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271: Ethical Conduction of Research in the Tactical, Austere Setting
ICEM 2008 Scientific Abstract Program of care,” in response to mounting evidence about medication errors at transition points of care. Medication reconciliation (Med Recon) involves gathering a comprehensive list of home medications and over-the-counter supplements for input into a patient’s medical record. Study Objectives: This study sought to determine whether initiating Med Recon would increase the time required to complete triage (T-duration) in the electronic medical record (EMR) we use at our high-volume urban ED. Methods: Data for this retrospective chart review was collected as part of routine patient care in our EMR for all adult patients presenting to the ED. Our EMR records time stamps at the initiation and at the end of the triage note. T-duration was calculated by comparing these 2 times for 3 time periods: Period 1 - 4 months prior to implementation of computerized med recon; Period 2 - one month after implementation; Period 3 - the subsequent 4 months. Cases where the apparent Tduration was ⬎ 90 minutes were excluded as outliers. Groups were analyzed using the Mann-Whitney U test. Results: 78,365 cases were analyzable in all groups after 0.2% of cases were excluded for T-duration ⬎ 90 minutes. The mean T-duration was 5.94, 6.74, and 6.27 minutes for time periods 1, 2, and 3 respectively. Differences between the means were significant to p ⬍0.0001 for all 3 comparison groups. Conclusion: Implementation of computerized Med Recon in the emergency department resulted in a small but measurable increase in the time required to complete triage. To our knowledge, this report is the first to measure the change in duration of triage after implementation of electronic Med Recon in the emergency department.
271
Ethical Conduction of Research in the Tactical, Austere Setting
McManus Jr JG, McClinton A, Eastridge B/Brooke Army Medical Center, Ft. Sam Houston, TX; US Army Institute of Surgical Research, Ft. Sam Houston, TX
Study Objectives: The conduction of research in the combat and disaster environment share many of the same fundamental principles and regulations that govern civilian biomedical research. Despite some similarities, Department of Defense research has additional requirements designed to preserve servicemembers’ informed consent rights, ethical standards and information that may be deemed classified. We reviewed studies that have been approved for conduction of research in current combat operations. Methods: This is a descriptive, retrospective study of protocols that have currently been approved for conduction of research in Operation Iraqi Freedom and Operation Enduring Freedom. Results: During the period of July 2005 through October 2007, 38 retrospective chart review protocols, 7 prospective studies requiring consent or an alteration of the consent document and 12 prospective observational studies were submitted through the Deployed Research Committee in Iraq for review and approval at the Brooke Army Medical Center Institutional Review Board (IRB). A total of 55 protocols were approved by the IRB for implementation in the Iraq combat theater. Most of these protocols involved trauma care treatment. One prospective study investigating the effects of blast-concussive injuries on US Soldiers in Iraq requiring informed consent was reviewed and approved. Conclusions: The conduct of military medical research has and will make an important contribution to both the civilian and military medical community. Although policies and regulations to conduct research and release associated findings often seem cumbersome and stringent, these added hurdles serve not only to ensure protection of human subjects, but also to prevent unintentional aid to unfriendly forces.
272
Do Initial PH Level and Sodium Bicarbonate Administration Have Relationship With First Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest Patients?
Hsu CW/Tri-service General Hospital, Taipei, Taiwan
Study Objectives: We assess the relationship of initial pH level and sodium bicarbonate administration with first return of spontaneous circulation (ROSC) in out- of-hospital cardiac arrest (OHCA) patients in the emergency department (ED). Methods: We conducted 1-year retrospective cohort study. Patients with OHCA were recruited from the ED of a tertiary hospital ED from January 1, 2005 to December 31, 2005. All eligible subjects in the ED were stratified into 2 groups
Volume , . : April
according to whether there was first return of spontaneous circulation (ROSC) after resuscitation. Baseline characteristics, including age, sex, medical history, initial ECG rhythm as well as beginning time of cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS), beginning time of first dose of epinephrine and bicarbonate, total doses of epinephrine and sodium bicarbonate and initial pH value were registered well before ROSC. Analysis of the difference between groups was tested by independent t-test in continuous data or Chi-Square test in categorical data. Results: A total of 90 eligible subjects (48 men and 42 women, mean age: 67.1⫾18.2 years) were recruited. The sex, percentages of sodium bicarbonate administration, initial rhythm of cardiac arrest, beginning time of CPR and ACLS, beginning time of first epinephrine and total doses of epinephrine were similar between groups. The initial pH value of ROSC group is higher than those without. (6.990⫾0.224 vs. 6.87⫾0.253). The total dose of sodium bicarbonate administration is higher in ROSC group compared with those without. (1.84⫾3.11 vs 0.8⫾1.98). Conclusion: A high initial pH level in the ED is an important predictor of ROSC in patients with OHCA. The benefit of administration sodium bicarbonate in OHCA need to be further clarified in the future randomized study.
273
How Has the Extension of Drinking Hours in England Affected Patterns of Emergency Department Use at a Large Urban Hospital?
Rudge G, Cheng K, Fillingham S, Cooke M, Stevens A/University of Birmingham, Birmingham, United Kingdom
Study Objectives: In November 2005, a change in alcohol licensing legislation extended the hours in which alcohol could be consumed in pubs and nightclubs across England and Wales. Most pubs could only serve until 11:00pm at weekends and 10:30pm in the week. Nightclubs could usually serve until 2:00am. Following the relaxation of the hours, most cities in England have outlets selling alcohol well into the early hours of the morning. Drunkenness and related violence are of grave concern in British cities recently, so this change in policy was of interest to providers of emergency medical services. However, owing to poor capture of presentation factors in British emergency departments (EDs), it has been difficult to determine if there has been a significant effect on caseloads. Some small-scale research published recently has suggested there have been significant increases in alcohol-related attendances, but at the time of writing no large scale study has been published. This study explores this question using a very large dataset. Methods: An observational before and after study was carried out using 2 52week periods before and after the change in legislation. Routinely collected attendance data, including a description of the main presenting complaint were examined using a series of text searching algorithms. Frequency of attendance of 2 distinct (but not mutually exclusive) groups, alcohol related or assault, was elucidated. Demographic and temporal patterns of presentation in these groups in both periods were analyzed and compared. The study was set in the hospital which provides most of the adult emergency care for the central area of Birmingham, the second largest city in England. Results: All cause attendance was 137,680 in period 1 and 138,655 in period 2. Alcohol-related presentations were 2.75% of all attendances in period 1 and 2.85% of all presentations in period 2. Assaults were 3.39% and 3.51% respectively. None of these increases were statistically significant. The demographic structure of presentations was surprising. In the alcohol-related group attendances did not peak in the 20-24 age group as expected but in the 40-44 age group, with large numbers also presenting in their late thirties. Assault victims did peak in the 20-24 age group as expected. There were apparent seasonal differences, with mean daily attendances in July and August being much larger in the year after the change, but attendance in winter and spring months being broadly similar or fewer. The paper goes on to discuss some of the possible reasons for this. Conclusion: The change in licensing hours in Birmingham was not associated with a significant increase in assault and alcohol-related ED attendance overall. However, these cases still represent several thousand preventable visits a year to the ED. The finding that large number of drinkers in their thirties and forties attended the ED suggests that this group are just as important a target for public health intervention as the younger drinkers who have been previously identified as a particular cause for concern.
Annals of Emergency Medicine 553
271
Ethical Conduction of Research in the Tactical, Austere Setting
McManus Jr JG, McClinton A, Eastridge B/Brooke Army Medical Center, Ft. Sam Houston, TX; US Army Institute of Surgical Research, Ft. Sam Houston, TX
Study Objectives: The conduction of research in the combat and disaster environment share many of the same fundamental principles and regulations that govern civilian biomedical research. Despite some similarities, Department of Defense research has additional requirements designed to preserve servicemembers’ informed consent rights, ethical standards and information that may be deemed classified. We reviewed studies that have been approved for conduction of research in current combat operations. Methods: This is a descriptive, retrospective study of protocols that have currently been approved for conduction of research in Operation Iraqi Freedom and Operation Enduring Freedom. Results: During the period of July 2005 through October 2007, 38 retrospective chart review protocols, 7 prospective studies requiring consent or an alteration of the consent document and 12 prospective observational studies were submitted through the Deployed Research Committee in Iraq for review and approval at the Brooke Army Medical Center Institutional Review Board (IRB). A total of 55 protocols were approved by the IRB for implementation in the Iraq combat theater. Most of these protocols involved trauma care treatment. One prospective study investigating the effects of blast-concussive injuries on US Soldiers in Iraq requiring informed consent was reviewed and approved. Conclusions: The conduct of military medical research has and will make an important contribution to both the civilian and military medical community. Although policies and regulations to conduct research and release associated findings often seem cumbersome and stringent, these added hurdles serve not only to ensure protection of human subjects, but also to prevent unintentional aid to unfriendly forces.
272
Do Initial PH Level and Sodium Bicarbonate Administration Have Relationship With First Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest Patients?
Hsu CW/Tri-service General Hospital, Taipei, Taiwan
Study Objectives: We assess the relationship of initial pH level and sodium bicarbonate administration with first return of spontaneous circulation (ROSC) in out- of-hospital cardiac arrest (OHCA) patients in the emergency department (ED). Methods: We conducted 1-year retrospective cohort study. Patients with OHCA were recruited from the ED of a tertiary hospital ED from January 1, 2005 to December 31, 2005. All eligible subjects in the ED were stratified into 2 groups
Volume , . : April
according to whether there was first return of spontaneous circulation (ROSC) after resuscitation. Baseline characteristics, including age, sex, medical history, initial ECG rhythm as well as beginning time of cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS), beginning time of first dose of epinephrine and bicarbonate, total doses of epinephrine and sodium bicarbonate and initial pH value were registered well before ROSC. Analysis of the difference between groups was tested by independent t-test in continuous data or Chi-Square test in categorical data. Results: A total of 90 eligible subjects (48 men and 42 women, mean age: 67.1⫾18.2 years) were recruited. The sex, percentages of sodium bicarbonate administration, initial rhythm of cardiac arrest, beginning time of CPR and ACLS, beginning time of first epinephrine and total doses of epinephrine were similar between groups. The initial pH value of ROSC group is higher than those without. (6.990⫾0.224 vs. 6.87⫾0.253). The total dose of sodium bicarbonate administration is higher in ROSC group compared with those without. (1.84⫾3.11 vs 0.8⫾1.98). Conclusion: A high initial pH level in the ED is an important predictor of ROSC in patients with OHCA. The benefit of administration sodium bicarbonate in OHCA need to be further clarified in the future randomized study.
273
How Has the Extension of Drinking Hours in England Affected Patterns of Emergency Department Use at a Large Urban Hospital?
Rudge G, Cheng K, Fillingham S, Cooke M, Stevens A/University of Birmingham, Birmingham, United Kingdom
Study Objectives: In November 2005, a change in alcohol licensing legislation extended the hours in which alcohol could be consumed in pubs and nightclubs across England and Wales. Most pubs could only serve until 11:00pm at weekends and 10:30pm in the week. Nightclubs could usually serve until 2:00am. Following the relaxation of the hours, most cities in England have outlets selling alcohol well into the early hours of the morning. Drunkenness and related violence are of grave concern in British cities recently, so this change in policy was of interest to providers of emergency medical services. However, owing to poor capture of presentation factors in British emergency departments (EDs), it has been difficult to determine if there has been a significant effect on caseloads. Some small-scale research published recently has suggested there have been significant increases in alcohol-related attendances, but at the time of writing no large scale study has been published. This study explores this question using a very large dataset. Methods: An observational before and after study was carried out using 2 52week periods before and after the change in legislation. Routinely collected attendance data, including a description of the main presenting complaint were examined using a series of text searching algorithms. Frequency of attendance of 2 distinct (but not mutually exclusive) groups, alcohol related or assault, was elucidated. Demographic and temporal patterns of presentation in these groups in both periods were analyzed and compared. The study was set in the hospital which provides most of the adult emergency care for the central area of Birmingham, the second largest city in England. Results: All cause attendance was 137,680 in period 1 and 138,655 in period 2. Alcohol-related presentations were 2.75% of all attendances in period 1 and 2.85% of all presentations in period 2. Assaults were 3.39% and 3.51% respectively. None of these increases were statistically significant. The demographic structure of presentations was surprising. In the alcohol-related group attendances did not peak in the 20-24 age group as expected but in the 40-44 age group, with large numbers also presenting in their late thirties. Assault victims did peak in the 20-24 age group as expected. There were apparent seasonal differences, with mean daily attendances in July and August being much larger in the year after the change, but attendance in winter and spring months being broadly similar or fewer. The paper goes on to discuss some of the possible reasons for this. Conclusion: The change in licensing hours in Birmingham was not associated with a significant increase in assault and alcohol-related ED attendance overall. However, these cases still represent several thousand preventable visits a year to the ED. The finding that large number of drinkers in their thirties and forties attended the ED suggests that this group are just as important a target for public health intervention as the younger drinkers who have been previously identified as a particular cause for concern.
Annals of Emergency Medicine 553