- Email: [email protected]
345 Severe Sepsis: What Gets it Right? A Comparison of the Quick Sequential Organ Failure Assessment Versus Systemic Inflammatory Response Syndrome Criteria
Research Forum Abstracts violence was ranked from 1 to 5 with five being the most violent. The pilot data was collected during the evening shift, across twelve evenings from midFebruary to mid-March. Data was collated and analyzed using GraphPad Prism software. Results: To date, we have recorded 267 calls in which the officers responded to an average of 22 calls per shift, the majority of which were to the ambulance bay and waiting room (40% and 18% respectively). Of the calls to the ambulance bay, 40% of those patients were taken to the psychiatric ED. Safety checks were a part of 78% of all calls, and by themselves accounted for 30% of all responses. The level of violence in 72% of the calls was rated as a 1. 2% of all calls were deemed dangerously violent, with 10% of the calls resulted in patients being placed in physical restraints. Overall officer users reported being very pleased with the tracking system. The summary section provided useful clarification on events such as, “Patient acting out with staff—4 point restraints, additional officers responded.” Conclusions: The study card has been successful and user friendly as a pilot tool for tracking protective services responses in the ED. Data from our study provides opportunities to plan, train and prevent potentially violent incidents in the future. We hope our study will help administration better understand where protective services are most needed and deploy staff more effectively. The waiting room appears to be a prime target for re-strategizing resource utilization and prevention. Next steps include a mobile app platform in current development to capture the data in a more portable fashion.
344
A Novel System for the Characterization and Tracking of Protective Services Utilization in the Emergency Department
Phalen T, Dong M, Alsaloum M, Costa D, Cohen T, Wong A/Yale University School of Medicine, New Haven, CT; Yale School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT
Study Objectives: Violent patients physically and verbally assault medical providers across clinical settings. Patients with behavioral emergencies often present with acute agitation, which increases the risk of injury to health care workers. Hospital protective services officers are often employed to assist staff during workplace violence events. However, in the emergency department, officers have cited challenges related to high numbers of potentially violent events and limited staffing. Currently, the characteristics of events requiring protective services response in the emergency department setting are unclear due to difficulty in accurately capturing data in situ and inconsistent reporting. We aim to pilot a new method to track the incidence and types of calls officers respond to during their shifts to gain insight into the nature, location, and degree of the violence occurring in the ED. The data will be employed to better utilize protective services resources, ultimately leading to process improvements that may be needed to improve safety. Methods: We co-developed a novel tool with protective services administration, modifying it based on feedback from front-line officers. The tool consisted of a portable survey card that captured details of each call for assistance including the following: date, time, location of call, level of violence, type of incidence, and a brief narrative summary of the incident. The level of
S132 Annals of Emergency Medicine
345
Severe Sepsis: What Gets it Right? A Comparison of the Quick Sequential Organ Failure Assessment Versus Systemic Inflammatory Response Syndrome Criteria
Weigle H, Trigonis R, Bunn D, Krakauer D, Long L, Perkins J/Virginia Tech Carillon, Roanoke, VA
Study Objectives: For over two decades, sepsis was defined as a suspected source of infection in the setting of 2 of the systemic inflammatory response syndrome
Volume 68, no. 4s : October 2016
Research Forum Abstracts (SIRS) criteria. Due to its simplicity, the SIRS criteria have been employed to assist in the early identification of sepsis. The sensitivity of these criteria, however, has recently been challenged. Further, The Third International Consensus Definitions for Sepsis and Septic Shock proposed the use of the quick sequential organ failure assessment (qSOFA) score. Our emergency department (ED) utilizes a “Sepsis Alert” (SA) protocol for our patients who have severe sepsis or septic shock. The SIRS criteria have been relied upon as a rapid identification tool to help providers consider sepsis. To more quickly identify patients with severe sepsis or septic shock, we seek to compare the sensitivity of the qSOFA to the SIRS criteria in our SA patient cohort. Methods: This was a retrospective chart review of patient records at a tertiary referral hospital with an annual census of 90,000 ED visits. All patients who triggered a SA protocol in our adult ED were eligible for enrollment. Patients were excluded if severe sepsis or septic shock was not listed as the primary reason for admission on the inpatient history and physical documentation. Three data abstractors utilized a standardized data abstraction algorithm and reviewed our hospital’s electronic medical record (EMR) to obtain a priori defined patient data variables including: vital signs (VS) during the first hour, initial white blood cell count, percentage of bands, and initial Glasgow Coma Scale (GCS). A qSOFA score and total SIRS criteria were calculated for each patient. Patients with a qSOFA score 2 were compared to the presence of 2 SIRS criteria. McNemar’s test was performed to compare the sensitivity of SIRS criteria and qSOFA for our cohort. A Mortality in the Emergency Department Sepsis (MEDS) score and in-hospital mortality were calculated to assess illness severity. Results: A total of 224 patients met the inclusion criteria. In-hospital mortality for this study cohort was 20.5%. The average MEDS score for the study cohort was 11.13 (95% CI, 10.50-11.77) predicting a high 28-day mortality. Utilizing data collected during the ED course, a qSOFA score of 2 was present in 129 cases (58%) of patients diagnosed with severe sepsis or septic shock. This was significantly lower than those meeting 2 SIRS criteria during their ED course, which was present in 205 cases (92%) of the same patient population (c2¼ 62.5, p<0.0001). Using only the initial set of vitals, laboratory results, and GCS, SIRS criteria sensitivity was 82% compared to 37% for qSOFA in our population (c2¼ 85.0, p<0.0001). Conclusion: This study is limited by its retrospective nature and relatively small sample size. However, our results demonstrate that the qSOFA criteria did not perform well in identifying our high mortality cohort of SA patients. And while the presence of 2 SIRS criteria was significantly more sensitive during the initial patient presentation, a sensitivity of 82% is still inadequate as a screening tool. Further efforts are needed as the pursuit for an effective screening tool for sepsis continues.
346
deemed to be DVA. A qualitative and quantitative analysis was performed on pre and post data, as well as determining patient factors that contributed to DVA status. Results: 135 patients were deemed to be DVA over a 5.5-month period. Of these 135 patients, the most common reason for DVA was prior history of multiple attempts (36.3%), IV drug use history (15.56%), and poor skin quality (12.59%). Additional categories were present in relatively equal frequency and included single arm access, dehydration, sick cell history, and obesity. Prior to the implantation of an AiM team, the mean IV order to completion time was 296.9 minutes (N¼41, Std. Dev. 265.85). Post-intervention, the mean IV order to completion time was much lower at an average of 182.47 minutes (N¼135, Std. Dev. 248.52). Given that the data was skewed to the right in both the pre and post implementation data, a Mann-Whitney U test was applied. A significant difference in distribution of time from order to access completion (in total minutes) between the pre-AiM and post-AiM group was demonstrated (U¼3,853, p< 0.0001). Conclusions: Utilizing an AiM team reduced the time to successful IV access for DVA patients. Patients with DVA tended to have similar characteristics, so future considerations include utilizing a predictive tool to determine which patients might qualify as DVA prior to any attempts at access being made. Patients with DVA may be able to be identified earlier in their ED stay to reduce the amount of time and the number of attempts for IV access, which in turn can enhance patient safety and satisfaction.
Development of a Difficult Access Team in the Adult Emergency Department Leads to Faster Intravenous Access
Wilson CL, Maliszewski B, Whalen M, Gardner H, Baptiste D/Johns Hopkins Hospital, Baltimore, MD
Study Objectives: To determine if the implementation of an Access in Minutes (AiM) team will reduce the IV access order to completion time for difficult venous access (DVA) patients as compared to current practice. Methods: Data collection took place at a level one, tertiary care, urban academic medical center that sees approximately 70,000 patients per year, where up to 70% of patients require definitive IV access. In order to obtain baseline data, a multi-disciplinary team composed of physicians, nurses, clinical technicians and administrators evaluated a convenience sample of patients who were deemed to have DVA. This cohort included patients in whom a clinical technician was unable to establish IV access after two attempts, and a different provider was also unsuccessful after two attempts, requiring a physician to obtain definitive access. Characteristics felt to contribute to DVA were recorded, as well as the time that elapsed from when an IV was ordered until the order was completed. After a cohort of patients were identified to demonstrate the need for an AiM team, a dedicated clinical technician was available in the ED as a pilot for patients who were
Volume 68, no. 4s : October 2016
347 348
Withdrawn
Ultrasound- and Fluoroscopy-Guided Reduction of Pediatric Forearm Fractures: A Prospective Observational Study
Auten JD, Hurst ND, Pennock AT, Naheedy JH, Hollenbach KA, Kanegaye JT/Naval Medical Center Portsmouth, Portsmouth, VA; Rady Children’s Hospital San Diego, San Diego, CA; University of California San Diego School of Medicine, San Diego, CA; University of California San Diego School of Medicine, San Diego, CA; University of California San Diego School of Pharmacy, San Diego, CA; University of California San Diego School of Medicine, San Diego, CA
Study Objective: The forearm is the most common pediatric fracture site requiring emergency department reduction. We sought to compare the post-reduction fracture images obtained by point-of-care ultrasonography (POCUS) with those obtained by fluoroscopy.
Annals of Emergency Medicine S133
344
A Novel System for the Characterization and Tracking of Protective Services Utilization in the Emergency Department
Phalen T, Dong M, Alsaloum M, Costa D, Cohen T, Wong A/Yale University School of Medicine, New Haven, CT; Yale School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT
Study Objectives: Violent patients physically and verbally assault medical providers across clinical settings. Patients with behavioral emergencies often present with acute agitation, which increases the risk of injury to health care workers. Hospital protective services officers are often employed to assist staff during workplace violence events. However, in the emergency department, officers have cited challenges related to high numbers of potentially violent events and limited staffing. Currently, the characteristics of events requiring protective services response in the emergency department setting are unclear due to difficulty in accurately capturing data in situ and inconsistent reporting. We aim to pilot a new method to track the incidence and types of calls officers respond to during their shifts to gain insight into the nature, location, and degree of the violence occurring in the ED. The data will be employed to better utilize protective services resources, ultimately leading to process improvements that may be needed to improve safety. Methods: We co-developed a novel tool with protective services administration, modifying it based on feedback from front-line officers. The tool consisted of a portable survey card that captured details of each call for assistance including the following: date, time, location of call, level of violence, type of incidence, and a brief narrative summary of the incident. The level of
S132 Annals of Emergency Medicine
345
Severe Sepsis: What Gets it Right? A Comparison of the Quick Sequential Organ Failure Assessment Versus Systemic Inflammatory Response Syndrome Criteria
Weigle H, Trigonis R, Bunn D, Krakauer D, Long L, Perkins J/Virginia Tech Carillon, Roanoke, VA
Study Objectives: For over two decades, sepsis was defined as a suspected source of infection in the setting of 2 of the systemic inflammatory response syndrome
Volume 68, no. 4s : October 2016
Research Forum Abstracts (SIRS) criteria. Due to its simplicity, the SIRS criteria have been employed to assist in the early identification of sepsis. The sensitivity of these criteria, however, has recently been challenged. Further, The Third International Consensus Definitions for Sepsis and Septic Shock proposed the use of the quick sequential organ failure assessment (qSOFA) score. Our emergency department (ED) utilizes a “Sepsis Alert” (SA) protocol for our patients who have severe sepsis or septic shock. The SIRS criteria have been relied upon as a rapid identification tool to help providers consider sepsis. To more quickly identify patients with severe sepsis or septic shock, we seek to compare the sensitivity of the qSOFA to the SIRS criteria in our SA patient cohort. Methods: This was a retrospective chart review of patient records at a tertiary referral hospital with an annual census of 90,000 ED visits. All patients who triggered a SA protocol in our adult ED were eligible for enrollment. Patients were excluded if severe sepsis or septic shock was not listed as the primary reason for admission on the inpatient history and physical documentation. Three data abstractors utilized a standardized data abstraction algorithm and reviewed our hospital’s electronic medical record (EMR) to obtain a priori defined patient data variables including: vital signs (VS) during the first hour, initial white blood cell count, percentage of bands, and initial Glasgow Coma Scale (GCS). A qSOFA score and total SIRS criteria were calculated for each patient. Patients with a qSOFA score 2 were compared to the presence of 2 SIRS criteria. McNemar’s test was performed to compare the sensitivity of SIRS criteria and qSOFA for our cohort. A Mortality in the Emergency Department Sepsis (MEDS) score and in-hospital mortality were calculated to assess illness severity. Results: A total of 224 patients met the inclusion criteria. In-hospital mortality for this study cohort was 20.5%. The average MEDS score for the study cohort was 11.13 (95% CI, 10.50-11.77) predicting a high 28-day mortality. Utilizing data collected during the ED course, a qSOFA score of 2 was present in 129 cases (58%) of patients diagnosed with severe sepsis or septic shock. This was significantly lower than those meeting 2 SIRS criteria during their ED course, which was present in 205 cases (92%) of the same patient population (c2¼ 62.5, p<0.0001). Using only the initial set of vitals, laboratory results, and GCS, SIRS criteria sensitivity was 82% compared to 37% for qSOFA in our population (c2¼ 85.0, p<0.0001). Conclusion: This study is limited by its retrospective nature and relatively small sample size. However, our results demonstrate that the qSOFA criteria did not perform well in identifying our high mortality cohort of SA patients. And while the presence of 2 SIRS criteria was significantly more sensitive during the initial patient presentation, a sensitivity of 82% is still inadequate as a screening tool. Further efforts are needed as the pursuit for an effective screening tool for sepsis continues.
346
deemed to be DVA. A qualitative and quantitative analysis was performed on pre and post data, as well as determining patient factors that contributed to DVA status. Results: 135 patients were deemed to be DVA over a 5.5-month period. Of these 135 patients, the most common reason for DVA was prior history of multiple attempts (36.3%), IV drug use history (15.56%), and poor skin quality (12.59%). Additional categories were present in relatively equal frequency and included single arm access, dehydration, sick cell history, and obesity. Prior to the implantation of an AiM team, the mean IV order to completion time was 296.9 minutes (N¼41, Std. Dev. 265.85). Post-intervention, the mean IV order to completion time was much lower at an average of 182.47 minutes (N¼135, Std. Dev. 248.52). Given that the data was skewed to the right in both the pre and post implementation data, a Mann-Whitney U test was applied. A significant difference in distribution of time from order to access completion (in total minutes) between the pre-AiM and post-AiM group was demonstrated (U¼3,853, p< 0.0001). Conclusions: Utilizing an AiM team reduced the time to successful IV access for DVA patients. Patients with DVA tended to have similar characteristics, so future considerations include utilizing a predictive tool to determine which patients might qualify as DVA prior to any attempts at access being made. Patients with DVA may be able to be identified earlier in their ED stay to reduce the amount of time and the number of attempts for IV access, which in turn can enhance patient safety and satisfaction.
Development of a Difficult Access Team in the Adult Emergency Department Leads to Faster Intravenous Access
Wilson CL, Maliszewski B, Whalen M, Gardner H, Baptiste D/Johns Hopkins Hospital, Baltimore, MD
Study Objectives: To determine if the implementation of an Access in Minutes (AiM) team will reduce the IV access order to completion time for difficult venous access (DVA) patients as compared to current practice. Methods: Data collection took place at a level one, tertiary care, urban academic medical center that sees approximately 70,000 patients per year, where up to 70% of patients require definitive IV access. In order to obtain baseline data, a multi-disciplinary team composed of physicians, nurses, clinical technicians and administrators evaluated a convenience sample of patients who were deemed to have DVA. This cohort included patients in whom a clinical technician was unable to establish IV access after two attempts, and a different provider was also unsuccessful after two attempts, requiring a physician to obtain definitive access. Characteristics felt to contribute to DVA were recorded, as well as the time that elapsed from when an IV was ordered until the order was completed. After a cohort of patients were identified to demonstrate the need for an AiM team, a dedicated clinical technician was available in the ED as a pilot for patients who were
Volume 68, no. 4s : October 2016
347 348
Withdrawn
Ultrasound- and Fluoroscopy-Guided Reduction of Pediatric Forearm Fractures: A Prospective Observational Study
Auten JD, Hurst ND, Pennock AT, Naheedy JH, Hollenbach KA, Kanegaye JT/Naval Medical Center Portsmouth, Portsmouth, VA; Rady Children’s Hospital San Diego, San Diego, CA; University of California San Diego School of Medicine, San Diego, CA; University of California San Diego School of Medicine, San Diego, CA; University of California San Diego School of Pharmacy, San Diego, CA; University of California San Diego School of Medicine, San Diego, CA
Study Objective: The forearm is the most common pediatric fracture site requiring emergency department reduction. We sought to compare the post-reduction fracture images obtained by point-of-care ultrasonography (POCUS) with those obtained by fluoroscopy.
Annals of Emergency Medicine S133