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21 Success of a Strategy to Reduce Unnecessary White Blood Cell Differentials in the Emergency Department
Research Forum Abstracts
21
Success of a Strategy to Reduce Unnecessary White Blood Cell Differentials in the Emergency Department
Eastin C, Baker C, Walter D, Hadden C, Seupaul R/University of Arkansas for Medical Sciences, Little Rock, AR
Study Objective: With rising costs of health care, many are looking for ways to decrease unnecessary test utilization. Previous data show changing default settings in computerized physician order entry (CPOE) can improve appropriate utilization of commonly ordered tests. One particular test that is frequently ordered, but is of unclear clinical utility in many patients, is the white blood cell (WBC) differential. We investigate the effect of a change in the default blood count (CBC) order from CBC with differential to plain CBC on ordering behavior in the emergency department (ED) setting. Methods: A retrospective analysis of a cohort of patient visits from a metropolitan ED was performed. Previously, CBC with differential was the default order. In December 2015 the CPOE was altered so that the default test would be the CBC without differential automatically included. The CBC with differential was still available to order at the physician’s discretion. Pre and post study periods were March through August 2015 and March through August 2016, respectively. The primary outcome was overall change in frequency of test orders. Predicted cost savings was also calculated. Results: A total of 61573 patient visits were evaluated, accounting for 32197 total tests ordered. There were no differences in number of patients, tests ordered, admission rates, discharge rates, ESI triage levels, or length of stay between the two study periods. Following the intervention, there was a 47% reduction in the number of CBC with differential (15655 to 7388) with a corresponding 4150% increase in CBC without differential (215 to 8939). Given that the cost difference when using CBC rather than CBC with differential is $11 per test, we calculated over $90,000 in savings in patient charges over a 6 month period, or over $180,000 saved per year. Conclusions: Changing the default CPOE order from CBC with differential to plain CBC successfully reduced CBC with differential orders by nearly half, resulting in a potential of over $180,000 in savings per year. Future studies will focus on ensuring this improved test utilization can maintain safe and appropriate quality of care.
22
Apneic Oxygenation Via Conventional Nasal Cannula to Prevent Oxygen Desaturation During Rapid Sequence Intubation in the Emergency Department and Intensive Care Unit: A Systematic Review and Meta-Analysis
West JR, Williams AB/Lincoln Medical and Mental Health Center, Bronx, NY
Study Objectives: To a systematic review and meta-analysis of the effect of apneic oxygenation (ApOx) by conventional nasal cannula (cNC) to reduce the frequency of oxygen desaturation to <90% and <80% during RSI in the emergency department (ED) and critical care (ICU) settings. Methods: We searched MEDLINE, Embase, CINAHL, Web of Science, and clinical trial registries using search terms aided by a librarian. We identified 63 studies, and 45 were excluded based on the abstract alone. 18 studies underwent full review for inclusion by the authors, and 12 were excluded because they used other methods of ApOx than cNC. Overall, 2 studies met our inclusion criteria. Data on our outcomes was not present in 4 studies excluded for lack of study outcomes, including one published in abstract form. We corresponded with these authors to obtain previously unpublished data. The author of one prospective study and an author of an ED abstract also registered as a completed RCT that is undergoing current manuscript review were able to provide data for our study outcomes and quality assessment included in our analysis. Ultimately, two prospective ED studies, one ED randomized controlled trial (RCT), and one ICU RCT were included in our analysis. We used GRADE methodology to assess the quality of the 4 included studies and used the Cochrane Risk of Bias Tool for the 2 included RCTs. Results: 1,112 patients were included in this analysis, and 57% received ApOx by cNC. 24% (150/629) of patients receiving ApOx by cNC and 37% (180/483) of patients without ApOx by cNC experienced oxygen desaturation
S10 Annals of Emergency Medicine
during intubation. The two prospective studies were classified as moderate quality evidence, and the two RTCs were classified as high quality evidence using GRADE methodology. The Cochrane Risk of Bias Tool of the 2 RCTs received a rating of low risk of bias. The prospective studies either excluded patients with low oxygen saturation prior to RSI or inconsistently applied pre-oxygenation. The RCTs included patients who underwent at least 3 minutes of pre-oxygenation. Composite odds ratios (OR) of the 4 included studies using a fixed effects model shows the use of ApOx via cNC reduces the odds of hypoxemia during intubation to less than 90% (OR ¼ 0.62; 95% CI 0.45 -0.83; I2 ¼68) and less than 80% (OR ¼ 0.56; 95% CI 0.37 - 0.85; I2¼33) oxygen saturation during RSI. We performed a subgroup analysis of the two RCTs (350 patients), and the relative risk for ApOx by cNC using a fixed effects model to prevent hypoxemia to <90% and was 1.00 (95% CI 0.73 - 1.37; I2¼ 0). Conclusions: The use of ApOx via cNC reduces the frequency of hypoxemia to <90% and <80% during RSI among the included prospective and RCT studies. However, in the subgroup analysis of the two RCTs, the use of ApOx by cNC was found to have no difference between desaturation rates to <90% during RSI. Further research is needed for the application of ApOx via cNC to prevent hypoxemia in ED and ICU patients with low oxygen saturation rates prior to RSI and those who cannot undergo adequate preoxygenation prior to RSI.
EMF
23
Mastery Standards for Emergency Medicine Comprehensive Airway Management
Panchal AR, Way D, King A, Terndrup TE, The Airway Mastery Collaborative/The Ohio State University, Columbus, OH
Study Objectives: The Emergency Medicine Milestone Project provides guidance for assessment of resident trainee airway management proficiency (PC10). Though this paradigm provides general structure for resident training, it does not define proficiency or mastery of airway management skills. The objective of this evaluation is to establish performance standards for comprehensive airway management by defining expectations for beginning and mastery level proficiency for emergency medicine trainees. Methods: Comprehensive airway management standards were derived using a modified Angoff standard setting procedure. A panel of residency education and airway management experts (11 experts) were convened to make judgments on how trainees would be expected to perform on individual tasks in a standardized airway management scenario. Experts were facilitated in a 2-hour discussion defining the airway management performance of a well-prepared beginning trainee and a mastery level EM trainee using patient safety as a reference. They were briefed on the high fidelity airway simulation and the 51 items/behaviors assessed through the experience. The simulation encompasses 4 areas: preparation, endotracheal intubation, ventilation, and use of back-up airway. Experts were then given a standard setting worksheet with the 51 items. Data were tabulated and descriptive
Volume 70, no. 4s : October 2017
21
Success of a Strategy to Reduce Unnecessary White Blood Cell Differentials in the Emergency Department
Eastin C, Baker C, Walter D, Hadden C, Seupaul R/University of Arkansas for Medical Sciences, Little Rock, AR
Study Objective: With rising costs of health care, many are looking for ways to decrease unnecessary test utilization. Previous data show changing default settings in computerized physician order entry (CPOE) can improve appropriate utilization of commonly ordered tests. One particular test that is frequently ordered, but is of unclear clinical utility in many patients, is the white blood cell (WBC) differential. We investigate the effect of a change in the default blood count (CBC) order from CBC with differential to plain CBC on ordering behavior in the emergency department (ED) setting. Methods: A retrospective analysis of a cohort of patient visits from a metropolitan ED was performed. Previously, CBC with differential was the default order. In December 2015 the CPOE was altered so that the default test would be the CBC without differential automatically included. The CBC with differential was still available to order at the physician’s discretion. Pre and post study periods were March through August 2015 and March through August 2016, respectively. The primary outcome was overall change in frequency of test orders. Predicted cost savings was also calculated. Results: A total of 61573 patient visits were evaluated, accounting for 32197 total tests ordered. There were no differences in number of patients, tests ordered, admission rates, discharge rates, ESI triage levels, or length of stay between the two study periods. Following the intervention, there was a 47% reduction in the number of CBC with differential (15655 to 7388) with a corresponding 4150% increase in CBC without differential (215 to 8939). Given that the cost difference when using CBC rather than CBC with differential is $11 per test, we calculated over $90,000 in savings in patient charges over a 6 month period, or over $180,000 saved per year. Conclusions: Changing the default CPOE order from CBC with differential to plain CBC successfully reduced CBC with differential orders by nearly half, resulting in a potential of over $180,000 in savings per year. Future studies will focus on ensuring this improved test utilization can maintain safe and appropriate quality of care.
22
Apneic Oxygenation Via Conventional Nasal Cannula to Prevent Oxygen Desaturation During Rapid Sequence Intubation in the Emergency Department and Intensive Care Unit: A Systematic Review and Meta-Analysis
West JR, Williams AB/Lincoln Medical and Mental Health Center, Bronx, NY
Study Objectives: To a systematic review and meta-analysis of the effect of apneic oxygenation (ApOx) by conventional nasal cannula (cNC) to reduce the frequency of oxygen desaturation to <90% and <80% during RSI in the emergency department (ED) and critical care (ICU) settings. Methods: We searched MEDLINE, Embase, CINAHL, Web of Science, and clinical trial registries using search terms aided by a librarian. We identified 63 studies, and 45 were excluded based on the abstract alone. 18 studies underwent full review for inclusion by the authors, and 12 were excluded because they used other methods of ApOx than cNC. Overall, 2 studies met our inclusion criteria. Data on our outcomes was not present in 4 studies excluded for lack of study outcomes, including one published in abstract form. We corresponded with these authors to obtain previously unpublished data. The author of one prospective study and an author of an ED abstract also registered as a completed RCT that is undergoing current manuscript review were able to provide data for our study outcomes and quality assessment included in our analysis. Ultimately, two prospective ED studies, one ED randomized controlled trial (RCT), and one ICU RCT were included in our analysis. We used GRADE methodology to assess the quality of the 4 included studies and used the Cochrane Risk of Bias Tool for the 2 included RCTs. Results: 1,112 patients were included in this analysis, and 57% received ApOx by cNC. 24% (150/629) of patients receiving ApOx by cNC and 37% (180/483) of patients without ApOx by cNC experienced oxygen desaturation
S10 Annals of Emergency Medicine
during intubation. The two prospective studies were classified as moderate quality evidence, and the two RTCs were classified as high quality evidence using GRADE methodology. The Cochrane Risk of Bias Tool of the 2 RCTs received a rating of low risk of bias. The prospective studies either excluded patients with low oxygen saturation prior to RSI or inconsistently applied pre-oxygenation. The RCTs included patients who underwent at least 3 minutes of pre-oxygenation. Composite odds ratios (OR) of the 4 included studies using a fixed effects model shows the use of ApOx via cNC reduces the odds of hypoxemia during intubation to less than 90% (OR ¼ 0.62; 95% CI 0.45 -0.83; I2 ¼68) and less than 80% (OR ¼ 0.56; 95% CI 0.37 - 0.85; I2¼33) oxygen saturation during RSI. We performed a subgroup analysis of the two RCTs (350 patients), and the relative risk for ApOx by cNC using a fixed effects model to prevent hypoxemia to <90% and was 1.00 (95% CI 0.73 - 1.37; I2¼ 0). Conclusions: The use of ApOx via cNC reduces the frequency of hypoxemia to <90% and <80% during RSI among the included prospective and RCT studies. However, in the subgroup analysis of the two RCTs, the use of ApOx by cNC was found to have no difference between desaturation rates to <90% during RSI. Further research is needed for the application of ApOx via cNC to prevent hypoxemia in ED and ICU patients with low oxygen saturation rates prior to RSI and those who cannot undergo adequate preoxygenation prior to RSI.
EMF
23
Mastery Standards for Emergency Medicine Comprehensive Airway Management
Panchal AR, Way D, King A, Terndrup TE, The Airway Mastery Collaborative/The Ohio State University, Columbus, OH
Study Objectives: The Emergency Medicine Milestone Project provides guidance for assessment of resident trainee airway management proficiency (PC10). Though this paradigm provides general structure for resident training, it does not define proficiency or mastery of airway management skills. The objective of this evaluation is to establish performance standards for comprehensive airway management by defining expectations for beginning and mastery level proficiency for emergency medicine trainees. Methods: Comprehensive airway management standards were derived using a modified Angoff standard setting procedure. A panel of residency education and airway management experts (11 experts) were convened to make judgments on how trainees would be expected to perform on individual tasks in a standardized airway management scenario. Experts were facilitated in a 2-hour discussion defining the airway management performance of a well-prepared beginning trainee and a mastery level EM trainee using patient safety as a reference. They were briefed on the high fidelity airway simulation and the 51 items/behaviors assessed through the experience. The simulation encompasses 4 areas: preparation, endotracheal intubation, ventilation, and use of back-up airway. Experts were then given a standard setting worksheet with the 51 items. Data were tabulated and descriptive
Volume 70, no. 4s : October 2017