Objectives: To determine the factors affecting time to delivery of antibiotics in adult patients with pneumonia. Methods: We performed a retrospective review of Emergency Department (ED) records for all patients aged 18 and older admitted with an ED diagnosis of pneumonia during the first six months of 2005, at the inception of an institution wide effort to comply with the Centers for Medicare and Medicaid Services (CMS) core measures. The study was performed at a single, urban, academically affiliated, tertiary medical center. Patient data gathered included: age, sex, source and mode of arrival, date and time of arrival, date and time of antibiotic delivery, ED length of stay (LOS), hospital occupancy for day of arrival, and ED census for day of arrival. We used the Emergency Severity Index (ESI) as a surrogate for severity of illness. The data collected was compiled in a Microsoft Excel database for analysis. LOS and age were broken down into quartiles for statistical purposes. Statistical significance was determined by using Chi-Square testing. Results: During our study period, 343 patients were admitted with an ED diagnosis of pneumonia. Patients with shorter LOS were more likely to receive antibiotics within four hours of triage (Q1 88%, Q4 57%, p ⬍ 0.001). Patients transported by EMS were more likely to receive antibiotics within four hours (EMS 76% vs. Ambulatory 67%, p ⬍ 0.05). Older patients were more likely to receive antibiotics within four hours (Q1 81%, Q4 62%, P ⬍ 0.025). Patients with the greatest illness severity at triage were more likely to receive antibiotics within four hours (ESI 1⫽88%, ESI 2⫽78%, ESI 3⫽65%, ESI 4⫽57%, P ⬍ 0.01). Conclusion: As measured in our study, the patient length of stay is significantly associated with a delay to delivery of antibiotics thus indicating that crowding has some impact on the timeliness of pneumonia care. Patients who are older and those who have a greater initial severity of illness are significantly more likely to receive antibiotics within the CMS four-hour window. To improve the timeliness of pneumonia care, emergency departments should focus their performance improvement efforts on walk-in, non-elder patients with lower acuity of illness at presentation. More validated measures of crowding are needed to better delineate the effects of crowding on the timeliness and quality of care.
17
Endotracheal Intubation in Patients Being Treated for Acute Decompensated Heart Failure: A Predictive Model
Levy PD, Wech R, Zalenski R/Wayne State University, Detroit, MI
Study Objective: To develop a predictive model for endotracheal intubation (ETI) in a cohort of patients with acutely decompensated heart (ADHF). Methods: This study was a retrospective analysis of institutional data compiled as part of a larger, national registry. Included were patients admitted to one of four hospital study sites within the Detroit Medical Center with a primary diagnosis of ADHF. Patients were dichotomized into those who did and did not require ETI. Using forward and backward step-wise logistic regression, a predictive model was developed to determine the probability of need for ETI. Demographics, prior medial histories, and presenting characteristics were considered as potential predictors. Hemodynamic variables also included in the model development process and were summated using the shock index (multiplied by 10 for scale). Results: A total of 1289 patients were included in the analysis. ETI was required in 56 (4.34%) patients. After controlling for potential interactions, 5 variables were identified as independent predictors of ETI and were included in the final model (see table). Anemia, which appeared to be protective, was retained as a 6th variable. Conclusions: Advanced age, increased serum creatinine, elevated shock index, a history of coronary artery disease and a primary symptom of dyspnea at rest are were identified as significant risk factors for ETI in patients with ADHF. Anemia
S6 Annals of Emergency Medicine
18
The Preferred Modifications and Relative Success Rates After First Attempt at Intubation Among Emergency Physicians
Shah K, Hazan A, Lipsky A, Newman D, Wiener D/St. Luke’s-Roosevelt Hospital, New York, NY; Harbor UCLA, Los Angeles, CA
Study Objectives: We sought to determine the preferred modifications chosen by emergency medicine residents and attendings after a missed first attempt intubation, and the relative success rates after each of these maneuvers. Methods: Between July, 2004 and March, 2006 we conducted a prospective, observational study of emergency medicine resident and attending intubation practices at two affiliated, urban hospitals with a 3-year EM residency program and an annual emergency department census of 150,000. The study population included all adult patients on whom intubation was attempted. Every laryngoscopist completed a data form immediately following laryngoscopy recording patient characteristics, factors that might make intubation more difficult, and maneuvers used if the first attempt was unsuccessful. Physicians reported all difficulty factors and modification maneuvers. Consecutiveness of the sample was monitored by trained research associates working in the ED approximately 18 hours per day. In addition to reporting descriptive statistics, we fit a logistic regression model to determine odds of success after a failed first attempt while controlling for training level, difficulty factors, and parallel maneuvers. Results: 439 physicians performed laryngoscopy with 274 (62%) successful and 165 unsuccessful (38%) first-attempt laryngoscopies. Among unsuccessful attempts, 67 (41%) were ‘Easy,’ 72 (44%) were ‘Restricted,’ and 26 (16%) were ‘Difficult’ based on the modified Cormack-Lehane Classification. The intubating physicians consisted of 29 PGY (post-graduate year) I (18%), 82 PGY II (50%), 34 PGY III (21%), and 20 attendings (12%). The most commonly reported reasons for unsuccessful initial attempt were inability to visualize the cords (n⫽98; 59%), short, thick neck (n⫽56; 34%), cervical spine immobilization (n⫽19; 12%), and difficulty anticipated by the “3-3-2” rule (n⫽19; 12%). The most common maneuvers used after initial unsuccessful attempt were changing the operator (n⫽77; 47%), changing the laryngoscope blade (n⫽42; 25%), choosing a smaller endotracheal tube size (n⫽31; 19%); and repositioning the patient (n⫽18; 11%). When controlling for significant predictors of difficulty and simultaneous maneuvers, we found that changing the laryngoscope blade was associated with a 3.2-fold increase in the odds of success (95% CI: 1.5-7.1; p⫽0.003), and using a smaller endotracheal tube was associated with a 2.6-fold increase in the odds of success (95% CI: 1.0-6.5; p⫽0.04). Conclusion: Although the most common maneuvers after initial missed intubation were changing the operator and the laryngoscope blade, when controlling for predictors of difficulty and simultaneous maneuvers, the maneuvers which resulted in significantly increased chances of success were changing the blade and selecting a smaller endotracheal tube. In our ED training cohort, emergency airway management was also noted to be associated with a high rate of failed first attempt intubation and laryngeal view restriction.
19
Pediatric Digital Intubation: Should Every Clinician Have This Technique in Their Bag of Airway Tricks?
Snyder S, Gibbons R, Hersey S, White S, Hays S, McKinney J, Han J, Storrow A/ Vanderbilt University Medical Center, Nashville, TN
Study Objectives: Digital or “finger” intubation is a technique for endotracheal tube placement which predates direct laryngoscopy. For some patients in which direct laryngoscopy is difficult or impossible, digital intubation may be a useful alternative technique for endotracheal tube placement; however, this has never been studied. In
Volume , . : October