- Email: [email protected]
119
Research Forum Abstracts
116
Prevalence of Chlamydia Trachomatis and Neisseria Gonorrhoeae Coinfection with Trichomonas Vaginalis in Female Emergency Department Patients: Are Wet Prep Results a Reliable Predictor?
Gordon JS, Pham KH, Matz TP/University Medical Center of Southern Nevada, Las Vegas, NV
Study Objectives: The goal of the study is to determine if the presence of Trichomonas vaginalis is associated with an increased risk of coinfection with Neisseria gonorrhoeae and/or Chlamydia trachomatis in adult female emergency department patients with symptoms suggestive of a sexually transmitted disease. Methods: This is a retrospective analysis of adult female emergency department patients that were tested for the presence of Trichomonas vaginalis by wet preparation and Neisseria gonorrhoeae and Chlamydia trachomatis by culture between March 2004 and November 2005. All females that presented to an inner-city teaching hospital that had pelvic cultures collected with complete results were included. The primary outcome measure is a significant positive likelihood ratio of patients with positive Trichomonas vaginalis by wet preparation that are co-infected with Neisseria gonorrhoeae and/or Chlamydia trachomatis by culture. Results: A total of 3348 patients were enrolled in the study. One hundred ninetythree patients (5.8%) tested positive for Trichomonas vaginalis and 3165 tested negative. Of the 193 Trichomonas vaginalis positive patients, 22 (11.4%) tested positive for Chlamydia trachomatis, 20 (10.4%) tested positive for Neisseria gonorrhoeae, and three (1.6%) tested positive for both. Of the 3165 Trichomonas vaginalis negative patients, 240 (7.6%) tested positive for Chlamydia trachomatis, 95 (3.0%) tested positive for Neisseria gonorrhoeae, and 29 (0.9%) tested positive for both. The prevalence of Neisseria gonorrhoeae and/or Chlamydia trachomatis in the Trichomonas vaginalis positive patients was 20.2% compared to an overall prevalence of 10.3% for the study population. Statistical analysis reveals a positive association for the presence of Neisseria gonorrhoeae and/or Chlamydia trachomatis in Trichomonas vaginalis positive patients, with a positive likelihood ratio of 2.20 (95% CI ⫽ 1.58 3.08). Conclusion: The presence of Trichomonas vaginalis in adult female patients presenting to the emergency department with symptoms suggestive of a sexually transmitted disease is associated with an increased risk of coinfection with Neisseria gonorrhoeae and/or Chlamydia trachomatis.
117
Sepsis Risk Factors Predictive of Mortality in ICU Transfers Within 72 Hours of ED Admission
D’Amore JZ, Panebianco N, Hussain E, Nelson M, Ward MF, Sama A, Wang H, Slesinger T/North Shore University Hospital, Manhasset, NY
Study Objectives: The objective of this study was to identify risk factors predicting mortality in ICU transfers within 72hrs of ED admission. Methods: This was a retrospective chart review of all patients who were transferred to ICU within 72hrs of admission from the ED 12/31/03-12/26/04. Charts were identified through a QA process. Data was extracted by physician investigators with a standardized data collection instrument. Setting: A 65k/yr visit tertiary care ED. Inclusion criteria: Patients ⬎ 18yrs of age admitted to the ICU within 72 hours of presentation to the ED carrying an infectious disease diagnosis were included. Exclusion criteria: Patients who were ⬍ 18 years old, had no evidence of infection, or DNR were excluded. Statistical analysis: For analysis purposes descriptive statistics and appropriate univariate analysis were used for continuous and categorical data. 95% confidence intervals (CI) are given where appropriate. A Bonferroni correction dictates p-values ⬍ 0.01 statistically significant. Results: 54 patients were enrolled. Clinical characteristics: Average age: 71, Male: 52%, ED admit: pneumonia 24 (44%), urinary tract infection 9 (17%) sepsis/septicemia 12 (22%). Percentage of patients with the indicated parameters: 15% with Mean arterial blood pressure ⬍ 65, 68% with heart rate ⬎ 90, 48% with respiratory rate ⬎ 20, 33% oxygen saturation⬍ 92%, 46% white blood cell (WBC) count ⬎ 12K, 20% anion gap ⬎ 12, 43% in acute renal failure, 13% Platelets ⬍ 100K, 20% altered mental status. 20% received an ICU consult in the ED but were rejected. Percentage of patients with 1 organ system failure: 32%, with 2: 28%, with 3: 17%, with 4: 6%. 53% of all patients had severe sepsis (⬎ 2 SIRS criteria and ⬎ 1 organ failure). Average Apache II score: 15.6. Overall mortality: 47%. Mortality with No ICU consult: 48% vs. 45% with ED ICU consult p⫽. 65. Comparing survivors with expired patients: Apache II scores 15.6 (9-24) vs. 15.7 (10-26) p⫽0.36. ⬎ 2 SIRS criteria 14% (6-20) vs.21% (14-27) p⫽ 0.44. MAP⬍ 65: 7.1% (4-15) vs. 23% (18-28) p⫽⬍ 0.01. Anion gap ⬎ 12: 18% (12-24) vs. 23% (17-33) p⫽ 0.27. ⬎ 2
Volume , . : October
organ system failures: 43% (36-48) vs. 59% (51-67) p ⬍ 0.01. Limitations include retrospective design, small sample size, and study does not account for patients admitted to the floor with similar characteristics who did not decompensate. Conclusion: Apache II scores do not appear predictive. Hypotension or ⬎ 2 organ failures on initial evaluation were significant indicators of mortality. A prospective cohort study attempting to identify prognostic criteria for decompensation and potential prophylactic intervention is the next logical step.
118
A Pilot Study of Inter-Alpha Inhibitor Protein (IaIp) in the Presentation of Adult Patients with Severe Sepsis to the Emergency Department
Lafleur J, Jay GD, Plante T, Clapprood A, Heath R, Lim YP/Brown Medical School, Providence, RI; ProThera Biologics LLC, Providence, RI
Study Objectives: To assess IaIp levels in adult patients presenting to the emergency department (ED) with severe sepsis. Methods: Design: observational nonrandomized controlled trial. Setting: adult emergency department. Participants: adult patients. Cases of severe sepsis and nonseptic patients (controls) with non-inflammatroy diagnoses and matched for age and gender were identified concurrent with hospital admission. Initial blood samples drawn in the ED were obtained for plasma IaIp determination via competitive ELISA. Results: The first group of 32 septic patients and 30 matched controls have been enrolled. Average age for both groups was 74 years (95%CI⫽69-79); percentage of females in both groups was 55%. Mean APACHE II scores were 16 (95%CI⫽14-18) in the septic group and 7 (95%CI⫽5.8-8.2) in the non-septic group. Among septic patients mean lactate level was 5.5 (95%CI⫽4.4-6.6) mean white count 15(95%CI⫽12.2-17.8) and mortality was 38%. The mean IaIp levels at initial presentation were not significantly different between the septic and the non-septic ED patient groups: 349 (95%CI⫽300-398) septic vs. 370 (95%CI⫽336-404) nonseptic. Among the non-survivors in the septic group (n⫽12) there was a nonsignificant trend toward decreased IaIp levels: 292 (95%CI⫽212-372), while the IaIp level in the surviving septic group: 383 (95%CI⫽321-445), was higher than that of the control group. Conclusion: IaIp, a ubiquitous and vital serine protease inhibitor, has recently received attention as potential theranostic, marker and therapeutic agent for sepsis. Recent in-hospital, ICU-based studies of adult septic patients showed significantly decreased levels of IaIp in septic patients compared to healthy controls. A recent study in neonates found significantly decreased IaIp levels in septic compared to non-septic newborns. This is the first study of IaIp in adult septic patients presenting to an emergency department. Our preliminary results indicate that in the majority of patients with severe sepsis a drop in IaIp levels had not yet occurred at the time of ED presentation. As IaIp levels have been shown to be significantly decreased in patients with severe sepsis in an ICU setting, it may be that the elevated systemic protease activity, increasingly recognized as an important aspect of sepsis, is relatively more amenable to therapeutic intervention early in the course of the disease. Ongoing recruitment of patients may reveal significant decrease in IaIp levels among non-surviving septic patients presenting to the ED. A longitudinal study to follow IaIp levels in patients presenting to the ED with severe sepsis is planned.
119
Reduction in the Risk of Pneumonia Following Oseltamivir Use for Influenza Among Pediatric Patients
Barr CE, Schulman KL, Iacuzio DA/Roche Laboratories, Nutley, NJ; Thomson Medstat, Cambridge, MA
Study Objectives: To assess the impact of oseltamivir on the risk of pneumonia and other influenza-related outcomes in children. Methods: This was a retrospective cohort study that utilized health insurance claims data (MedStat MarketScan Research Data) from 2000-2005 to identify patients aged 1-12 years with influenza. Patients receiving a prescription for oseltamivir within one day of influenza diagnosis were compared to those receiving no antiviral therapy. Primary outcomes included frequency of pneumonia and rates of hospitalization. Results: A total of 15,161 children 1-12 years of age were diagnosed with influenza. Of this total, 7,772 (51%) were identified as receiving oseltamivir and propensity matched to a control cohort of patients who received no antiviral
Annals of Emergency Medicine S37
Research Forum Abstracts treatment. Patients receiving oseltamivir had a 52% risk reduction of pneumonia (RR⫽0.485, 95% CI: 0.344, 0.684). Children ages 1-2 and 6-12 had the largest reductions in pneumonia risk of 52% (RR⫽0.483, 95% CI: 0.237, 0.986) and 57% (RR⫽0.428, 95% CI: 0.257, 0.713) respectively. Overall there was a 43% reduction in hospitalization for pneumonia among oseltamivir users, although this trend did not achieve statistical significance (RR⫽0.570, 95% CI: 0.207, 1.57). Conclusion: Oseltamivir was effective in reducing the risk of pneumonia when prescribed immediately on presentation of influenza in children 1-12 years of age.
120
Emergency Department Management of Disaster Situations With Use of a Radio Frequency Identification Microchip
Mandel JB, Duldner JE Jr, McAllister P, Williams CJ/Akron General Medical Center, Akron, OH
Study Objectives: Technologies now exist to provide emergency care workers with up-to-date medical information on patients. These technologies would be helpful in a myriad of emergency situations from mass caualty settings to elderly patients with complex medical conditions and a long list of medications. Patients however may be skeptical about new technologies. We were interested in determining patients’ knowledge and opinions of the use of Radio Frequency Identification (RFID) microchips as an adjunct to their medical care. Methods: Design: Anonymous Survey. Setting: Urban, community academic ED. Subjects: Convenience sample of ED patients or family of ED patients. Present sample is 103 respondents. No patients approached denied participation. Results: Mean age was 46.6 years (range, 18-91), 61.2% were female. Eighty percent were Caucasian, 19% were African-American. 58% completed high school. Only 16.5% had a 4 year college degree. Insurance coverage included 56.3% private, 9.7% medicaid, 18.4% medicare and 15.5% self-pay. 41.8% of patients did not know their complete medical history and all the medications they are currently taking. Nineteen percent felt it was their own responsibility to maintain their medical records, the remainder thought it was the hospital’s or the doctor’s responsibility. Ninety-seven percent felt that it is important for emergency care providers to have up-to-date information. 58% had never heard of RFID, but 63% would consider having a RFID microchip implanted. Twenty-six percent did not want a microchip in their body, while 18% felt the technology was not necessary. Although these patients like the idea of storing their medical records with a microchip implant, 41.8% are concerned about privacy and confidentiality. Thirty-seven percent of all patients surveyed would not ever consider having a RFID microchip implanted. Of those denying the RFID, 36.8% feared the microchip would be a tracking and privacy issue. Religious reasons would prevent 10.5% from considering the implant. Eight percent would not get the implant for various reasons such as a fear of needles, unproven technology and bad experiences with birth control implants. Patients offered to pay anywhere from $20-2000 dollars, but most common answers were from $100-200 dollars. Conclusion: Most ED respondents are not aware of RFID, but are interested. Many understand a RFID microchip could provide efficient emergency medical care. There is considerable concern among patients about the safety and confidentiality with the use of a RFID microchip. Cost may be a concern, but patients are willing to pay.
121
Automated Collection of Emergency Department Vital Signs
Finnell J, Bagwell S/Indiana University, Indianapolis, IN
Study Objectives: Emergency medicine providers commonly measure vital signs to evaluate hemodynamic stability of patients initially presenting to the emergency department (ED). While vital signs are routinely obtained, there is little information regarding what, if any, predictive value they have for hospital admission. We sought to 1) describe the ‘normal’ range of triage vital signs in emergency department patients and 2) determine the utility of initial vital signs to predict hospital admission. Methods: Indiana University’s IRB approved this retrospective study. We studied adult patients presenting to a Level I trauma center, County ED with an annual census of 100,000. Beginning in November 2005, one of the two available triage booths in the main ED entrance were equipped to allow triage personnel to electronically collect vital signs. While they were encouraged to collect vital signs they were not required to do so. Temperature, Respiration, Pain Scale and Glucose measurements required manual entry. For this five-month study period, we merged
S38 Annals of Emergency Medicine
the initial ED vital sign data with disposition data from our tracking system using standard SQL queries. Predictor variables were classified into ‘Normal’ or ‘Abnormal’ using standardized adult parameters. Univariate and multivariate analysis were performed with the outcome of interest being hospital admission. Descriptive statistics and modeling were performed using SAS software (SAS Institute, Cary, NC). Results: 39,075 patients were registered during the five-month period (11/7/2005-3/31/2006). 30,583 (78%) patients arrived through the main ambulatory ED entrance. Of these, 3,307 (11%) patients had their vital signs stored electronically and 170 (5%) of the 3,283 with dispositions recorded were admitted. The mean values (ranges) of Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Pulse (P), Respiration (R), Temperature (T) and Oximetry (Ox) were 135(80-258), 83(32-165), 90(44-162), 19(12-46), 97.5(93.4-104.7) and 98(88-100) respectively. Univariate odds ratios (95% CI) for admission were significant for Ox 13.7 (5.832.5), R 3.2 (2.3-4.6), Shock Index (SI) ⬎ 0.9 defined as P/SBP ⫽ 3.2 (2.2-4.7) and P 2.1 (1.5-2.9). Controlling for T, R, SI, Ox, Age and Pain Scale: multivariate odds ratios (95% CI) for admission were significant for SI ⫽ 8.6 (3.8-19.2) and R 2.2 (1.1-4.3). Conclusion: Our data highlight the importance of vital sign collection in the ambulatory adult ED population. Collecting these data in an automated computerrecognizable format may lead to improved patient care through automation of existing care processes and appropriate computerized reminders. Secondarily, we’ve identified specific vital sign components more likely to predict hospital admission. Early identification of these patients could lead to improved through put times and a decrease in overall ED length of stay.
122
In a Computerized Physician Order Entry Environment, Is Removing Coagulation Test Availability From Convenience Order Screens an Effective Method to Adapt Clinician Behavior Without Causing Clinical Harm?
Satz W, McNamara RM, Murphy RJ/Temple University, Philadelphia, PA
Study Objectives: There is an increasing percent of hospitals that have moved to Computerized Physician Order Entry(CPOE). There is limited research on the effectiveness of changing clinician test ordering menus regarding results and unforeseen clinical effects. General laboratory screening that includes prothrombin tests, without specific indications, has been shown to have minimal clinical value. We hypothesized many clinicians excessively order coagulation tests do to prior behavior, and convenience of ordering. If we removed the convenience option from the ED laboratory order screen, would there be a significant decrease in prothrombin test(PT) ordering with no serious patient effects? Methods: Setting: Adult ED in a 550 bed tertiary care center with 100% CPOE. As part of a performance improvement project the PT test selection option was removed from the ED laboratory order screen. The test could be ordered by using the Master laboratory order screen. Total PT tests ordered by the ED were collected for 2 months pre and post this change. A surveillance system was established to monitor patient effects of this change. All admitted patients with elevated PT tests ordered within 72 hours of the ED visit were reviewed for clinical significance based on predetermined ED indications: known or suspicion of liver disease, active hemorrhage, significant trauma, preexisting anticoagulation with minor trauma, preexisting anticoagulation with presentation related to thrombotic disease, and sepsis. A McNemar chi-square was used to analyze the frequency in PT tests ordered. Results: There was a 44.6% reduction in PT tests ordered from the ED. In the two month period prior to the order screen change, there was an 18.8% order rate (1627 PT tests ordered, ED census of 8645). In the two months post test removal, the order rate was 10.4% (891 PT tests ordered, ED census of 8579) P⫽ 0.001. There were 25 patients who did not have PT tests ordered in the ED, but did have an elevated result within 72 hours of admission. 23/25 elevated results were secondary to adding anticoagulation to patient therapy. Two patients were on anticoagulation prior to the ED visit and were admitted for infectious diagnosis that met PT test indications. There were no clinical sequelae from the delayed PT test results. Limitations: There was no surveillance during the pre-change period for clinically indicated PT tests not ordered from the ED. Conclusion: Modifying CPOE laboratory ordering screens can be an effective way to adjust clinician behavior. A surveillance system should be in place prior to changes to monitor anticipated and unforeseen patient care events.
Volume , . : October
116
Prevalence of Chlamydia Trachomatis and Neisseria Gonorrhoeae Coinfection with Trichomonas Vaginalis in Female Emergency Department Patients: Are Wet Prep Results a Reliable Predictor?
Gordon JS, Pham KH, Matz TP/University Medical Center of Southern Nevada, Las Vegas, NV
Study Objectives: The goal of the study is to determine if the presence of Trichomonas vaginalis is associated with an increased risk of coinfection with Neisseria gonorrhoeae and/or Chlamydia trachomatis in adult female emergency department patients with symptoms suggestive of a sexually transmitted disease. Methods: This is a retrospective analysis of adult female emergency department patients that were tested for the presence of Trichomonas vaginalis by wet preparation and Neisseria gonorrhoeae and Chlamydia trachomatis by culture between March 2004 and November 2005. All females that presented to an inner-city teaching hospital that had pelvic cultures collected with complete results were included. The primary outcome measure is a significant positive likelihood ratio of patients with positive Trichomonas vaginalis by wet preparation that are co-infected with Neisseria gonorrhoeae and/or Chlamydia trachomatis by culture. Results: A total of 3348 patients were enrolled in the study. One hundred ninetythree patients (5.8%) tested positive for Trichomonas vaginalis and 3165 tested negative. Of the 193 Trichomonas vaginalis positive patients, 22 (11.4%) tested positive for Chlamydia trachomatis, 20 (10.4%) tested positive for Neisseria gonorrhoeae, and three (1.6%) tested positive for both. Of the 3165 Trichomonas vaginalis negative patients, 240 (7.6%) tested positive for Chlamydia trachomatis, 95 (3.0%) tested positive for Neisseria gonorrhoeae, and 29 (0.9%) tested positive for both. The prevalence of Neisseria gonorrhoeae and/or Chlamydia trachomatis in the Trichomonas vaginalis positive patients was 20.2% compared to an overall prevalence of 10.3% for the study population. Statistical analysis reveals a positive association for the presence of Neisseria gonorrhoeae and/or Chlamydia trachomatis in Trichomonas vaginalis positive patients, with a positive likelihood ratio of 2.20 (95% CI ⫽ 1.58 3.08). Conclusion: The presence of Trichomonas vaginalis in adult female patients presenting to the emergency department with symptoms suggestive of a sexually transmitted disease is associated with an increased risk of coinfection with Neisseria gonorrhoeae and/or Chlamydia trachomatis.
117
Sepsis Risk Factors Predictive of Mortality in ICU Transfers Within 72 Hours of ED Admission
D’Amore JZ, Panebianco N, Hussain E, Nelson M, Ward MF, Sama A, Wang H, Slesinger T/North Shore University Hospital, Manhasset, NY
Study Objectives: The objective of this study was to identify risk factors predicting mortality in ICU transfers within 72hrs of ED admission. Methods: This was a retrospective chart review of all patients who were transferred to ICU within 72hrs of admission from the ED 12/31/03-12/26/04. Charts were identified through a QA process. Data was extracted by physician investigators with a standardized data collection instrument. Setting: A 65k/yr visit tertiary care ED. Inclusion criteria: Patients ⬎ 18yrs of age admitted to the ICU within 72 hours of presentation to the ED carrying an infectious disease diagnosis were included. Exclusion criteria: Patients who were ⬍ 18 years old, had no evidence of infection, or DNR were excluded. Statistical analysis: For analysis purposes descriptive statistics and appropriate univariate analysis were used for continuous and categorical data. 95% confidence intervals (CI) are given where appropriate. A Bonferroni correction dictates p-values ⬍ 0.01 statistically significant. Results: 54 patients were enrolled. Clinical characteristics: Average age: 71, Male: 52%, ED admit: pneumonia 24 (44%), urinary tract infection 9 (17%) sepsis/septicemia 12 (22%). Percentage of patients with the indicated parameters: 15% with Mean arterial blood pressure ⬍ 65, 68% with heart rate ⬎ 90, 48% with respiratory rate ⬎ 20, 33% oxygen saturation⬍ 92%, 46% white blood cell (WBC) count ⬎ 12K, 20% anion gap ⬎ 12, 43% in acute renal failure, 13% Platelets ⬍ 100K, 20% altered mental status. 20% received an ICU consult in the ED but were rejected. Percentage of patients with 1 organ system failure: 32%, with 2: 28%, with 3: 17%, with 4: 6%. 53% of all patients had severe sepsis (⬎ 2 SIRS criteria and ⬎ 1 organ failure). Average Apache II score: 15.6. Overall mortality: 47%. Mortality with No ICU consult: 48% vs. 45% with ED ICU consult p⫽. 65. Comparing survivors with expired patients: Apache II scores 15.6 (9-24) vs. 15.7 (10-26) p⫽0.36. ⬎ 2 SIRS criteria 14% (6-20) vs.21% (14-27) p⫽ 0.44. MAP⬍ 65: 7.1% (4-15) vs. 23% (18-28) p⫽⬍ 0.01. Anion gap ⬎ 12: 18% (12-24) vs. 23% (17-33) p⫽ 0.27. ⬎ 2
Volume , . : October
organ system failures: 43% (36-48) vs. 59% (51-67) p ⬍ 0.01. Limitations include retrospective design, small sample size, and study does not account for patients admitted to the floor with similar characteristics who did not decompensate. Conclusion: Apache II scores do not appear predictive. Hypotension or ⬎ 2 organ failures on initial evaluation were significant indicators of mortality. A prospective cohort study attempting to identify prognostic criteria for decompensation and potential prophylactic intervention is the next logical step.
118
A Pilot Study of Inter-Alpha Inhibitor Protein (IaIp) in the Presentation of Adult Patients with Severe Sepsis to the Emergency Department
Lafleur J, Jay GD, Plante T, Clapprood A, Heath R, Lim YP/Brown Medical School, Providence, RI; ProThera Biologics LLC, Providence, RI
Study Objectives: To assess IaIp levels in adult patients presenting to the emergency department (ED) with severe sepsis. Methods: Design: observational nonrandomized controlled trial. Setting: adult emergency department. Participants: adult patients. Cases of severe sepsis and nonseptic patients (controls) with non-inflammatroy diagnoses and matched for age and gender were identified concurrent with hospital admission. Initial blood samples drawn in the ED were obtained for plasma IaIp determination via competitive ELISA. Results: The first group of 32 septic patients and 30 matched controls have been enrolled. Average age for both groups was 74 years (95%CI⫽69-79); percentage of females in both groups was 55%. Mean APACHE II scores were 16 (95%CI⫽14-18) in the septic group and 7 (95%CI⫽5.8-8.2) in the non-septic group. Among septic patients mean lactate level was 5.5 (95%CI⫽4.4-6.6) mean white count 15(95%CI⫽12.2-17.8) and mortality was 38%. The mean IaIp levels at initial presentation were not significantly different between the septic and the non-septic ED patient groups: 349 (95%CI⫽300-398) septic vs. 370 (95%CI⫽336-404) nonseptic. Among the non-survivors in the septic group (n⫽12) there was a nonsignificant trend toward decreased IaIp levels: 292 (95%CI⫽212-372), while the IaIp level in the surviving septic group: 383 (95%CI⫽321-445), was higher than that of the control group. Conclusion: IaIp, a ubiquitous and vital serine protease inhibitor, has recently received attention as potential theranostic, marker and therapeutic agent for sepsis. Recent in-hospital, ICU-based studies of adult septic patients showed significantly decreased levels of IaIp in septic patients compared to healthy controls. A recent study in neonates found significantly decreased IaIp levels in septic compared to non-septic newborns. This is the first study of IaIp in adult septic patients presenting to an emergency department. Our preliminary results indicate that in the majority of patients with severe sepsis a drop in IaIp levels had not yet occurred at the time of ED presentation. As IaIp levels have been shown to be significantly decreased in patients with severe sepsis in an ICU setting, it may be that the elevated systemic protease activity, increasingly recognized as an important aspect of sepsis, is relatively more amenable to therapeutic intervention early in the course of the disease. Ongoing recruitment of patients may reveal significant decrease in IaIp levels among non-surviving septic patients presenting to the ED. A longitudinal study to follow IaIp levels in patients presenting to the ED with severe sepsis is planned.
119
Reduction in the Risk of Pneumonia Following Oseltamivir Use for Influenza Among Pediatric Patients
Barr CE, Schulman KL, Iacuzio DA/Roche Laboratories, Nutley, NJ; Thomson Medstat, Cambridge, MA
Study Objectives: To assess the impact of oseltamivir on the risk of pneumonia and other influenza-related outcomes in children. Methods: This was a retrospective cohort study that utilized health insurance claims data (MedStat MarketScan Research Data) from 2000-2005 to identify patients aged 1-12 years with influenza. Patients receiving a prescription for oseltamivir within one day of influenza diagnosis were compared to those receiving no antiviral therapy. Primary outcomes included frequency of pneumonia and rates of hospitalization. Results: A total of 15,161 children 1-12 years of age were diagnosed with influenza. Of this total, 7,772 (51%) were identified as receiving oseltamivir and propensity matched to a control cohort of patients who received no antiviral
Annals of Emergency Medicine S37
Research Forum Abstracts treatment. Patients receiving oseltamivir had a 52% risk reduction of pneumonia (RR⫽0.485, 95% CI: 0.344, 0.684). Children ages 1-2 and 6-12 had the largest reductions in pneumonia risk of 52% (RR⫽0.483, 95% CI: 0.237, 0.986) and 57% (RR⫽0.428, 95% CI: 0.257, 0.713) respectively. Overall there was a 43% reduction in hospitalization for pneumonia among oseltamivir users, although this trend did not achieve statistical significance (RR⫽0.570, 95% CI: 0.207, 1.57). Conclusion: Oseltamivir was effective in reducing the risk of pneumonia when prescribed immediately on presentation of influenza in children 1-12 years of age.
120
Emergency Department Management of Disaster Situations With Use of a Radio Frequency Identification Microchip
Mandel JB, Duldner JE Jr, McAllister P, Williams CJ/Akron General Medical Center, Akron, OH
Study Objectives: Technologies now exist to provide emergency care workers with up-to-date medical information on patients. These technologies would be helpful in a myriad of emergency situations from mass caualty settings to elderly patients with complex medical conditions and a long list of medications. Patients however may be skeptical about new technologies. We were interested in determining patients’ knowledge and opinions of the use of Radio Frequency Identification (RFID) microchips as an adjunct to their medical care. Methods: Design: Anonymous Survey. Setting: Urban, community academic ED. Subjects: Convenience sample of ED patients or family of ED patients. Present sample is 103 respondents. No patients approached denied participation. Results: Mean age was 46.6 years (range, 18-91), 61.2% were female. Eighty percent were Caucasian, 19% were African-American. 58% completed high school. Only 16.5% had a 4 year college degree. Insurance coverage included 56.3% private, 9.7% medicaid, 18.4% medicare and 15.5% self-pay. 41.8% of patients did not know their complete medical history and all the medications they are currently taking. Nineteen percent felt it was their own responsibility to maintain their medical records, the remainder thought it was the hospital’s or the doctor’s responsibility. Ninety-seven percent felt that it is important for emergency care providers to have up-to-date information. 58% had never heard of RFID, but 63% would consider having a RFID microchip implanted. Twenty-six percent did not want a microchip in their body, while 18% felt the technology was not necessary. Although these patients like the idea of storing their medical records with a microchip implant, 41.8% are concerned about privacy and confidentiality. Thirty-seven percent of all patients surveyed would not ever consider having a RFID microchip implanted. Of those denying the RFID, 36.8% feared the microchip would be a tracking and privacy issue. Religious reasons would prevent 10.5% from considering the implant. Eight percent would not get the implant for various reasons such as a fear of needles, unproven technology and bad experiences with birth control implants. Patients offered to pay anywhere from $20-2000 dollars, but most common answers were from $100-200 dollars. Conclusion: Most ED respondents are not aware of RFID, but are interested. Many understand a RFID microchip could provide efficient emergency medical care. There is considerable concern among patients about the safety and confidentiality with the use of a RFID microchip. Cost may be a concern, but patients are willing to pay.
121
Automated Collection of Emergency Department Vital Signs
Finnell J, Bagwell S/Indiana University, Indianapolis, IN
Study Objectives: Emergency medicine providers commonly measure vital signs to evaluate hemodynamic stability of patients initially presenting to the emergency department (ED). While vital signs are routinely obtained, there is little information regarding what, if any, predictive value they have for hospital admission. We sought to 1) describe the ‘normal’ range of triage vital signs in emergency department patients and 2) determine the utility of initial vital signs to predict hospital admission. Methods: Indiana University’s IRB approved this retrospective study. We studied adult patients presenting to a Level I trauma center, County ED with an annual census of 100,000. Beginning in November 2005, one of the two available triage booths in the main ED entrance were equipped to allow triage personnel to electronically collect vital signs. While they were encouraged to collect vital signs they were not required to do so. Temperature, Respiration, Pain Scale and Glucose measurements required manual entry. For this five-month study period, we merged
S38 Annals of Emergency Medicine
the initial ED vital sign data with disposition data from our tracking system using standard SQL queries. Predictor variables were classified into ‘Normal’ or ‘Abnormal’ using standardized adult parameters. Univariate and multivariate analysis were performed with the outcome of interest being hospital admission. Descriptive statistics and modeling were performed using SAS software (SAS Institute, Cary, NC). Results: 39,075 patients were registered during the five-month period (11/7/2005-3/31/2006). 30,583 (78%) patients arrived through the main ambulatory ED entrance. Of these, 3,307 (11%) patients had their vital signs stored electronically and 170 (5%) of the 3,283 with dispositions recorded were admitted. The mean values (ranges) of Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Pulse (P), Respiration (R), Temperature (T) and Oximetry (Ox) were 135(80-258), 83(32-165), 90(44-162), 19(12-46), 97.5(93.4-104.7) and 98(88-100) respectively. Univariate odds ratios (95% CI) for admission were significant for Ox 13.7 (5.832.5), R 3.2 (2.3-4.6), Shock Index (SI) ⬎ 0.9 defined as P/SBP ⫽ 3.2 (2.2-4.7) and P 2.1 (1.5-2.9). Controlling for T, R, SI, Ox, Age and Pain Scale: multivariate odds ratios (95% CI) for admission were significant for SI ⫽ 8.6 (3.8-19.2) and R 2.2 (1.1-4.3). Conclusion: Our data highlight the importance of vital sign collection in the ambulatory adult ED population. Collecting these data in an automated computerrecognizable format may lead to improved patient care through automation of existing care processes and appropriate computerized reminders. Secondarily, we’ve identified specific vital sign components more likely to predict hospital admission. Early identification of these patients could lead to improved through put times and a decrease in overall ED length of stay.
122
In a Computerized Physician Order Entry Environment, Is Removing Coagulation Test Availability From Convenience Order Screens an Effective Method to Adapt Clinician Behavior Without Causing Clinical Harm?
Satz W, McNamara RM, Murphy RJ/Temple University, Philadelphia, PA
Study Objectives: There is an increasing percent of hospitals that have moved to Computerized Physician Order Entry(CPOE). There is limited research on the effectiveness of changing clinician test ordering menus regarding results and unforeseen clinical effects. General laboratory screening that includes prothrombin tests, without specific indications, has been shown to have minimal clinical value. We hypothesized many clinicians excessively order coagulation tests do to prior behavior, and convenience of ordering. If we removed the convenience option from the ED laboratory order screen, would there be a significant decrease in prothrombin test(PT) ordering with no serious patient effects? Methods: Setting: Adult ED in a 550 bed tertiary care center with 100% CPOE. As part of a performance improvement project the PT test selection option was removed from the ED laboratory order screen. The test could be ordered by using the Master laboratory order screen. Total PT tests ordered by the ED were collected for 2 months pre and post this change. A surveillance system was established to monitor patient effects of this change. All admitted patients with elevated PT tests ordered within 72 hours of the ED visit were reviewed for clinical significance based on predetermined ED indications: known or suspicion of liver disease, active hemorrhage, significant trauma, preexisting anticoagulation with minor trauma, preexisting anticoagulation with presentation related to thrombotic disease, and sepsis. A McNemar chi-square was used to analyze the frequency in PT tests ordered. Results: There was a 44.6% reduction in PT tests ordered from the ED. In the two month period prior to the order screen change, there was an 18.8% order rate (1627 PT tests ordered, ED census of 8645). In the two months post test removal, the order rate was 10.4% (891 PT tests ordered, ED census of 8579) P⫽ 0.001. There were 25 patients who did not have PT tests ordered in the ED, but did have an elevated result within 72 hours of admission. 23/25 elevated results were secondary to adding anticoagulation to patient therapy. Two patients were on anticoagulation prior to the ED visit and were admitted for infectious diagnosis that met PT test indications. There were no clinical sequelae from the delayed PT test results. Limitations: There was no surveillance during the pre-change period for clinically indicated PT tests not ordered from the ED. Conclusion: Modifying CPOE laboratory ordering screens can be an effective way to adjust clinician behavior. A surveillance system should be in place prior to changes to monitor anticipated and unforeseen patient care events.
Volume , . : October