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419: Work-Induced Memory Decline in Emergency Medicine Attending Physicians
Research Forum Abstracts
417
Cardiovascular Abnormalities Among Children Presenting With Chest Pain to a Community Hospital and Compliance to Follow-Up
Kondamudi N, Raghuthaman T, VinZant E, Ramakrishnan P, Tatachar P/The Brooklyn Hospital Center, Brooklyn, NY
Study Objectives: The objective of this study is to determine the prevalence of cardiovascular abnormalities among children presenting to a community hospital emergency department (ED) with chest pain and compliance to follow-up. Methods: Study conducted at the pediatric ED of a community teaching hospital with 15000 annual visits. All children ⬍ 18 years old presenting to the ED with a chief complaint of chest pain were identified using the ED Log that is maintained in the department. Medical records of these patients were reviewed and pertinent data collected. Records were reviewed to see if compliance occurred and reasons for noncompliance were sought by telephone interview using a structured questionnaire. Variables were analyzed using SPSS for Windows (Version 16). Results: Medical records were available to review for 220 patients of the 266 children identified in the ED log (prevalence: 266/60,000 ⫽ 0.4%). The mean age was 12.8 years (range: 5–17) with female preponderance (57%). Majority had a pain score ⬎ 7 (n ⫽172, 78%). The most frequent insurance was Medicaid HMO (n⫽103, 47%), followed by commercial HMO (n⫽50,23%) and self pay (n⫽36, 16%). Increased blood pressure for age was noted in 9%(n⫽19), but remained high at discharge in only 3 (1%) children. Cardiomegaly on chest radiograph was seen in one child with previously surgically corrected hypoplastic left heart. Abnormal EKG findings (n⫽15, 7%) consisted of prolonged PR interval in 7 children, right bundle branch block pattern in 3, ventricular ectopy in 2 and one child each with left ventricular hypertrophy and right ventricular hypertrophy. Echocardiography done in 30 patients identified one child with mild pulmonary stenosis and one child with mitral valve prolapse, both of whom demonstrated normal hemodynamic function. The third abnormal echo was that of the known child with corrected hypoplastic left heart which was unchanged compared to the previous study. Cardiac enzyme studies were obtained in 23 (11%) and were normal. Cardiology follow-up was recommended to 126 (57%) but only 30 (24%) were compliant. The most frequent response for non-compliance was “no time to take him for the appointment” in 48% (n⫽46) of the children. There was no statistically significant association between non-compliance and factors such as age, type of insurance, pain score, and diagnosis. Conclusion: A small proportion of children with chest pain presenting to the ED have identifiable cardiovascular abnormalities that are mostly benign and unrelated to the etiology of chest pain. Compliance to follow-up is low.
418
Parental Expectation to Receive Anti-Tussive Medications for Their Coughing Children Presenting to the Emergency Department: Impact on Satisfaction
Kondamudi N, Patel T, Tatachar P/The Brooklyn Hospital Center, Brooklyn, NY
Study Objectives: The aim of this study is to determine the prevalence of anti-tussive medication use among children presenting to a community emergency department (ED), parental expectation to receive a recommendation or script for anti-tussive medication and impact on parent satisfaction when recommendation/script denied. Methods: Study Design: Anonymous questionnaire survey (English and Spanish) before physician evaluation (to determine prevalence and expectation) and at discharge (to determine satisfaction). Setting: Community pediatric ED with 15000 annual PED visits and an 8% admission rate. Participants: Parents of children ⬍ 18 years old, presenting to the PED with cough as one of the primary symptoms. Data: Demographic data of the family included age, education level, employment status, insurance type, number of children at home, use of the OTC cough medicines and expectation for a prescription for antitussive. Patient satisfaction survey done at discharge by an independent research volunteer using a 5-point Likert scale. Statistics: Collected data analyzed to determine the impact of denying antitussive medication on parent satisfaction using Chi square analysis and multivariate logistic regression model. Results: A convenience sample of 211 caregivers of 217 children was interviewed. Majority of caregivers were in the 18 –30 year age group (n⫽ 87, 41% ), finished high school (n⫽ 184, 87% ) and had Medicaid or Medicaid HMO insurance (n⫽104, 50%). Majority of children were in the 1–2 year age group (n⫽94, 45%) group and had cough for ⬎ 2 days (n⫽122, 58%). Prevalence of antitussive medication use was 37% (n⫽79). Parental expectation for cough medication occurred in 40% (n⫽84, 33% (n⫽69) felt no need for antitussives and the remaining 27% (n⫽58) were unsure. Less satisfaction occurred overall in 16% (n⫽33) caregivers, There was no association between denial of antitussive medication and level of satisfaction (p⫽0.4).
S132 Annals of Emergency Medicine
Conclusion: Prevalence of antitussive medication use is still significant and denial of prescription and advice against their use did not impact patient satisfaction.
419
Work-Induced Memory Decline in Emergency Medicine Attending Physicians
Machi MS, Suyama J, Rittenberger JC, Guyette III FX, Moore CG, Jeong K, Callaway CW, Hoslter III DP/University of Pittsburgh, Pittsburgh, PA
Study Objective: Shift work is known to result in desynchronosis and cognitive decline. The 24-hour coverage of the emergency medicine (EM) specialty requires shift work, but any decline in cognitive performance could potentially jeopardize patient care. We employed a battery of validated neuropsychiatric tests to measure changes in cognition, executive function, and impulsiveness in emergency medicine attending physicians before and after day and overnight shifts. This study tested the hypothesis that the work-induced decline in cognition would differ between day and overnight shifts. Methods: We conducted a prospective study of academic emergency physicians working in an urban trauma center. Eleven physicians were tested before and after day and overnight shifts (N⫽2 to 6 shifts per physician). We administered four neuropsychiatric tests that require 20 –30 minutes to complete: Paced Auditory Serial Addition Test (PASAT), University of Southern California Repeatable Episodic Memory Test (USC-REMT), Trail Making Test (TMT), and Stroop Test. The differences in scores between pre-shift and post-shift and 95% confidence intervals (95% CI) were estimated under the independence assumption of observations within a physician. Because pre- and post-shift scores within a physician were not independent, the adjusted estimate and 95% CI were also calculated from a random effect model. The same analyses assessed the effect of day versus overnight shifts, using the difference between day and overnight shifts within a trial. Results: No post-shift changes were seen in the PASAT indicating preserved attention and arithmetic ability. No decrements in post-shift performance were identified for the TMT and the Stroop Test indicating preserved executive function. Significantly fewer words were recalled on the USC-REMT after both day (⫺4.10, 95% CI ⫺6.85, ⫺1.34) and overnight shifts (⫺4.51, 95% CI ⫺6.82, ⫺2.20). However, there was no difference in the number of words recalled between day and overnight shifts. There was a significant post-shift increase in words recalled from the last third of the USC-REMT list compared to the first and middle thirds after both day (4.36%, 95% CI 0.25, 8.46) and overnight (7.79%, 95% CI 2.53, 13.1) shifts. Conclusion: Executive function, attention, and arithmetic ability were unaffected by day and overnight shifts in these emergency physicians, but short-term memory declined over the shifts. There was no difference in this effect on short-term memory between day and overnight shifts. Whether memory decline could result in errors during patient care could be examined in future studies.
420
Clinical Features of Fitz-Hugh-Curtis Syndrome and Length of the Emergency Department Stay
Moon S, Baek S, Han C, Lee S, Choi S, Hong Y/Korea University, Ansan City, Kyunggido, Republic of Korea
Study Objectives: As CT scanning being used more frequently, diagnosing FitzHugh-Curtis syndrome (FHCS) in the emergency department (ED) is no longer a rare circumstance. But if the physicians do not appreciate the characteristic clinical features, primary diagnosis would be confused and this will lengthen the stay in the ED. Therefore, we aimed to overview the clinical features of FHCS patients, at the same time, investigate the difference of the length of stay in the ED depending on primary impression. Methods: We reviewed charts of the patients who registered as FHCS in the ED from 2006 to 2008. The diagnosis of FHCS was made when reproductive-aged women showed right upper quadrant pain and perihepatic contrast enhancement on abdominal CT scanning without any evidence of other disease except female pelvic inflammatory disease. We overviewed the patient’s demographic data and findings of physical examination. The results of the gynecologic consultation were reviewed to identify the presence of female pelvic inflammatory disease. The results of Chlamydia antibody IgG and IgM were also reviewed. The patients were divided into two groups according to whether or not FHCS was included in the primary impressions on admission and verified if there was significant difference in the length of the ED stay in both groups. Results: Thirty patients were registered as FHCS during the period and 6 patients were excluded because perihepatic contrast enhancement were not apparent on the abdominal CT scanning. The average age of the remaining 24 patients was 32 ⫾ 8 years old. Only 6 patients (25%) had fever and 8 patients (33%) showed leukocytosis on admission. 17 patients (71%) had symptoms for more than 5 days and had a history of being managed at other hospitals but none were diagnosed as FHCS at that time. Only 7
Volume , . : September
417
Cardiovascular Abnormalities Among Children Presenting With Chest Pain to a Community Hospital and Compliance to Follow-Up
Kondamudi N, Raghuthaman T, VinZant E, Ramakrishnan P, Tatachar P/The Brooklyn Hospital Center, Brooklyn, NY
Study Objectives: The objective of this study is to determine the prevalence of cardiovascular abnormalities among children presenting to a community hospital emergency department (ED) with chest pain and compliance to follow-up. Methods: Study conducted at the pediatric ED of a community teaching hospital with 15000 annual visits. All children ⬍ 18 years old presenting to the ED with a chief complaint of chest pain were identified using the ED Log that is maintained in the department. Medical records of these patients were reviewed and pertinent data collected. Records were reviewed to see if compliance occurred and reasons for noncompliance were sought by telephone interview using a structured questionnaire. Variables were analyzed using SPSS for Windows (Version 16). Results: Medical records were available to review for 220 patients of the 266 children identified in the ED log (prevalence: 266/60,000 ⫽ 0.4%). The mean age was 12.8 years (range: 5–17) with female preponderance (57%). Majority had a pain score ⬎ 7 (n ⫽172, 78%). The most frequent insurance was Medicaid HMO (n⫽103, 47%), followed by commercial HMO (n⫽50,23%) and self pay (n⫽36, 16%). Increased blood pressure for age was noted in 9%(n⫽19), but remained high at discharge in only 3 (1%) children. Cardiomegaly on chest radiograph was seen in one child with previously surgically corrected hypoplastic left heart. Abnormal EKG findings (n⫽15, 7%) consisted of prolonged PR interval in 7 children, right bundle branch block pattern in 3, ventricular ectopy in 2 and one child each with left ventricular hypertrophy and right ventricular hypertrophy. Echocardiography done in 30 patients identified one child with mild pulmonary stenosis and one child with mitral valve prolapse, both of whom demonstrated normal hemodynamic function. The third abnormal echo was that of the known child with corrected hypoplastic left heart which was unchanged compared to the previous study. Cardiac enzyme studies were obtained in 23 (11%) and were normal. Cardiology follow-up was recommended to 126 (57%) but only 30 (24%) were compliant. The most frequent response for non-compliance was “no time to take him for the appointment” in 48% (n⫽46) of the children. There was no statistically significant association between non-compliance and factors such as age, type of insurance, pain score, and diagnosis. Conclusion: A small proportion of children with chest pain presenting to the ED have identifiable cardiovascular abnormalities that are mostly benign and unrelated to the etiology of chest pain. Compliance to follow-up is low.
418
Parental Expectation to Receive Anti-Tussive Medications for Their Coughing Children Presenting to the Emergency Department: Impact on Satisfaction
Kondamudi N, Patel T, Tatachar P/The Brooklyn Hospital Center, Brooklyn, NY
Study Objectives: The aim of this study is to determine the prevalence of anti-tussive medication use among children presenting to a community emergency department (ED), parental expectation to receive a recommendation or script for anti-tussive medication and impact on parent satisfaction when recommendation/script denied. Methods: Study Design: Anonymous questionnaire survey (English and Spanish) before physician evaluation (to determine prevalence and expectation) and at discharge (to determine satisfaction). Setting: Community pediatric ED with 15000 annual PED visits and an 8% admission rate. Participants: Parents of children ⬍ 18 years old, presenting to the PED with cough as one of the primary symptoms. Data: Demographic data of the family included age, education level, employment status, insurance type, number of children at home, use of the OTC cough medicines and expectation for a prescription for antitussive. Patient satisfaction survey done at discharge by an independent research volunteer using a 5-point Likert scale. Statistics: Collected data analyzed to determine the impact of denying antitussive medication on parent satisfaction using Chi square analysis and multivariate logistic regression model. Results: A convenience sample of 211 caregivers of 217 children was interviewed. Majority of caregivers were in the 18 –30 year age group (n⫽ 87, 41% ), finished high school (n⫽ 184, 87% ) and had Medicaid or Medicaid HMO insurance (n⫽104, 50%). Majority of children were in the 1–2 year age group (n⫽94, 45%) group and had cough for ⬎ 2 days (n⫽122, 58%). Prevalence of antitussive medication use was 37% (n⫽79). Parental expectation for cough medication occurred in 40% (n⫽84, 33% (n⫽69) felt no need for antitussives and the remaining 27% (n⫽58) were unsure. Less satisfaction occurred overall in 16% (n⫽33) caregivers, There was no association between denial of antitussive medication and level of satisfaction (p⫽0.4).
S132 Annals of Emergency Medicine
Conclusion: Prevalence of antitussive medication use is still significant and denial of prescription and advice against their use did not impact patient satisfaction.
419
Work-Induced Memory Decline in Emergency Medicine Attending Physicians
Machi MS, Suyama J, Rittenberger JC, Guyette III FX, Moore CG, Jeong K, Callaway CW, Hoslter III DP/University of Pittsburgh, Pittsburgh, PA
Study Objective: Shift work is known to result in desynchronosis and cognitive decline. The 24-hour coverage of the emergency medicine (EM) specialty requires shift work, but any decline in cognitive performance could potentially jeopardize patient care. We employed a battery of validated neuropsychiatric tests to measure changes in cognition, executive function, and impulsiveness in emergency medicine attending physicians before and after day and overnight shifts. This study tested the hypothesis that the work-induced decline in cognition would differ between day and overnight shifts. Methods: We conducted a prospective study of academic emergency physicians working in an urban trauma center. Eleven physicians were tested before and after day and overnight shifts (N⫽2 to 6 shifts per physician). We administered four neuropsychiatric tests that require 20 –30 minutes to complete: Paced Auditory Serial Addition Test (PASAT), University of Southern California Repeatable Episodic Memory Test (USC-REMT), Trail Making Test (TMT), and Stroop Test. The differences in scores between pre-shift and post-shift and 95% confidence intervals (95% CI) were estimated under the independence assumption of observations within a physician. Because pre- and post-shift scores within a physician were not independent, the adjusted estimate and 95% CI were also calculated from a random effect model. The same analyses assessed the effect of day versus overnight shifts, using the difference between day and overnight shifts within a trial. Results: No post-shift changes were seen in the PASAT indicating preserved attention and arithmetic ability. No decrements in post-shift performance were identified for the TMT and the Stroop Test indicating preserved executive function. Significantly fewer words were recalled on the USC-REMT after both day (⫺4.10, 95% CI ⫺6.85, ⫺1.34) and overnight shifts (⫺4.51, 95% CI ⫺6.82, ⫺2.20). However, there was no difference in the number of words recalled between day and overnight shifts. There was a significant post-shift increase in words recalled from the last third of the USC-REMT list compared to the first and middle thirds after both day (4.36%, 95% CI 0.25, 8.46) and overnight (7.79%, 95% CI 2.53, 13.1) shifts. Conclusion: Executive function, attention, and arithmetic ability were unaffected by day and overnight shifts in these emergency physicians, but short-term memory declined over the shifts. There was no difference in this effect on short-term memory between day and overnight shifts. Whether memory decline could result in errors during patient care could be examined in future studies.
420
Clinical Features of Fitz-Hugh-Curtis Syndrome and Length of the Emergency Department Stay
Moon S, Baek S, Han C, Lee S, Choi S, Hong Y/Korea University, Ansan City, Kyunggido, Republic of Korea
Study Objectives: As CT scanning being used more frequently, diagnosing FitzHugh-Curtis syndrome (FHCS) in the emergency department (ED) is no longer a rare circumstance. But if the physicians do not appreciate the characteristic clinical features, primary diagnosis would be confused and this will lengthen the stay in the ED. Therefore, we aimed to overview the clinical features of FHCS patients, at the same time, investigate the difference of the length of stay in the ED depending on primary impression. Methods: We reviewed charts of the patients who registered as FHCS in the ED from 2006 to 2008. The diagnosis of FHCS was made when reproductive-aged women showed right upper quadrant pain and perihepatic contrast enhancement on abdominal CT scanning without any evidence of other disease except female pelvic inflammatory disease. We overviewed the patient’s demographic data and findings of physical examination. The results of the gynecologic consultation were reviewed to identify the presence of female pelvic inflammatory disease. The results of Chlamydia antibody IgG and IgM were also reviewed. The patients were divided into two groups according to whether or not FHCS was included in the primary impressions on admission and verified if there was significant difference in the length of the ED stay in both groups. Results: Thirty patients were registered as FHCS during the period and 6 patients were excluded because perihepatic contrast enhancement were not apparent on the abdominal CT scanning. The average age of the remaining 24 patients was 32 ⫾ 8 years old. Only 6 patients (25%) had fever and 8 patients (33%) showed leukocytosis on admission. 17 patients (71%) had symptoms for more than 5 days and had a history of being managed at other hospitals but none were diagnosed as FHCS at that time. Only 7
Volume , . : September