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382: Pericardial Effusions Diagnosed by Bedside Emergency Department Ultrasound
Research Forum Abstracts
381
A Brief Training Module Improves Recognition of Echocardiographic Wall Motion Abnormalities by Emergency Physicians
Kerwin C, Patel G, Kulstad E/Advocate Christ Medical Center, Oak Lawn, IL
Study Objectives: Although echocardiographic detection of wall motion abnormalities has been shown to be more sensitive in detecting cardiac ischemia than the electrocardiogram, the bedside use of echocardiography in the emergency department by emergency physicians has been limited. A scarcity of data evaluating the ability of emergency physicians to interpret regional wall motion abnormalities on echocardiograms may contribute to this underutilization. We sought to determine the effect of a brief training module on the ability of emergency physicians to recognize wall motion abnormalities on echocardiograms. Methods: We developed a brief training and testing module using images available from multiple sources and presented it to a group of 23 emergency physicians in various stages of training or practice. First, to establish baseline performance, we tested their interpretation of 15 echocardiograms. We then presented the training module (over approximately 30 minutes) in which we demonstrated basic interpretation of echocardiographic wall motion abnormalities, and afterwards administered a new test of 15 different echocardiograms. For each echocardiogram, physicians were asked to interpret the wall motion as normal or abnormal on a scoring sheet which also asked demographic, background and previous training information. Results: Emergency physicians showed a significant improvement in their ability to recognize wall motion abnormalities after the brief training module. Median score on the baseline test was 73%, interquartile range (IQR) 67% to 80%, while the median score on the post-training test was 87%, IQR 80% to 93%, p⫽.001, using Wilcoxon Signed Ranks test. Multivariable regression showed no statistically significant dependence on final test score with time in practice (or residency), prior completion of an ultrasound rotation, or self-reported comfort and frequency of use of ultrasound. Conclusion: With brief training on how to recognize regional wall motion abnormalities on echocardiograms, emergency physicians show significant improvement in accuracy.
382
Pericardial Effusions Diagnosed by Bedside Emergency Department Ultrasound
Drumheller BC, Johnson AB, Lee DC, Bahl A, Nelson M, Chiricolo G, Chen J, Raio CC, Sama AE/North Shore University Hospital, Manhasset, NY
Study Objectives: The use of bedside ultrasound (US) in the emergency department (ED) has dramatically increased in the past decade. This new practice pattern has improved diagnosis and management of patient illnesses. However, there are limited studies and data on the presentation, management, and outcomes of patients diagnosed with pericardial effusion by ED bedside US. Few studies compared ED US with a second confirmatory test. Our objective is to describe the presentation of patients with pericardial effusion diagnosed by ED ultrasound and confirmed with a secondary test (cardiology-based echocardiography, CT scan using contrast, surgical intervention, or autopsy). Our second objective is to determine the positive predictive value of bedside ED US in diagnosing pericardial effusion. Methods: We performed a retrospective chart review of all ED patients diagnosed with pericardial effusion by ED physicians using bedside ultrasound from 1/2006 4/2007. This study was performed at an academic, suburban, tertiary care hospital with an annual census of 68,000 patients. Charts were identified by on-going departmental ultrasound logs that are maintained by the Department of Emergency Medicine. We recorded demographic data, confirmatory testing, treatment of effusion, length-of-stay, and mortality on a standardized collection tool. Twenty percent of charts were reviewed by 2 or more investigators and all conflicting data was resolved by the investigators. We used descriptive statistics to analyze the data. Results: Twenty-eight charts were identified that had pericardial effusions diagnosed by ED US. One chart lacked complete data and was not included in analysis. Three patients did not receive a confirmatory test and one patient did not have pericardial effusion on confirmatory testing. The main chief complaints of the 23 patients were: respiratory complaints 30%(7/23), chest pain 30%(7/23), abdominal pain 21%(5/23), and weakness 17% (4/23). However, on further review 70%(16/23) complained of shortness of breath and only 30%(7/23) complained of chest pain. Electrocardiograms (ECG) showing low voltage were seen in 30% (7/23)
S120 Annals of Emergency Medicine
of patients. Cardiomegaly or enlarged cardiac silhouette on chest x-ray was seen in 30% (7/23) of patients. Four patients presented with hypotension (systolic blood pressure less than 90). Two patients were diagnosed with cardiac tamponade by ED US. Two patients expired in the ED (autopsy diagnosis was sepsis and myocarditis). The positive predictive value of bedside ED US to diagnose pericardial effusion was 96% (95% CI: 78.1-100). Conclusion: Bedside US performed by ED physicians has good positive predictive value. The majority of patients had respiratory complaints and less than 1/3 of patients had chest pain. ECG and chest radiographs were suggestive of effusion in less than 1/3 of cases.
383
Disparities in Computed Tomography Utilization for Adult Patients Presenting to the Emergency Department With Headache
Harris B, Hwang U, Richardson LD, Lee W/Mount Sinai School of Medicine, New York, NY
Study Objective: Headache is an important reason for emergency department (ED) visits. Some patients are selected by their physicians to undergo computed tomography (CT) to evaluate for more serious causes of headache based on clinical history or physical exam. It is not known how patient-related characteristics may influence this clinical decision. The goal of this study was to identify patient-related factors associated with the choice of CT evaluation for adult patients with headache. Methods: Cohort review of patients ⱖ18 y.o. enrolled by presenting illness during a study period of 7/05 and 12/05 at an academic, urban ED. Study eligibility was based on chief complaint of headache or head injury and final diagnosis of the same. Detailed demographic (age, gender, race/ethnicity, insurance) and clinical (Emergency Severity Index (ESI), Charlson comorbidity score) data were abstracted from the ED medical record. Results: A total of 155 patients were enrolled. Mean age was 42 years (sd⫾18), 75% were female, 70% were black or Hispanic, and 77% were insured; mean ESI was 3.06 (sd⫾0.64) and Charlson score was 0.60 (sd⫾1.55). Thirty-seven percent of patients underwent head CT. Patients were more likely to undergo head CT if they had greater comorbidity [Charlson score ⱖ 3](OR⫽6.52, p⫽0.01) or severity [ESI ⱕ 3] (OR⫽3.34, p⫽0.01), but were less likely to undergo head CT if they were black or Hispanic (OR⫽0.42, p⫽0.01). These associations remained significant in multivariate models adjusting for each other as well as for patient age, sex and insurance status. Conclusion: In this study, racial and ethnic disparities exist for patients evaluated for headache or head injury. Patients who are black or Hispanic were less likely to undergo head CT during their ED evaluation.
384
Are Laboratory and Objective Clinical Data Predictive of Complicated Acute Diverticulitis in Emergency Department Patients?
Barlas D/New York Hospital Queens, Flushing, NY
Study Objectives: Acute diverticulitis has varying severity and potential for complications. If ED patients with complicated disease (perforation and/or abscess) could be identified by objective clinical and laboratory data prior to undergoing computed tomography (CT) imaging, prompt management and consultation could be initiated with the aim of minimizing morbidity. Methods: Design: retrospective review. Participants: All patients ⬎18 years seen over a 1 year period at an urban university-affiliated urban ED with a discharge diagnosis of acute diverticulitis. Interventions: Subjects with complicated disease (free air and/or abscess on CT) were identified and compared with subjects without these findings. Vital signs, serum carbon dioxide (CO2), and total white blood cell (WBC) and polymorphonuclear (%PMN) leukocyte counts were abstracted. The MannWhitney test was used to determine any differences between groups at an alpha level of 0.05. Results: Of 133 encounters, 7 had incomplete data, 92 had uncomplicated acute diverticulitis on CT, and 34 (27.0%) had complicated disease (14 with free air, 16 with abscess, and 4 with both). Vital signs (temperature, pulse, systolic BP, diastolic BP) were similar between the groups, as was serum CO2. The average WBC was higher for subjects with complicated disease (13.7 SD ⫾4.4) than for those with
Volume , . : September
381
A Brief Training Module Improves Recognition of Echocardiographic Wall Motion Abnormalities by Emergency Physicians
Kerwin C, Patel G, Kulstad E/Advocate Christ Medical Center, Oak Lawn, IL
Study Objectives: Although echocardiographic detection of wall motion abnormalities has been shown to be more sensitive in detecting cardiac ischemia than the electrocardiogram, the bedside use of echocardiography in the emergency department by emergency physicians has been limited. A scarcity of data evaluating the ability of emergency physicians to interpret regional wall motion abnormalities on echocardiograms may contribute to this underutilization. We sought to determine the effect of a brief training module on the ability of emergency physicians to recognize wall motion abnormalities on echocardiograms. Methods: We developed a brief training and testing module using images available from multiple sources and presented it to a group of 23 emergency physicians in various stages of training or practice. First, to establish baseline performance, we tested their interpretation of 15 echocardiograms. We then presented the training module (over approximately 30 minutes) in which we demonstrated basic interpretation of echocardiographic wall motion abnormalities, and afterwards administered a new test of 15 different echocardiograms. For each echocardiogram, physicians were asked to interpret the wall motion as normal or abnormal on a scoring sheet which also asked demographic, background and previous training information. Results: Emergency physicians showed a significant improvement in their ability to recognize wall motion abnormalities after the brief training module. Median score on the baseline test was 73%, interquartile range (IQR) 67% to 80%, while the median score on the post-training test was 87%, IQR 80% to 93%, p⫽.001, using Wilcoxon Signed Ranks test. Multivariable regression showed no statistically significant dependence on final test score with time in practice (or residency), prior completion of an ultrasound rotation, or self-reported comfort and frequency of use of ultrasound. Conclusion: With brief training on how to recognize regional wall motion abnormalities on echocardiograms, emergency physicians show significant improvement in accuracy.
382
Pericardial Effusions Diagnosed by Bedside Emergency Department Ultrasound
Drumheller BC, Johnson AB, Lee DC, Bahl A, Nelson M, Chiricolo G, Chen J, Raio CC, Sama AE/North Shore University Hospital, Manhasset, NY
Study Objectives: The use of bedside ultrasound (US) in the emergency department (ED) has dramatically increased in the past decade. This new practice pattern has improved diagnosis and management of patient illnesses. However, there are limited studies and data on the presentation, management, and outcomes of patients diagnosed with pericardial effusion by ED bedside US. Few studies compared ED US with a second confirmatory test. Our objective is to describe the presentation of patients with pericardial effusion diagnosed by ED ultrasound and confirmed with a secondary test (cardiology-based echocardiography, CT scan using contrast, surgical intervention, or autopsy). Our second objective is to determine the positive predictive value of bedside ED US in diagnosing pericardial effusion. Methods: We performed a retrospective chart review of all ED patients diagnosed with pericardial effusion by ED physicians using bedside ultrasound from 1/2006 4/2007. This study was performed at an academic, suburban, tertiary care hospital with an annual census of 68,000 patients. Charts were identified by on-going departmental ultrasound logs that are maintained by the Department of Emergency Medicine. We recorded demographic data, confirmatory testing, treatment of effusion, length-of-stay, and mortality on a standardized collection tool. Twenty percent of charts were reviewed by 2 or more investigators and all conflicting data was resolved by the investigators. We used descriptive statistics to analyze the data. Results: Twenty-eight charts were identified that had pericardial effusions diagnosed by ED US. One chart lacked complete data and was not included in analysis. Three patients did not receive a confirmatory test and one patient did not have pericardial effusion on confirmatory testing. The main chief complaints of the 23 patients were: respiratory complaints 30%(7/23), chest pain 30%(7/23), abdominal pain 21%(5/23), and weakness 17% (4/23). However, on further review 70%(16/23) complained of shortness of breath and only 30%(7/23) complained of chest pain. Electrocardiograms (ECG) showing low voltage were seen in 30% (7/23)
S120 Annals of Emergency Medicine
of patients. Cardiomegaly or enlarged cardiac silhouette on chest x-ray was seen in 30% (7/23) of patients. Four patients presented with hypotension (systolic blood pressure less than 90). Two patients were diagnosed with cardiac tamponade by ED US. Two patients expired in the ED (autopsy diagnosis was sepsis and myocarditis). The positive predictive value of bedside ED US to diagnose pericardial effusion was 96% (95% CI: 78.1-100). Conclusion: Bedside US performed by ED physicians has good positive predictive value. The majority of patients had respiratory complaints and less than 1/3 of patients had chest pain. ECG and chest radiographs were suggestive of effusion in less than 1/3 of cases.
383
Disparities in Computed Tomography Utilization for Adult Patients Presenting to the Emergency Department With Headache
Harris B, Hwang U, Richardson LD, Lee W/Mount Sinai School of Medicine, New York, NY
Study Objective: Headache is an important reason for emergency department (ED) visits. Some patients are selected by their physicians to undergo computed tomography (CT) to evaluate for more serious causes of headache based on clinical history or physical exam. It is not known how patient-related characteristics may influence this clinical decision. The goal of this study was to identify patient-related factors associated with the choice of CT evaluation for adult patients with headache. Methods: Cohort review of patients ⱖ18 y.o. enrolled by presenting illness during a study period of 7/05 and 12/05 at an academic, urban ED. Study eligibility was based on chief complaint of headache or head injury and final diagnosis of the same. Detailed demographic (age, gender, race/ethnicity, insurance) and clinical (Emergency Severity Index (ESI), Charlson comorbidity score) data were abstracted from the ED medical record. Results: A total of 155 patients were enrolled. Mean age was 42 years (sd⫾18), 75% were female, 70% were black or Hispanic, and 77% were insured; mean ESI was 3.06 (sd⫾0.64) and Charlson score was 0.60 (sd⫾1.55). Thirty-seven percent of patients underwent head CT. Patients were more likely to undergo head CT if they had greater comorbidity [Charlson score ⱖ 3](OR⫽6.52, p⫽0.01) or severity [ESI ⱕ 3] (OR⫽3.34, p⫽0.01), but were less likely to undergo head CT if they were black or Hispanic (OR⫽0.42, p⫽0.01). These associations remained significant in multivariate models adjusting for each other as well as for patient age, sex and insurance status. Conclusion: In this study, racial and ethnic disparities exist for patients evaluated for headache or head injury. Patients who are black or Hispanic were less likely to undergo head CT during their ED evaluation.
384
Are Laboratory and Objective Clinical Data Predictive of Complicated Acute Diverticulitis in Emergency Department Patients?
Barlas D/New York Hospital Queens, Flushing, NY
Study Objectives: Acute diverticulitis has varying severity and potential for complications. If ED patients with complicated disease (perforation and/or abscess) could be identified by objective clinical and laboratory data prior to undergoing computed tomography (CT) imaging, prompt management and consultation could be initiated with the aim of minimizing morbidity. Methods: Design: retrospective review. Participants: All patients ⬎18 years seen over a 1 year period at an urban university-affiliated urban ED with a discharge diagnosis of acute diverticulitis. Interventions: Subjects with complicated disease (free air and/or abscess on CT) were identified and compared with subjects without these findings. Vital signs, serum carbon dioxide (CO2), and total white blood cell (WBC) and polymorphonuclear (%PMN) leukocyte counts were abstracted. The MannWhitney test was used to determine any differences between groups at an alpha level of 0.05. Results: Of 133 encounters, 7 had incomplete data, 92 had uncomplicated acute diverticulitis on CT, and 34 (27.0%) had complicated disease (14 with free air, 16 with abscess, and 4 with both). Vital signs (temperature, pulse, systolic BP, diastolic BP) were similar between the groups, as was serum CO2. The average WBC was higher for subjects with complicated disease (13.7 SD ⫾4.4) than for those with
Volume , . : September