- Email: [email protected]
196EMF Impact of Emergency Care Training on Outcomes and Care in a Ugandan Emergency Department
Research Forum Abstracts Methods: We reviewed medical records for patients who died of suspected YF (defined as a patient who presented with fever and jaundice <14 days of symptom onset) in four referral hospitals in municipalities reporting the highest case burden in Luanda province. Resuscitation was defined as any documentation of cardiopulmonary resuscitation or administration of epinephrine. Charts were reviewed by two physician abstractors, and a selection of charts was reviewed by both abstractors for quality control. Abstraction was assisted by hospital physicians and municipal surveillance epidemiologists, by interpretation of handwritten abbreviations. Results: The four studied hospitals provided basic medical specialty care; range of inpatient beds was 101-534. We reviewed charts for all 94 in-hospital patient deaths with suspected YF. Among those, 11 (12%) had documented resuscitation; 56 (60%) had received intravenous fluids; and 57 (61%) had documented vital signs. Average length of stay from hospitalization to death was 2.4 days (range: 1-13 days). Average age was 18.3 years (range: 8 months-51 years); 51% were male. Patients who received resuscitation were similar by sex distribution and average length of stay from hospitalization to death, but were older (average age was 22.5 years versus 17.8 years among patients not receiving resuscitation [p ¼ 0.001]). Among the 11 patients who received resuscitation, a disproportionate 7 (63%) were from one 250-bed hospital. All 94 patients were otherwise healthy; no documented preexisting medical comorbidities were noted. None had documented “Do Not Resuscitate” orders or documentation of futility of further care. Conclusion: This study represents the largest chart review of resuscitation efforts in referral hospitals in SSA. Despite in-hospital deaths among patients who died with suspected YF, a very limited number had documented resuscitation. Possible reasons for limited resuscitation include previously published barriers such as limited training and supplies, and anecdotal reports of overworked staff, crowded hospitals and perceived futility of resuscitation because of a lack of intensive care resources. Additional studies are necessary in Angola as well as more broadly in SSA to further characterize causes of the observed low resuscitative efforts in an outbreak setting, further characterize resuscitative efforts in all causes of death, and to identify sustainable solutions.
EMF
196
Impact of Emergency Care Training on Outcomes and Care in a Ugandan Emergency Department
Rice BT, Periyanayagam U, Bisanzo M/NYU School of Medicine, New York, NY; Brigham and Women’s Hospital, Boston, MA; University of Vermont, Burlington, VT
Study Objectives: While new data is emerging regarding the epidemiology of emergency care in low income countries, there is limited evidence assessing the impact of introducing emergency medicine into a health care system. This study presents data collected during the introduction of non-physician emergency care providers (ECPs) into an urban Ugandan referral hospital. The objective of the study was to compare the care and three-day mortality outcomes for patients seen by ECPs to the care and outcomes for patients seen by the untrained providers customarily used in these settings. Methods: Data for this prospective cohort study was collected at Masaka Regional Referral Hospital from October 2015 until April 2016. All patients presenting to the emergency department were seen either by a junior physician or medical officer (customary care) or by an ECP, a non-physician clinician trained specifically in emergency care. Both groups had access to identical resources. Demographics, vitals, medications, lab testing, procedures and disposition were recorded and three-day follow-up to assess patient clinical status and survival via phone or bedside visit was attempted for all patients. A single blinded researcher extracted, cleaned and analyzed the data with Stata. Chi-squared test was used to compare proportions and p<0.05 was considered significant. Results: Overall, 7,281 patients were seen, with junior physicians and medical officers caring for 5,171 patients and ECPs caring for 2,110 patients. No significant difference existed between age groups, sex, or HIV status for each cohort. Admission rate was statistically lower in ECP care (57.0% vs 59.9%, p¼0.02). Three-day mortality outcomes were similar for ECPs and customary care for discharged (0.23% versus 0.20%, p¼0.9) and admitted (5.69% versus 5.60%, p¼0.9) patients. Patients cared for by the ECPs were significantly more likely to have antibiotics (9.83% versus 4.41%, p<0.001) or anti-malarials (6.39% versus 1.77%, p<0.001) initiated in the ED, to have a confirmed diagnosis made in the ED (35.6% versus 27.7%, p<0.001), have vitals taken (54.3% versus 28.6%, p<0.001), and to receive fluid resuscitation for abnormal vitals (7.29% versus 5.28%, p¼0.03). When comparing only patients with
Volume 68, no. 4s : October 2016
vitals taken, ECP care significantly reduced mortality rates for patients presenting without abnormal vitals (2.59% versus 5.51%, p¼0.02). Conclusion: While the cohort of patients cared for by specialty-trained nonphysician ECPs and the junior physicians and medical officers were similar in terms of demographic features and overall mortality, ECP care produced a mortality benefit in at least one subset of patients, and displayed higher rates of ED treatment and testing associated with a higher quality of care. These results suggest that targeted emergency care training has the ability to significantly impact quality of care and patient outcomes even without expansion of resources available for care.
EMF
197
Orthopedic Knowledge and Need in the Provincial Philippines: A Population-Based Survey in Romblon Province
Courtney C, Kirsch T/Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Study Objectives: There is increasing recognition of the gaps of surgical and other specialty care in developing countries, particularly in rural areas. Our objective was to perform an assessment of orthopedic knowledge and need in the remote provincial islands of the Philippines. It was conducted as a preliminary assessment for regional or national implementation. Methods: Two independent surveys were conducted of households and first response providers in June 2015 to describe the local health care system, identify barriers to care, and assess gaps in knowledge for acute orthopedic injuries. Population proportional sampling was utilized to assess a total of 100 households from 25 local Barangay communities. Questions focused on level of existing knowledge regarding orthopedic injuries and barriers to care. The provider survey focused on health care worker level of knowledge and barriers to care regarding acute traumatic orthopedic injuries. Ten school nurses and midwives representing 25 local Barangay were surveyed. Results: In the household survey 84% reported cost was either always or sometimes a barrier to care while 73% cited transportation as a barrier. 68% of respondents reported that they would seek care at the provincial hospital for a suspected broken bone. 72% believed broken bones making an arm or leg crooked could be corrected without surgery, but only 55% percent reported that they believed care should be sought within 6 hours of injury. 37% stated that greater than 3 days after injury was within the appropriate timeframe for seeking care. Of the providers surveyed, 90% reported that they would refer possible broken bones to a higher level of care. Aggregate ranking of barriers to care from greatest to least were: cost, transportation, knowledge of time sensitive nature of treatment, religious beliefs, and other (not specified). 100% reported that an education initiative regarding acute orthopedic injuries would increase the number of patients seeking care within 12 hours. Conclusion: Although there was reasonable understanding of the need for care for suspected fractures, there were numerous barriers identified. With some modification, this survey tool could be expanded and utilized on a regional or national level to assess gaps in knowledge and barriers to acute orthopedic care.
198
A Cost Analysis of the Choosing Wisely Campaign Recommendation to Reduce Emergency Department Imaging for Nontraumatic Back Pain
Lin MP, Richardson LD, Schuur JD, Ward MJ/Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women’s Hospital, Boston, MA; Vanderbilt University School of Medicine, Nashville, TN
Study Objectives: In 2014, ACEP published a Choosing Wisely recommendation to reduce imaging for ED patients with non-traumatic back pain; however, a formal cost analysis was not conducted. We aim to determine potential cost savings associated with implementing the CW recommendation to reduce ED imaging for back pain. Methods: We conducted a cost analysis by developing a decision model comparing current rates of ED imaging with implementation of the Choosing Wisely campaign for the evaluation of non-traumatic back pain. The base case was a 45-year-old healthy man with non-traumatic back pain and no neurologic deficits enrolled in a typical bronze-tier health insurance plan. We used standard decision analytic software (TreeAge Pro, 2015) to calculate costs over one year for each scenario. We used
Annals of Emergency Medicine S77
EMF
196
Impact of Emergency Care Training on Outcomes and Care in a Ugandan Emergency Department
Rice BT, Periyanayagam U, Bisanzo M/NYU School of Medicine, New York, NY; Brigham and Women’s Hospital, Boston, MA; University of Vermont, Burlington, VT
Study Objectives: While new data is emerging regarding the epidemiology of emergency care in low income countries, there is limited evidence assessing the impact of introducing emergency medicine into a health care system. This study presents data collected during the introduction of non-physician emergency care providers (ECPs) into an urban Ugandan referral hospital. The objective of the study was to compare the care and three-day mortality outcomes for patients seen by ECPs to the care and outcomes for patients seen by the untrained providers customarily used in these settings. Methods: Data for this prospective cohort study was collected at Masaka Regional Referral Hospital from October 2015 until April 2016. All patients presenting to the emergency department were seen either by a junior physician or medical officer (customary care) or by an ECP, a non-physician clinician trained specifically in emergency care. Both groups had access to identical resources. Demographics, vitals, medications, lab testing, procedures and disposition were recorded and three-day follow-up to assess patient clinical status and survival via phone or bedside visit was attempted for all patients. A single blinded researcher extracted, cleaned and analyzed the data with Stata. Chi-squared test was used to compare proportions and p<0.05 was considered significant. Results: Overall, 7,281 patients were seen, with junior physicians and medical officers caring for 5,171 patients and ECPs caring for 2,110 patients. No significant difference existed between age groups, sex, or HIV status for each cohort. Admission rate was statistically lower in ECP care (57.0% vs 59.9%, p¼0.02). Three-day mortality outcomes were similar for ECPs and customary care for discharged (0.23% versus 0.20%, p¼0.9) and admitted (5.69% versus 5.60%, p¼0.9) patients. Patients cared for by the ECPs were significantly more likely to have antibiotics (9.83% versus 4.41%, p<0.001) or anti-malarials (6.39% versus 1.77%, p<0.001) initiated in the ED, to have a confirmed diagnosis made in the ED (35.6% versus 27.7%, p<0.001), have vitals taken (54.3% versus 28.6%, p<0.001), and to receive fluid resuscitation for abnormal vitals (7.29% versus 5.28%, p¼0.03). When comparing only patients with
Volume 68, no. 4s : October 2016
vitals taken, ECP care significantly reduced mortality rates for patients presenting without abnormal vitals (2.59% versus 5.51%, p¼0.02). Conclusion: While the cohort of patients cared for by specialty-trained nonphysician ECPs and the junior physicians and medical officers were similar in terms of demographic features and overall mortality, ECP care produced a mortality benefit in at least one subset of patients, and displayed higher rates of ED treatment and testing associated with a higher quality of care. These results suggest that targeted emergency care training has the ability to significantly impact quality of care and patient outcomes even without expansion of resources available for care.
EMF
197
Orthopedic Knowledge and Need in the Provincial Philippines: A Population-Based Survey in Romblon Province
Courtney C, Kirsch T/Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Study Objectives: There is increasing recognition of the gaps of surgical and other specialty care in developing countries, particularly in rural areas. Our objective was to perform an assessment of orthopedic knowledge and need in the remote provincial islands of the Philippines. It was conducted as a preliminary assessment for regional or national implementation. Methods: Two independent surveys were conducted of households and first response providers in June 2015 to describe the local health care system, identify barriers to care, and assess gaps in knowledge for acute orthopedic injuries. Population proportional sampling was utilized to assess a total of 100 households from 25 local Barangay communities. Questions focused on level of existing knowledge regarding orthopedic injuries and barriers to care. The provider survey focused on health care worker level of knowledge and barriers to care regarding acute traumatic orthopedic injuries. Ten school nurses and midwives representing 25 local Barangay were surveyed. Results: In the household survey 84% reported cost was either always or sometimes a barrier to care while 73% cited transportation as a barrier. 68% of respondents reported that they would seek care at the provincial hospital for a suspected broken bone. 72% believed broken bones making an arm or leg crooked could be corrected without surgery, but only 55% percent reported that they believed care should be sought within 6 hours of injury. 37% stated that greater than 3 days after injury was within the appropriate timeframe for seeking care. Of the providers surveyed, 90% reported that they would refer possible broken bones to a higher level of care. Aggregate ranking of barriers to care from greatest to least were: cost, transportation, knowledge of time sensitive nature of treatment, religious beliefs, and other (not specified). 100% reported that an education initiative regarding acute orthopedic injuries would increase the number of patients seeking care within 12 hours. Conclusion: Although there was reasonable understanding of the need for care for suspected fractures, there were numerous barriers identified. With some modification, this survey tool could be expanded and utilized on a regional or national level to assess gaps in knowledge and barriers to acute orthopedic care.
198
A Cost Analysis of the Choosing Wisely Campaign Recommendation to Reduce Emergency Department Imaging for Nontraumatic Back Pain
Lin MP, Richardson LD, Schuur JD, Ward MJ/Icahn School of Medicine at Mount Sinai, New York, NY; Brigham and Women’s Hospital, Boston, MA; Vanderbilt University School of Medicine, Nashville, TN
Study Objectives: In 2014, ACEP published a Choosing Wisely recommendation to reduce imaging for ED patients with non-traumatic back pain; however, a formal cost analysis was not conducted. We aim to determine potential cost savings associated with implementing the CW recommendation to reduce ED imaging for back pain. Methods: We conducted a cost analysis by developing a decision model comparing current rates of ED imaging with implementation of the Choosing Wisely campaign for the evaluation of non-traumatic back pain. The base case was a 45-year-old healthy man with non-traumatic back pain and no neurologic deficits enrolled in a typical bronze-tier health insurance plan. We used standard decision analytic software (TreeAge Pro, 2015) to calculate costs over one year for each scenario. We used
Annals of Emergency Medicine S77