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185: Quality Indicators of Headache Evaluation and Treatment in U.S. Emergency Department Patients
Research Forum Abstracts
185
Quality Indicators of Headache Evaluation and Treatment in U.S. Emergency Department Patients
Roberts JS, Hafner Jr JW, Hubler JR, Sullivan DJ/University of Illinois College of Medicine at Peoria, Peoria, IL; Cook County Hospital/Rush Medical College, Chicago, IL
Study Objectives: Patients with a chief complaint of non-traumatic headache (HA) represented 2.7% of emergency department (ED) visits in 2005 (3.1 million visits). Although the majority of these patients represent benign etiologies, some have serious and life-threatening conditions. Distinguishing patients who require urgent diagnostic studies and treatment requires the application of accepted evidence-based strategies and measurable indicators of quality care. These strategies and indicators are useful in understand patterns of care delivered and improving patient outcomes. This study describes specific quality identifiers of a 2-year national ED quality assessment for HA patients. Methods: An explicit review of the audit chart database from the Sullivan Group’s Emergency Medicine Risk Initiative (EMRI) was conducted for ED visits occurring between 1/1/2006 and 03/19/2008 representing 52 separate EDs nationwide. The EMRI is a national ED chart review and quality assessment product designed to review provider compliance with EM quality indicators in core chief complaint categories. ED charts are reviewed by trained individual hospital staff using a template Web-based system and collated into a central national data repository. Records were analyzed if patient, provider and hospital abstracted information were complete for the ED visit. Quality scores were derived from the ratio of documented-tototal quality indicators (21 possible indicators). Pearson’s chi square and one-way ANOVA was used for bivariant analysis with p ⬍ 0.05 considered statistically significant. Binary logistic regression analysis was performed to determine the associations between visit characteristics and quality scores above and below the mean. Results: During the study period 2494 ED visits were included representing 52 individual EDs. HA patients were mostly female (75.7%) and eventually discharged from the ED (95.8%). Primary medical providers for the ED visits were medical physicians (MD) (80.4% of visits), osteopathic physicians (DO) (13.8%), nurse practitioners (NP) (1.6%) and physician assistants (PA) (4.3%). Patients rated their pain severity most often using a 10 point scale (87.9%), with most reporting initial scores of 8, 9, or 10 (60.8%). Most providers performed a detailed neurological exam (76.8%) and administered pain medication (83.9% overall; 67.6% parenteral medications). Forty-six percent of HA patients had a head computed tomography (CT) performed, with 7 SAH (0.3%) and 3 intracranial hemorrhage (0.1%) diagnoses reported. Of patients with negative head CT imaging, only 27% received a follow-up lumbar puncture (LP) or had a documented informed refusal of the LP. Factors associated with a higher than mean overall quality score were non-university teaching hospitals, use of an ED discharge instructions program, a lack of resident physicians, physician providers (MD and DO), and trauma level 3 facilities. Conclusions: In a national sample of ED HA patients, the 21 quality indicators, such as LP following a negative CT and others, varied widely with provider type and facility characteristics. The majority of HA patients were discharged after receiving parenteral medication, but a minority had serious pathology.
186
The Effectiveness of Emergency Medical Service and Emergency Physician Use of the F.A.S.T. Exam and Activation of a Dedicated Stroke Pager to Reduce Times to CT Scanning and tPA Intervention in Acute Cerebral Thrombosis
Farber AM, Talkad A, Jackson M, Jahnel J, Hevesy G, Robinson C/OSF Saint Francis Medical Center, Peoria, IL
Study Objectives: To evaluate the effectiveness of emergency medical service (EMS) and emergency department (ED) physician use of the Cincinnati Stroke Scale F.A.S.T. exam to activate a stroke pager dedicated to mobilizing multiple hospital personnel in order to streamline and ultimately reduce time to IV-tPA in acute cerebral thrombotic events. Methods: This was a prospective, double blind study conducted during an 8month period in a regional Level 1 trauma center with a dedicated stroke team. The EMS system that serves the area is both public and private with skill levels ranging from BLS to ACLS. The system studied here is ACLS trained. Paramedics, emergency physicians and ED nurses were inserviced in the use of the Cincinnati Stroke Scale (F.A.S.T) to predict cerebral vascular accidents (CVA). EMS was to administer the test and notify the physician of a positive test during their radio call. If the patient arrived by private vehicle, the nurse or physician was to do the exam. A positive exam activated a stroke pager (assuming time from symptom onset was less than 180
S100 Annals of Emergency Medicine
minutes) which notified the stroke team and CT scanner. After proper evaluation, the stroke team determined the use of IV-tPA. Retrospective data was collected to compare times to CT scanner and IV-tPA to the current data. Results: One hundred twenty three patients were seen with activation of the pager and CT scans were performed on 111. Of these 111, 29 (26%) received IVtPA. The average time from F.A.S.T exam to IV-tPA was 68 minutes (95% confidence interval 52-84 minutes), improved from the pre-F.A.S.T exam (93 minutes with a 95% confidence interval of 67-119 minutes). Time from F.A.S.T. exam to CT scan completion was 25 minutes (95% C.I. of 21.5-29.5 minutes). This is also improved from previous arrival times to CT scan (53 minutes with 95% C.I. of 44-62 minutes). Conclusion: There was improvement in both times to CT scan and IV-tPA when the F.A.S.T exam was used and the stroke pager activated. Although times to IV-tPA use was not statistically significant, some improvement was seen. This is important because any reduction in time to revascularization by IV-tPA may have a beneficial clinical effect for the patient.
187
Hyperglycemia as a Predictor of Death in Patients With Transient Ischemic Attack and No Prior History of Diabetes Mellitus
Bellolio MF, Suravaram S, Gilmore RM, Enduri S, Bhagra A, Brown RD, Decker WW, Stead LG/Mayo Clinic College of Medicine, Rochester, MN
Study Objective: To determine if differences in mortality exist between diabetic and non-diabetic patients who present to the emergency department (ED) with transient ischemic attack and elevated blood glucose. Methods: This is a prospective cohort study conducted in the ED of a tertiary level academic medical center with an annual census of 77, 000. The study population consisted of 340 consecutive patients who presented to the ED with a transient ischemic attack over a 3-year period. Blood glucose was measured on presentation in 307 (90.3%). Results were stratified according to those with and without prior history of diabetes mellitus (DM). Mortality and subsequent myocardial infarction and stroke were recorded over one-year follow-up. Results: Of the 307, 51.8% were male, with a mean age of 72.8 years (SD 13.2). Hyperglycemia was defined as glucose levels ⬎130 mg/dL (7.2 mmol/L) and was present in 75 (24.4%), and 57 patients (18.6%) had diabetes mellitus. Overall 25 deaths occurred in one year. The 90-day mortality was 2.9%. Patients with hyperglycemia at presentation were 3.27 times more likely to die than those with normoglycemia (95%CI 1.41 to 7.53, p⬍0.004). Those who died had mean glucose levels of 146 ⫹/⫺ 57 mg/dL and those alive at one year had glucose levels of 117⫹/ ⫺ 38 mg/dL; p⬍0.001. Among 75 patients with hyperglycemia, 42 had no prior history of DM. Patients with hyperglycemia and no prior history of known DM were 5.1 times more likely to be dead at one year (95%CI 1.86 to 14.0, p⬍0.001) in comparison to those with hyperglycemia and known DM. Conclusions: Hyperglycemia on presentation was associated with significantly higher mortality rate at one year following a transient ischemic attack. Patients with hyperglycemia but no prior history of diabetes mellitus have a particularly poor prognosis, worse than that for patients with known diabetes and hyperglycemia.
188
Dizziness Presentations in U.S. Emergency Departments, 1995-2004: Doing More, Getting Less?
Meurer WJ, West BT, Fendrick AM, Kerber KA/University of Michigan, Ann Arbor, MI
Background: Dizziness is one of the most common reasons that patients present to physician’s offices, hospital outpatient departments, and emergency departments (ED) in the United States. Study Objective: This study sought to determine clinical characteristics and health care utilization information for the common presentation of dizziness in the ED. Methods: From the National Hospital Ambulatory Medical Care Survey (years 1995 to 2004), sampled patient visits with vertigo-dizziness as a reason for visiting an emergency department were identified. Sample data were weighted to produce nationally representative estimates. Patient characteristics, diagnoses, and health care utilization information were obtained. Trends in the proportion and rate of vertigodizziness presentations, diagnoses, and test utilization were assessed using a weighted least squares regression analysis.
Volume , . : October
185
Quality Indicators of Headache Evaluation and Treatment in U.S. Emergency Department Patients
Roberts JS, Hafner Jr JW, Hubler JR, Sullivan DJ/University of Illinois College of Medicine at Peoria, Peoria, IL; Cook County Hospital/Rush Medical College, Chicago, IL
Study Objectives: Patients with a chief complaint of non-traumatic headache (HA) represented 2.7% of emergency department (ED) visits in 2005 (3.1 million visits). Although the majority of these patients represent benign etiologies, some have serious and life-threatening conditions. Distinguishing patients who require urgent diagnostic studies and treatment requires the application of accepted evidence-based strategies and measurable indicators of quality care. These strategies and indicators are useful in understand patterns of care delivered and improving patient outcomes. This study describes specific quality identifiers of a 2-year national ED quality assessment for HA patients. Methods: An explicit review of the audit chart database from the Sullivan Group’s Emergency Medicine Risk Initiative (EMRI) was conducted for ED visits occurring between 1/1/2006 and 03/19/2008 representing 52 separate EDs nationwide. The EMRI is a national ED chart review and quality assessment product designed to review provider compliance with EM quality indicators in core chief complaint categories. ED charts are reviewed by trained individual hospital staff using a template Web-based system and collated into a central national data repository. Records were analyzed if patient, provider and hospital abstracted information were complete for the ED visit. Quality scores were derived from the ratio of documented-tototal quality indicators (21 possible indicators). Pearson’s chi square and one-way ANOVA was used for bivariant analysis with p ⬍ 0.05 considered statistically significant. Binary logistic regression analysis was performed to determine the associations between visit characteristics and quality scores above and below the mean. Results: During the study period 2494 ED visits were included representing 52 individual EDs. HA patients were mostly female (75.7%) and eventually discharged from the ED (95.8%). Primary medical providers for the ED visits were medical physicians (MD) (80.4% of visits), osteopathic physicians (DO) (13.8%), nurse practitioners (NP) (1.6%) and physician assistants (PA) (4.3%). Patients rated their pain severity most often using a 10 point scale (87.9%), with most reporting initial scores of 8, 9, or 10 (60.8%). Most providers performed a detailed neurological exam (76.8%) and administered pain medication (83.9% overall; 67.6% parenteral medications). Forty-six percent of HA patients had a head computed tomography (CT) performed, with 7 SAH (0.3%) and 3 intracranial hemorrhage (0.1%) diagnoses reported. Of patients with negative head CT imaging, only 27% received a follow-up lumbar puncture (LP) or had a documented informed refusal of the LP. Factors associated with a higher than mean overall quality score were non-university teaching hospitals, use of an ED discharge instructions program, a lack of resident physicians, physician providers (MD and DO), and trauma level 3 facilities. Conclusions: In a national sample of ED HA patients, the 21 quality indicators, such as LP following a negative CT and others, varied widely with provider type and facility characteristics. The majority of HA patients were discharged after receiving parenteral medication, but a minority had serious pathology.
186
The Effectiveness of Emergency Medical Service and Emergency Physician Use of the F.A.S.T. Exam and Activation of a Dedicated Stroke Pager to Reduce Times to CT Scanning and tPA Intervention in Acute Cerebral Thrombosis
Farber AM, Talkad A, Jackson M, Jahnel J, Hevesy G, Robinson C/OSF Saint Francis Medical Center, Peoria, IL
Study Objectives: To evaluate the effectiveness of emergency medical service (EMS) and emergency department (ED) physician use of the Cincinnati Stroke Scale F.A.S.T. exam to activate a stroke pager dedicated to mobilizing multiple hospital personnel in order to streamline and ultimately reduce time to IV-tPA in acute cerebral thrombotic events. Methods: This was a prospective, double blind study conducted during an 8month period in a regional Level 1 trauma center with a dedicated stroke team. The EMS system that serves the area is both public and private with skill levels ranging from BLS to ACLS. The system studied here is ACLS trained. Paramedics, emergency physicians and ED nurses were inserviced in the use of the Cincinnati Stroke Scale (F.A.S.T) to predict cerebral vascular accidents (CVA). EMS was to administer the test and notify the physician of a positive test during their radio call. If the patient arrived by private vehicle, the nurse or physician was to do the exam. A positive exam activated a stroke pager (assuming time from symptom onset was less than 180
S100 Annals of Emergency Medicine
minutes) which notified the stroke team and CT scanner. After proper evaluation, the stroke team determined the use of IV-tPA. Retrospective data was collected to compare times to CT scanner and IV-tPA to the current data. Results: One hundred twenty three patients were seen with activation of the pager and CT scans were performed on 111. Of these 111, 29 (26%) received IVtPA. The average time from F.A.S.T exam to IV-tPA was 68 minutes (95% confidence interval 52-84 minutes), improved from the pre-F.A.S.T exam (93 minutes with a 95% confidence interval of 67-119 minutes). Time from F.A.S.T. exam to CT scan completion was 25 minutes (95% C.I. of 21.5-29.5 minutes). This is also improved from previous arrival times to CT scan (53 minutes with 95% C.I. of 44-62 minutes). Conclusion: There was improvement in both times to CT scan and IV-tPA when the F.A.S.T exam was used and the stroke pager activated. Although times to IV-tPA use was not statistically significant, some improvement was seen. This is important because any reduction in time to revascularization by IV-tPA may have a beneficial clinical effect for the patient.
187
Hyperglycemia as a Predictor of Death in Patients With Transient Ischemic Attack and No Prior History of Diabetes Mellitus
Bellolio MF, Suravaram S, Gilmore RM, Enduri S, Bhagra A, Brown RD, Decker WW, Stead LG/Mayo Clinic College of Medicine, Rochester, MN
Study Objective: To determine if differences in mortality exist between diabetic and non-diabetic patients who present to the emergency department (ED) with transient ischemic attack and elevated blood glucose. Methods: This is a prospective cohort study conducted in the ED of a tertiary level academic medical center with an annual census of 77, 000. The study population consisted of 340 consecutive patients who presented to the ED with a transient ischemic attack over a 3-year period. Blood glucose was measured on presentation in 307 (90.3%). Results were stratified according to those with and without prior history of diabetes mellitus (DM). Mortality and subsequent myocardial infarction and stroke were recorded over one-year follow-up. Results: Of the 307, 51.8% were male, with a mean age of 72.8 years (SD 13.2). Hyperglycemia was defined as glucose levels ⬎130 mg/dL (7.2 mmol/L) and was present in 75 (24.4%), and 57 patients (18.6%) had diabetes mellitus. Overall 25 deaths occurred in one year. The 90-day mortality was 2.9%. Patients with hyperglycemia at presentation were 3.27 times more likely to die than those with normoglycemia (95%CI 1.41 to 7.53, p⬍0.004). Those who died had mean glucose levels of 146 ⫹/⫺ 57 mg/dL and those alive at one year had glucose levels of 117⫹/ ⫺ 38 mg/dL; p⬍0.001. Among 75 patients with hyperglycemia, 42 had no prior history of DM. Patients with hyperglycemia and no prior history of known DM were 5.1 times more likely to be dead at one year (95%CI 1.86 to 14.0, p⬍0.001) in comparison to those with hyperglycemia and known DM. Conclusions: Hyperglycemia on presentation was associated with significantly higher mortality rate at one year following a transient ischemic attack. Patients with hyperglycemia but no prior history of diabetes mellitus have a particularly poor prognosis, worse than that for patients with known diabetes and hyperglycemia.
188
Dizziness Presentations in U.S. Emergency Departments, 1995-2004: Doing More, Getting Less?
Meurer WJ, West BT, Fendrick AM, Kerber KA/University of Michigan, Ann Arbor, MI
Background: Dizziness is one of the most common reasons that patients present to physician’s offices, hospital outpatient departments, and emergency departments (ED) in the United States. Study Objective: This study sought to determine clinical characteristics and health care utilization information for the common presentation of dizziness in the ED. Methods: From the National Hospital Ambulatory Medical Care Survey (years 1995 to 2004), sampled patient visits with vertigo-dizziness as a reason for visiting an emergency department were identified. Sample data were weighted to produce nationally representative estimates. Patient characteristics, diagnoses, and health care utilization information were obtained. Trends in the proportion and rate of vertigodizziness presentations, diagnoses, and test utilization were assessed using a weighted least squares regression analysis.
Volume , . : October