- Email: [email protected]
307: Plain Chest Radiography is an Inadequate Screening Tool in Elderly Blunt Trauma Patients
Research Forum Abstracts ED diagnosis of pneumonia and time to antibiotics in hospitalized patients in geriatric patients (⬎ 65 years old) versus younger patients (⬍65 years old). Methods: This was a secondary analysis of a prospective, observational study of consecutive, ED pneumonia patients admitted at an academic hospital between September 2003 and April 2004. All patients were given a dx of CAP by ED physicians and admitted for inpatient care. Demographic information, clinical variables to calculate a Pneumonia Patient Outcomes Research Team (PORT) score, time to antibiotics, and discharge dx were collected. Descriptive statistics were utilized to describe this population. Fisher’s exact and an unpaired t-test were used to compare the groups. Results: Overall, 325 patients were enrolled during the study period. 48 (15%) were excluded for missing data. 134 patients were ⬎ 65 years and 143 patients ⬍ 65 years old. Time to antibiotic administration was similar between geriatric (mean 4.6 hours; 95% CI 4.0 to 5.2 hrs) and younger pateints (5.2 hours; 95% CI 4.5 to 5.9 hrs). Geriatric patients were more likely to have a confirmed diagnosis of pneumonia (69%) than younger patients (57%; OR 0.61; 95% CI 0.37, 1.00). Conclusions: There were no differences in the time to antibiotic administration in geriatric versus younger CAP patients and the time to administration was greater than 4 hours irrespective of age. While the specificity of the diagnosis of CAP appears better in geriatric patients, further efforts are needed to improve time to antibiotic administration in this age group.
305
Awareness of Stroke Symptoms in the Highest Risk Group: The Elderly
Bellolio MF, Vaidyanathan L, Kashyap R, Enduri S, Nash DL, Decker WW, Stead LG/Mayo Clinic College of Medicine. Division of Emergency Medicine Research, Rochester, MN
Study Objectives: To assess awareness of acute brain ischemia in geriatric patients presenting with acute ischemic stroke (AIS) or transient ischemic attack (TIA). Methods: We prospectively enrolled a consecutive cohort of patients presenting with AIS or TIA over a 17-month period. We collected demographic variables, time from symptom onset to presentation to the emergency department (ED), any reasons for delay in presentation, understanding of stroke symptoms, and knowledge of acute stroke treatment modalities. Results: The overall cohort consisted of 344 patients older than age 65 (41.6% of them older than 80 years). Fifty one percent males; 71.8% presented with AIS and 28.2% with TIA. A total of 81% had hypertension, 55% hyperlipidemia, 27% coronary artery disease, 27% Diabetes mellitus and 18% were active smokers. The median time from symptoms onset to presentation was 2.79 hrs (IQR 1.2510.96; range 10 minutes to 8 days). Delayed presentation was seen in both genders. Only 51.4% thought they were having a stroke or TIA. Regarding the nature of stroke onset, 212 (62.7%) thought that a stroke came on suddenly vs. gradually, and only a little over one half (57%) thought immediate presentation was crucial. One fifth of the cohort (21.8%) patients had heard of thrombolysis, though 23.4% of the cohort had a prior stroke and 26.3% a prior TIA. In the stratified analysis comparing 65-79 versus 80-98 years old (“old” and “oldest old“ groups), we found a statistical difference by sex, being women older than men (p⬍0.0001). A total of 85% of the “old”, compared to 73% of the “very old” group were dismissed home after their stroke or TIA with an odds ratio of 2.15 (95%CI 1.23 to 3.76; p⬍0.007). Interestingly, 26% of the old, compared to a 42 % of the very old group lived alone before the cerebrovascular accident (OR: 2.11; 95%CI 1.33 to 3.34; p⫽0.001), with 96% of the old and 89% of the very old patients independent in their daily activities. There was no difference in mode of arrival, hours from symptom onset to presentation or knowledge about cerebrovascular disease, between the “old” and “very old” groups. Conclusion: Community knowledge about stroke symptoms and treatment needs to be increased in the high risk group of patients older than 65 years.
306
DNR in Emergency Patients
Hogan TM, Waugh AD, Gallagher C, Chan SB/Resurrection Medical Center, Chicago, IL
Introduction: For patients presenting to the emergency department (ED) with terminal conditions or at the end of life, intervention may not be desired or appropriate.
S96 Annals of Emergency Medicine
Study Objectives: The study purpose is to examine the use and application of DNR (do not resuscitate) status in patients presenting to the ED, likely at the end of life. Methods: Urban community teaching hospital retrospective review of hospitalized ED patients with one of the following: hospice, known metastatic cancer, or known pancreatic cancer. Data included DNR status, mortality, pre-hospital and ED resource utilization. Kaplan-Meier survival curves compared mortality rates while adjusted hazard ratios (HR), and 95% confidence intervals were calculated using Cox Regression. Results: Of 215 patients, 22.8% had DNR status both in the ED and as inpatient (ED-DNR), an additional 36.7% had DNR status after admission (HOSP-DNR), and 40.5% never had DNR status (NO-DNR). At 26.5%, 55.7%, and 4.6%, EDDNR and HOSP-DNR both had unadjusted mortality higher than the NO-DNR group (HR⫽6.30; 95%CI: 1.90-20.9) and (HR⫽8.74; 95%CI: 3.07-24.8). KaplanMeier survival curve during the first 10 days of hospitalization were the same for EDDNR and HOSP-DNR. The ED-DNR group used less IV (P⫽0.009), medications (P⫽0.009), and ICU beds (P ⫽ 0.005). There were four ED intubations but none in the ED-DNR group. Conclusion: In this study of terminal ED patients, those with pre-existing DNR used fewer resources. Patients designated DNR while in the hospital have the same outcome as the pre-existing group. This group should have pre-hospital designation of DNR status to improve ED resource utilization.
307
Plain Chest Radiography is an Inadequate Screening Tool in Elderly Blunt Trauma Patients
Paula Jr. R, LeBlanc H/University of South Florida, Tampa, FL
Study Objectives: The purpose of this study is to determine the sensitivity of the chest or abdomen computed tomography (CT) compared to the chest radiograph in the elderly blunt trauma population. It is expected that the CT will identify many additional injuries that the chest radiograph failed to show. This study will help determine the utility of CT in elderly blunt trauma patients. The initial screening in a blunt trauma patient usually begins with a chest radiograph. Most recent research has shown a trend to include CT in addition to the radiograph. There is controversy over whether the chest CT is essential in picking up occult but serious injuries or whether it is being over utilized, as opposed to the abdomen CT which has been recognized as useful. There is an abundance of literature showing that chest or abdomen CT is better at picking up certain injuries than a chest radiograph. Many authors describe the chest CT as significantly more effective in detecting: pneumothorax, lung contusion, mediastinal hematomas, fractured ribs, scapula, sternum, and vertebrae, and that chest radiography was unreliable for screening for aortic injury. Trauma is the fifth leading cause of death in our elder patients. Analyses of trauma registries have shown elderly patients with rib fractures following blunt chest trauma have twice the mortality of younger patients with similar injuries. Bulger also found that for each additional rib fracture in the elderly, the mortality increased by 19%. However, just because a test identifies new information it does not mean it is necessary, or helpful the new data does not affect management or outcome. Plurad completed a seven-year retrospective chart review examining both significant findings on the imaging studies and the changes in management. The study did show a more effective identification of pneumothorax, hemothorax, rib fractures, and lung contusion by chest CT. However, the researchers felt that the identification of these injuries did not result in a large change in management. Methods: A retrospective review was performed on approximately 3 years of data (9/1/02 to 12/31/05) provided by the Tampa General Hospital trauma registry, which records consecutive trauma alert patients presenting to our Level I trauma center. All patients ⬎/⫽ 65 yrs old with blunt trauma were eligible, those enrolled had to have CXR, and abdomen or chest CT. Results: We found records available for review on 154 patients, 151 chest radiographs were performed, 105 chest CTs performed on 105 patients, and153 abdomen CTs. Either abdomen CT or chest was much more sensitive in detecting significant injuries. Conclusion: Computed tomography is a useful tool in detecting significant thoracoabdominal injuries missed by plain chest radiography in elderly trauma patients. Both abdomen and chest CT found more injuries than plain chest radiography. Injury detection is even more important in this patent population due to the proven increased morbidity with seemingly minor injuries such as rib fractures. The CT, and the chest CT specifically should be used as a screening tool in elderly trauma patients in order to maximally detect possibly significant injury.
Volume , . : September
Research Forum Abstracts
308
Experience of Emergency Medical Personnel in Medical Mission Trips to Central America: Patients’ Complaints are Mostly Similar to US Patients
Mun ˜iz AE, Foster RL/The University of Texas Medical School at Houston, Houston, TX; Virginia Commonwealth University Medical Center, Richmond, VA
Study Objectives: The epidemiology of diseases that emergency medicine personnel may see in a medical mission trip to Central America is unknown. We hypothesize that patients in Central America may have similar illnesses as patients in the United States except for those disease endemic to their area. Methods: Prospective evaluations of all patients who arrived to a week-long medical clinic for 4 consecutive years (2002 to 2005). The clinic was staffed by 1 to 2 emergency medicine attendings, 1 to 2 emergency medicine residents, 2 to 3 emergency department nurses, and 1 medical student. In addition there were 4 to 5 translators who also aided in taking vital signs. Data was analyzed using Statistica 6.0 with continuous variables expressed as means and categorical variables as percentages of occurrence. Results: There were 4,504 patients. There were 2, 584 (57.3%) females with 2,052 (45.5%) ⬍ 18 year-old. There were 116 with known past medical history, most common were hypertension 48 (1%), diabetes 32 (0.7%), and asthma 28 (0.6%). Medications were taken by 124 (2.7%), most common included antihypertensive 32 (0.7%) and acetaminophen 24 (0.5%). Abnormal vitals signs included elevated temperature 88 (1.9%) and elevated blood pressure 536 (11.9%). Most common complaint included cough 1,028 (22.8%), fever 840 (18.6%), headache 744 (16.5%), back pain 752 (16.6%), and anorexia 516 (11.4%). Accu-check was taken in 60 patients with 56 having a new diagnosis of diabetes. There were 94 different diagnosis and most common were suspected parasitic infection 816 (18.1%), arthritis pain 592 (13.1%), headache 584 (12.9%), back pain (12.3%), URI 492 (10.9%) and gastritis/GERD 472 (10.4%). The most common medication given: NSAIDs 1,852 (41.1%), antiparasitic 828 (18.3%), antibiotics 796 (17.6%), H2-blockers 440 (9.7%), anti-tussives 432 (9.5%), and acetaminophen 424 (9.4%). Conclusions: The most common diagnosis included parasitic infection; after that the diagnosis and treatment are very similar to the diseases seen in the United States.
309
Short-Term Implementation of a Non-Clinical Physician Pneumonia Czar Leads to Significant Improvement in Attainment of the 4-Hours-toAntibiotic JCAHO/CMS Core Quality Measure in the Treatment of Community-Acquired Pneumonia: A Novel Approach
Jerrard DA, Geroff A/University of Maryland, Baltimore, MD
Study Objective: Supplementation of a nursing triage protocol with daily real time attending and resident education during clinical hours with regards to new JCAHO Hospital Quality Measures can significantly increase the percentage of those patients receiving antibiotics within 4 hours as well as decrease mean time to antibiotic administration. Methods: Ambispective cohort study performed at an urban academic emergency department with 33,000 annual visits. All patients who were both admitted through the emergency department and discharged with the diagnosis of pneumonia (ICD-9 486) were included in the study. The preimplementation time period block included September 2005 through April 2006. The time block from May 2006 through December 2006 represented the time during which the nurse triage protocols for rapid radiograph procurement on those patients suspected of having pneumonia was supplemented with the use of a non-clinical attending who was designated on a daily basis to either call to the ED and/or do a
Volume , . : September
walk through the department on a q shift, 24 hour cycle. This time period was chosen so as to accommodate the “4 hour to antibiotic” core measure and aid in the capture and compliant treatment of patients who might have or were newly diagnosed with pneumonia. This non-clinical physician, unencumbered by other clinical responsibilities, functioned as a consistent daily educator to the staff (attendings and housetaff) as to the need for rapid identification of those patients who may have pneumonia, thus, expediting the rapid read of chest radiographs, and further facilitation of rapid administration and documentation of times of antibiotics dispensation by the nursing staff. It was felt that the implementation of this strategy would also serve to detect a number of cases of poor or absent nursing documentation as to time of antibiotic administration which would further enable timely and compliant treatment of patients. Results: During the preimplementation time period, 98 of 140 patients admitted for pneumonia (70%) received antibiotics within a time period of 4 hours. After the implementation of the non-clinical physician pneumonia czar model, 106/118 patients hospitalized for pneumonia met the treatment within 4 hour mandate (90%)(p⬍0.01, mean treatment time 2.4 hours). Conclusion: The percentage of those patients receiving their antibiotics within 4 hours dramatically increased during the implementation of this non-clinical physician strategy. Average mean times to antibiotic administration decreased significantly. We maintain that physicians themselves may have the greatest impact in seeing to achievement of this core performance measure. Short term implementation of this strategy may be beneficial to those centers having difficulty in meeting this performance measure. Data is currently being reviewed to show if these results are sustained once cessation of this model occurs.
310
Simplified Acute Physiology Score II, pH, and Serum Lactate as Predictors of Hospital Mortality in Severe Sepsis and Septic Shock Patients
Lee S, Kim S, Hong Y, Park J, Choi S, Kim N/Korea University Ansan Hospital, Ansan Kyunggi-do, Republic of Korea; Korea University Medical School, Seoul, Republic of Korea
Study Objectives: To determine whether serum lactate, acid-base data, and physiologic data obtained in emergency department correlate with outcome from severe sepsis and septic shock patients receiving early goal-directed therapy. Methods: This is a prospective observation study of a convenience cohort of 113 patients with severe sepsis and septic shock from January 2005 to March 2007 in an emergency department (ED) of university hospital. The hemodynamic variables, arterial blood gas studies, serum lactate, and sepsis related organ failure assessment (SOFA) score were obtained at presentation (0 hour) and at 4 hours. Simplified acute physiologic score II (SAPS II) at emergency department was recorded. Data were presented as mean ⫾ SD. Results: Thirty-three patients died in hospital. Septic shock was encountered in 48 patients. The mean arterial blood pressure (MAP), central venous pressure (CVP), and central venous oxygen saturation (Scvo2) were improved after resuscitation in ED. Patients with low MAP (⬍65 mmHg), low urine output (⬍40 ml/hour during 4 hours), low arterial pH (⬍7.35), and high serum lactate level (⬎ 2 mg/dL) at both 0 and 4 hour, respectively showed significantly high in-hospital mortality than other patients (83.3%, 46.9%, 66.7%, and 47.5%, respectively). SAPS II, persistent low pH, and persistent hyperlactatemia were independently associated with mortality. In-hospital mortality were 0% of SAPS II ⱕ 20, 4.9% of SAPS II 21-40, 35.1% of SAPS II 41-60, 85.7% of SAPS II 61-80, and 75.0% of SAPS II ⱖ 81, respectively. Patients with MAP ⱖ 65mmHg, CVP ⱖ 10 cmH2O, and Scvo2 ⱖ 70% at 4 hour were 57 persons. Among the 57 patients, patients with lactate ⬎ 2 mg/dL of 0 hour and ⱕ 2 of 4 hour showed lower in-hospital mortality than patients with persistent high serum lactate (7.7% vs. 42.3%, p⫽0.013). Conclusion: High SAPS II, persistent acidosis, and persistent hyperlactatemia were found to be independent variables for predicting mortality. Improvement of physiologic conditions and serum lactate level of septic patient may be used as a guideline for the resuscitation of severe sepsis and septic shock patients in emergency department.
Annals of Emergency Medicine S97
305
Awareness of Stroke Symptoms in the Highest Risk Group: The Elderly
Bellolio MF, Vaidyanathan L, Kashyap R, Enduri S, Nash DL, Decker WW, Stead LG/Mayo Clinic College of Medicine. Division of Emergency Medicine Research, Rochester, MN
Study Objectives: To assess awareness of acute brain ischemia in geriatric patients presenting with acute ischemic stroke (AIS) or transient ischemic attack (TIA). Methods: We prospectively enrolled a consecutive cohort of patients presenting with AIS or TIA over a 17-month period. We collected demographic variables, time from symptom onset to presentation to the emergency department (ED), any reasons for delay in presentation, understanding of stroke symptoms, and knowledge of acute stroke treatment modalities. Results: The overall cohort consisted of 344 patients older than age 65 (41.6% of them older than 80 years). Fifty one percent males; 71.8% presented with AIS and 28.2% with TIA. A total of 81% had hypertension, 55% hyperlipidemia, 27% coronary artery disease, 27% Diabetes mellitus and 18% were active smokers. The median time from symptoms onset to presentation was 2.79 hrs (IQR 1.2510.96; range 10 minutes to 8 days). Delayed presentation was seen in both genders. Only 51.4% thought they were having a stroke or TIA. Regarding the nature of stroke onset, 212 (62.7%) thought that a stroke came on suddenly vs. gradually, and only a little over one half (57%) thought immediate presentation was crucial. One fifth of the cohort (21.8%) patients had heard of thrombolysis, though 23.4% of the cohort had a prior stroke and 26.3% a prior TIA. In the stratified analysis comparing 65-79 versus 80-98 years old (“old” and “oldest old“ groups), we found a statistical difference by sex, being women older than men (p⬍0.0001). A total of 85% of the “old”, compared to 73% of the “very old” group were dismissed home after their stroke or TIA with an odds ratio of 2.15 (95%CI 1.23 to 3.76; p⬍0.007). Interestingly, 26% of the old, compared to a 42 % of the very old group lived alone before the cerebrovascular accident (OR: 2.11; 95%CI 1.33 to 3.34; p⫽0.001), with 96% of the old and 89% of the very old patients independent in their daily activities. There was no difference in mode of arrival, hours from symptom onset to presentation or knowledge about cerebrovascular disease, between the “old” and “very old” groups. Conclusion: Community knowledge about stroke symptoms and treatment needs to be increased in the high risk group of patients older than 65 years.
306
DNR in Emergency Patients
Hogan TM, Waugh AD, Gallagher C, Chan SB/Resurrection Medical Center, Chicago, IL
Introduction: For patients presenting to the emergency department (ED) with terminal conditions or at the end of life, intervention may not be desired or appropriate.
S96 Annals of Emergency Medicine
Study Objectives: The study purpose is to examine the use and application of DNR (do not resuscitate) status in patients presenting to the ED, likely at the end of life. Methods: Urban community teaching hospital retrospective review of hospitalized ED patients with one of the following: hospice, known metastatic cancer, or known pancreatic cancer. Data included DNR status, mortality, pre-hospital and ED resource utilization. Kaplan-Meier survival curves compared mortality rates while adjusted hazard ratios (HR), and 95% confidence intervals were calculated using Cox Regression. Results: Of 215 patients, 22.8% had DNR status both in the ED and as inpatient (ED-DNR), an additional 36.7% had DNR status after admission (HOSP-DNR), and 40.5% never had DNR status (NO-DNR). At 26.5%, 55.7%, and 4.6%, EDDNR and HOSP-DNR both had unadjusted mortality higher than the NO-DNR group (HR⫽6.30; 95%CI: 1.90-20.9) and (HR⫽8.74; 95%CI: 3.07-24.8). KaplanMeier survival curve during the first 10 days of hospitalization were the same for EDDNR and HOSP-DNR. The ED-DNR group used less IV (P⫽0.009), medications (P⫽0.009), and ICU beds (P ⫽ 0.005). There were four ED intubations but none in the ED-DNR group. Conclusion: In this study of terminal ED patients, those with pre-existing DNR used fewer resources. Patients designated DNR while in the hospital have the same outcome as the pre-existing group. This group should have pre-hospital designation of DNR status to improve ED resource utilization.
307
Plain Chest Radiography is an Inadequate Screening Tool in Elderly Blunt Trauma Patients
Paula Jr. R, LeBlanc H/University of South Florida, Tampa, FL
Study Objectives: The purpose of this study is to determine the sensitivity of the chest or abdomen computed tomography (CT) compared to the chest radiograph in the elderly blunt trauma population. It is expected that the CT will identify many additional injuries that the chest radiograph failed to show. This study will help determine the utility of CT in elderly blunt trauma patients. The initial screening in a blunt trauma patient usually begins with a chest radiograph. Most recent research has shown a trend to include CT in addition to the radiograph. There is controversy over whether the chest CT is essential in picking up occult but serious injuries or whether it is being over utilized, as opposed to the abdomen CT which has been recognized as useful. There is an abundance of literature showing that chest or abdomen CT is better at picking up certain injuries than a chest radiograph. Many authors describe the chest CT as significantly more effective in detecting: pneumothorax, lung contusion, mediastinal hematomas, fractured ribs, scapula, sternum, and vertebrae, and that chest radiography was unreliable for screening for aortic injury. Trauma is the fifth leading cause of death in our elder patients. Analyses of trauma registries have shown elderly patients with rib fractures following blunt chest trauma have twice the mortality of younger patients with similar injuries. Bulger also found that for each additional rib fracture in the elderly, the mortality increased by 19%. However, just because a test identifies new information it does not mean it is necessary, or helpful the new data does not affect management or outcome. Plurad completed a seven-year retrospective chart review examining both significant findings on the imaging studies and the changes in management. The study did show a more effective identification of pneumothorax, hemothorax, rib fractures, and lung contusion by chest CT. However, the researchers felt that the identification of these injuries did not result in a large change in management. Methods: A retrospective review was performed on approximately 3 years of data (9/1/02 to 12/31/05) provided by the Tampa General Hospital trauma registry, which records consecutive trauma alert patients presenting to our Level I trauma center. All patients ⬎/⫽ 65 yrs old with blunt trauma were eligible, those enrolled had to have CXR, and abdomen or chest CT. Results: We found records available for review on 154 patients, 151 chest radiographs were performed, 105 chest CTs performed on 105 patients, and153 abdomen CTs. Either abdomen CT or chest was much more sensitive in detecting significant injuries. Conclusion: Computed tomography is a useful tool in detecting significant thoracoabdominal injuries missed by plain chest radiography in elderly trauma patients. Both abdomen and chest CT found more injuries than plain chest radiography. Injury detection is even more important in this patent population due to the proven increased morbidity with seemingly minor injuries such as rib fractures. The CT, and the chest CT specifically should be used as a screening tool in elderly trauma patients in order to maximally detect possibly significant injury.
Volume , . : September
Research Forum Abstracts
308
Experience of Emergency Medical Personnel in Medical Mission Trips to Central America: Patients’ Complaints are Mostly Similar to US Patients
Mun ˜iz AE, Foster RL/The University of Texas Medical School at Houston, Houston, TX; Virginia Commonwealth University Medical Center, Richmond, VA
Study Objectives: The epidemiology of diseases that emergency medicine personnel may see in a medical mission trip to Central America is unknown. We hypothesize that patients in Central America may have similar illnesses as patients in the United States except for those disease endemic to their area. Methods: Prospective evaluations of all patients who arrived to a week-long medical clinic for 4 consecutive years (2002 to 2005). The clinic was staffed by 1 to 2 emergency medicine attendings, 1 to 2 emergency medicine residents, 2 to 3 emergency department nurses, and 1 medical student. In addition there were 4 to 5 translators who also aided in taking vital signs. Data was analyzed using Statistica 6.0 with continuous variables expressed as means and categorical variables as percentages of occurrence. Results: There were 4,504 patients. There were 2, 584 (57.3%) females with 2,052 (45.5%) ⬍ 18 year-old. There were 116 with known past medical history, most common were hypertension 48 (1%), diabetes 32 (0.7%), and asthma 28 (0.6%). Medications were taken by 124 (2.7%), most common included antihypertensive 32 (0.7%) and acetaminophen 24 (0.5%). Abnormal vitals signs included elevated temperature 88 (1.9%) and elevated blood pressure 536 (11.9%). Most common complaint included cough 1,028 (22.8%), fever 840 (18.6%), headache 744 (16.5%), back pain 752 (16.6%), and anorexia 516 (11.4%). Accu-check was taken in 60 patients with 56 having a new diagnosis of diabetes. There were 94 different diagnosis and most common were suspected parasitic infection 816 (18.1%), arthritis pain 592 (13.1%), headache 584 (12.9%), back pain (12.3%), URI 492 (10.9%) and gastritis/GERD 472 (10.4%). The most common medication given: NSAIDs 1,852 (41.1%), antiparasitic 828 (18.3%), antibiotics 796 (17.6%), H2-blockers 440 (9.7%), anti-tussives 432 (9.5%), and acetaminophen 424 (9.4%). Conclusions: The most common diagnosis included parasitic infection; after that the diagnosis and treatment are very similar to the diseases seen in the United States.
309
Short-Term Implementation of a Non-Clinical Physician Pneumonia Czar Leads to Significant Improvement in Attainment of the 4-Hours-toAntibiotic JCAHO/CMS Core Quality Measure in the Treatment of Community-Acquired Pneumonia: A Novel Approach
Jerrard DA, Geroff A/University of Maryland, Baltimore, MD
Study Objective: Supplementation of a nursing triage protocol with daily real time attending and resident education during clinical hours with regards to new JCAHO Hospital Quality Measures can significantly increase the percentage of those patients receiving antibiotics within 4 hours as well as decrease mean time to antibiotic administration. Methods: Ambispective cohort study performed at an urban academic emergency department with 33,000 annual visits. All patients who were both admitted through the emergency department and discharged with the diagnosis of pneumonia (ICD-9 486) were included in the study. The preimplementation time period block included September 2005 through April 2006. The time block from May 2006 through December 2006 represented the time during which the nurse triage protocols for rapid radiograph procurement on those patients suspected of having pneumonia was supplemented with the use of a non-clinical attending who was designated on a daily basis to either call to the ED and/or do a
Volume , . : September
walk through the department on a q shift, 24 hour cycle. This time period was chosen so as to accommodate the “4 hour to antibiotic” core measure and aid in the capture and compliant treatment of patients who might have or were newly diagnosed with pneumonia. This non-clinical physician, unencumbered by other clinical responsibilities, functioned as a consistent daily educator to the staff (attendings and housetaff) as to the need for rapid identification of those patients who may have pneumonia, thus, expediting the rapid read of chest radiographs, and further facilitation of rapid administration and documentation of times of antibiotics dispensation by the nursing staff. It was felt that the implementation of this strategy would also serve to detect a number of cases of poor or absent nursing documentation as to time of antibiotic administration which would further enable timely and compliant treatment of patients. Results: During the preimplementation time period, 98 of 140 patients admitted for pneumonia (70%) received antibiotics within a time period of 4 hours. After the implementation of the non-clinical physician pneumonia czar model, 106/118 patients hospitalized for pneumonia met the treatment within 4 hour mandate (90%)(p⬍0.01, mean treatment time 2.4 hours). Conclusion: The percentage of those patients receiving their antibiotics within 4 hours dramatically increased during the implementation of this non-clinical physician strategy. Average mean times to antibiotic administration decreased significantly. We maintain that physicians themselves may have the greatest impact in seeing to achievement of this core performance measure. Short term implementation of this strategy may be beneficial to those centers having difficulty in meeting this performance measure. Data is currently being reviewed to show if these results are sustained once cessation of this model occurs.
310
Simplified Acute Physiology Score II, pH, and Serum Lactate as Predictors of Hospital Mortality in Severe Sepsis and Septic Shock Patients
Lee S, Kim S, Hong Y, Park J, Choi S, Kim N/Korea University Ansan Hospital, Ansan Kyunggi-do, Republic of Korea; Korea University Medical School, Seoul, Republic of Korea
Study Objectives: To determine whether serum lactate, acid-base data, and physiologic data obtained in emergency department correlate with outcome from severe sepsis and septic shock patients receiving early goal-directed therapy. Methods: This is a prospective observation study of a convenience cohort of 113 patients with severe sepsis and septic shock from January 2005 to March 2007 in an emergency department (ED) of university hospital. The hemodynamic variables, arterial blood gas studies, serum lactate, and sepsis related organ failure assessment (SOFA) score were obtained at presentation (0 hour) and at 4 hours. Simplified acute physiologic score II (SAPS II) at emergency department was recorded. Data were presented as mean ⫾ SD. Results: Thirty-three patients died in hospital. Septic shock was encountered in 48 patients. The mean arterial blood pressure (MAP), central venous pressure (CVP), and central venous oxygen saturation (Scvo2) were improved after resuscitation in ED. Patients with low MAP (⬍65 mmHg), low urine output (⬍40 ml/hour during 4 hours), low arterial pH (⬍7.35), and high serum lactate level (⬎ 2 mg/dL) at both 0 and 4 hour, respectively showed significantly high in-hospital mortality than other patients (83.3%, 46.9%, 66.7%, and 47.5%, respectively). SAPS II, persistent low pH, and persistent hyperlactatemia were independently associated with mortality. In-hospital mortality were 0% of SAPS II ⱕ 20, 4.9% of SAPS II 21-40, 35.1% of SAPS II 41-60, 85.7% of SAPS II 61-80, and 75.0% of SAPS II ⱖ 81, respectively. Patients with MAP ⱖ 65mmHg, CVP ⱖ 10 cmH2O, and Scvo2 ⱖ 70% at 4 hour were 57 persons. Among the 57 patients, patients with lactate ⬎ 2 mg/dL of 0 hour and ⱕ 2 of 4 hour showed lower in-hospital mortality than patients with persistent high serum lactate (7.7% vs. 42.3%, p⫽0.013). Conclusion: High SAPS II, persistent acidosis, and persistent hyperlactatemia were found to be independent variables for predicting mortality. Improvement of physiologic conditions and serum lactate level of septic patient may be used as a guideline for the resuscitation of severe sepsis and septic shock patients in emergency department.
Annals of Emergency Medicine S97