- Email: [email protected]
367 Treatment and Referral of Markedly Elevated Blood Pressure in an Urban Emergency Department: How Well Do Emergency Physicians Adhere to American College of Emergency Physicians Clinical Guidelines?
Research Forum Abstracts Methods: We performed a retrospective chart review of patients with ICD-9 codes associated with pneumonia on admission between July 1, 2014 and December 31, 2014 as well as January 1, 2015 through April 15, 2015. A total of 269 patients were included. Those excluded were patients who were admitted to the observation unit, discharged from the ED, or miscoded. We collected the pertinent information detailed below. Results: Between July 1, 2014 and December 31, 2014 there were 152 patients admitted to the hospital versus 117 patients admitted between January 1, 2015 and April 15, 2015 with ICD-9 codes for pneumonia. In the pre-retirement group, 145/152, or 95.4% (95% CI: 90-95%), of patients were given the correct antibiotics. The most common fallouts included administering azithromycin without ceftriaxone (3/152, 2%, 95% CI: 0.7-5%). These patients also had COPD; however, they were diagnosed as having pneumonia, not a COPD flare or bacterial bronchitis. The second source of errors included ICU patients (3/152, 2%, 95% CI:0.7-5%). These patients often received vancomycin and cefepime (2/ 152, 1%, 0.6-3%) rather than cipro/cefepime/vanco to adequately cover for pseudomonas, with 1/152 (0.3%, 95% CI 0.2-2%) receiving vancomycin and piperacillin/tazobactam. Lastly, an ESRD requiring dialysis was incorrectly classified and treated as having CAP (1/152, 0.3%, 95% CI 0.2-2%). After core measures were retired, 114/117 (97.4%), 95% CI 93-99%)patients were given the correct antibiotic. The fallouts included one patient receiving ceftriaxone and sulfamethoxazole/trimethoprim, another cefepime and vancomycin, and the third vancomycin, rocephin, and moxifloxacin. Conclusion: Compliance with Pneumonia Core Measure was not affected by retirement of this core measure. Based on this pilot data, we believe that these treatment strategies are hardwired into ED clinical culture.
366
Does the Emergency Department Recognize and Isolate Obvious Clostridium Difficile Diarrhea?
Kniess C, Kelly JJ, Dominici P, Deitch K/Einstein Healthcare Network, Philadelphia, PA; Einstein Healtchcare Network, Philadelphia, PA
Study Objectives: The purpose of this study was to determine the emergency department (ED) recognition rate and immediate isolation practice in the hospital admission process with potential Clostridium difficile infection (CDI). Methods: This was a retrospective chart review completed by emergency physicians at an urban 772-bed tertiary-care teaching center. A hospital microbiology database compiled all adult patient charts with positive test results for Clostridium difficile toxigenic stool cultures or molecular PCR assays test results from January 2014 to March 2015. A blinded, experienced physician chart abstractor trained in retrospective research reviewed all electronic medical emergency visit-related documents and order entries using a standardized source document to identify if physician history, review of systems, physical examination, admitting notes, and nursing notes reflected concern or caution for CDI and immediately placed patients on correct isolation precautions. Primary variables included whether or not the ED documented diarrhea and ordered specific Clostridium difficile isolation precautions. CDI was defined based on the standard set by the Centers for Disease Control and Prevention, which includes clinically significant diarrhea and a positive result for Clostridium difficile toxin A/B or a toxin-producing Clostridium difficile organism. Secondary variables included type of admission inpatient unit and timing of Clostridium difficile testing. Results: The microbiology database identified 202 cases with positive Clostridium difficile test results over 15 months. However, only 64 cases had clinically significant diarrhea in the ED (31.7%, 95% CI: 26-38%). Out of these 64 cases, possible CDI was recognized in 24 cases (37.5%), 95% CI 27-50%) and appropriate isolation instituted in 10 cases (15.6% 95% CI:9-26%). When emergency physicians ordered Clostridium difficile testing for 20 patients, they appropriately isolated 7 patients (35.0%, 95% CI 18-56%). Inpatient physicians ordered testing within 24 hours for 20 patients and within 48 hours for 14 patients (53.13%, 95% CI:41-64%). Half of all patients with positive Clostridium difficile test results 51/102 were admitted to the intensive care unit (26%, 95% CI 18-24%) or intermediate progressive care unit (24%, 95% CI 16-23%). All of these admissions tested positive for CDI within one week of admission, 53 of which tested positive within 3 days of admission (51.96% 95% CI 42-61%). Conclusion: In this study, approximately one third of patients with Clostridium difficile diarrhea received diagnostic testing in the ED. Appropriate isolation for active Clostridium difficile occurred in only one of seven ED patients. When emergency physicians did not recognize CDI by ordering appropriate testing, inpatient physicians
S132 Annals of Emergency Medicine
identified over half of CDI. However, this took 48 hours from admission. Based on these results at a large urban teaching hospital, emergency physicians and admitting hospitalists must innovate to improve screening, testing practices, and isolation of patients with CDI signs/symptoms before stool cultures finally reveal CDI. We urge other institutions to critically appraise their practice standards and combat this increasingly prevalent disease.
367
Treatment and Referral of Markedly Elevated Blood Pressure in an Urban Emergency Department: How Well Do Emergency Physicians Adhere to American College of Emergency Physicians Clinical Guidelines?
Hughes GB, Velez J, Heinert S, Brown SB, Purakal JD, Del Rios M/University of Illinois at Chicago, Chicago, IL
Study Objectives: In 2013, the American College of Emergency Physicians (ACEP) published a revision of its 2006 clinical policy on the evaluation and management of asymptomatic hypertension (HTN) in the emergency department (ED). The update states that in patients with asymptomatic markedly elevated blood pressure (BP), routine medical intervention in the ED is not required but recommends referral for long term treatment. The policy also states that physicians may choose to treat and/or initiate therapy in select patient populations, ie, those with poor follow-up, limited access to care, older patients (age60), and black patients. The goal of this study was to assess adherence to these guidelines in an urban ED. Methods: We performed a retrospective chart review of patients with markedly elevated BP who presented over a four-month period to the ED of a large urban teaching hospital in Chicago. BP was defined according to the 2003 JNC 7 classification for stage 2 HTN as a systolic or diastolic blood pressure of >160 mmHg or >100 mmHg, respectively on two consecutive measurements. Demographics, medical history, ED medications, ED diagnosis, and follow-up instructions were abstracted from electronic health records. Bivariate logistic regression modeling was used to determine the association between patient characteristics and treatment with an antihypertensive in the ED and discharge with antihypertensive prescription. Results: Four hundred forty-one patients presented to the ED with markedly elevated BPs. 14% were treated with an antihypertensive during the ED visit, with 13% discharged with an prescription. For non-Hispanic black (NHB) patients, the odds of being treated with antihypertensives in the ED were 2.1 times higher (P ¼ .04) than for other races. Patients without a prior history of HTN were 95% less likely to be treated with antihypertensive in the ED than those with a HTN diagnosis (P ¼ .003). No significant association was found for older patients age60 (OR¼0.57, P ¼ .10) or insurance status (OR ¼ 0.85, P ¼ .70). Older patients and those without a prior diagnosis of HTN were less likely to be discharged with a prescription for an antihypertensive (65%, P ¼ .006 and 66%, P ¼ .016, respectively). NHB had 1.98 times higher odds of being discharged from the ED with antihypertensive than other races (P ¼ .054). No significant association was found for insurance status (0.65, P ¼ .29). HTN was not listed as a diagnosis in 79% of patients in this sample and 77% were not provided discharge instructions for HTN. Follow-up with primary care within 72 hours was recommended for 43% of all patients. Conclusion: The issue of patients presenting to the ED with asymptomatic markedly elevated BP is a frequent treatment dilemma. In our patient population, >10% were treated and/or discharged with an antihypertensive. NHB were given antihypertensives in the ED with a trend towards more frequent prescriptions of antihypertensives upon discharge. Other groups of interest were less likely to be prescribed antihypertensive upon discharge suggesting inconsistent adherence to ACEP clinical guidelines. Moreover, there was an overall failure to provide discharge information or to recommend timely followup. Further education of emergency physicians to better manage asymptomatic HTN and help prevent long-term consequences of HTN is needed.
368
Sonographic Assessment of Inadvertent Vascular Puncture During Paracentesis Using the Traditional Landmark Approach
Adams A, Roggio A, Wilkerson RG/University of Maryland School of Medicine, Baltimore, MD
Study Objectives: Ultrasound-guided paracentesis has become common practice in many hospitals. This technique offers several potential advantages over the traditional
Volume 66, no. 4s : October 2015
366
Does the Emergency Department Recognize and Isolate Obvious Clostridium Difficile Diarrhea?
Kniess C, Kelly JJ, Dominici P, Deitch K/Einstein Healthcare Network, Philadelphia, PA; Einstein Healtchcare Network, Philadelphia, PA
Study Objectives: The purpose of this study was to determine the emergency department (ED) recognition rate and immediate isolation practice in the hospital admission process with potential Clostridium difficile infection (CDI). Methods: This was a retrospective chart review completed by emergency physicians at an urban 772-bed tertiary-care teaching center. A hospital microbiology database compiled all adult patient charts with positive test results for Clostridium difficile toxigenic stool cultures or molecular PCR assays test results from January 2014 to March 2015. A blinded, experienced physician chart abstractor trained in retrospective research reviewed all electronic medical emergency visit-related documents and order entries using a standardized source document to identify if physician history, review of systems, physical examination, admitting notes, and nursing notes reflected concern or caution for CDI and immediately placed patients on correct isolation precautions. Primary variables included whether or not the ED documented diarrhea and ordered specific Clostridium difficile isolation precautions. CDI was defined based on the standard set by the Centers for Disease Control and Prevention, which includes clinically significant diarrhea and a positive result for Clostridium difficile toxin A/B or a toxin-producing Clostridium difficile organism. Secondary variables included type of admission inpatient unit and timing of Clostridium difficile testing. Results: The microbiology database identified 202 cases with positive Clostridium difficile test results over 15 months. However, only 64 cases had clinically significant diarrhea in the ED (31.7%, 95% CI: 26-38%). Out of these 64 cases, possible CDI was recognized in 24 cases (37.5%), 95% CI 27-50%) and appropriate isolation instituted in 10 cases (15.6% 95% CI:9-26%). When emergency physicians ordered Clostridium difficile testing for 20 patients, they appropriately isolated 7 patients (35.0%, 95% CI 18-56%). Inpatient physicians ordered testing within 24 hours for 20 patients and within 48 hours for 14 patients (53.13%, 95% CI:41-64%). Half of all patients with positive Clostridium difficile test results 51/102 were admitted to the intensive care unit (26%, 95% CI 18-24%) or intermediate progressive care unit (24%, 95% CI 16-23%). All of these admissions tested positive for CDI within one week of admission, 53 of which tested positive within 3 days of admission (51.96% 95% CI 42-61%). Conclusion: In this study, approximately one third of patients with Clostridium difficile diarrhea received diagnostic testing in the ED. Appropriate isolation for active Clostridium difficile occurred in only one of seven ED patients. When emergency physicians did not recognize CDI by ordering appropriate testing, inpatient physicians
S132 Annals of Emergency Medicine
identified over half of CDI. However, this took 48 hours from admission. Based on these results at a large urban teaching hospital, emergency physicians and admitting hospitalists must innovate to improve screening, testing practices, and isolation of patients with CDI signs/symptoms before stool cultures finally reveal CDI. We urge other institutions to critically appraise their practice standards and combat this increasingly prevalent disease.
367
Treatment and Referral of Markedly Elevated Blood Pressure in an Urban Emergency Department: How Well Do Emergency Physicians Adhere to American College of Emergency Physicians Clinical Guidelines?
Hughes GB, Velez J, Heinert S, Brown SB, Purakal JD, Del Rios M/University of Illinois at Chicago, Chicago, IL
Study Objectives: In 2013, the American College of Emergency Physicians (ACEP) published a revision of its 2006 clinical policy on the evaluation and management of asymptomatic hypertension (HTN) in the emergency department (ED). The update states that in patients with asymptomatic markedly elevated blood pressure (BP), routine medical intervention in the ED is not required but recommends referral for long term treatment. The policy also states that physicians may choose to treat and/or initiate therapy in select patient populations, ie, those with poor follow-up, limited access to care, older patients (age60), and black patients. The goal of this study was to assess adherence to these guidelines in an urban ED. Methods: We performed a retrospective chart review of patients with markedly elevated BP who presented over a four-month period to the ED of a large urban teaching hospital in Chicago. BP was defined according to the 2003 JNC 7 classification for stage 2 HTN as a systolic or diastolic blood pressure of >160 mmHg or >100 mmHg, respectively on two consecutive measurements. Demographics, medical history, ED medications, ED diagnosis, and follow-up instructions were abstracted from electronic health records. Bivariate logistic regression modeling was used to determine the association between patient characteristics and treatment with an antihypertensive in the ED and discharge with antihypertensive prescription. Results: Four hundred forty-one patients presented to the ED with markedly elevated BPs. 14% were treated with an antihypertensive during the ED visit, with 13% discharged with an prescription. For non-Hispanic black (NHB) patients, the odds of being treated with antihypertensives in the ED were 2.1 times higher (P ¼ .04) than for other races. Patients without a prior history of HTN were 95% less likely to be treated with antihypertensive in the ED than those with a HTN diagnosis (P ¼ .003). No significant association was found for older patients age60 (OR¼0.57, P ¼ .10) or insurance status (OR ¼ 0.85, P ¼ .70). Older patients and those without a prior diagnosis of HTN were less likely to be discharged with a prescription for an antihypertensive (65%, P ¼ .006 and 66%, P ¼ .016, respectively). NHB had 1.98 times higher odds of being discharged from the ED with antihypertensive than other races (P ¼ .054). No significant association was found for insurance status (0.65, P ¼ .29). HTN was not listed as a diagnosis in 79% of patients in this sample and 77% were not provided discharge instructions for HTN. Follow-up with primary care within 72 hours was recommended for 43% of all patients. Conclusion: The issue of patients presenting to the ED with asymptomatic markedly elevated BP is a frequent treatment dilemma. In our patient population, >10% were treated and/or discharged with an antihypertensive. NHB were given antihypertensives in the ED with a trend towards more frequent prescriptions of antihypertensives upon discharge. Other groups of interest were less likely to be prescribed antihypertensive upon discharge suggesting inconsistent adherence to ACEP clinical guidelines. Moreover, there was an overall failure to provide discharge information or to recommend timely followup. Further education of emergency physicians to better manage asymptomatic HTN and help prevent long-term consequences of HTN is needed.
368
Sonographic Assessment of Inadvertent Vascular Puncture During Paracentesis Using the Traditional Landmark Approach
Adams A, Roggio A, Wilkerson RG/University of Maryland School of Medicine, Baltimore, MD
Study Objectives: Ultrasound-guided paracentesis has become common practice in many hospitals. This technique offers several potential advantages over the traditional
Volume 66, no. 4s : October 2015