- Email: [email protected]
376 Documentation of Endotracheal Tube Position Confirmation Among Different Emergency Department Providers
Research Forum Abstracts Conclusion: In a community-based, multi-hospital system, therapeutic hypothermia does not appear to provide any mortality benefit in patients with cardiac arrest. Further studies will be needed to determine those most likely to benefit from therapeutic hypothermia in a community based setting.
376
Documentation of Endotracheal Tube Position Confirmation Among Different Emergency Department Providers
Phelan MP, Hustey F, Joyce M, Schrump S, Konwinski J, Yin D/Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner Institute, Cleveland, OH; MetroHealth/ Cleveland Clinic, Cleveland, OH; Metrohealth/Cleveland Clinic, Cleveland, OH
Study Objective: The objective of this study was to assess the prevalence of appropriate documentation of endotracheal tube position confirmation in intubated emergency department (ED) patients among ED health care providers. Methods: Prospective, observational. Inclusions: all patients in the ED of a tertiary care center undergoing endotracheal tube placement in the study ED or arriving with an endotracheal tube placed in an outside setting. Exclusions: patients with surgical airways. A surveillance process was developed to prospectively capture all intubated patients. This process included a standardized airway registry form that was completed by the ED physician. Forms were used to identify all study patients and then medical records were reviewed using a standardized audit form. Appropriate documentation of endotracheal tube position confirmation was defined according to American College of Emergency Physician (ACEP)’s 3 recommended. Methods: End-tidal CO2 detection, re-evaluation with direct laryngoscopy, or an esophageal detection device (EDD). Proportions with 95% confidence intervals and p values are reported. Results: 344/346 patients in the registry undergoing endotracheal intubation between March 1, 2010 and June 30th, 2011 had complete data and were included. 116 were intubated prior to ED arrival and the remaining 228 were intubated in the study site ED. 9 of 344 (2.6%; 95%CI, 1-5%) had no documentation of confirmation by any provider. Overall documentation rates for confirmation of ET tube placement were 76.7% (264/344) for physicians, 91.0% (312/344) for respiratory therapists (RT) and 53.8% (185/344) for nurses. Documentation rates were highest across provider types for patients intubated in the ED compared to those intubated in an outside setting (Table 1). Physicians and nurses were less likely to document endotracheal tube position confirmation in patients intubated in an OSH as opposed to those intubated by emergency medical services (31% versus 50%, p⫽.0567 and 21% versus 47%, p⫽.0057). Overall there were 1032 documentation opportunities (three provider types across 344 patients), with appropriate documentation occurring in only 73.7% (761/1032; 95%CI, 71.0-76.3%). Conclusion: Documentation of endotracheal tube position confirmation for patients intubated at outside hospitals is low across the disciplines. Providers are less likely to document endotracheal tube position confirmation for patients arriving to the ED with an endotracheal tube tube already in place. Opportunities exist to improve documentation of confirmation of endotracheal tube position across health care providers. Differences in ED provider documentation of ET position confirmation by location of intubation Provider
compared rate
p value
MD RT RN
ED (215/228, 94.3%) vs OH* (49/116, 42.2%) ED (216/228, 94.7%) vs OH* (96/116, 82.8%) ED (143/228, 62.7%) vs OH* (42/116, 36.2%)
p ⬍ 0.0001 p ⫽ 0.0006 p ⬍ 0.0001
*Documentation rates for patients intubated by EMS or by an outside hospital (OSH) were combined and represented by OH. Two tailed p values were determined by Fishers Exact Test using GraphPad statistical software.
377
The Association Between Post-Assault Physical Appearance and Behaviors in the Emergency Department and Assault Types
Mounessa JS, De Cicco S, Akerman M, McCullough M, Pastrana T, Castaneda J, Aziz-Bose R, Gurr D, Rudolph G, Ward MF/North Shore-LIJ Health System, Manhasset, NY
Study Objectives: Emergency department (ED) clinicians can help alleviate the psychological and physical impact of sexual assault through proper care of the sexual assault survivor. The physical exam serves to address medical needs, collect forensic
Volume , . : October
evidence, and document observational findings; however, an exhaustive literature search revealed that no literature exists on whether specific post-assault appearance or behaviors can be linked to types of assault. The study aims to determine if a sexual assault survivor’s post-assault appearance and behaviors are associated with types of assault. We hypothesize that post-assault appearance and behavior are linked to assault types. Methods: This was a retrospective, consecutive chart review of sexual assault survivors treated by sexual assault nurse examiners (SANEs) in the ED of a suburban teaching hospital from 1/1/2006 through 10/3/2010. Sexual assault survivors with documented appearance including calm, quiet, tense, restless, poor eye contact, and behaviors including reluctant to answer questions, posture/gait, agitated, twisting fingers, responsive to questions, crying, other, were studied with respect to whether they were assaulted by a known assailant or had a loss of consciousness. The chisquare test was used to compare groups (known versus unknown assailant or loss versus no loss of consciousness) with physical appearance and behaviors. Subjects with missing pertinent data were excluded from sub-analyses. Results: A total of 823 charts were reviewed. A higher percentage of “quiet” sexual assault survivors was assaulted by a known assailant (74.8%, n⫽249) than by an unknown assailant (25.2%, n⫽84; p ⬍0.014). Of the SASs who were “twisting [their] fingers,” a higher percentage knew the assailant (59.4%, n⫽41) than did not (40.6%, n⫽28; p⬍0.039); a higher percentage was conscious during the assault (91.7%, n⫽58) than was not (8.3%, n⫽5; p⬍0.002). Additionally, a higher percentage of sexual assault survivors who were “reluctant to answer questions” was conscious during the assault (90.6%, n⫽55) than was not (9.4%, n⫽5; p⬍0.003). No significant relationships existed between other appearances or behaviors and knowing the assailant or having a loss of consciousness. Conclusion: Our results suggest that ED clinicians should be mindful that postassault appearance and behaviors such as quietness, twisting fingers, and reluctance to answer questions may be associated with assault types such as relationship to assailant or loss of consciousness.
378
A Comparison of Post-Assault Times to Emergency Department Presentation in Sexual Assault Survivors
Mounessa JS, De Cicco S, Akerman M, D’Amore J, Pastrana T, Aziz-Bose R, Ruvolo B, Maurice K, Ward MF/North Shore-LIJ Health System, Manhasset, NY
Study Objectives: Delayed medical care after sexual assault can be associated with adverse consequences for the sexual assault survivor including loss of forensic evidence and postponement of medical treatment. Although ample research supports the importance of early presentation to the emergency department (ED), scant literature exists on the role that the individuals who accompany sexual assault survivors play on the time to ED presentation. The objective of this study is to compare the ED presentation times of sexual assault survivors who present alone, with a friend/family member, or with a law enforcement agent. We hypothesize that those who are accompanied by a law enforcement agent will have the earliest time to ED presentation post-assault. Methods: This was a retrospective, consecutive chart review of sexual assault survivors treated by sexual assault nurse examiners in the ED of a suburban teaching hospital from 1/2/2002 through 12/28/2010. Point estimate presentation times, the difference between time of assault and ED triage time, as well as 95% confidence intervals (CI), were calculated for 3 groups of sexual assault survivors: those who presented to the ED alone, with a friend/family member, or with a law enforcement agent. Subjects with invalid point estimate presentation times or strata values were excluded from further analysis. The log-rank test was used to compare the point estimate presentation times to ED presentation between these 3 groups. Results: 845 charts were reviewed, with a 100% patient capture rate. A total of 716 subjects had documentation of presenting to the ED either alone (n⫽191, 26.7%), with a friend/family member (n⫽213, 29.7%), or with a law enforcement agent (n⫽312, 43.6%). Significant differences in point estimate presentation times existed among the 3 analyzed groups (p⬍0.001). Those who presented with either a friend/family member had the longest point estimate presentation times (16.1 hours, CI: 13.8 - 18.0), followed by those who presented to the ED alone (15.0 hours, CI: 12.3 - 17.5). Those who presented with a law enforcement agent had the shortest point estimate ED presentation times (7.6 hours, CI: 6.0 - 10.1). Conclusion: Our results suggest that sexual assault survivors who presented to the ED with a law enforcement agent had significantly earlier times to presentation than those who presented alone or with a friend/family member. These results suggest that sexual assault survivors should be encouraged to promptly report assaults to law
Annals of Emergency Medicine S133
376
Documentation of Endotracheal Tube Position Confirmation Among Different Emergency Department Providers
Phelan MP, Hustey F, Joyce M, Schrump S, Konwinski J, Yin D/Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner Institute, Cleveland, OH; MetroHealth/ Cleveland Clinic, Cleveland, OH; Metrohealth/Cleveland Clinic, Cleveland, OH
Study Objective: The objective of this study was to assess the prevalence of appropriate documentation of endotracheal tube position confirmation in intubated emergency department (ED) patients among ED health care providers. Methods: Prospective, observational. Inclusions: all patients in the ED of a tertiary care center undergoing endotracheal tube placement in the study ED or arriving with an endotracheal tube placed in an outside setting. Exclusions: patients with surgical airways. A surveillance process was developed to prospectively capture all intubated patients. This process included a standardized airway registry form that was completed by the ED physician. Forms were used to identify all study patients and then medical records were reviewed using a standardized audit form. Appropriate documentation of endotracheal tube position confirmation was defined according to American College of Emergency Physician (ACEP)’s 3 recommended. Methods: End-tidal CO2 detection, re-evaluation with direct laryngoscopy, or an esophageal detection device (EDD). Proportions with 95% confidence intervals and p values are reported. Results: 344/346 patients in the registry undergoing endotracheal intubation between March 1, 2010 and June 30th, 2011 had complete data and were included. 116 were intubated prior to ED arrival and the remaining 228 were intubated in the study site ED. 9 of 344 (2.6%; 95%CI, 1-5%) had no documentation of confirmation by any provider. Overall documentation rates for confirmation of ET tube placement were 76.7% (264/344) for physicians, 91.0% (312/344) for respiratory therapists (RT) and 53.8% (185/344) for nurses. Documentation rates were highest across provider types for patients intubated in the ED compared to those intubated in an outside setting (Table 1). Physicians and nurses were less likely to document endotracheal tube position confirmation in patients intubated in an OSH as opposed to those intubated by emergency medical services (31% versus 50%, p⫽.0567 and 21% versus 47%, p⫽.0057). Overall there were 1032 documentation opportunities (three provider types across 344 patients), with appropriate documentation occurring in only 73.7% (761/1032; 95%CI, 71.0-76.3%). Conclusion: Documentation of endotracheal tube position confirmation for patients intubated at outside hospitals is low across the disciplines. Providers are less likely to document endotracheal tube position confirmation for patients arriving to the ED with an endotracheal tube tube already in place. Opportunities exist to improve documentation of confirmation of endotracheal tube position across health care providers. Differences in ED provider documentation of ET position confirmation by location of intubation Provider
compared rate
p value
MD RT RN
ED (215/228, 94.3%) vs OH* (49/116, 42.2%) ED (216/228, 94.7%) vs OH* (96/116, 82.8%) ED (143/228, 62.7%) vs OH* (42/116, 36.2%)
p ⬍ 0.0001 p ⫽ 0.0006 p ⬍ 0.0001
*Documentation rates for patients intubated by EMS or by an outside hospital (OSH) were combined and represented by OH. Two tailed p values were determined by Fishers Exact Test using GraphPad statistical software.
377
The Association Between Post-Assault Physical Appearance and Behaviors in the Emergency Department and Assault Types
Mounessa JS, De Cicco S, Akerman M, McCullough M, Pastrana T, Castaneda J, Aziz-Bose R, Gurr D, Rudolph G, Ward MF/North Shore-LIJ Health System, Manhasset, NY
Study Objectives: Emergency department (ED) clinicians can help alleviate the psychological and physical impact of sexual assault through proper care of the sexual assault survivor. The physical exam serves to address medical needs, collect forensic
Volume , . : October
evidence, and document observational findings; however, an exhaustive literature search revealed that no literature exists on whether specific post-assault appearance or behaviors can be linked to types of assault. The study aims to determine if a sexual assault survivor’s post-assault appearance and behaviors are associated with types of assault. We hypothesize that post-assault appearance and behavior are linked to assault types. Methods: This was a retrospective, consecutive chart review of sexual assault survivors treated by sexual assault nurse examiners (SANEs) in the ED of a suburban teaching hospital from 1/1/2006 through 10/3/2010. Sexual assault survivors with documented appearance including calm, quiet, tense, restless, poor eye contact, and behaviors including reluctant to answer questions, posture/gait, agitated, twisting fingers, responsive to questions, crying, other, were studied with respect to whether they were assaulted by a known assailant or had a loss of consciousness. The chisquare test was used to compare groups (known versus unknown assailant or loss versus no loss of consciousness) with physical appearance and behaviors. Subjects with missing pertinent data were excluded from sub-analyses. Results: A total of 823 charts were reviewed. A higher percentage of “quiet” sexual assault survivors was assaulted by a known assailant (74.8%, n⫽249) than by an unknown assailant (25.2%, n⫽84; p ⬍0.014). Of the SASs who were “twisting [their] fingers,” a higher percentage knew the assailant (59.4%, n⫽41) than did not (40.6%, n⫽28; p⬍0.039); a higher percentage was conscious during the assault (91.7%, n⫽58) than was not (8.3%, n⫽5; p⬍0.002). Additionally, a higher percentage of sexual assault survivors who were “reluctant to answer questions” was conscious during the assault (90.6%, n⫽55) than was not (9.4%, n⫽5; p⬍0.003). No significant relationships existed between other appearances or behaviors and knowing the assailant or having a loss of consciousness. Conclusion: Our results suggest that ED clinicians should be mindful that postassault appearance and behaviors such as quietness, twisting fingers, and reluctance to answer questions may be associated with assault types such as relationship to assailant or loss of consciousness.
378
A Comparison of Post-Assault Times to Emergency Department Presentation in Sexual Assault Survivors
Mounessa JS, De Cicco S, Akerman M, D’Amore J, Pastrana T, Aziz-Bose R, Ruvolo B, Maurice K, Ward MF/North Shore-LIJ Health System, Manhasset, NY
Study Objectives: Delayed medical care after sexual assault can be associated with adverse consequences for the sexual assault survivor including loss of forensic evidence and postponement of medical treatment. Although ample research supports the importance of early presentation to the emergency department (ED), scant literature exists on the role that the individuals who accompany sexual assault survivors play on the time to ED presentation. The objective of this study is to compare the ED presentation times of sexual assault survivors who present alone, with a friend/family member, or with a law enforcement agent. We hypothesize that those who are accompanied by a law enforcement agent will have the earliest time to ED presentation post-assault. Methods: This was a retrospective, consecutive chart review of sexual assault survivors treated by sexual assault nurse examiners in the ED of a suburban teaching hospital from 1/2/2002 through 12/28/2010. Point estimate presentation times, the difference between time of assault and ED triage time, as well as 95% confidence intervals (CI), were calculated for 3 groups of sexual assault survivors: those who presented to the ED alone, with a friend/family member, or with a law enforcement agent. Subjects with invalid point estimate presentation times or strata values were excluded from further analysis. The log-rank test was used to compare the point estimate presentation times to ED presentation between these 3 groups. Results: 845 charts were reviewed, with a 100% patient capture rate. A total of 716 subjects had documentation of presenting to the ED either alone (n⫽191, 26.7%), with a friend/family member (n⫽213, 29.7%), or with a law enforcement agent (n⫽312, 43.6%). Significant differences in point estimate presentation times existed among the 3 analyzed groups (p⬍0.001). Those who presented with either a friend/family member had the longest point estimate presentation times (16.1 hours, CI: 13.8 - 18.0), followed by those who presented to the ED alone (15.0 hours, CI: 12.3 - 17.5). Those who presented with a law enforcement agent had the shortest point estimate ED presentation times (7.6 hours, CI: 6.0 - 10.1). Conclusion: Our results suggest that sexual assault survivors who presented to the ED with a law enforcement agent had significantly earlier times to presentation than those who presented alone or with a friend/family member. These results suggest that sexual assault survivors should be encouraged to promptly report assaults to law
Annals of Emergency Medicine S133