- Email: [email protected]
304 Appropriateness of Epinephrine Use in Emergency Department Anaphylaxis Patients
Research Forum Abstracts
304
Appropriateness of Epinephrine Use in Emergency Department Anaphylaxis Patients
Baalmann DV, Hagan JB, Li JTC, Hess EP, Campbell RL/Mayo Clinic, Rochester, MN
Study Objectives: Anaphylaxis is a potentially fatal allergic reaction that is most commonly treated in the emergency department (ED). Epinephrine is the treatment of choice for anaphylaxis. Studies have demonstrated low rates of ED epinephrine administration among patients with anaphylaxis suggesting that anaphylaxis is frequently undertreated in the ED. However, there have been no prospective studies evaluating ED epinephrine administration based on individual patient presentations to estimate the appropriateness of ED anaphylaxis management. The objective of our study was to assess appropriateness of ED epinephrine utilization in the management of anaphylaxis. Methods: This was a prospective observational study involving ED patients who presented with symptoms of a suspected allergic reaction or anaphylaxis to a single academic medical center with 73,000 annual patient visits. Patients and ED providers completed questionnaires regarding symptom onset, trigger, signs and symptoms and out-of-hospital treatment. Two board-certified allergists independently reviewed the prospectively collected patient data as well as electronic health records to determine if the cases represented anaphylaxis and if ED utilization of epinephrine was appropriate based on consensus decision after independent review. Categorical features are reported with frequency counts and percentages with corresponding 95% confidential intervals (CIs). Results: One hundred seventy-four patients were enrolled between April 2010 through March 2013, of which 61 (35%) were confirmed to have anaphylaxis after case review by 2 board-certified allergists. Among the 61 patients, 38 (62%) were female and the median age was 37 years old; 13 (21%) were children (< 18 years of age). The overall concordance between the allergists with regard to the determination of appropriateness of ED epinephrine administration or nonadministration was 95%. Twenty-four (39%) patients received epinephrine and 37 (61%) did not receive epinephrine in the ED. Among the 37 patients who did not receive epinephrine in the ED, 23 (62%) had received epinephrine prior to arrival. Overall, 47 (78%) patients received epinephrine either prior to ED arrival or in the ED. Of the 24 patients who received epinephrine in the ED, the allergists determined that epinephrine administration was appropriate in all cases (100%, 95% CI 86%-100%). Of the 37 patients who did not receive epinephrine, the allergists determined that non-administration of epinephrine was appropriate in 36 (97%, 95% CI 86%-99%) of the patients, but determined that epinephrine should have been administered in 1 (3%, 95% CI 0.3%-9%) patient who did not receive it. Thus, overall, the allergists determined that ED management was appropriate in 60 of 61 (98%, 95% CI 91%-99%) patients with anaphylaxis. Conclusion: Although over 60% of anaphylaxis patients did not receive epinephrine in the ED, the management was deemed to be appropriate after allergist review in 98% of cases. Previous retrospective studies may underestimate appropriateness of anaphylaxis ED management particularly when out-of-hospital epinephrine administration is not reported.
305
Efficiency and Effectiveness of a Chest Pain Protocol in an Urban Hospital Emergency Department
Kumar VA, Antoniolli M, Suguitan M, Kulek A, Papale N, Poltouri K, Fritz HA, Reed B, Mohamad T, O’Neil B, Levy P/Wayne State University, Detroit, MI
Study Objectives: Chest pain (CP) is a very common presenting complaint of patients presenting to the emergency department (ED) of which a very small percentage truly have acute coronary syndrome. This leads to overuse of resources and unnecessary admissions. To improve upon this, a comprehensive CP protocol was implemented at our facility in November 2012. The objective of this study is to test the efficiency and effectiveness of the CP protocol, which encompasses all aspects of management from inpatient treatment to outpatient follow-up. Methods: This is a retrospective cohort of patients visiting a single center ED with a chief complaint of chest pain during a one-year period (6 months each pre and post protocol). The CP protocol utilizes the thrombolysis in myocardial infarction (TIMI) risk score, electrocardiography and contemporary sensitivity troponin I to triage patients to one of the following groups: low risk (TIMI 0,1) who are discharged from the ED with an appointment in our cardiology clinic within 48 hours; intermediate risk (TIMI 2,3) who are admitted for observation; high risk
S108 Annals of Emergency Medicine
(TIMI 4,5 or 6 with a negative troponin) who are admitted inpatients under the cardiology service; and highest risk (any positive troponin) who are admitted to the coronary care unit. Charts for the post-protocol period were evaluated with tracking of adherence to the protocol and, for both periods, outcome measures (upgrade of service from the observation unit, 30-day ED recidivism, and 60-day mortality [using social security death index]) were compiled. Statistical analysis was performed using SAS. Results: There were a total of 2985 patients pre and 2876 post protocol. The pre and post protocol population were demographically similar with mean ages of 47.1 and 47.7 years, respectively; 52% in both the groups were male. There was a 9.2 % increase in ED discharges post protocol along with a drop of 8.8% in inpatient admissions (Table). The majority of patients in both periods were considered low risk (66% preand 68% post-protocol), more of whom were discharged home from the ED postprotocol (79% versus 89%; diff ¼ 10% [95% CI: 8.2, 11.8]). Among the patients who were admitted to the observation unit, there was a statistically significant drop from 14.0% to 4.3% (diff ¼ -9.7% [-11.2, -8.3]) patients upgraded to inpatient status. The TIMI risk scores (available for 1827 pre and 1766 post-protocol patients) were used to compare ED recidivism. The recidivism was uncommon in either period but greater in the low risk group (diff¼ 9% [1,18]) and lesser among the highest risk patients post-protocol (diff¼ -9% [-13.6, -4.7]). Sixty-day mortality rates were similar. Adherence to the protocol was modest with physicians failing to document a calculated TIMI risk score 75% of the time and compliance with cardiology follow-up in only 45% of low-risk patients. Conclusion: Post-initiation of our CP protocol, ED discharges and hospital admissions decreased, and fewer patients were upgraded from observation status. However, ED recidivism was higher among low risk CP patients and compliance with outpatient follow-up by patients was poor. While our approach to CP patient disposition appears to be efficient, improving adherence to outpatient components of the protocol are needed to enhance clinical effectiveness.
Table. Comparison Pre and Post Protocol Outcome
Pre-Protocol (n[ 2985)
Post-Protocol (n[ 2876)
Discharged from 1666 (55.8%) the ED Admit to Observation 429 (14.3%) Unit Admit to Inpatient Unit 890 (29.8%) 60-day mortality 18 (0.6%) ED Recidivism 154 (5.2%) TIMI Risk Score Low Risk 79 (51%) Intermediate Risk 47 (31%) High Risk 11 (7%) Highest Risk 17 (11%)
306
Difference (95% CI)
1868 (65%)
9.2% (6.6, 11.6)
407 (14%)
0.3% (1.5, 2.0)
601 (21%) 14 (0.5%) 90 (3.1%)
8.8% (11.1, 6.7) 0.1% (0.5, 0.5) 2.1% (1, 3)
54 27 7 2
(60%) (30%) (8%) (2%)
9% 1% 1% 9%
(1, 18) (7, 9) (1, 7) (13.6, 4.7)
Do Clinicians Recommend Cardiovascular Testing Less Frequently in Women? An a Priori Secondary Analysis of Videographic Data in the Chest Pain Choice Trial
Anderson RT, Gilani WI, Leblanc A, Branda ME, Bellolio MF, Phelan S, Hess EP/Mayo Medical School, Rochester, MN; Mayo Clinic, Rochester, MN
Study Objectives: Cardiovascular disease affects more women than men in the U.S., yet women presenting to the emergency department (ED) with chest pain less frequently undergo cardiac testing. A prior survey-based study by Golden, Chang, and Hollander suggests that lower rates of clinician recommendation for cardiac testing may partially explain this difference. We sought to measure the frequency of clinician recommendation for cardiac testing in the ED and the rate of cardiac testing by sex during the index ED visit. Methods: The Chest Pain Choice trial was a single-center patient-level parallel randomized trial conducted at an academic tertiary care ED with 73,000 annual patient visits. Patients presenting to the ED with chest pain being considered for admission to the ED observation unit for cardiac stress testing were randomized to shared decisionmaking or usual care. We analyzed the following data: study arm; age; sex; cardiovascular risk factors; and whether the patient underwent cardiac testing
Volume 64, no. 4s : October 2014
304
Appropriateness of Epinephrine Use in Emergency Department Anaphylaxis Patients
Baalmann DV, Hagan JB, Li JTC, Hess EP, Campbell RL/Mayo Clinic, Rochester, MN
Study Objectives: Anaphylaxis is a potentially fatal allergic reaction that is most commonly treated in the emergency department (ED). Epinephrine is the treatment of choice for anaphylaxis. Studies have demonstrated low rates of ED epinephrine administration among patients with anaphylaxis suggesting that anaphylaxis is frequently undertreated in the ED. However, there have been no prospective studies evaluating ED epinephrine administration based on individual patient presentations to estimate the appropriateness of ED anaphylaxis management. The objective of our study was to assess appropriateness of ED epinephrine utilization in the management of anaphylaxis. Methods: This was a prospective observational study involving ED patients who presented with symptoms of a suspected allergic reaction or anaphylaxis to a single academic medical center with 73,000 annual patient visits. Patients and ED providers completed questionnaires regarding symptom onset, trigger, signs and symptoms and out-of-hospital treatment. Two board-certified allergists independently reviewed the prospectively collected patient data as well as electronic health records to determine if the cases represented anaphylaxis and if ED utilization of epinephrine was appropriate based on consensus decision after independent review. Categorical features are reported with frequency counts and percentages with corresponding 95% confidential intervals (CIs). Results: One hundred seventy-four patients were enrolled between April 2010 through March 2013, of which 61 (35%) were confirmed to have anaphylaxis after case review by 2 board-certified allergists. Among the 61 patients, 38 (62%) were female and the median age was 37 years old; 13 (21%) were children (< 18 years of age). The overall concordance between the allergists with regard to the determination of appropriateness of ED epinephrine administration or nonadministration was 95%. Twenty-four (39%) patients received epinephrine and 37 (61%) did not receive epinephrine in the ED. Among the 37 patients who did not receive epinephrine in the ED, 23 (62%) had received epinephrine prior to arrival. Overall, 47 (78%) patients received epinephrine either prior to ED arrival or in the ED. Of the 24 patients who received epinephrine in the ED, the allergists determined that epinephrine administration was appropriate in all cases (100%, 95% CI 86%-100%). Of the 37 patients who did not receive epinephrine, the allergists determined that non-administration of epinephrine was appropriate in 36 (97%, 95% CI 86%-99%) of the patients, but determined that epinephrine should have been administered in 1 (3%, 95% CI 0.3%-9%) patient who did not receive it. Thus, overall, the allergists determined that ED management was appropriate in 60 of 61 (98%, 95% CI 91%-99%) patients with anaphylaxis. Conclusion: Although over 60% of anaphylaxis patients did not receive epinephrine in the ED, the management was deemed to be appropriate after allergist review in 98% of cases. Previous retrospective studies may underestimate appropriateness of anaphylaxis ED management particularly when out-of-hospital epinephrine administration is not reported.
305
Efficiency and Effectiveness of a Chest Pain Protocol in an Urban Hospital Emergency Department
Kumar VA, Antoniolli M, Suguitan M, Kulek A, Papale N, Poltouri K, Fritz HA, Reed B, Mohamad T, O’Neil B, Levy P/Wayne State University, Detroit, MI
Study Objectives: Chest pain (CP) is a very common presenting complaint of patients presenting to the emergency department (ED) of which a very small percentage truly have acute coronary syndrome. This leads to overuse of resources and unnecessary admissions. To improve upon this, a comprehensive CP protocol was implemented at our facility in November 2012. The objective of this study is to test the efficiency and effectiveness of the CP protocol, which encompasses all aspects of management from inpatient treatment to outpatient follow-up. Methods: This is a retrospective cohort of patients visiting a single center ED with a chief complaint of chest pain during a one-year period (6 months each pre and post protocol). The CP protocol utilizes the thrombolysis in myocardial infarction (TIMI) risk score, electrocardiography and contemporary sensitivity troponin I to triage patients to one of the following groups: low risk (TIMI 0,1) who are discharged from the ED with an appointment in our cardiology clinic within 48 hours; intermediate risk (TIMI 2,3) who are admitted for observation; high risk
S108 Annals of Emergency Medicine
(TIMI 4,5 or 6 with a negative troponin) who are admitted inpatients under the cardiology service; and highest risk (any positive troponin) who are admitted to the coronary care unit. Charts for the post-protocol period were evaluated with tracking of adherence to the protocol and, for both periods, outcome measures (upgrade of service from the observation unit, 30-day ED recidivism, and 60-day mortality [using social security death index]) were compiled. Statistical analysis was performed using SAS. Results: There were a total of 2985 patients pre and 2876 post protocol. The pre and post protocol population were demographically similar with mean ages of 47.1 and 47.7 years, respectively; 52% in both the groups were male. There was a 9.2 % increase in ED discharges post protocol along with a drop of 8.8% in inpatient admissions (Table). The majority of patients in both periods were considered low risk (66% preand 68% post-protocol), more of whom were discharged home from the ED postprotocol (79% versus 89%; diff ¼ 10% [95% CI: 8.2, 11.8]). Among the patients who were admitted to the observation unit, there was a statistically significant drop from 14.0% to 4.3% (diff ¼ -9.7% [-11.2, -8.3]) patients upgraded to inpatient status. The TIMI risk scores (available for 1827 pre and 1766 post-protocol patients) were used to compare ED recidivism. The recidivism was uncommon in either period but greater in the low risk group (diff¼ 9% [1,18]) and lesser among the highest risk patients post-protocol (diff¼ -9% [-13.6, -4.7]). Sixty-day mortality rates were similar. Adherence to the protocol was modest with physicians failing to document a calculated TIMI risk score 75% of the time and compliance with cardiology follow-up in only 45% of low-risk patients. Conclusion: Post-initiation of our CP protocol, ED discharges and hospital admissions decreased, and fewer patients were upgraded from observation status. However, ED recidivism was higher among low risk CP patients and compliance with outpatient follow-up by patients was poor. While our approach to CP patient disposition appears to be efficient, improving adherence to outpatient components of the protocol are needed to enhance clinical effectiveness.
Table. Comparison Pre and Post Protocol Outcome
Pre-Protocol (n[ 2985)
Post-Protocol (n[ 2876)
Discharged from 1666 (55.8%) the ED Admit to Observation 429 (14.3%) Unit Admit to Inpatient Unit 890 (29.8%) 60-day mortality 18 (0.6%) ED Recidivism 154 (5.2%) TIMI Risk Score Low Risk 79 (51%) Intermediate Risk 47 (31%) High Risk 11 (7%) Highest Risk 17 (11%)
306
Difference (95% CI)
1868 (65%)
9.2% (6.6, 11.6)
407 (14%)
0.3% (1.5, 2.0)
601 (21%) 14 (0.5%) 90 (3.1%)
8.8% (11.1, 6.7) 0.1% (0.5, 0.5) 2.1% (1, 3)
54 27 7 2
(60%) (30%) (8%) (2%)
9% 1% 1% 9%
(1, 18) (7, 9) (1, 7) (13.6, 4.7)
Do Clinicians Recommend Cardiovascular Testing Less Frequently in Women? An a Priori Secondary Analysis of Videographic Data in the Chest Pain Choice Trial
Anderson RT, Gilani WI, Leblanc A, Branda ME, Bellolio MF, Phelan S, Hess EP/Mayo Medical School, Rochester, MN; Mayo Clinic, Rochester, MN
Study Objectives: Cardiovascular disease affects more women than men in the U.S., yet women presenting to the emergency department (ED) with chest pain less frequently undergo cardiac testing. A prior survey-based study by Golden, Chang, and Hollander suggests that lower rates of clinician recommendation for cardiac testing may partially explain this difference. We sought to measure the frequency of clinician recommendation for cardiac testing in the ED and the rate of cardiac testing by sex during the index ED visit. Methods: The Chest Pain Choice trial was a single-center patient-level parallel randomized trial conducted at an academic tertiary care ED with 73,000 annual patient visits. Patients presenting to the ED with chest pain being considered for admission to the ED observation unit for cardiac stress testing were randomized to shared decisionmaking or usual care. We analyzed the following data: study arm; age; sex; cardiovascular risk factors; and whether the patient underwent cardiac testing
Volume 64, no. 4s : October 2014