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Trajectories of approaching death in the emergency department
236 of Level 1, Level 2 and Level 3 participants are comparable (no different) with p-value ⬎ 0.05, but the performance of Level 4 are significantly different from the rest of the groups in the sense that it is lower (p-value ⬍ 0.05). In post-test, the results of Level 1 and Level 2 participants are comparable (p-value ⬎ 0.05). On the other hand the results of Level 3 and Level 4 participants are comparable (p ⬎ 0.05). However Level 1 and Level 2 candidates differ significantly in performance when compared with Level 3 and Level 4 candidates (p ⬍ 0.05). Conclusion: A classroom-based training can be enhanced and maximized with favorable results. The use of classroom training and simulation clearly improves the knowledge of a disaster plan significantly. It can be used with low cost, relatively-easy to conduct, fun and complete nature. All levels of participant (from specialists to drivers) can be grouped together for classroom training and simulation. They score differing marks but each gain significant increase of knowledge. This form of training is well-received by all the participants. Classroom Training and Simulation can overcome the problem of deaddocument phenomenon or paper-plan syndrome in which disaster plans remain on paper and are not frequently practiced.
Trimethoprim sulfamethoxazole resistance in urinary tract infections: which is next? ¨ zlem Gu¨neysel, Mustafa Erdede, Arzu Denizba O Background: Urinary tract infections (UTI) are important health problems, especially among reproductive age women. In the 20th century, the discovery of antibiotics was a great step forward in treating UTIs. In the 1970s, overuse of amoxicillin resulted in bacterial resistance; so trimethoprim sulfamethoxazole (TMP-SMX) became first line therapy. According to recent guidelines for the treatment of UTI, the use of TMPSMX was limited because of resistance due to overuse. Objectives: The aims of this study were to investigate TMP-SMX resistance rate in UTI patients; to determine highly prescribed empiric antibiotics in the emergency department (ED) and to provide the appropriate antibiotic choice in UTI. Methods: We conducted our investigation at Marmara University Hospital ED (20,000 patients/year) between 01 June-31 - December 2004 (study period). Inclusion criteria: adult age (over 16), UTI complaints without any prior treatment, and uncomplicated UTI diagnosed in the ED. Exclusion criteria: age under 16 yo, UTI with anatomical disease, treatment resistant urinary tract reinfection. Demographic data, urinalysis and culture results were recorded on a datasheet. Data was collected from ED and microbiology laboratory archives. Results: 213 patients were included in the study (67.1% female, 32.9% male). Bacterial growth was found in 109 patients (51.2%). The main bacterial growth in culture media was E coli (35.8%). The most prescribed antibiotic group was fluoroquinolone (FQ) group (96%). TMP-SMX resistance rate was 34.8%. Conclusion: According to international guidelines, FQ antibiotics become the first line therapy when TMP-SMX resistance rate is more than 20%. In our study TMP-SMX resistance rate was 34.8% and the most prescribed antibiotic group was FQ, both data are comparable with the literature. According to studies published
The Journal of Emergency Medicine between 1995–2001, the FQ resistance was increasing due to overuse (from 0.7 to 2.5%). In our region the most prescribed antibiotic group was FQ and this suggests in the near future, empiric FQ use may result in bacterial resistance.
Trajectories of approaching death in the emergency department Garrett K. Chan, RN, PhD, CEN Background: Very little is known about the end-of-life experience in the emergency department (ED) setting. However, death is common in the ED. Patients arrive suddenly with unexpected injuries or illnesses, chronic disease exacerbations, or terminal illnesses seeking life-saving or life-prolonging treatment. Relationships among healthcare providers, patients, and families are hastily forged. Limited, suboptimal, or perhaps erroneous information is provided to the ED staff. Emergency departments are places of high-stress; they are fast-paced and are generally a place of transition in the hospital. This lack of a full understanding of the patient’s values, wishes for care, or previous health conditions needed to guide care decisions potentially inhibits ED clinicians from providing good end-of-life care. End-of-life care has been reported as being substandard in the United States. The National Institutes of Health convened a Consensus Conference to review the relevant literature, examine the results of research and programmatic efforts to evaluate the current State-of-the-Science and to identify directions for future research in end-of-life care (National Institutes of Health [NIH], 2004). The State-of-the-Science panel concluded that the evidence does not yet support a definition of the interval referred to as the “end-of-life” or its “transitions.” These “transitions” have not been well articulated, and there is a lack of definitional clarity to the concept of “end-of-life care,” especially in the ED. Objective: To describe the trajectories of approaching death and dying of medical and trauma patients admitted to the emergency department (ED). Describing these trajectories will improve our understanding of death and dying in an effort to improve clinical judgment and decision making in a time of high-stress and crisis. Methods: ED clinicians underwent open-ended interviews, and participant observations were conducted in the clinical setting. Audiorecorded interviews were transcribed verbatim and analyzed following the interpretive ethnography tradition, including paradigm cases, exemplars, and thematic analysis. The study was conducted in a non-academic Level II trauma center ED. Results: An analysis of observations of clinician, patient and family interactions (n ⫽ 10); brief interviews with physicians, nurses and respiratory therapists (n ⫽ 8); and a convenience sample of in-depth interviews with ED physicians (n ⫽ 3), ED nurses (n ⫽ 5), and respiratory therapists (n ⫽ 3) for a total of 108 exemplars/ observations revealed seven trajectories of death and dying: 1) dead on arrival; 2) resuscitation in the field, resuscitative efforts in the ED, died in the ED; 3) resuscitation in the field, resuscitative efforts in the ED, resuscitated and admitted to the hospital; 4) terminally ill, comes to the ED; 5) frail, hovering near death; 6) arrives at the ED alive then dies suddenly in the ED; and 7) potentially preventable death by omission or com-
Abstracts
237
mission. Conclusions: For some ED patients, the transition to end-of-life occurs suddenly and without warning. For others, transitions to the end-of-life care in the ED are more apparent. However, the sudden and unforseen is common in the ED. This research study is a first step to address one issue posed by the NIH State-of-the-Science Panel calling for an improved understanding of the “end-of-life” and its “transitions” in rural and frontier areas. This descriptive articulation of the various trajectories can add a new vision of caring to the scope of practice and duty of ED clinicians at the end-of-life. Understanding the trajectories and discussion of the clinicians’ actions and communication strategies can elucidate how each of the trajectories, if recognized earlier, could benefit from anticipatory planning and creation of guidelines for care at the end-of-life in a time of high-stress and crisis. Since little is known about how people die in the ED, it must be considered a frontier area for end-oflife research. Future research must include a thick description of current “best practices” in EDs to help create guidelines for ED end-of-life, palliative, and bereavement care. In addition, educational intervention studies regarding effective communication strategies should be considered to improve care and decrease the potential for conflict.
p ⬍ 0.0001; SBP 121 vs. 123, NS; DBP 79 vs. 83, p ⫽ 0.001]. Standing pre and post blood loss similarly showed changes attributable to compensation, although SBP and DBP showed a marked drop [HR 81 vs. 88, p ⬍ 0.0001; SBP 136 vs. 123, p ⬍ 0.0001; DBP 89 vs. 83, p ⬍ 0.0001]. These results were expected, however comparison of supine pre and post donation parameters also revealed significant SBP changes [HR 69 vs. 69, NS; SBP 129 vs. 121, p ⫽ 0.009; DBP 81 vs. 79, NS]. Supine pre and post hemorrhage SI showed no significant changes [0.558 vs. 0.563, p ⫽ 0.59] as did supine pre and post IRI [8.99 vs. 9.14, p ⫽ 0.08]. Standing pre and post hemorrhage SI and IRI both showed highly significant changes [0.604 vs. 0.728, p ⬍ 0.0001; 9.81 vs. 11.89, p ⬍ 0.0001]. Conclusions: Clinically significant systolic difference before and after blood loss in this human model of Class 1 hemorrhagic shock were demonstrated, despite conventional teaching that there are no discernible changes in hemodynamic parameters. Loss of compensation was seen in many patients on standing. The SI and the IRI performed no better than conventional measured variables, however the IRI may show promise in some cases and further investigation into its use in trauma and hemorrhage may be warranted.
Diagnostic physiological scoring in a model of early haemorrhagic shock Paul Middleton, Prince of Wales Hospital P, P University of New South Wales
Dutch emergency department patient characteristics: implications for an emergency medicine residency program J. Elshove-Bolk; F. Mencl; B. van Rijswijck; E. Weiss; M. Simons; A. van Vugt
Objectives: Shock due to hemorrhage may be categorized into 4 classes according to volume loss. Class 1 shock, with blood loss less than 750mls, is said to produce no discernible changes in heart rate or blood pressure, and is thus difficult to diagnose clinically. The Shock Index (SI) is said to be more sensitive at diagnosing early haemorrhagic shock than these traditionally measured variables. We wished to investigate this in a human model of hemorrhagic shock. We further wanted to assess the utility of a novel physiological score in early hemorrhagic shock, originally used in the context of ST elevation myocardial infarction. This score includes a term for age which is absent in the SI. We termed this measure the Illness Risk Index (IRI). Methods: We investigated heart rate and blood pressure, in both supine and standing positions, both before and after a blood donation of 500mls by healthy volunteers. These parameters were recorded after a short period of rest after arrival in the National Blood Service donor center. Pre and post donation values were compared for all parameters, and statistical testing was performed appropriate to the distribution of the results. Parameters are summarised as means ⫹ SE unless otherwise stated. Heart rates are given in beats/minute (bpm) and blood pressure in millimeters of mercury (mmHg). We further computed SI and IRI, using the formulae: SI ⫽ HR / SBP, and IRI ⫽ HR ⫻ [(Age/10)P2P] / SBP. Results: 81 volunteers were studied, with ages between 22 and 70. Pre-donation heart rate and blood pressure showed predictable postural changes [HR 72 vs. 81, p ⬍ 0.0001; SBP 131 vs. 136, p ⬍ 0.001; DBP 81 vs. 89, p ⬍ 0.0001]. Post donation heart rate and blood pressure showed postural compensation for blood loss [HR 69 vs. 88,
Objectives: Emergency Medicine (EM) does not yet exist as a specialty in the Netherlands, and there is no consensus on the scope of practice for future emergency physicians, nor a defined EM curriculum. We set out to study ED patient characteristics at a busy level 2 trauma center in Amsterdam in order to gain insight into the practice of EM and determine any implications for EM training in the Netherlands. Methods: From May 27Pth Puntil July 4Pth P2001 (39 days), the following data was prospectively recorded from the charts of all patients presenting to the ED at the OLVG, a busy teaching hospital in Amsterdam, with an EM residency training program already in place: age, sex, time and form of presentation, diagnostics, treatment, disposition and the single best diagnosis (ICD-10 classification). All charts are numbered and inclusion was 100%. Results: During the study period 5234 patients (134/day), were treated in the ED. The majority of these patients (4383, 84%) were self-referred and seen initially by the ED physician, while 851 (16%) were referred directly to specialist care, most commonly by the GP. EMS transported 573 (11%) of all patients. Self-referred patients tended to be younger (average age ⫽ 33 years), presented more often outside of regular office hours, and infrequently required diagnostics (1607, 37%), or treatment (2160, 49%). More than half (2259, 52%) had a trauma diagnosis. Specialist consultation was requested for 750 (17%) and only 4% (177) needed admission, mostly to regular wards. Most of the GP referrals were to surgery (46%), internal medicine (20%) and cardiology (17%). The referred patients were older (average age 50 years), sicker and 41% needed admission (84% med-surg floor, 5% to
Trimethoprim sulfamethoxazole resistance in urinary tract infections: which is next? ¨ zlem Gu¨neysel, Mustafa Erdede, Arzu Denizba O Background: Urinary tract infections (UTI) are important health problems, especially among reproductive age women. In the 20th century, the discovery of antibiotics was a great step forward in treating UTIs. In the 1970s, overuse of amoxicillin resulted in bacterial resistance; so trimethoprim sulfamethoxazole (TMP-SMX) became first line therapy. According to recent guidelines for the treatment of UTI, the use of TMPSMX was limited because of resistance due to overuse. Objectives: The aims of this study were to investigate TMP-SMX resistance rate in UTI patients; to determine highly prescribed empiric antibiotics in the emergency department (ED) and to provide the appropriate antibiotic choice in UTI. Methods: We conducted our investigation at Marmara University Hospital ED (20,000 patients/year) between 01 June-31 - December 2004 (study period). Inclusion criteria: adult age (over 16), UTI complaints without any prior treatment, and uncomplicated UTI diagnosed in the ED. Exclusion criteria: age under 16 yo, UTI with anatomical disease, treatment resistant urinary tract reinfection. Demographic data, urinalysis and culture results were recorded on a datasheet. Data was collected from ED and microbiology laboratory archives. Results: 213 patients were included in the study (67.1% female, 32.9% male). Bacterial growth was found in 109 patients (51.2%). The main bacterial growth in culture media was E coli (35.8%). The most prescribed antibiotic group was fluoroquinolone (FQ) group (96%). TMP-SMX resistance rate was 34.8%. Conclusion: According to international guidelines, FQ antibiotics become the first line therapy when TMP-SMX resistance rate is more than 20%. In our study TMP-SMX resistance rate was 34.8% and the most prescribed antibiotic group was FQ, both data are comparable with the literature. According to studies published
The Journal of Emergency Medicine between 1995–2001, the FQ resistance was increasing due to overuse (from 0.7 to 2.5%). In our region the most prescribed antibiotic group was FQ and this suggests in the near future, empiric FQ use may result in bacterial resistance.
Trajectories of approaching death in the emergency department Garrett K. Chan, RN, PhD, CEN Background: Very little is known about the end-of-life experience in the emergency department (ED) setting. However, death is common in the ED. Patients arrive suddenly with unexpected injuries or illnesses, chronic disease exacerbations, or terminal illnesses seeking life-saving or life-prolonging treatment. Relationships among healthcare providers, patients, and families are hastily forged. Limited, suboptimal, or perhaps erroneous information is provided to the ED staff. Emergency departments are places of high-stress; they are fast-paced and are generally a place of transition in the hospital. This lack of a full understanding of the patient’s values, wishes for care, or previous health conditions needed to guide care decisions potentially inhibits ED clinicians from providing good end-of-life care. End-of-life care has been reported as being substandard in the United States. The National Institutes of Health convened a Consensus Conference to review the relevant literature, examine the results of research and programmatic efforts to evaluate the current State-of-the-Science and to identify directions for future research in end-of-life care (National Institutes of Health [NIH], 2004). The State-of-the-Science panel concluded that the evidence does not yet support a definition of the interval referred to as the “end-of-life” or its “transitions.” These “transitions” have not been well articulated, and there is a lack of definitional clarity to the concept of “end-of-life care,” especially in the ED. Objective: To describe the trajectories of approaching death and dying of medical and trauma patients admitted to the emergency department (ED). Describing these trajectories will improve our understanding of death and dying in an effort to improve clinical judgment and decision making in a time of high-stress and crisis. Methods: ED clinicians underwent open-ended interviews, and participant observations were conducted in the clinical setting. Audiorecorded interviews were transcribed verbatim and analyzed following the interpretive ethnography tradition, including paradigm cases, exemplars, and thematic analysis. The study was conducted in a non-academic Level II trauma center ED. Results: An analysis of observations of clinician, patient and family interactions (n ⫽ 10); brief interviews with physicians, nurses and respiratory therapists (n ⫽ 8); and a convenience sample of in-depth interviews with ED physicians (n ⫽ 3), ED nurses (n ⫽ 5), and respiratory therapists (n ⫽ 3) for a total of 108 exemplars/ observations revealed seven trajectories of death and dying: 1) dead on arrival; 2) resuscitation in the field, resuscitative efforts in the ED, died in the ED; 3) resuscitation in the field, resuscitative efforts in the ED, resuscitated and admitted to the hospital; 4) terminally ill, comes to the ED; 5) frail, hovering near death; 6) arrives at the ED alive then dies suddenly in the ED; and 7) potentially preventable death by omission or com-
Abstracts
237
mission. Conclusions: For some ED patients, the transition to end-of-life occurs suddenly and without warning. For others, transitions to the end-of-life care in the ED are more apparent. However, the sudden and unforseen is common in the ED. This research study is a first step to address one issue posed by the NIH State-of-the-Science Panel calling for an improved understanding of the “end-of-life” and its “transitions” in rural and frontier areas. This descriptive articulation of the various trajectories can add a new vision of caring to the scope of practice and duty of ED clinicians at the end-of-life. Understanding the trajectories and discussion of the clinicians’ actions and communication strategies can elucidate how each of the trajectories, if recognized earlier, could benefit from anticipatory planning and creation of guidelines for care at the end-of-life in a time of high-stress and crisis. Since little is known about how people die in the ED, it must be considered a frontier area for end-oflife research. Future research must include a thick description of current “best practices” in EDs to help create guidelines for ED end-of-life, palliative, and bereavement care. In addition, educational intervention studies regarding effective communication strategies should be considered to improve care and decrease the potential for conflict.
p ⬍ 0.0001; SBP 121 vs. 123, NS; DBP 79 vs. 83, p ⫽ 0.001]. Standing pre and post blood loss similarly showed changes attributable to compensation, although SBP and DBP showed a marked drop [HR 81 vs. 88, p ⬍ 0.0001; SBP 136 vs. 123, p ⬍ 0.0001; DBP 89 vs. 83, p ⬍ 0.0001]. These results were expected, however comparison of supine pre and post donation parameters also revealed significant SBP changes [HR 69 vs. 69, NS; SBP 129 vs. 121, p ⫽ 0.009; DBP 81 vs. 79, NS]. Supine pre and post hemorrhage SI showed no significant changes [0.558 vs. 0.563, p ⫽ 0.59] as did supine pre and post IRI [8.99 vs. 9.14, p ⫽ 0.08]. Standing pre and post hemorrhage SI and IRI both showed highly significant changes [0.604 vs. 0.728, p ⬍ 0.0001; 9.81 vs. 11.89, p ⬍ 0.0001]. Conclusions: Clinically significant systolic difference before and after blood loss in this human model of Class 1 hemorrhagic shock were demonstrated, despite conventional teaching that there are no discernible changes in hemodynamic parameters. Loss of compensation was seen in many patients on standing. The SI and the IRI performed no better than conventional measured variables, however the IRI may show promise in some cases and further investigation into its use in trauma and hemorrhage may be warranted.
Diagnostic physiological scoring in a model of early haemorrhagic shock Paul Middleton, Prince of Wales Hospital P, P University of New South Wales
Dutch emergency department patient characteristics: implications for an emergency medicine residency program J. Elshove-Bolk; F. Mencl; B. van Rijswijck; E. Weiss; M. Simons; A. van Vugt
Objectives: Shock due to hemorrhage may be categorized into 4 classes according to volume loss. Class 1 shock, with blood loss less than 750mls, is said to produce no discernible changes in heart rate or blood pressure, and is thus difficult to diagnose clinically. The Shock Index (SI) is said to be more sensitive at diagnosing early haemorrhagic shock than these traditionally measured variables. We wished to investigate this in a human model of hemorrhagic shock. We further wanted to assess the utility of a novel physiological score in early hemorrhagic shock, originally used in the context of ST elevation myocardial infarction. This score includes a term for age which is absent in the SI. We termed this measure the Illness Risk Index (IRI). Methods: We investigated heart rate and blood pressure, in both supine and standing positions, both before and after a blood donation of 500mls by healthy volunteers. These parameters were recorded after a short period of rest after arrival in the National Blood Service donor center. Pre and post donation values were compared for all parameters, and statistical testing was performed appropriate to the distribution of the results. Parameters are summarised as means ⫹ SE unless otherwise stated. Heart rates are given in beats/minute (bpm) and blood pressure in millimeters of mercury (mmHg). We further computed SI and IRI, using the formulae: SI ⫽ HR / SBP, and IRI ⫽ HR ⫻ [(Age/10)P2P] / SBP. Results: 81 volunteers were studied, with ages between 22 and 70. Pre-donation heart rate and blood pressure showed predictable postural changes [HR 72 vs. 81, p ⬍ 0.0001; SBP 131 vs. 136, p ⬍ 0.001; DBP 81 vs. 89, p ⬍ 0.0001]. Post donation heart rate and blood pressure showed postural compensation for blood loss [HR 69 vs. 88,
Objectives: Emergency Medicine (EM) does not yet exist as a specialty in the Netherlands, and there is no consensus on the scope of practice for future emergency physicians, nor a defined EM curriculum. We set out to study ED patient characteristics at a busy level 2 trauma center in Amsterdam in order to gain insight into the practice of EM and determine any implications for EM training in the Netherlands. Methods: From May 27Pth Puntil July 4Pth P2001 (39 days), the following data was prospectively recorded from the charts of all patients presenting to the ED at the OLVG, a busy teaching hospital in Amsterdam, with an EM residency training program already in place: age, sex, time and form of presentation, diagnostics, treatment, disposition and the single best diagnosis (ICD-10 classification). All charts are numbered and inclusion was 100%. Results: During the study period 5234 patients (134/day), were treated in the ED. The majority of these patients (4383, 84%) were self-referred and seen initially by the ED physician, while 851 (16%) were referred directly to specialist care, most commonly by the GP. EMS transported 573 (11%) of all patients. Self-referred patients tended to be younger (average age ⫽ 33 years), presented more often outside of regular office hours, and infrequently required diagnostics (1607, 37%), or treatment (2160, 49%). More than half (2259, 52%) had a trauma diagnosis. Specialist consultation was requested for 750 (17%) and only 4% (177) needed admission, mostly to regular wards. Most of the GP referrals were to surgery (46%), internal medicine (20%) and cardiology (17%). The referred patients were older (average age 50 years), sicker and 41% needed admission (84% med-surg floor, 5% to