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116: Stress, Fatigue, and Procedures During an Emergency Medicine Shift
ICEM 2008 Scientific Abstract Program
116
Stress, Fatigue, and Procedures During an Emergency Medicine Shift
Colucci N, Chan SB, Fister C/Resurrection Medical Center, Chicago, IL
Study Objectives: Most studies and discussions focus on the number of work hours as the etiology of emergency medicine resident physician fatigue. However, other factors such as stress levels during a shift, number of patients seen, and procedures performed in the emergency department (ED) may be as important. This study investigates the role a physical determinant, such as miles walked while working, has on perceived stress and fatigue at the end of a shift. The impact of procedures performed in the ED is also evaluated. Methods: Senior residents from a single emergency medicine residency program volunteered to wear pedometers and keep a detailed log for three consecutive 10hours shifts, recording procedures and assigning shift fatigue and stress levels on a ten point scale. Correlation between stress, fatigue, mileage, and procedures were evaluated using Pearson’s coefficient and independence of predictors tested using a multivariate model. Results: A total of 33 shifts by 11 emergency residents were analyzed. At the end of their shifts, the mean stress level out of ten was 4.9 (SD: 1.8, range 1-8) and the mean fatigue level was 4.7 (SD: 1.9, range 1-9). The residents walked an average of 2.64 miles per shift (SD: 1.16, range 0.39-4.84). There were 30 procedures performed during 14 of the 33 shifts with an average time of 24.0 minutes per procedure. There was significant correlation between perceived stress and miles walked (Pearson’s r ⫽ .362, P⫽.038) and between stress and fatigue (Pearson’s r ⫽ .467, P⫽.006). However, there was no correlation between fatigue and miles walked (Pearson’s r ⫽ .060, P⫽.739). Number of procedures and time spent were not correlated with either stress or fatigue. On the multivariate model, both miles walked and fatigue levels were independently associated with perceived stress. Conclusion: Stress perceived by emergency residents is independently associated with miles walked during an ED shift and fatigue as recorded at the end of a shift. Procedures performed during a shift did not influence either fatigue or stress.
117
Presence of Pain in Patients With Stroke or Transient Ischemic Attack Coming to the Emergency Department
Suravaram S, Bellolio MF, Enduri S, Kashyap R, Brown Jr RD, Decker WW, Stead LG/Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: Evaluate the presence of headache and pain at the onset of ischemic stroke and transient ischemic attack (TIA), and evaluate any association between the severity of the pain and blood pressure, age, sex, past history of migraine and other comorbidities. Methods: We conducted a prospective cohort study of 374 consecutive ischemic stroke and TIA patients who presented to the emergency department (ED) during a 10 month period. We collected demographic information, vitals, and pain on a scale of 0-10 at the time of ED arrival. T-test and non-parametric tests were used according to the distribution of data. Statistical analyses were performed in JMP version 6.0 SAS Institute. Results: Of the 374 patients, 154 had recorded pain information (41%). The mean age was 68.1⫹/⫺Standard Deviation 15.9, with 39% of them being females. It was found that 18.2% of the patients had a pain score ⬎⫽ to 1, meaning that they have some pain while in the ED. A total of 21.8% had headache; other sources of pain were chest and neck pain. There was a linear relationship between the severity of pain and diastolic blood pressure (p⫽0.028). Patients younger than 60 years have more severity of pain compared to older patients (p⫽0.008). There was no relationship between the presence of pain and sex (p⫽0.17). There was no difference in the severity of pain recorded in TIA versus stroke patients. There was no correlation between presence of comorbidities and severity of pain (p⫽0.62). Only 7 patients had past history of migraine, and there was no relation between migraine and the presence of pain at onset of stroke or TIA (p⫽0.77). We compared those with pain information as part of clinical care recorded versus not recorded. We were not able to address the reason why pain information was not recorded in some patients, but this information was less frequently recorded in females (p⫽0.002), with males being 1.91 times more likely to have pain information recorded than females (95% Confidence Interval Odds Ratio⫽ 1.252.91). Patients presenting with TIA had pain information recorded more frequently than patients with stroke (Odds Ratio: 2.1; 95% Confidence Interval: 1.3-3.23). Conclusions: Our study suggests that pain is present in about 1 in 5 patients presenting to the ED with ischemic stroke or TIA, and 22% report headache at the
Volume , . : April
time of cerebrovascular ischemic symptom onset. The pain is usually under recorded as part of standard clinical care, especially in females, and in stroke versus TIA patients.
118
Use of Lumber Puncture in Patients With Suspected Acute Subarachnoid Haemorrhage and Normal Head CT
Chaudhry M, Hajarnavis J/University Hospital of Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
Background: The group of patients who present with a suspected diagnosis of acute SAH but who have a negative computed tomogram (CT) of head in the emergency department (ED) present a great diagnostic dilemma for emergency physicians. In vast majority of patients with SAH, the diagnosis is confirmed on the basis of head CT with a false negative result rate of approximately 2-3%1,2. Moreover, there is high (3-4%) risk of re-bleeding in the first 24 hours for untreated ruptured aneurysms. This risk of re-bleed continues at 1-2% per day for 3 months and 3% per year after that with high mortality.3 Therefore, lumbar puncture (LP) analysis is used to identify the patients who will require further imaging and intervention. LP is an invasive procedure associated with a number of adverse complications. Traumatic tap may cause false positive results in up to 20% of the cases. With post-test probability of about 0.15% there is only 1 in 650 chance of finding SAH4. Study Objectives: To determine the usefulness of positive LP findings on disposition and treatment of the patients in ED who present with history suggestive of acute SAH but a negative CT scan of head. Methods: A retrospective review of medical records of all the patients who presented with a history of suspected acute SAH and have had normal CT scan and abnormal results on LP analysis during March 2005 to March 2006 period. The details of the patients were identified from pathology lab. Hospital notes were requested for the eligible patients and the data abstracted into Excel. Results: During the study period, 15 patients out of 27 were eligible for inclusion. Over the study period, 73% of patients presented with Glasgow Coma Scale (GSC) of 15/15. 14 scans were reported to be normal and one scan confirmed arteriovenous malformation (AVM). Over 86% of the scans were done within 24 hours. There were 4 traumatic taps and 4 patients had increased cerebro spinal fluid (CSF) bilirubin with oxyhemoglobin consistent with acute SAH. 5 patients had only oxyhaemoglobin and 2 were positive for gram positive cocci. Out of 13 patients who have had abnormal LP results suggestive of SAH, 6 patients under went CT angiogram and 6 have had magnetic resonance angiogram. These confirmed one AVM and one aneurysm. Conclusions: Significant number of our patients (13%) who have had initially normal CT head and abnormal LP results were later found to be positive for aneurysm and AVM. This study confirms the inevitable role of LP in patients with suspected acute SAH with normal CT. Further research is needed on this group of patients on a large scale using high resolution CT scan within 4-6 hours to determine the need of LP in future.
119
Prevalance of Sleep Apnea in Acute Ischemic Stroke and TIAs
Enduri S, Suravaram S, Bellolio MF, Kuniyoshi FH, Kashyap R, Somers VK, Stead LG/Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: To evaluate the risk of obstructive sleep apnea (OSA) in patients presenting with acute ischemic stroke and transient ischemic attacks (TIAs). Methods: We conducted a prospective cohort study in 128 consecutive patients presenting with acute ischemic stroke or transient ischemic attack to our emergency department during a 5 month period in 2007. We administered the Berlin Sleep questionnaire to assess for the risk of OSA. Patients were stratified into high-risk or low-risk for groups for OSA based on their responses in three symptom categories. The symptom categories are: presence of snoring, sleep quality and presence of hypertension or obesity defined as BMI ⬎ 30 m/kg2. High risk for OSA was defined as a patient having significant symptoms in 2 of the 3 categories Quantitative variables were analysed using a Student’s t-test and Chi-square test. Results: For the 128 patients, the mean age⫹/⫺SD was 69.2⫹/⫺14 year (range: 18 to 96 yrs), 55.5% of the cohort was female. A total of 80 patients (62.5%) had a high risk of sleep apnea, and only three of these had a previous diagnosis of obstructive sleep apnea. There was no difference by sex or age in the prevalence of high or low risk for sleep apnea. Conclusion: It is important to screen for sleep apnea in patients presenting with
Annals of Emergency Medicine 507
116
Stress, Fatigue, and Procedures During an Emergency Medicine Shift
Colucci N, Chan SB, Fister C/Resurrection Medical Center, Chicago, IL
Study Objectives: Most studies and discussions focus on the number of work hours as the etiology of emergency medicine resident physician fatigue. However, other factors such as stress levels during a shift, number of patients seen, and procedures performed in the emergency department (ED) may be as important. This study investigates the role a physical determinant, such as miles walked while working, has on perceived stress and fatigue at the end of a shift. The impact of procedures performed in the ED is also evaluated. Methods: Senior residents from a single emergency medicine residency program volunteered to wear pedometers and keep a detailed log for three consecutive 10hours shifts, recording procedures and assigning shift fatigue and stress levels on a ten point scale. Correlation between stress, fatigue, mileage, and procedures were evaluated using Pearson’s coefficient and independence of predictors tested using a multivariate model. Results: A total of 33 shifts by 11 emergency residents were analyzed. At the end of their shifts, the mean stress level out of ten was 4.9 (SD: 1.8, range 1-8) and the mean fatigue level was 4.7 (SD: 1.9, range 1-9). The residents walked an average of 2.64 miles per shift (SD: 1.16, range 0.39-4.84). There were 30 procedures performed during 14 of the 33 shifts with an average time of 24.0 minutes per procedure. There was significant correlation between perceived stress and miles walked (Pearson’s r ⫽ .362, P⫽.038) and between stress and fatigue (Pearson’s r ⫽ .467, P⫽.006). However, there was no correlation between fatigue and miles walked (Pearson’s r ⫽ .060, P⫽.739). Number of procedures and time spent were not correlated with either stress or fatigue. On the multivariate model, both miles walked and fatigue levels were independently associated with perceived stress. Conclusion: Stress perceived by emergency residents is independently associated with miles walked during an ED shift and fatigue as recorded at the end of a shift. Procedures performed during a shift did not influence either fatigue or stress.
117
Presence of Pain in Patients With Stroke or Transient Ischemic Attack Coming to the Emergency Department
Suravaram S, Bellolio MF, Enduri S, Kashyap R, Brown Jr RD, Decker WW, Stead LG/Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: Evaluate the presence of headache and pain at the onset of ischemic stroke and transient ischemic attack (TIA), and evaluate any association between the severity of the pain and blood pressure, age, sex, past history of migraine and other comorbidities. Methods: We conducted a prospective cohort study of 374 consecutive ischemic stroke and TIA patients who presented to the emergency department (ED) during a 10 month period. We collected demographic information, vitals, and pain on a scale of 0-10 at the time of ED arrival. T-test and non-parametric tests were used according to the distribution of data. Statistical analyses were performed in JMP version 6.0 SAS Institute. Results: Of the 374 patients, 154 had recorded pain information (41%). The mean age was 68.1⫹/⫺Standard Deviation 15.9, with 39% of them being females. It was found that 18.2% of the patients had a pain score ⬎⫽ to 1, meaning that they have some pain while in the ED. A total of 21.8% had headache; other sources of pain were chest and neck pain. There was a linear relationship between the severity of pain and diastolic blood pressure (p⫽0.028). Patients younger than 60 years have more severity of pain compared to older patients (p⫽0.008). There was no relationship between the presence of pain and sex (p⫽0.17). There was no difference in the severity of pain recorded in TIA versus stroke patients. There was no correlation between presence of comorbidities and severity of pain (p⫽0.62). Only 7 patients had past history of migraine, and there was no relation between migraine and the presence of pain at onset of stroke or TIA (p⫽0.77). We compared those with pain information as part of clinical care recorded versus not recorded. We were not able to address the reason why pain information was not recorded in some patients, but this information was less frequently recorded in females (p⫽0.002), with males being 1.91 times more likely to have pain information recorded than females (95% Confidence Interval Odds Ratio⫽ 1.252.91). Patients presenting with TIA had pain information recorded more frequently than patients with stroke (Odds Ratio: 2.1; 95% Confidence Interval: 1.3-3.23). Conclusions: Our study suggests that pain is present in about 1 in 5 patients presenting to the ED with ischemic stroke or TIA, and 22% report headache at the
Volume , . : April
time of cerebrovascular ischemic symptom onset. The pain is usually under recorded as part of standard clinical care, especially in females, and in stroke versus TIA patients.
118
Use of Lumber Puncture in Patients With Suspected Acute Subarachnoid Haemorrhage and Normal Head CT
Chaudhry M, Hajarnavis J/University Hospital of Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
Background: The group of patients who present with a suspected diagnosis of acute SAH but who have a negative computed tomogram (CT) of head in the emergency department (ED) present a great diagnostic dilemma for emergency physicians. In vast majority of patients with SAH, the diagnosis is confirmed on the basis of head CT with a false negative result rate of approximately 2-3%1,2. Moreover, there is high (3-4%) risk of re-bleeding in the first 24 hours for untreated ruptured aneurysms. This risk of re-bleed continues at 1-2% per day for 3 months and 3% per year after that with high mortality.3 Therefore, lumbar puncture (LP) analysis is used to identify the patients who will require further imaging and intervention. LP is an invasive procedure associated with a number of adverse complications. Traumatic tap may cause false positive results in up to 20% of the cases. With post-test probability of about 0.15% there is only 1 in 650 chance of finding SAH4. Study Objectives: To determine the usefulness of positive LP findings on disposition and treatment of the patients in ED who present with history suggestive of acute SAH but a negative CT scan of head. Methods: A retrospective review of medical records of all the patients who presented with a history of suspected acute SAH and have had normal CT scan and abnormal results on LP analysis during March 2005 to March 2006 period. The details of the patients were identified from pathology lab. Hospital notes were requested for the eligible patients and the data abstracted into Excel. Results: During the study period, 15 patients out of 27 were eligible for inclusion. Over the study period, 73% of patients presented with Glasgow Coma Scale (GSC) of 15/15. 14 scans were reported to be normal and one scan confirmed arteriovenous malformation (AVM). Over 86% of the scans were done within 24 hours. There were 4 traumatic taps and 4 patients had increased cerebro spinal fluid (CSF) bilirubin with oxyhemoglobin consistent with acute SAH. 5 patients had only oxyhaemoglobin and 2 were positive for gram positive cocci. Out of 13 patients who have had abnormal LP results suggestive of SAH, 6 patients under went CT angiogram and 6 have had magnetic resonance angiogram. These confirmed one AVM and one aneurysm. Conclusions: Significant number of our patients (13%) who have had initially normal CT head and abnormal LP results were later found to be positive for aneurysm and AVM. This study confirms the inevitable role of LP in patients with suspected acute SAH with normal CT. Further research is needed on this group of patients on a large scale using high resolution CT scan within 4-6 hours to determine the need of LP in future.
119
Prevalance of Sleep Apnea in Acute Ischemic Stroke and TIAs
Enduri S, Suravaram S, Bellolio MF, Kuniyoshi FH, Kashyap R, Somers VK, Stead LG/Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: To evaluate the risk of obstructive sleep apnea (OSA) in patients presenting with acute ischemic stroke and transient ischemic attacks (TIAs). Methods: We conducted a prospective cohort study in 128 consecutive patients presenting with acute ischemic stroke or transient ischemic attack to our emergency department during a 5 month period in 2007. We administered the Berlin Sleep questionnaire to assess for the risk of OSA. Patients were stratified into high-risk or low-risk for groups for OSA based on their responses in three symptom categories. The symptom categories are: presence of snoring, sleep quality and presence of hypertension or obesity defined as BMI ⬎ 30 m/kg2. High risk for OSA was defined as a patient having significant symptoms in 2 of the 3 categories Quantitative variables were analysed using a Student’s t-test and Chi-square test. Results: For the 128 patients, the mean age⫹/⫺SD was 69.2⫹/⫺14 year (range: 18 to 96 yrs), 55.5% of the cohort was female. A total of 80 patients (62.5%) had a high risk of sleep apnea, and only three of these had a previous diagnosis of obstructive sleep apnea. There was no difference by sex or age in the prevalence of high or low risk for sleep apnea. Conclusion: It is important to screen for sleep apnea in patients presenting with
Annals of Emergency Medicine 507