- Email: [email protected]
171
Research Forum Abstracts
168
Quality Assessment of Nurse Triage: Which Factors Are Associated to Mistriage in Emergency Patients?
Parenti N, Ghetti G, Manfredi R, Bagnaresi A, Lanzoni S, Lenzi T/Santa Maria della Scaletta Hospital, Imola, Italy
Study Objectives: We compared a group of emergency patients with right triage to a group with mistriage to found the causes of mistriage and to study its impact on the waiting time for physician examination. Methods: This is an observational retrospective study of 414 patients admitted to our ED from Dec. 2005 to Jan 2006. All medical records were examined by 4 nurses expert of triage and reviewed by two physicians. We excluded patients who needed immediate treatment for life-threatening conditions. We collected: nurse triage category, time of initial evaluation by a triage nurse and by a physician, physician’s diagnosis, demographic and clinical characteristics, the means of transport used (ambulance or self admitted), duty time (beginning vs end of turn), nurse experience in triage, ED crowding. We considered mistriage a triage with disagreement on the urgency category among examined nurses and investigators or with incomplete documentation: date and time of assessment, name of triage officer, chief presenting problem, revelant history, vital signs, initial triage category, assessment area allocated, retriage category. The triage urgency category (UC) were: urgency 1⫽immediate response; urgency 2,3,4 assessment within 20,60,120 minutes. T or chi square test were used to compare 2 groups. We calculated the odds ratio (OR) and the logistic regression coefficient (r) with NCSS statistical software. Results: 307 patients were included in the right triage group and 107 in the mistriage group, mean age 55.8 and 53.3 yrs (p⫽0.5). In the mistriage group 64% of patients had an incomplete documentation and 36% had an under-triage. In the under triage group 10% (4/39) of pat. in urgency category (UC) 4 were assigned by investigators in UC 3; 82% in UC 3 were assigned in UC 2; 8% in UC 2 were assigned in U.C. 1. In the mistriage group there were more women (57% vs 42.3%; p⫽0.03), more urgency category 3 (72% vs 62%; p ⬍ 0.05), more foreigners (22.4% vs 8% , p ⬍ 0.05) , more self admitted patients (81.3% vs 58.6% p ⬍ 0.01). Women (OR⫽ 1.8 ; r ⫽ 0.31), foreigners (OR⫽ 3.26 ; r⫽ 0.39), self admitted patients (OR⫽3.07 ; r⫽ 0.35) were at risk of mistriage. In the under-triage group, few patients (22%, 7/32) in U.C. 3 (right U.C. 2) were examined by a physician within 20 min. (expected time for right U.C.). Moreover in this group the average waiting for physician examination in U.C. 3 (right U.C. 2) and in UC 2 (right UC 1) was longer than expected time for real UC : 73.7 min vs 13.7 min. Conclusion: In our study women, foreigners, self admitted patients or with triage UC 3 are at risk of mistriage. Unexpectedly the nurse experience in triage, the duty time and ED crowding don’t seem to influence the performance of triage. Incomplete documentation is the main cause of mistriage. The under-triage has a very bad impact on the waiting time for physician examination.
169
Interfacility Helicopter Transport of Patients with Leaking Aortic Aneurysms Directly Into the Operating Room
Shewakramani S, Harrison TH, Gates JD, Thomas SH/Harvard Affiliated Emergency Medicine Residency, Boston, MA, Boston, MA; Boston MedFlight, Bedford, MA; Dept of Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA; Department of Emergency Services, Massachusetts General Hospital/Harvard Medical School, Boston, MA
Study Objectives: Interfacility transport of patients with ruptured abdominal aortic aneurysm (RAAA) is time-critical. To streamline care of such patients, our helicopter transport program (MedFlight) and receiving trauma centers have collaborated on a protocol allowing for direct transport into the receiving center OR. Another MedFlight protocol allows for automatic, rotating-roster assignation of receiving hospital such that helicopter dispatch occurs before MD-to-MD communications. This study’s objectives were to assess performance of the direct-toOR protocol, to determine if patients arriving at receiving hospitals during “off hours” (1900-0700 or on weekends) had delays in time-to-OR, and to determine if use of the roster system resulted in times-to-OR comparable to those achieved for patients in whom receiving hospitals had been identified prior to initial MedFlight call. Methods: This was a retrospective review of a consecutive-case series of 29 RAAA patients transported from 17 referring hospitals, during 1999-2004, by a nurseparamedic helicopter program, into 4 Level I centers. Data including demographics, diagnoses, times, and outcomes were obtained for analysis; statistics (p ⫽ .05)
Volume , . : October
included medians with interquartile range (IQR), chi-square and Kruskal-Wallis testing, and multivariate logistic regression calculating odds ratios with 95% confidence interval (CI). Results: Of 29 patients, with age median of 75 (IQR 59-94), 17 (59%) were hypotensive and 20 (69%) were intubated. Median transport distance was 30 miles (IQR 12-51) and the median time MedFlight crew spent with patients was 40 minutes (IQR 34-48). Median interval from MedFlight arrival at receiving center to OR arrival was 8.5 minutes (IQR 4-15); the interval was no longer (and survival was no different) in the 10 patients (35%) who arrived at receiving centers during offhours. Overall, survival through OR was achieved in 22 cases (76%), and 15 (52%) survived to hospital discharge. For 16 (55.2%) of 29 patients, the Roster group, MedFlight assigned the receiving hospital. Analysis adjusting for transport mileage found that Roster patients got to the OR just as quickly as, and had equivalent survival to, patients for whom an accepting physician had already been identified before the initial MedFlight call. Conclusion: 1) Implementation of a direct-to-OR protocol for RAAA patients streamlined care, resulting in relatively rapid times-to-OR for patients presenting at all times of the day. 2) Use of a rotating roster system, allowing simultaneous helicopter dispatch and facilitation of MD-to-MD communications, also contributed to expediting operative care for RAAA.
170
Medication Use and Suicidal Ideation in Emergency Department Patients
Larkin GL, Farman DB/UT Southwestern Medical School, Dallas, TX
Study Objectives: To measure the association between medication use and suicidal ideation (SI) in a multiethnic, non-psychiatric emergency department population. Methods: Prospective cohort of ambulatory adult (⬎ 18 years) patients recruited during random time blocks using a bilingual, computerized, confidential, mental health screen in an urban, 145,000-visit ED. Patients presenting with overt mental health complaints were excluded. Uni- and multivariate comparisons were made with chi-square and logistic regression to assess differences of proportion between ideators and non-ideators. Results: The sample of 1,590 patients was representative of the overall ED population, with 29% white, 39% African American, and 32% Hispanic ethnicity; 845 (53%) were male. Suicidal ideation was present in 184 (11.6%) but did not differ by age, gender, insurance status, marital status, employment status or presenting complaint. Multivariate logistic regression models with 100 bootstraps confirmed that SI was significantly higher among non-Hispanic blacks than nonblacks (14.2% v. 9.9%; p ⬍ .01), those with exposure to a significantly traumatic life events (21.1% vs 6.0%; p ⬍ 0.001 ), those with at risk or binge drinking, (15.4% vs. 10.0%; p ⬍ 0.01), and those on the following medications: antipsychotics (26.9% SI), analgesics (19.4% SI), and anti-lipid agents (17.1% SI). Antidepressants were associated with SI in only 10.7% of cases and were confirmed in multivariate modeling not to be predictive of suicidal ideation in this cohort. Specific plans for suicide were present in 2% of the overall sample. Conclusion: The use of medications other than antidepressants were significantly associated with suicidal ideation in this multiethnic cohort of non-psychiatric ED patients.
171
Is Prehospital GCS Alone Adequate to Determine Need for a Trauma Center?
Isaak S, Levin L, Silvestri S, Papa L/Orlando Regional Medical Center, Orlando, FL
Study Objectives: It has been suggested that GCS ⱕ14 as a sole prehospital physiologic parameter may be adequate to determine need for a trauma center (TC). We assessed whether a prehospital GCS score ⱕ14 was predictive of needing a TC in our trauma population. Methods: This retrospective cohort study assessed consecutive adult patients transported to an 80,000 volume Level I TC meeting statewide prehospital trauma triage criteria (PTTC) for TC transport. The sensitivity and specificity for determining need for a TC in all patients and in those with isolated head injury were calculated for standard PTTC and were compared to prehospital GCS score. Need for a TC was defined by death in ED or during hospitalization, admission to the OR⬍ 6hrs after injury, ICU admission, or need for intubation, thoracotomy/thoracostomy, DPL, or angiography. Analysis was performed using
Annals of Emergency Medicine S53
Research Forum Abstracts Fisher’s Exact Test with p⫽0.05 and sensitivity and specificity for needing a TC calculated. Results: Over the 9-month study period there were 261 trauma patients transported based on standard PTTC. Of these 104 (40%) actually met need for TC criteria. There were 127 patients (49%) with a GCS of 15 and 35 (28%) who met need for TC criteria. There were 29 patients transported secondary to a head injury alone. Using standard PTTC for TC transport yielded a sensitivity of 96% and specificity of 28% with an overall accuracy of 56% for needing a TC (2⫽28.1). Using the PTTC of GCS ⱕ14 yielded a sensitivity of 66% and specificity of 59% with an overall accuracy of 62% (2⫽15.6). When we isolated head injury as the sole reason for transport (n⫽29) sensitivity and specificity for the GCSⱕ14 criteria became 100% and 6% respectively. Conclusion: As a sole criteria for transport to a TC, GCSⱕ14 lacks sensitivity. As a sole criteria for head injured patients, it lacks specificity. Although GCS is an essential component of PTTC, in isolation it lacks accuracy. Future studies should address this issue prospectively.
172
An International Survey of Priorities of Emergency Physicians for Future Development of Clinical Decision Rules
Stiell IG, Eagles D, Clement CM, Brehaut J, Kelly A, Mason S, Kellermann A, Perry JJ/University of Ottawa, Ottawa, Ontario, Canada; Western Hospital, Footscray, Australia; The University of Sheffield, Sheffield, United Kingdom; Emory University, Atlanta, GA
Study Objectives: The use of clinical decision rules is widely accepted in emergency medicine. This study compared the clinical priorities of emergency physicians (EPs) working in Australasia, Canada, the UK and the US for the development of future decision rules. Methods: We administered a prospective email and postal survey to members of 4 national EP associations using a modified Dillman technique. Random samples of members from ACEM (Australasia), CAEP (Canada), BAEM (UK) and ACEP (US) were selected. A prenotification letter and 4 surveys were sent to optimize response. Analyses included univariate and descriptive statistics with 95% CIs. Results: Overall, 1043 (35%) responses were received: Australasia 53%, Canada 57%, UK 12% and US 41%. The respondents were male 74%, mean age 46 years and mean experience 16 years. The clinical problems most often identified by % of physicians and ranking are shown in the table. Conclusions: Among the study countries, there is consistency in identification of clinical problems but considerable variation in prioritization. The top priorities overall were identification of central/serious vertigo and imaging for TIA. These results should help researchers target relevant areas for future development of clinical decision rules in emergency medicine.
173
Ambulance Transport: Why ED Patients Choose as They Do
Jacob S, Jacoby J, James R, Heller M/St. Lukes Hospital, Bethlehem, PA
Study Objectives: Although ED physicians commonly believe that there is a serious problem with ambulance over-utilization, there are few data available that critically examine correlates of ambulance usage in a general ED population. The objective of this study was to define the clinical and demographic characteristics of ED patients who utilized ambulance transport (USERS) as compared to contemporaneous non-ambulance users (NONUSERS). Methods: A single researcher queried consecutive consenting ED patients regarding their reasons for choice of transport to the ED, knowledge of ambulance cost, and self-estimation of illness or injury severity on a 5 point Likert scale. We also
S54 Annals of Emergency Medicine
asked if the treating physician agreed with transport choice. The study was conducted at a community teaching hospital which is a designated level one trauma center with an ED census of 57,000. Patients presenting as a Trauma alert were excluded. This survey occurred during 4 twelve hour shifts covering days and nights, weekday and weeknight. Results: 322 consecutive patients were approached; 311 participated (97%). 22.3% were USERS; they were more likely than NONUSERS to be older (53yrs. vs. 35yrs., p ⬍ .0001), have both a higher patient rated severity (3.1 vs. 3.5, p⫽.026) and nurse triage score (2.9 vs. 3.4, p ⬍ .0001), and be admitted to the hospital (37% vs. 15%, p ⬍ .0001). 50% of USERS had the ambulance called for them by someone else, often (85%) noting this as their sole reason for transport choice. 19.7% felt that they were “too sick to come to the hospital” by any other means; 10.6% felt that they had “no other way” to get to the ED. Of NONUSERS, 127 patients (52.4%) indicated that they were “not sick enough”; 48 (20%) “had someone else” to bring them, and 24 (10%) “could not afford” the ambulance. There was no difference in insurance status between USERS and NONUSERS (53/69 vs. 208/242, p⫽.925). The 87 patients (28%) stating that they knew the cost of ambulance transport were less likely to have been USERS (9/58 vs. 78/218, p⫽.003). 22.5% of patients arriving to the ED during the day (0800 - 2000 hrs) arrived by ambulance, as did 21.2% (P⫽NS) of patients arriving at night (2000 - 0800 hrs). The most common chief complaint of USERS was MVA related trauma (17/68, 25%) and respiratory ailments (13/68, 19%), while that of the NONUSERS was non-chest pain or injury not related to MVA (70/252, 28%) and GI/GU/reproductive (48/252, 19%). Physicians agreed with transport method in 68% of USERS and 92% of NONUSERS (overall kappa ⫽ 0.6). Conclusions: Ambulance users were more likely to be sicker by all measured parameters than non users. Although there is room for improvement, the patient’s decision, especially regarding the nonuse of an ambulance, is frequently in agreement with the physician’s judgment.
174
Plasma Lactate Concentrations Correlate with Physiological Responses in Cyanide Poisoning But Not Other Types of Acute Poisoning
Baud F, Lapostolle F, Borron S/Hopital Lariboisiere/Universite Paris, Paris, France; Hopital Avicenne, Paris, France; University of Texas Health Science Center, San Antonio, TX
Study Objectives: Confirmation of cyanide poisoning (CNP) by laboratory measurement of blood cyanide concentrations generally takes hours to days, and is seldom available to aid in decisions regarding antidote use. Lactic acidosis may be a useful marker of CNP-induced cellular hypoxia. To understand the extent to which lactic acidosis is a direct result of cyanide effects on oxidative phosphorylation versus a secondary response to cardiovascular shock, we examined the correlation between blood lactate levels and physiological responses in patients with acute poisoning due to cyanide in comparison with other agents. Methods: Plasma lactate concentrations, blood chemistry/gases, and vital signs were measured in 9 patients with acute CNP and 9 patients with acute non-CNP [psychotropic drugs (4/9), cardiotropic drugs (3/9), and other toxicants (2/9)] matched for age (mean age 39 years), sex (5 men/4 women), and blood pressure (mean systolic CNP 84 mm Hg/non-CNP 89 mm Hg). Groups were compared using the Wilcoxon signed rank test. Correlations were made using the Spearman test. Results: Mean blood cyanide concentration was 156.0⫾ 84.3 mol/L and mean plasma lactate concentration was 22.0⫾ 17.6 mmol/L (⬃10x normal) in the CNP group. Plasma lactate concentrations in the CNP group were significantly increased in comparison with those measured in the non-CNP group (2.5⫾ 1.8 mmol/L) (P ⬍ 0.008). There were no significant differences in prothrombin time, blood glucose, serum AST, arterial blood gases, or outcomes between groups. Blood cyanide concentrations positively correlated with plasma lactate concentrations (r⫽0.783; p⫽0.017) and inversely with arterial pH (r⫽-0.900; p⫽ 0.002). In the CNP group, systolic blood pressure inversely correlated with plasma lactate concentrations (r⫽0.833; p⫽0.008) and positively with the arterial pH (r⫽0.700; p⫽ 0.043). In the non-CNP group, there was no correlation between blood pressure and plasma lactate concentrations. Conclusion: Plasma lactate concentrations are markedly increased in patients with acute CNP, but not in patients with other types of acute poisoning. Correlations between blood lactate levels and physiological responses were only observed in CNP, suggesting that hemodynamic compromise alone does not explain the elevated lactate concentrations observed in CNP. Plasma lactate levels can serve as an early indicator
Volume , . : October
168
Quality Assessment of Nurse Triage: Which Factors Are Associated to Mistriage in Emergency Patients?
Parenti N, Ghetti G, Manfredi R, Bagnaresi A, Lanzoni S, Lenzi T/Santa Maria della Scaletta Hospital, Imola, Italy
Study Objectives: We compared a group of emergency patients with right triage to a group with mistriage to found the causes of mistriage and to study its impact on the waiting time for physician examination. Methods: This is an observational retrospective study of 414 patients admitted to our ED from Dec. 2005 to Jan 2006. All medical records were examined by 4 nurses expert of triage and reviewed by two physicians. We excluded patients who needed immediate treatment for life-threatening conditions. We collected: nurse triage category, time of initial evaluation by a triage nurse and by a physician, physician’s diagnosis, demographic and clinical characteristics, the means of transport used (ambulance or self admitted), duty time (beginning vs end of turn), nurse experience in triage, ED crowding. We considered mistriage a triage with disagreement on the urgency category among examined nurses and investigators or with incomplete documentation: date and time of assessment, name of triage officer, chief presenting problem, revelant history, vital signs, initial triage category, assessment area allocated, retriage category. The triage urgency category (UC) were: urgency 1⫽immediate response; urgency 2,3,4 assessment within 20,60,120 minutes. T or chi square test were used to compare 2 groups. We calculated the odds ratio (OR) and the logistic regression coefficient (r) with NCSS statistical software. Results: 307 patients were included in the right triage group and 107 in the mistriage group, mean age 55.8 and 53.3 yrs (p⫽0.5). In the mistriage group 64% of patients had an incomplete documentation and 36% had an under-triage. In the under triage group 10% (4/39) of pat. in urgency category (UC) 4 were assigned by investigators in UC 3; 82% in UC 3 were assigned in UC 2; 8% in UC 2 were assigned in U.C. 1. In the mistriage group there were more women (57% vs 42.3%; p⫽0.03), more urgency category 3 (72% vs 62%; p ⬍ 0.05), more foreigners (22.4% vs 8% , p ⬍ 0.05) , more self admitted patients (81.3% vs 58.6% p ⬍ 0.01). Women (OR⫽ 1.8 ; r ⫽ 0.31), foreigners (OR⫽ 3.26 ; r⫽ 0.39), self admitted patients (OR⫽3.07 ; r⫽ 0.35) were at risk of mistriage. In the under-triage group, few patients (22%, 7/32) in U.C. 3 (right U.C. 2) were examined by a physician within 20 min. (expected time for right U.C.). Moreover in this group the average waiting for physician examination in U.C. 3 (right U.C. 2) and in UC 2 (right UC 1) was longer than expected time for real UC : 73.7 min vs 13.7 min. Conclusion: In our study women, foreigners, self admitted patients or with triage UC 3 are at risk of mistriage. Unexpectedly the nurse experience in triage, the duty time and ED crowding don’t seem to influence the performance of triage. Incomplete documentation is the main cause of mistriage. The under-triage has a very bad impact on the waiting time for physician examination.
169
Interfacility Helicopter Transport of Patients with Leaking Aortic Aneurysms Directly Into the Operating Room
Shewakramani S, Harrison TH, Gates JD, Thomas SH/Harvard Affiliated Emergency Medicine Residency, Boston, MA, Boston, MA; Boston MedFlight, Bedford, MA; Dept of Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA; Department of Emergency Services, Massachusetts General Hospital/Harvard Medical School, Boston, MA
Study Objectives: Interfacility transport of patients with ruptured abdominal aortic aneurysm (RAAA) is time-critical. To streamline care of such patients, our helicopter transport program (MedFlight) and receiving trauma centers have collaborated on a protocol allowing for direct transport into the receiving center OR. Another MedFlight protocol allows for automatic, rotating-roster assignation of receiving hospital such that helicopter dispatch occurs before MD-to-MD communications. This study’s objectives were to assess performance of the direct-toOR protocol, to determine if patients arriving at receiving hospitals during “off hours” (1900-0700 or on weekends) had delays in time-to-OR, and to determine if use of the roster system resulted in times-to-OR comparable to those achieved for patients in whom receiving hospitals had been identified prior to initial MedFlight call. Methods: This was a retrospective review of a consecutive-case series of 29 RAAA patients transported from 17 referring hospitals, during 1999-2004, by a nurseparamedic helicopter program, into 4 Level I centers. Data including demographics, diagnoses, times, and outcomes were obtained for analysis; statistics (p ⫽ .05)
Volume , . : October
included medians with interquartile range (IQR), chi-square and Kruskal-Wallis testing, and multivariate logistic regression calculating odds ratios with 95% confidence interval (CI). Results: Of 29 patients, with age median of 75 (IQR 59-94), 17 (59%) were hypotensive and 20 (69%) were intubated. Median transport distance was 30 miles (IQR 12-51) and the median time MedFlight crew spent with patients was 40 minutes (IQR 34-48). Median interval from MedFlight arrival at receiving center to OR arrival was 8.5 minutes (IQR 4-15); the interval was no longer (and survival was no different) in the 10 patients (35%) who arrived at receiving centers during offhours. Overall, survival through OR was achieved in 22 cases (76%), and 15 (52%) survived to hospital discharge. For 16 (55.2%) of 29 patients, the Roster group, MedFlight assigned the receiving hospital. Analysis adjusting for transport mileage found that Roster patients got to the OR just as quickly as, and had equivalent survival to, patients for whom an accepting physician had already been identified before the initial MedFlight call. Conclusion: 1) Implementation of a direct-to-OR protocol for RAAA patients streamlined care, resulting in relatively rapid times-to-OR for patients presenting at all times of the day. 2) Use of a rotating roster system, allowing simultaneous helicopter dispatch and facilitation of MD-to-MD communications, also contributed to expediting operative care for RAAA.
170
Medication Use and Suicidal Ideation in Emergency Department Patients
Larkin GL, Farman DB/UT Southwestern Medical School, Dallas, TX
Study Objectives: To measure the association between medication use and suicidal ideation (SI) in a multiethnic, non-psychiatric emergency department population. Methods: Prospective cohort of ambulatory adult (⬎ 18 years) patients recruited during random time blocks using a bilingual, computerized, confidential, mental health screen in an urban, 145,000-visit ED. Patients presenting with overt mental health complaints were excluded. Uni- and multivariate comparisons were made with chi-square and logistic regression to assess differences of proportion between ideators and non-ideators. Results: The sample of 1,590 patients was representative of the overall ED population, with 29% white, 39% African American, and 32% Hispanic ethnicity; 845 (53%) were male. Suicidal ideation was present in 184 (11.6%) but did not differ by age, gender, insurance status, marital status, employment status or presenting complaint. Multivariate logistic regression models with 100 bootstraps confirmed that SI was significantly higher among non-Hispanic blacks than nonblacks (14.2% v. 9.9%; p ⬍ .01), those with exposure to a significantly traumatic life events (21.1% vs 6.0%; p ⬍ 0.001 ), those with at risk or binge drinking, (15.4% vs. 10.0%; p ⬍ 0.01), and those on the following medications: antipsychotics (26.9% SI), analgesics (19.4% SI), and anti-lipid agents (17.1% SI). Antidepressants were associated with SI in only 10.7% of cases and were confirmed in multivariate modeling not to be predictive of suicidal ideation in this cohort. Specific plans for suicide were present in 2% of the overall sample. Conclusion: The use of medications other than antidepressants were significantly associated with suicidal ideation in this multiethnic cohort of non-psychiatric ED patients.
171
Is Prehospital GCS Alone Adequate to Determine Need for a Trauma Center?
Isaak S, Levin L, Silvestri S, Papa L/Orlando Regional Medical Center, Orlando, FL
Study Objectives: It has been suggested that GCS ⱕ14 as a sole prehospital physiologic parameter may be adequate to determine need for a trauma center (TC). We assessed whether a prehospital GCS score ⱕ14 was predictive of needing a TC in our trauma population. Methods: This retrospective cohort study assessed consecutive adult patients transported to an 80,000 volume Level I TC meeting statewide prehospital trauma triage criteria (PTTC) for TC transport. The sensitivity and specificity for determining need for a TC in all patients and in those with isolated head injury were calculated for standard PTTC and were compared to prehospital GCS score. Need for a TC was defined by death in ED or during hospitalization, admission to the OR⬍ 6hrs after injury, ICU admission, or need for intubation, thoracotomy/thoracostomy, DPL, or angiography. Analysis was performed using
Annals of Emergency Medicine S53
Research Forum Abstracts Fisher’s Exact Test with p⫽0.05 and sensitivity and specificity for needing a TC calculated. Results: Over the 9-month study period there were 261 trauma patients transported based on standard PTTC. Of these 104 (40%) actually met need for TC criteria. There were 127 patients (49%) with a GCS of 15 and 35 (28%) who met need for TC criteria. There were 29 patients transported secondary to a head injury alone. Using standard PTTC for TC transport yielded a sensitivity of 96% and specificity of 28% with an overall accuracy of 56% for needing a TC (2⫽28.1). Using the PTTC of GCS ⱕ14 yielded a sensitivity of 66% and specificity of 59% with an overall accuracy of 62% (2⫽15.6). When we isolated head injury as the sole reason for transport (n⫽29) sensitivity and specificity for the GCSⱕ14 criteria became 100% and 6% respectively. Conclusion: As a sole criteria for transport to a TC, GCSⱕ14 lacks sensitivity. As a sole criteria for head injured patients, it lacks specificity. Although GCS is an essential component of PTTC, in isolation it lacks accuracy. Future studies should address this issue prospectively.
172
An International Survey of Priorities of Emergency Physicians for Future Development of Clinical Decision Rules
Stiell IG, Eagles D, Clement CM, Brehaut J, Kelly A, Mason S, Kellermann A, Perry JJ/University of Ottawa, Ottawa, Ontario, Canada; Western Hospital, Footscray, Australia; The University of Sheffield, Sheffield, United Kingdom; Emory University, Atlanta, GA
Study Objectives: The use of clinical decision rules is widely accepted in emergency medicine. This study compared the clinical priorities of emergency physicians (EPs) working in Australasia, Canada, the UK and the US for the development of future decision rules. Methods: We administered a prospective email and postal survey to members of 4 national EP associations using a modified Dillman technique. Random samples of members from ACEM (Australasia), CAEP (Canada), BAEM (UK) and ACEP (US) were selected. A prenotification letter and 4 surveys were sent to optimize response. Analyses included univariate and descriptive statistics with 95% CIs. Results: Overall, 1043 (35%) responses were received: Australasia 53%, Canada 57%, UK 12% and US 41%. The respondents were male 74%, mean age 46 years and mean experience 16 years. The clinical problems most often identified by % of physicians and ranking are shown in the table. Conclusions: Among the study countries, there is consistency in identification of clinical problems but considerable variation in prioritization. The top priorities overall were identification of central/serious vertigo and imaging for TIA. These results should help researchers target relevant areas for future development of clinical decision rules in emergency medicine.
173
Ambulance Transport: Why ED Patients Choose as They Do
Jacob S, Jacoby J, James R, Heller M/St. Lukes Hospital, Bethlehem, PA
Study Objectives: Although ED physicians commonly believe that there is a serious problem with ambulance over-utilization, there are few data available that critically examine correlates of ambulance usage in a general ED population. The objective of this study was to define the clinical and demographic characteristics of ED patients who utilized ambulance transport (USERS) as compared to contemporaneous non-ambulance users (NONUSERS). Methods: A single researcher queried consecutive consenting ED patients regarding their reasons for choice of transport to the ED, knowledge of ambulance cost, and self-estimation of illness or injury severity on a 5 point Likert scale. We also
S54 Annals of Emergency Medicine
asked if the treating physician agreed with transport choice. The study was conducted at a community teaching hospital which is a designated level one trauma center with an ED census of 57,000. Patients presenting as a Trauma alert were excluded. This survey occurred during 4 twelve hour shifts covering days and nights, weekday and weeknight. Results: 322 consecutive patients were approached; 311 participated (97%). 22.3% were USERS; they were more likely than NONUSERS to be older (53yrs. vs. 35yrs., p ⬍ .0001), have both a higher patient rated severity (3.1 vs. 3.5, p⫽.026) and nurse triage score (2.9 vs. 3.4, p ⬍ .0001), and be admitted to the hospital (37% vs. 15%, p ⬍ .0001). 50% of USERS had the ambulance called for them by someone else, often (85%) noting this as their sole reason for transport choice. 19.7% felt that they were “too sick to come to the hospital” by any other means; 10.6% felt that they had “no other way” to get to the ED. Of NONUSERS, 127 patients (52.4%) indicated that they were “not sick enough”; 48 (20%) “had someone else” to bring them, and 24 (10%) “could not afford” the ambulance. There was no difference in insurance status between USERS and NONUSERS (53/69 vs. 208/242, p⫽.925). The 87 patients (28%) stating that they knew the cost of ambulance transport were less likely to have been USERS (9/58 vs. 78/218, p⫽.003). 22.5% of patients arriving to the ED during the day (0800 - 2000 hrs) arrived by ambulance, as did 21.2% (P⫽NS) of patients arriving at night (2000 - 0800 hrs). The most common chief complaint of USERS was MVA related trauma (17/68, 25%) and respiratory ailments (13/68, 19%), while that of the NONUSERS was non-chest pain or injury not related to MVA (70/252, 28%) and GI/GU/reproductive (48/252, 19%). Physicians agreed with transport method in 68% of USERS and 92% of NONUSERS (overall kappa ⫽ 0.6). Conclusions: Ambulance users were more likely to be sicker by all measured parameters than non users. Although there is room for improvement, the patient’s decision, especially regarding the nonuse of an ambulance, is frequently in agreement with the physician’s judgment.
174
Plasma Lactate Concentrations Correlate with Physiological Responses in Cyanide Poisoning But Not Other Types of Acute Poisoning
Baud F, Lapostolle F, Borron S/Hopital Lariboisiere/Universite Paris, Paris, France; Hopital Avicenne, Paris, France; University of Texas Health Science Center, San Antonio, TX
Study Objectives: Confirmation of cyanide poisoning (CNP) by laboratory measurement of blood cyanide concentrations generally takes hours to days, and is seldom available to aid in decisions regarding antidote use. Lactic acidosis may be a useful marker of CNP-induced cellular hypoxia. To understand the extent to which lactic acidosis is a direct result of cyanide effects on oxidative phosphorylation versus a secondary response to cardiovascular shock, we examined the correlation between blood lactate levels and physiological responses in patients with acute poisoning due to cyanide in comparison with other agents. Methods: Plasma lactate concentrations, blood chemistry/gases, and vital signs were measured in 9 patients with acute CNP and 9 patients with acute non-CNP [psychotropic drugs (4/9), cardiotropic drugs (3/9), and other toxicants (2/9)] matched for age (mean age 39 years), sex (5 men/4 women), and blood pressure (mean systolic CNP 84 mm Hg/non-CNP 89 mm Hg). Groups were compared using the Wilcoxon signed rank test. Correlations were made using the Spearman test. Results: Mean blood cyanide concentration was 156.0⫾ 84.3 mol/L and mean plasma lactate concentration was 22.0⫾ 17.6 mmol/L (⬃10x normal) in the CNP group. Plasma lactate concentrations in the CNP group were significantly increased in comparison with those measured in the non-CNP group (2.5⫾ 1.8 mmol/L) (P ⬍ 0.008). There were no significant differences in prothrombin time, blood glucose, serum AST, arterial blood gases, or outcomes between groups. Blood cyanide concentrations positively correlated with plasma lactate concentrations (r⫽0.783; p⫽0.017) and inversely with arterial pH (r⫽-0.900; p⫽ 0.002). In the CNP group, systolic blood pressure inversely correlated with plasma lactate concentrations (r⫽0.833; p⫽0.008) and positively with the arterial pH (r⫽0.700; p⫽ 0.043). In the non-CNP group, there was no correlation between blood pressure and plasma lactate concentrations. Conclusion: Plasma lactate concentrations are markedly increased in patients with acute CNP, but not in patients with other types of acute poisoning. Correlations between blood lactate levels and physiological responses were only observed in CNP, suggesting that hemodynamic compromise alone does not explain the elevated lactate concentrations observed in CNP. Plasma lactate levels can serve as an early indicator
Volume , . : October