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235 Effectiveness of Electronic Medical Record Care Plans at Decreasing Emergency Department Recidivism and Narcotic Prescribing
Research Forum Abstracts sharing of information, including guidelines and standing orders, is important in facilitating the use of EBPPM practices, but this may be especially true for EDs in more rural settings.
235
Effectiveness of Electronic Medical Record Care Plans at Decreasing Emergency Department Recidivism and Narcotic Prescribing
Kapur R, Siff J, Emerman C/MetroHealth Medical Center, Cleveland, OH
Study Objectives: Patients utilize the emergency department for a wide variety of reasons. In some cases, they present repeatedly for problems which do not resolve in the ED. In particular, prescription narcotic abuse is a rampant medical and public health concern, with a group of patients frequenting the ED for chronic pain or abuse. Unfortunately, attempts at creating lists of problem patients or developing care coordination plans have met with mixed results. This study analyzes the effect of an EMR-based care plan system on ED recidivism and narcotic prescribing, as well as the effect of a pre-existing psychiatric condition on the usefulness of the care plans. Methods: Medical, psychiatric and narcotic care plans are written at our institution after review of the medical record upon request by multiple different specialty providers. These care plans are indicated by a change in the font color of the patient’s name upon opening the patient’s EMR. A retrospective chart review was conducted including all patients with any type of care plan assigned between December, 2007 and June, 2010, at an urban academic hospital. Data was abstracted including baseline psychiatric conditions, and number of visits, hospitalizations and narcotic prescriptions for 6 months before and after care plan institution. Descriptive statistics, as well as Student’s t-tests and a generalized linear modeling for ANOVA were performed to assess care plan effects. Results: Investigators identified 194 patients with care plans. Patients were more likely to be males (54.64%) and middle aged (41.1 ⫾11.7 years), while narcotic care plans (80.41%) were most prevalent. The average number of ED visits prior to care plan initiation was 7.28 ⫾ 7.53 with a maximum of 54 visits over 6 months. Hospitalizations occurred 1.44 ⫾ 2.91 times on average prior to care plan initiation. After care plan institution, emergency department visits decreased significantly by 3.51 ⫾ 6.24 (p⬍0.0001), and hospitalizations decreased significantly by 0.95 ⫾ 2.91 (p⬍0.0001). There was no significant difference in the effectiveness of the care plan in reducing ED visits depending on care plan type (p⫽0.55). There was no significant difference in recurrent ED visits in patients with pre-existing psychiatric illness compared to those without a psychiatric diagnosis (4.65 visits vs. 3.12 visits, respectively, p⫽.1095) or in hospital admissions (p⫽0.92). Institution of a narcotic care plan reduced the number of patients receiving narcotic prescriptions to 18% (95% CI 14.7-27.3%). Conclusions: This analysis demonstrates the effectiveness of EMR-based care plans reducing ED visits and recurrent narcotic prescriptions. The care plans include referrals to primary care physicians and now include options to contact a hospital ombudsman in the event the patient wishes to challenge the care plan. Further study may investigate the effectiveness of institutional means of addressing these patients’ ongoing needs.
236
Extensor Zone Single Hit Ouchless Technique (EZSHOT) Digital Block versus Traditional Digital Block for Anesthesia of the Finger
Cambridge B, Cummings A, Vora S, Wang H/OSF St. Francis Medical Center, Peoria, IL
Study Objectives: This study compared a newly devised method of instilling digital blocks, the extensor zone single hit ouchless technique (EZ-SHOT), with the traditional digital block (TDB) according to the degree of discomfort caused by injection and to the onset and the duration of anesthesia. Methods: This was a prospective, randomized, double-blinded, and controlled study. The same investigator performed all blocks to the middle fingers of each hand. The hand anesthetized and type of block (TDB or EZ-SHOT) received first were both randomized. An orientation was given to the 30 participants detailing how to evaluate their own degree of anesthesia. This orientation included establishing a baseline of sensation with a safety pin, a description and diagram of 12 zones of the finger, an explanation of the 10-cm visual analog pain scale, and an explanation of how to record anesthesia progress in the fingers. On completion of each block, the subjects recorded the degree of pain and time to anesthesia in each finger zone. The EZ-SHOT was performed as follows: with the patient’s hand pronated, the skin overlying the MP joint was tented up and the injection site made at the direct center
S256 Annals of Emergency Medicine
of the dorsal surface of the finger at the proximal side of the skin tent, at the base of the digit. The needle was inserted perpendicular to the skin surface but at a 45 degree angle to the bone and advanced toward the palmar side of the hand until bone resistance was felt, injecting lidocaine along the insertion track. Without fully withdrawing the needle, the syringe was pulled back then fanned to either side of the proximal phalange. A bolus of lidocaine was infiltrated laterally down each side of the bone. Results: Thirty subjects received 1 TDB and 1 EZ-SHOT for a total of 60 blocks. The TDB received a mean rating for pain of 3.47 (out of 10) versus 3.23 for the EZSHOT (p⫽.328). The TDB took 3.86 minutes on average to take effect, whereas the EZ-SHOT took 5.73 minutes, a difference of 1.87 minutes. This was statistically significant in 10 of the 12 zones. The return of sensation from the EZ-SHOT on average was 50.47 minutes versus 56.15 for the TDB. On average EZ-SHOT lasted 5.68 minutes less than TDB which was statistically significant in 10 of the 12 zones. Overall we defined the block as effective if it caused complete anesthesia in all 12 zones. The EZ-SHOT was effective in 56.7% of blocks versus 93.3% of blocks using the TDB method (p⫽.001). When the EZ-SHOT was done on the left hand it was 69.2% effective versus 47.1% effective when done on the right hand (p⫽0.225). The TDB was 100% effective on the right hand, 88.2% effective on the left hand (p⫽0.201). Conclusion: The effect of EZ-SHOT is similar to that of TDB in terms of pain perception. The EZ-SHOT has slower onset to anesthesia than the TDB and the effect wears off quicker. Overall, the TDB more frequently provides complete anesthesia of the digit than the EZ-SHOT. However additional study will be needed to see if the effectiveness of the EZ-SHOT improves as the operator becomes more accustomed to instilling the block.
237
The Association of Pain Scores and Vital Signs in the Emergency Department
Betcher J, Kutsche K, Ebadi-Tehrani M, Springsteen C, Phu J, Jones JS/Michigan State University College of Human Medicine, Spectrum Health, Grand Rapids, MI
Study Objectives: Health care providers commonly believe that pain is associated with abnormal vital signs, such as tachycardia or hypertension. In fact, some presume that with normal vital signs, any claim of pain by patients should be questioned. This study was conducted to determine if an association between self-reported pain and heart rate (HR), respiratory rate (RR), and blood pressure (BP) exist. Methods: In this retrospective, observational study, all emergency department patients older than 4 years with verifiable painful diagnoses (including nephrolithiasis, fracture, burn, crush injury, corneal abrasion, and dislocation) were identified. Data were extracted from the hospital’s database, including patients’ age, sex, emergency department diagnosis, self-reported pain score, heart rate, blood pressure, and respiratory rate. The Faces Pain Scale (FPS) was used in children aged 5-12 years. Mean vital signs and 95% confidence intervals (CIs) were calculated for each pain score. The distribution of vital signs was further depicted using box plots, with a box at each pain score. Analysis of variance was used to examine the potential for an effect due to patient characteristics on the pain/vital sign relationships. Results: Among 1224 subjects, the most common diagnoses were fractures (77%; n ⫽ 940) and nephrolithiasis (15%; n ⫽ 183). The mean age was 51 (⫹/⫺ 29) years; 329 (27%) were less than 18 years of age. The mean triage pain score was 6 (⫹/⫺ 3) in adults. Mean pain scores in children using the FPS was 7 (⫹/⫺ 3). The mean heart rate was 84 (⫹/⫺ 17) beats/min, mean systolic blood pressure was 137 (⫹/⫺ 25) mm Hg, and mean respiratory rate was 19 (⫹/⫺ 3) breaths/min. There were no clinically significant differences in mean vital signs across the individual pain scores, as demonstrated by overlapping confidence intervals across pain scores. Using analysis of variance, there was no indication that the effect of HR, systolic BP, or RR on pain differed by sex, diagnosis group, or age (all interaction p-values ⬎0.05). Conclusion: A lack of any meaningful correlation between pain scores and changes in vital signs in this population demonstrates that these signs cannot be used to validate the severity of pain reported by pediatric or adult patients.
238
Vancomycin Is Under Dosed in the Emergency Department: Pharmacy Educational Initiatives Can Improve Appropriate Vancomycin Dosing
Patel K, Buehler G, Kuo D/Ben Taub General Hospital, Houston, TX; Baylor College of Medicine, Houston, TX
Study Objective: Recent guidelines from the Infectious Disease Society of America have raised the dosage of vancomycin to 15-20mg/kg based upon actual
Volume , . : October
235
Effectiveness of Electronic Medical Record Care Plans at Decreasing Emergency Department Recidivism and Narcotic Prescribing
Kapur R, Siff J, Emerman C/MetroHealth Medical Center, Cleveland, OH
Study Objectives: Patients utilize the emergency department for a wide variety of reasons. In some cases, they present repeatedly for problems which do not resolve in the ED. In particular, prescription narcotic abuse is a rampant medical and public health concern, with a group of patients frequenting the ED for chronic pain or abuse. Unfortunately, attempts at creating lists of problem patients or developing care coordination plans have met with mixed results. This study analyzes the effect of an EMR-based care plan system on ED recidivism and narcotic prescribing, as well as the effect of a pre-existing psychiatric condition on the usefulness of the care plans. Methods: Medical, psychiatric and narcotic care plans are written at our institution after review of the medical record upon request by multiple different specialty providers. These care plans are indicated by a change in the font color of the patient’s name upon opening the patient’s EMR. A retrospective chart review was conducted including all patients with any type of care plan assigned between December, 2007 and June, 2010, at an urban academic hospital. Data was abstracted including baseline psychiatric conditions, and number of visits, hospitalizations and narcotic prescriptions for 6 months before and after care plan institution. Descriptive statistics, as well as Student’s t-tests and a generalized linear modeling for ANOVA were performed to assess care plan effects. Results: Investigators identified 194 patients with care plans. Patients were more likely to be males (54.64%) and middle aged (41.1 ⫾11.7 years), while narcotic care plans (80.41%) were most prevalent. The average number of ED visits prior to care plan initiation was 7.28 ⫾ 7.53 with a maximum of 54 visits over 6 months. Hospitalizations occurred 1.44 ⫾ 2.91 times on average prior to care plan initiation. After care plan institution, emergency department visits decreased significantly by 3.51 ⫾ 6.24 (p⬍0.0001), and hospitalizations decreased significantly by 0.95 ⫾ 2.91 (p⬍0.0001). There was no significant difference in the effectiveness of the care plan in reducing ED visits depending on care plan type (p⫽0.55). There was no significant difference in recurrent ED visits in patients with pre-existing psychiatric illness compared to those without a psychiatric diagnosis (4.65 visits vs. 3.12 visits, respectively, p⫽.1095) or in hospital admissions (p⫽0.92). Institution of a narcotic care plan reduced the number of patients receiving narcotic prescriptions to 18% (95% CI 14.7-27.3%). Conclusions: This analysis demonstrates the effectiveness of EMR-based care plans reducing ED visits and recurrent narcotic prescriptions. The care plans include referrals to primary care physicians and now include options to contact a hospital ombudsman in the event the patient wishes to challenge the care plan. Further study may investigate the effectiveness of institutional means of addressing these patients’ ongoing needs.
236
Extensor Zone Single Hit Ouchless Technique (EZSHOT) Digital Block versus Traditional Digital Block for Anesthesia of the Finger
Cambridge B, Cummings A, Vora S, Wang H/OSF St. Francis Medical Center, Peoria, IL
Study Objectives: This study compared a newly devised method of instilling digital blocks, the extensor zone single hit ouchless technique (EZ-SHOT), with the traditional digital block (TDB) according to the degree of discomfort caused by injection and to the onset and the duration of anesthesia. Methods: This was a prospective, randomized, double-blinded, and controlled study. The same investigator performed all blocks to the middle fingers of each hand. The hand anesthetized and type of block (TDB or EZ-SHOT) received first were both randomized. An orientation was given to the 30 participants detailing how to evaluate their own degree of anesthesia. This orientation included establishing a baseline of sensation with a safety pin, a description and diagram of 12 zones of the finger, an explanation of the 10-cm visual analog pain scale, and an explanation of how to record anesthesia progress in the fingers. On completion of each block, the subjects recorded the degree of pain and time to anesthesia in each finger zone. The EZ-SHOT was performed as follows: with the patient’s hand pronated, the skin overlying the MP joint was tented up and the injection site made at the direct center
S256 Annals of Emergency Medicine
of the dorsal surface of the finger at the proximal side of the skin tent, at the base of the digit. The needle was inserted perpendicular to the skin surface but at a 45 degree angle to the bone and advanced toward the palmar side of the hand until bone resistance was felt, injecting lidocaine along the insertion track. Without fully withdrawing the needle, the syringe was pulled back then fanned to either side of the proximal phalange. A bolus of lidocaine was infiltrated laterally down each side of the bone. Results: Thirty subjects received 1 TDB and 1 EZ-SHOT for a total of 60 blocks. The TDB received a mean rating for pain of 3.47 (out of 10) versus 3.23 for the EZSHOT (p⫽.328). The TDB took 3.86 minutes on average to take effect, whereas the EZ-SHOT took 5.73 minutes, a difference of 1.87 minutes. This was statistically significant in 10 of the 12 zones. The return of sensation from the EZ-SHOT on average was 50.47 minutes versus 56.15 for the TDB. On average EZ-SHOT lasted 5.68 minutes less than TDB which was statistically significant in 10 of the 12 zones. Overall we defined the block as effective if it caused complete anesthesia in all 12 zones. The EZ-SHOT was effective in 56.7% of blocks versus 93.3% of blocks using the TDB method (p⫽.001). When the EZ-SHOT was done on the left hand it was 69.2% effective versus 47.1% effective when done on the right hand (p⫽0.225). The TDB was 100% effective on the right hand, 88.2% effective on the left hand (p⫽0.201). Conclusion: The effect of EZ-SHOT is similar to that of TDB in terms of pain perception. The EZ-SHOT has slower onset to anesthesia than the TDB and the effect wears off quicker. Overall, the TDB more frequently provides complete anesthesia of the digit than the EZ-SHOT. However additional study will be needed to see if the effectiveness of the EZ-SHOT improves as the operator becomes more accustomed to instilling the block.
237
The Association of Pain Scores and Vital Signs in the Emergency Department
Betcher J, Kutsche K, Ebadi-Tehrani M, Springsteen C, Phu J, Jones JS/Michigan State University College of Human Medicine, Spectrum Health, Grand Rapids, MI
Study Objectives: Health care providers commonly believe that pain is associated with abnormal vital signs, such as tachycardia or hypertension. In fact, some presume that with normal vital signs, any claim of pain by patients should be questioned. This study was conducted to determine if an association between self-reported pain and heart rate (HR), respiratory rate (RR), and blood pressure (BP) exist. Methods: In this retrospective, observational study, all emergency department patients older than 4 years with verifiable painful diagnoses (including nephrolithiasis, fracture, burn, crush injury, corneal abrasion, and dislocation) were identified. Data were extracted from the hospital’s database, including patients’ age, sex, emergency department diagnosis, self-reported pain score, heart rate, blood pressure, and respiratory rate. The Faces Pain Scale (FPS) was used in children aged 5-12 years. Mean vital signs and 95% confidence intervals (CIs) were calculated for each pain score. The distribution of vital signs was further depicted using box plots, with a box at each pain score. Analysis of variance was used to examine the potential for an effect due to patient characteristics on the pain/vital sign relationships. Results: Among 1224 subjects, the most common diagnoses were fractures (77%; n ⫽ 940) and nephrolithiasis (15%; n ⫽ 183). The mean age was 51 (⫹/⫺ 29) years; 329 (27%) were less than 18 years of age. The mean triage pain score was 6 (⫹/⫺ 3) in adults. Mean pain scores in children using the FPS was 7 (⫹/⫺ 3). The mean heart rate was 84 (⫹/⫺ 17) beats/min, mean systolic blood pressure was 137 (⫹/⫺ 25) mm Hg, and mean respiratory rate was 19 (⫹/⫺ 3) breaths/min. There were no clinically significant differences in mean vital signs across the individual pain scores, as demonstrated by overlapping confidence intervals across pain scores. Using analysis of variance, there was no indication that the effect of HR, systolic BP, or RR on pain differed by sex, diagnosis group, or age (all interaction p-values ⬎0.05). Conclusion: A lack of any meaningful correlation between pain scores and changes in vital signs in this population demonstrates that these signs cannot be used to validate the severity of pain reported by pediatric or adult patients.
238
Vancomycin Is Under Dosed in the Emergency Department: Pharmacy Educational Initiatives Can Improve Appropriate Vancomycin Dosing
Patel K, Buehler G, Kuo D/Ben Taub General Hospital, Houston, TX; Baylor College of Medicine, Houston, TX
Study Objective: Recent guidelines from the Infectious Disease Society of America have raised the dosage of vancomycin to 15-20mg/kg based upon actual
Volume , . : October