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190 In Case of a Primary Care Crisis Please Go to the Emergency Room: An Investigation of Patient Referral to the Emergency Department by Non-Health Care Providers
Research Forum Abstracts
190
In Case of a Primary Care Crisis Please Go to the Emergency Room: An Investigation of Patient Referral to the Emergency Department by Non-Health Care Providers
Hill R, Gest A, Smith C, Guardiola J, Gonzalez J, Ha J, Apolinario M, Richman PB/Christus Spohn-Texas A&M College of Medicine, Corpus Christi, TX; Texas A&M Corpus Christi, Corpus Christi, TX
Background: The shortage of primary care physicians (PCP) in the U.S has the potential to significantly impact patient volumes for emergency departments (ED) that are already crowded. Currently, there is a paucity of research to identify the background/level of medical training for PCP office personnel who participate in the referral of patients to the ED. Study Objective: We hypothesized that a significant percentage of patients who are referred to the ED after calling their PCP’s office receive such instructions without the input of a physician. Methods: We prospectively enrolled a convenience sample of consenting, oriented, stable adults at an inner-city, academic ED (consecutive enrollment occurred during hours at which trained research associates were available). The ED has an annual patient census of 45,000 patient visits per year. Patients provided answers to a structured, written survey that included demographic data, chief complaint, and information regarding contact with their primary care office prior to the ED visit. The survey instrument afforded patients the opportunity to indicate who they spoke to in the PCP office, whether an effort was made to set up an outpatient appointment, and identified the personnel involved in the decision to refer the patient to the ED. Continuous data are presented as means +/- standard deviation. Categorical data are presented as frequency of occurrence. 95% confidence intervals were calculated. Results: A total of 660 patients were enrolled with a mean age of 41.7 +/- 14.7 years. 53.8% were female, 32.2% had not completed high school, and 72.6% had an income level below $20,000/year. Within the study group, 472 patients (71.51%; 67.9%-74.8%) indicated that they had a PCP; 155 patients (23.0%; 19.9%-26.4%) called to contact their PCP prior to coming to the ED. For patients who called their PCP office and were directed by phone to the ED, the referral pattern was observed as follows: 31/98 (31.63%; 23.2%-41.4%) by a non-health care provider without physician input, 11/98 (11.2%; 6.2%-19.1%) by a non-health care provider after consultation with a physician, 12/98 (12.3%; 7.7%20.3%) by a nurse without physician input, and 14/98 (14.3%; 8.6%- 22.7%) by a nurse after consultation with a physician. An additional 11/98, 11.2%; 6.2-19.1%) only listened to a recorded message and felt the message was directing them to the ED. Including patients who believed they were referred to the ED by phone message, a total of 55 patients (8.3%; 6.4%-10.7) within our study group were directed to the ED after calling their PCP’s office but without physician input. Twenty-three patients (14.8%; 10.0%-21.4%) who called their PCP had an appointment scheduled within 1-4 days and were still referred to come to the ED. Conclusion: A relatively small percentage of patients were referred to the ED without the consultation of a physician in our population. However, if similar patterns are observed within other settings, then, by extrapolation, we estimate that several million annual U.S. ED visits would be the result of telephone referrals by nonphysician personnel within PCP offices. Further study is warranted to assess the medical necessity/outcomes of these referrals and whether better methods of outpatient triage are needed to provide for appropriate utilization of emergency services.
191
Administered chloride load, administered volume load, change in serum chloride concentration (peak-baseline), and “volume-adjusted chloride load” (total chloride/ total volume). Outcome Measure: In-hospital mortality. Results: Mortality was significantly lower among patients receiving lower total chloride loads, lower total volume loads, and among patients experiencing the smallest increase in serum chloride concentration during resuscitation (all P<.05). Controlling for administered volume showed that a lower volume-adjusted chloride load (105-115 mEq/ L) was associated with lower mortality than a higher volume-adjusted chloride load. Conclusions: In patients with SIRS, a fluid resuscitation strategy that employs a lower administered chloride load may be associated with lower in-hospital mortality. This effect is independent of the total volume of fluid administered. These data support existing evidence that crystalloids with lower chloride content may be preferable for use in the critically ill.
192
Non-Invasive Positive Pressure Ventilation in Acute Respiratory Failure: Predictors of Outcome
Ali HEM/Hamad Medical Corporation, Doha, Qatar
Background: Noninvasive positive pressure ventilation (NIPPV) has emerged as a significant advancement in the management of acute respiratory failure in the emergency department. Study Objective: To identify factors, based on clinical and laboratory parameters, for predicting the outcome of NIPPV in patients with acute respiratory failure. Materials and Methods: Sixty-four patients were included in the study. Inclusion criteria were RR>30 breaths/ min, PaO2<60 mm Hg, PaO2/FiO2<300, pCO2 > 45 mm Hg and signs of increased work of breathing. Baseline clinical parameters and arterial blood gas (ABG) were recorded before initiating NIPPV. Clinical parameters including heart rate, respiratory rate, oxygen saturation and ABG was revaluated at 1, 4, 12, 24 hours after initiation of NIPPV. Change in these parameters and need for intubation was evaluated (Figures). Results: Of the 64 patients, 49 (76%) showed clinical and ABG improvement. Out of 15 (24%) patients who failed to respond, 10 (67%) needed endo tracheal intubation within 1 hour. There was significant improvement in
Effect of Chloride Load from Intravenous Crystalloid Infusion on Mortality in Hospitalized Patients Following Fluid Resuscitation
Shaw AD, Raghunathan K, Peyerl F, Munson SH, Paluszkiewicz SM, Schermer C/Vanderbilt University, Nashville, TN; Duke University, Durham, NC; Boston Strategic Partners, Boston, MA; Baxter Healthcare, Deerfield, IL
Study Objective: Intravenous infusion of crystalloids (in particular saline) is common. Recent data suggest that both elevated serum chloride levels and volume overload may be harmful, but the relationship between these two is unclear. The purpose of this study was to examine the relationship between administered chloride load and in-hospital mortality with and without adjustment for administered volume. Methods: Design: Retrospective cohort of prospectively collected data from 109,836 patients from 124 hospitals. Setting: US inpatient electronic health records database (Cerner). Participants: Adult inpatients who met systemic inflammatory response syndrome (SIRS) criteria and received crystalloid fluid resuscitation. Exposures:
Volume 64, no. 4s : October 2014
Annals of Emergency Medicine S69
190
In Case of a Primary Care Crisis Please Go to the Emergency Room: An Investigation of Patient Referral to the Emergency Department by Non-Health Care Providers
Hill R, Gest A, Smith C, Guardiola J, Gonzalez J, Ha J, Apolinario M, Richman PB/Christus Spohn-Texas A&M College of Medicine, Corpus Christi, TX; Texas A&M Corpus Christi, Corpus Christi, TX
Background: The shortage of primary care physicians (PCP) in the U.S has the potential to significantly impact patient volumes for emergency departments (ED) that are already crowded. Currently, there is a paucity of research to identify the background/level of medical training for PCP office personnel who participate in the referral of patients to the ED. Study Objective: We hypothesized that a significant percentage of patients who are referred to the ED after calling their PCP’s office receive such instructions without the input of a physician. Methods: We prospectively enrolled a convenience sample of consenting, oriented, stable adults at an inner-city, academic ED (consecutive enrollment occurred during hours at which trained research associates were available). The ED has an annual patient census of 45,000 patient visits per year. Patients provided answers to a structured, written survey that included demographic data, chief complaint, and information regarding contact with their primary care office prior to the ED visit. The survey instrument afforded patients the opportunity to indicate who they spoke to in the PCP office, whether an effort was made to set up an outpatient appointment, and identified the personnel involved in the decision to refer the patient to the ED. Continuous data are presented as means +/- standard deviation. Categorical data are presented as frequency of occurrence. 95% confidence intervals were calculated. Results: A total of 660 patients were enrolled with a mean age of 41.7 +/- 14.7 years. 53.8% were female, 32.2% had not completed high school, and 72.6% had an income level below $20,000/year. Within the study group, 472 patients (71.51%; 67.9%-74.8%) indicated that they had a PCP; 155 patients (23.0%; 19.9%-26.4%) called to contact their PCP prior to coming to the ED. For patients who called their PCP office and were directed by phone to the ED, the referral pattern was observed as follows: 31/98 (31.63%; 23.2%-41.4%) by a non-health care provider without physician input, 11/98 (11.2%; 6.2%-19.1%) by a non-health care provider after consultation with a physician, 12/98 (12.3%; 7.7%20.3%) by a nurse without physician input, and 14/98 (14.3%; 8.6%- 22.7%) by a nurse after consultation with a physician. An additional 11/98, 11.2%; 6.2-19.1%) only listened to a recorded message and felt the message was directing them to the ED. Including patients who believed they were referred to the ED by phone message, a total of 55 patients (8.3%; 6.4%-10.7) within our study group were directed to the ED after calling their PCP’s office but without physician input. Twenty-three patients (14.8%; 10.0%-21.4%) who called their PCP had an appointment scheduled within 1-4 days and were still referred to come to the ED. Conclusion: A relatively small percentage of patients were referred to the ED without the consultation of a physician in our population. However, if similar patterns are observed within other settings, then, by extrapolation, we estimate that several million annual U.S. ED visits would be the result of telephone referrals by nonphysician personnel within PCP offices. Further study is warranted to assess the medical necessity/outcomes of these referrals and whether better methods of outpatient triage are needed to provide for appropriate utilization of emergency services.
191
Administered chloride load, administered volume load, change in serum chloride concentration (peak-baseline), and “volume-adjusted chloride load” (total chloride/ total volume). Outcome Measure: In-hospital mortality. Results: Mortality was significantly lower among patients receiving lower total chloride loads, lower total volume loads, and among patients experiencing the smallest increase in serum chloride concentration during resuscitation (all P<.05). Controlling for administered volume showed that a lower volume-adjusted chloride load (105-115 mEq/ L) was associated with lower mortality than a higher volume-adjusted chloride load. Conclusions: In patients with SIRS, a fluid resuscitation strategy that employs a lower administered chloride load may be associated with lower in-hospital mortality. This effect is independent of the total volume of fluid administered. These data support existing evidence that crystalloids with lower chloride content may be preferable for use in the critically ill.
192
Non-Invasive Positive Pressure Ventilation in Acute Respiratory Failure: Predictors of Outcome
Ali HEM/Hamad Medical Corporation, Doha, Qatar
Background: Noninvasive positive pressure ventilation (NIPPV) has emerged as a significant advancement in the management of acute respiratory failure in the emergency department. Study Objective: To identify factors, based on clinical and laboratory parameters, for predicting the outcome of NIPPV in patients with acute respiratory failure. Materials and Methods: Sixty-four patients were included in the study. Inclusion criteria were RR>30 breaths/ min, PaO2<60 mm Hg, PaO2/FiO2<300, pCO2 > 45 mm Hg and signs of increased work of breathing. Baseline clinical parameters and arterial blood gas (ABG) were recorded before initiating NIPPV. Clinical parameters including heart rate, respiratory rate, oxygen saturation and ABG was revaluated at 1, 4, 12, 24 hours after initiation of NIPPV. Change in these parameters and need for intubation was evaluated (Figures). Results: Of the 64 patients, 49 (76%) showed clinical and ABG improvement. Out of 15 (24%) patients who failed to respond, 10 (67%) needed endo tracheal intubation within 1 hour. There was significant improvement in
Effect of Chloride Load from Intravenous Crystalloid Infusion on Mortality in Hospitalized Patients Following Fluid Resuscitation
Shaw AD, Raghunathan K, Peyerl F, Munson SH, Paluszkiewicz SM, Schermer C/Vanderbilt University, Nashville, TN; Duke University, Durham, NC; Boston Strategic Partners, Boston, MA; Baxter Healthcare, Deerfield, IL
Study Objective: Intravenous infusion of crystalloids (in particular saline) is common. Recent data suggest that both elevated serum chloride levels and volume overload may be harmful, but the relationship between these two is unclear. The purpose of this study was to examine the relationship between administered chloride load and in-hospital mortality with and without adjustment for administered volume. Methods: Design: Retrospective cohort of prospectively collected data from 109,836 patients from 124 hospitals. Setting: US inpatient electronic health records database (Cerner). Participants: Adult inpatients who met systemic inflammatory response syndrome (SIRS) criteria and received crystalloid fluid resuscitation. Exposures:
Volume 64, no. 4s : October 2014
Annals of Emergency Medicine S69