- Email: [email protected]
25. Pediatric Emergency Department Utilization for Nonurgent Complaints
RESEARCH ABSTRACTS
Conclusions: Oral contrast use in the blunt trauma population is not supported in the trauma/emergency medicine literature. Sharing this literature and changing from a practice of always using oral contrast to physician choice resulted in a decrease in oral contrast use by 89.4%. ED nurses (who were in the habit of routinely giving contrast as part of the protocol) now needed to be informed of this potential change in practice and reasons why the change was being made. In the early weeks of the study, some patients received contrast before the physician had the opportunity to instruct the nurse otherwise. However, it took only a few weeks before the nurses adapted to the change. Implications for further study would be a comparison of the number of nasogastric tubes inserted and the number of patients who vomit the contrast in a patient population where the use of oral contrast is the norm versus a patient population where the use of oral contrast is no longer the practice. doi: 10.1016/j.jen.2004.07.029
24. Patient Complaints Brought to Legal Counsel. Wilma Yu, RN, MSN, MS, CEN, Christianacare Health System, 30 Boulder Brook Dr, Wilmington, DE 19803 Purpose: Examining malpractice cases may aid in the development of recommendations that will improve patient care and reduce the health professional’s risk for malpractice litigation. The purpose of this study is to examine medical malpractice cases rejected from litigation to identify reasons individuals seek legal counsel. Design/Setting/Sample: This study is a retrospective review of attorney client records to determine patient complaints against health care providers. Only cases rejected for litigation are examined. This group represents the majority of complaintants and had not been previously studied. Client records are from a medical malpractice attorney group in Delaware. Files were released to the investigator with patient identifying data removed. Methodology: The study reviewed the 288 cases filed with the practice between 1994 and 1998. Of these, 192 files contained sufficient data for analysis with 392 complaints identified by the investigator from patient or family descriptions of the perceived incidents as related to legal counsel. Results: The primary factors identified for dissatisfaction were communication problems (n = 95) including lack of or conf licting information, timely notification, not listening, not answering questions, not being taken seriously and rudeness. Secondary were treatment issues (n = 89) involving adverse outcomes and refusal by ED to admit, (3) emotional issues (n = 75) including grief reactions, anger, threats to self image and major emotional crisis unrelated to illness or injury, (4) perceived malpractice or negligence (n = 74) with misdiagnosis, delayed treatment, falls, medication errors, physician notification promptness, inattention and neglect and (5) patient issues due to financial concerns.
October 2004
30:5
Conclusions: The subjects in this study instituted legal malpractice action against their health care providers. Communication and sensitivity issues were consistently identified from the legal records. Four areas were identified that health care providers could consider improving in order to reduce their risk of litigation: (1) develop excellent communication skills; (2) become aware of provider behaviors that lead to dissatisfaction, such as not listening, not acknowledging patient concerns, rudeness, failing to provide adequate information; (3) recognize emotional issues in patients and families that heighten their assessment of care; and (4) develop and implement strategies for acute and ongoing emotional support for patients and families experiencing adverse events or outcomes. Understanding the issues, training in effective communication, and developing support skills and resources may help to improve patient and family care and reduce exposure to litigation. Future research would involve larger study groups in other geographic locations. Due to patient and staff stressors innately present in the emergency department, dissatisfaction will occur. The data would be useful in developing a program for ED staff to become more proficient in communication skills with heightened awareness of dissatisfaction issues. doi: 10.1016/j.jen.2004.07.030
25. Pediatric Emergency Department Utilization for Nonurgent Complaints. Kimberly Childers, RN, MSN, CEN, CPNP, Texas Children’s Hospital, 6621 Fannin St, A210/MC 1-1481, Houston, TX 77030-2399 Purpose: Approximately 1 of 4 ED visits is a pediatric visit. Data from the National Center for Health Statistics indicates that between one third and half of these visits are for a nonurgent complaint. The purpose of this study was to identify reasons for nonurgent ED utilization. Design: A descriptive design was used. Setting: This study was conducted in the emergency department of a tertiary children’s hospital located in the southwestern United States. This emergency department experiences approximately 70,000 pediatric-only visits per year. Sample: The sample consisted of 256 randomly selected English-speaking and Spanish-speaking families who had visited the urgent care area of the emergency department from May 1–June 30 of 2002 and had been identified as having a nonurgent discharge diagnosis code agreed to participate. All patients had heath insurance. Methodology: Telephone interviews were conducted in Spanish or English. Parents were asked questions targeting the following areas: (1) parental/child demographics, (2) past medical care utilization, (3) current illness experience, and (4) ED experience. Interview questions resulted from a pilot study of 39 families who were interviewed in the urgent care area during July 2002. Information from these open-ended questions provided the basis for the telephone interview, which consisted of 29 multiple-choice questions.
JOURNAL OF EMERGENCY NURSING
415
RESEARCH ABSTRACTS
Results: Interviews were conducted in English (84%) and Spanish (16%). Commonly cited reasons for utilization of the emergency department for non-urgent complaints were: (1) perceived advantages over doctor’s office (26% cited access to specialists in the emergency department and increased time spent with patient by emergency physician as key), (2) access to care (57%—doctor’s office was closed), and (3) limited knowledge of managed care (50% had been with their health insurance plan for less than 1 year). Hispanic parents reported greater value in the ED than Caucasians in this sample. The majority of parents (94%) reported established relationships with their regular doctors. Conclusions: Interventions should be aimed at qualifying need for extended hours access, creating extended hours network of providers, and putting in place a communication program that would allow users to identify extended hours care. doi: 10.1016/j.jen.2004.07.031
26. Postdischarge Pain Intensity and Functional Status of Patients Who Presented to the Emergency Department in Pain. Garrett Chan, RN, MS, CEN, Martha L. Neighbor MD, Larry L. LaBossiere, (LT/NC/USN), RN, MS, CEN, Kathleen A. Puntillo, RN, DNSc, FAAN, University of California, San Francisco, Department of Physiological Nursing, 2 Koret Way, Box 0160, San Francisco, CA 94143-0610 Purpose: Little is known about how discharge interventions affect pain relief, produce bothersome side effects, or how continued pain interferes with functional status of patients after discharge from the emergency department. The purpose of this study was to evaluate the discharge pain management interventions after an ED visit and to investigate how pain intensity inf luenced functional status of patients who presented to the emergency department with a chief complaint of pain. Design/Setting: This prospective, descriptive study was conducted at 2 level I trauma center hospitals in California. Sample: While in the emergency department, 29 patients consented to participate in follow-up phone calls from a larger sample of 180 subjects participating in a study investigating the experiences of pain and pain management in the emergency department. The 29 subjects had presented to the emergency department with chief complaints of abdominal pain (n = 8), chronic pain (n = 10), abscess (n = 2), and trauma-related pain (n = 9). Methodology: As part of the larger study, the study patients reported pain intensity upon ED discharge using a 0 to 10 numeric rating scale (NRS) (0 = no pain, 10 = worst possible pain). Follow-up data were collected via telephone interview an average of 72 hours after discharge. Questionnaire items assessed aspects of pain including pain intensity (0 to 10 NRS), amount of pain relief (0 to 10 NRS; 0 = no relief, 10 = complete relief ) how bothersome the side effects of medications were (0 to 4 Likert, 0 = not bothered, 4 = extremely bothered), and functional interference due to pain (0 to10 NRS; 0 = no interference, 10 = severe interference).
416
Results: Upon discharge, patients reported moderate pain intensity that had not decreased significantly at the time of the home interview (4.3 F 2.4 versus 3.9 F 3.1, P = .359). However, most patients (79%) used ED-prescribed medications and reported a high level of relief (7.2 F 2.1). The most common side effect was sleepiness (34%), but the subjects were not bothered by this side effect (0.9 F 1.4). Pain also interfered with patients’ ability to work (7.3 F 3.8), to go outside for social activities (6.5 F 4.1), and to walk (5.0 F 4.1). Conclusions: Pain intensity within 72 hours after discharge from the emergency department continued to be moderate. Despite this moderate pain, patients reported a high level of pain relief from their prescribed analgesics. They were not bothered substantially by medication side effects. However, interference with functions of daily living due to pain was substantial. Further studies are needed to examine the paradoxical reports of moderate pain intensity, high pain relief, and the substantial functional limitations after ED discharge. doi: 10.1016/j.jen.2004.07.032
27. Rapid Onset of Absorption with Olanzapine Orally Disintegrating Tablets. Robert F. Bergstrom, PhD,1 Malcolm Mitchell, MD,2 Jennifer Witcher, PharmD, 2 John P. Houston, MD, PhD,1 Angela L. Hill, PharmD,1 Cindy Coe Taylor, PharmD,1 Donald P. Hay, MD,1 Hong Liu-Seifert, PhD,1 1Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN 46285; 2Lilly Research Centre, Windlesham, Surrey, UK Purpose: Orally disintegrating tablets (ODT) of olanzapine may be useful as an alternative formulation for acutely agitated patients and are favored by clinicians because of a clinical impression of rapid action. In a posthoc analysis, we evaluated olanzapine concentration profiles following ODT and standard oral tablets (SOT) to assess differences in absorption. Design: Healthy subjects participated in three randomized, open-label crossover bioequivalence studies and received olanzapine SOT and ODT. Setting: Subjects remained at the study site from the evening prior to dosing until 36 hours later. Subjects fasted overnight until 4 hours after dosing. SOT was given with 100 mL water. ODT was given without water. Sample: Subjects were mostly white men with a mean age of 30 years. Methodology: Subjects were randomized to receive singledose olanzapine ODT either 5 mg (n = 19), 10 mg (n = 20), or 20 mg (n = 20) once and a corresponding dose of SOT on a separate occasion (with z13 days between dosing). Peak plasma concentration (Cmax), time of peak plasma concentration (Tmax), and plasma concentration over time (AUC) was measured. A posthoc analysis was conducted to assess the early onset of absorption. Results: ODT and SOT treatments exhibited similar plasma concentration profiles (Cmax, Tmax, AUC) and were statistically evaluated as being bioequivalent. In the 5-mg trial, 79% of ODT versus 0% of SOT patients had measurable olanzapine concentrations at 15 minutes. Significantly more subjects receiving ODT had higher olanzapine concentrations
JOURNAL OF EMERGENCY NURSING
30:5
October 2004
Conclusions: Oral contrast use in the blunt trauma population is not supported in the trauma/emergency medicine literature. Sharing this literature and changing from a practice of always using oral contrast to physician choice resulted in a decrease in oral contrast use by 89.4%. ED nurses (who were in the habit of routinely giving contrast as part of the protocol) now needed to be informed of this potential change in practice and reasons why the change was being made. In the early weeks of the study, some patients received contrast before the physician had the opportunity to instruct the nurse otherwise. However, it took only a few weeks before the nurses adapted to the change. Implications for further study would be a comparison of the number of nasogastric tubes inserted and the number of patients who vomit the contrast in a patient population where the use of oral contrast is the norm versus a patient population where the use of oral contrast is no longer the practice. doi: 10.1016/j.jen.2004.07.029
24. Patient Complaints Brought to Legal Counsel. Wilma Yu, RN, MSN, MS, CEN, Christianacare Health System, 30 Boulder Brook Dr, Wilmington, DE 19803 Purpose: Examining malpractice cases may aid in the development of recommendations that will improve patient care and reduce the health professional’s risk for malpractice litigation. The purpose of this study is to examine medical malpractice cases rejected from litigation to identify reasons individuals seek legal counsel. Design/Setting/Sample: This study is a retrospective review of attorney client records to determine patient complaints against health care providers. Only cases rejected for litigation are examined. This group represents the majority of complaintants and had not been previously studied. Client records are from a medical malpractice attorney group in Delaware. Files were released to the investigator with patient identifying data removed. Methodology: The study reviewed the 288 cases filed with the practice between 1994 and 1998. Of these, 192 files contained sufficient data for analysis with 392 complaints identified by the investigator from patient or family descriptions of the perceived incidents as related to legal counsel. Results: The primary factors identified for dissatisfaction were communication problems (n = 95) including lack of or conf licting information, timely notification, not listening, not answering questions, not being taken seriously and rudeness. Secondary were treatment issues (n = 89) involving adverse outcomes and refusal by ED to admit, (3) emotional issues (n = 75) including grief reactions, anger, threats to self image and major emotional crisis unrelated to illness or injury, (4) perceived malpractice or negligence (n = 74) with misdiagnosis, delayed treatment, falls, medication errors, physician notification promptness, inattention and neglect and (5) patient issues due to financial concerns.
October 2004
30:5
Conclusions: The subjects in this study instituted legal malpractice action against their health care providers. Communication and sensitivity issues were consistently identified from the legal records. Four areas were identified that health care providers could consider improving in order to reduce their risk of litigation: (1) develop excellent communication skills; (2) become aware of provider behaviors that lead to dissatisfaction, such as not listening, not acknowledging patient concerns, rudeness, failing to provide adequate information; (3) recognize emotional issues in patients and families that heighten their assessment of care; and (4) develop and implement strategies for acute and ongoing emotional support for patients and families experiencing adverse events or outcomes. Understanding the issues, training in effective communication, and developing support skills and resources may help to improve patient and family care and reduce exposure to litigation. Future research would involve larger study groups in other geographic locations. Due to patient and staff stressors innately present in the emergency department, dissatisfaction will occur. The data would be useful in developing a program for ED staff to become more proficient in communication skills with heightened awareness of dissatisfaction issues. doi: 10.1016/j.jen.2004.07.030
25. Pediatric Emergency Department Utilization for Nonurgent Complaints. Kimberly Childers, RN, MSN, CEN, CPNP, Texas Children’s Hospital, 6621 Fannin St, A210/MC 1-1481, Houston, TX 77030-2399 Purpose: Approximately 1 of 4 ED visits is a pediatric visit. Data from the National Center for Health Statistics indicates that between one third and half of these visits are for a nonurgent complaint. The purpose of this study was to identify reasons for nonurgent ED utilization. Design: A descriptive design was used. Setting: This study was conducted in the emergency department of a tertiary children’s hospital located in the southwestern United States. This emergency department experiences approximately 70,000 pediatric-only visits per year. Sample: The sample consisted of 256 randomly selected English-speaking and Spanish-speaking families who had visited the urgent care area of the emergency department from May 1–June 30 of 2002 and had been identified as having a nonurgent discharge diagnosis code agreed to participate. All patients had heath insurance. Methodology: Telephone interviews were conducted in Spanish or English. Parents were asked questions targeting the following areas: (1) parental/child demographics, (2) past medical care utilization, (3) current illness experience, and (4) ED experience. Interview questions resulted from a pilot study of 39 families who were interviewed in the urgent care area during July 2002. Information from these open-ended questions provided the basis for the telephone interview, which consisted of 29 multiple-choice questions.
JOURNAL OF EMERGENCY NURSING
415
RESEARCH ABSTRACTS
Results: Interviews were conducted in English (84%) and Spanish (16%). Commonly cited reasons for utilization of the emergency department for non-urgent complaints were: (1) perceived advantages over doctor’s office (26% cited access to specialists in the emergency department and increased time spent with patient by emergency physician as key), (2) access to care (57%—doctor’s office was closed), and (3) limited knowledge of managed care (50% had been with their health insurance plan for less than 1 year). Hispanic parents reported greater value in the ED than Caucasians in this sample. The majority of parents (94%) reported established relationships with their regular doctors. Conclusions: Interventions should be aimed at qualifying need for extended hours access, creating extended hours network of providers, and putting in place a communication program that would allow users to identify extended hours care. doi: 10.1016/j.jen.2004.07.031
26. Postdischarge Pain Intensity and Functional Status of Patients Who Presented to the Emergency Department in Pain. Garrett Chan, RN, MS, CEN, Martha L. Neighbor MD, Larry L. LaBossiere, (LT/NC/USN), RN, MS, CEN, Kathleen A. Puntillo, RN, DNSc, FAAN, University of California, San Francisco, Department of Physiological Nursing, 2 Koret Way, Box 0160, San Francisco, CA 94143-0610 Purpose: Little is known about how discharge interventions affect pain relief, produce bothersome side effects, or how continued pain interferes with functional status of patients after discharge from the emergency department. The purpose of this study was to evaluate the discharge pain management interventions after an ED visit and to investigate how pain intensity inf luenced functional status of patients who presented to the emergency department with a chief complaint of pain. Design/Setting: This prospective, descriptive study was conducted at 2 level I trauma center hospitals in California. Sample: While in the emergency department, 29 patients consented to participate in follow-up phone calls from a larger sample of 180 subjects participating in a study investigating the experiences of pain and pain management in the emergency department. The 29 subjects had presented to the emergency department with chief complaints of abdominal pain (n = 8), chronic pain (n = 10), abscess (n = 2), and trauma-related pain (n = 9). Methodology: As part of the larger study, the study patients reported pain intensity upon ED discharge using a 0 to 10 numeric rating scale (NRS) (0 = no pain, 10 = worst possible pain). Follow-up data were collected via telephone interview an average of 72 hours after discharge. Questionnaire items assessed aspects of pain including pain intensity (0 to 10 NRS), amount of pain relief (0 to 10 NRS; 0 = no relief, 10 = complete relief ) how bothersome the side effects of medications were (0 to 4 Likert, 0 = not bothered, 4 = extremely bothered), and functional interference due to pain (0 to10 NRS; 0 = no interference, 10 = severe interference).
416
Results: Upon discharge, patients reported moderate pain intensity that had not decreased significantly at the time of the home interview (4.3 F 2.4 versus 3.9 F 3.1, P = .359). However, most patients (79%) used ED-prescribed medications and reported a high level of relief (7.2 F 2.1). The most common side effect was sleepiness (34%), but the subjects were not bothered by this side effect (0.9 F 1.4). Pain also interfered with patients’ ability to work (7.3 F 3.8), to go outside for social activities (6.5 F 4.1), and to walk (5.0 F 4.1). Conclusions: Pain intensity within 72 hours after discharge from the emergency department continued to be moderate. Despite this moderate pain, patients reported a high level of pain relief from their prescribed analgesics. They were not bothered substantially by medication side effects. However, interference with functions of daily living due to pain was substantial. Further studies are needed to examine the paradoxical reports of moderate pain intensity, high pain relief, and the substantial functional limitations after ED discharge. doi: 10.1016/j.jen.2004.07.032
27. Rapid Onset of Absorption with Olanzapine Orally Disintegrating Tablets. Robert F. Bergstrom, PhD,1 Malcolm Mitchell, MD,2 Jennifer Witcher, PharmD, 2 John P. Houston, MD, PhD,1 Angela L. Hill, PharmD,1 Cindy Coe Taylor, PharmD,1 Donald P. Hay, MD,1 Hong Liu-Seifert, PhD,1 1Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN 46285; 2Lilly Research Centre, Windlesham, Surrey, UK Purpose: Orally disintegrating tablets (ODT) of olanzapine may be useful as an alternative formulation for acutely agitated patients and are favored by clinicians because of a clinical impression of rapid action. In a posthoc analysis, we evaluated olanzapine concentration profiles following ODT and standard oral tablets (SOT) to assess differences in absorption. Design: Healthy subjects participated in three randomized, open-label crossover bioequivalence studies and received olanzapine SOT and ODT. Setting: Subjects remained at the study site from the evening prior to dosing until 36 hours later. Subjects fasted overnight until 4 hours after dosing. SOT was given with 100 mL water. ODT was given without water. Sample: Subjects were mostly white men with a mean age of 30 years. Methodology: Subjects were randomized to receive singledose olanzapine ODT either 5 mg (n = 19), 10 mg (n = 20), or 20 mg (n = 20) once and a corresponding dose of SOT on a separate occasion (with z13 days between dosing). Peak plasma concentration (Cmax), time of peak plasma concentration (Tmax), and plasma concentration over time (AUC) was measured. A posthoc analysis was conducted to assess the early onset of absorption. Results: ODT and SOT treatments exhibited similar plasma concentration profiles (Cmax, Tmax, AUC) and were statistically evaluated as being bioequivalent. In the 5-mg trial, 79% of ODT versus 0% of SOT patients had measurable olanzapine concentrations at 15 minutes. Significantly more subjects receiving ODT had higher olanzapine concentrations
JOURNAL OF EMERGENCY NURSING
30:5
October 2004