- Email: [email protected]
42: Cost-Effectiveness of Emergency Department Penicillin Skin Testing to Guide Antibiotic Treatment of Odontogenic Infections
Research Forum Abstracts coronary syndrome, stroke, do not resuscitate status within 24 hours, immediate surgery within 24 hours, and pancreatic, pituitary or adrenal malignancies. Statistical Analyses: Descriptive statistics and univariate analyses using the chi-square test or Fisher’s exact test were used to analyze categorical variables. The Mann-Whitney test was used to analyze continuous data (comparing patients between the 2 groups of interest). Factors associated with mortality, ICU transfer or LOS in the univariate analyses (p⬍0.10) were included in their respective logistic regression models. Backwards selection was used to remove variables that did not significantly contribute information to each of the models. Results: 473 cases (380 non-diabetic) were enrolled, 43.86% were male. Data is presented as non-diabetic vs diabetic in means plus standard deviations and as odds ratios with 95% CI. Mean age: 68.99⫾18.90 vs 72.56⫾13.71; glucose: 123.19⫾39.41 vs 169.08⫾69.99; APACHE II: 12.18⫾4.40 vs 12.18⫾3.86. ED hyperglycemia was not predictive of in-hospital patient outcomes in nondiabetics. In diabetics, every 25mg/dl increase of ED serum glucose levels increased the odds of mortality by a factor of 1.9 (CI:1.17-3.05). In both nondiabetic and diabetics, an increase in APACHE II score by 1 increased the odds of mortality by a factor of 1.23 (CI:1.11-1.38, p⬍0.0002) and OR⫽1.25 (CI: 1.01-1.55, p⬍0.045). In non-diabetics, an increase in APACHE II score by 1 increased both the odds of ICU transfer by 1.17 (95%CI:1.07-1.29, p⬍0.0009) and hospital LOS by a factor of 1.07 (CI:1.01-1.13, p⬍0.0185). Non-diabetic patients who did not take statins were more likely to have a LOS longer than 4 days (OR⫽2.00, CI:1.21-3.31). Conclusion: Hyperglycemia was only predictive of mortality in diabetics. APACHE II scores were associated with all three outcomes in non-diabetic patients and only mortality in diabetic patients. Statins may have an effect on certain immune functions, which may explain their impact on hospital LOS. Future studies should analyze the effect of hyperglycemia and the use of statins on patients with a sepsis diagnoses.
40
Factors Predictive of 28-Day In-Patient Mortality Among Adult Emergency Department Patients Admitted for Suspected Infection
Berger T, Green JP, Garg N, Bhar A, Radeos MS/New York Hospital Queens, Flushing, NY
Study Objectives: To determine demographic and clinical data of adult patients screened in the emergency department (ED) for suspicion of sepsis associated with 28-day inpatient mortality. Methods: Design: Prospective observational cohort. Setting: urban teaching hospital (90,000 annual visits). Inclusion criteria: Adult patients with emergency physician suspicion for infection screened for severe sepsis or septic shock (SS/SS) and admitted during a 6-month period (2/2007-7/2007). Exclusion criteria: patients not screened for SS/SS and patients discharged home from the ED. Data Collection: All patients screened were prospectively identified. Vital signs, laboratory data, demographics, length of hospital stay and 28-day inpatient mortality were collected. Patients discharged from the hospital prior to 28 days were considered survivors. Univariate analysis was performed using chi-square and Mann-Whitney U test as appropriate. Factors significantly associated with mortality on univariate analysis were included in logistic regression to determine factors associated with 28-day mortality. Results: 931 unique patients were identified during the 6-month study period. 854 (92%) were admitted to the hospital with records available for 714 (84%); median age 78 (IQR 65-86); 51.8% female; mean SIRS score 2.16⫾1.15. 96 (11.4% [95% CI 9.28 to 13.6%]) patients died in hospital within 28 days. Factors associated with 28-day inpatient mortality on logistic regression included serum albumin ⬍ 2.5 g/dL, OR 7.73 (95% CI 4.41 to 13.57); serum lactate ⬎ 2.5 mmol/L, OR 2.76 (95% CI 1.63 to 4.72); serum creatinine⬎1.5 mg/dL, OR 2.18 (95% CI 1.25 to 3.79); serum CRP ⬎ 8.5 mg/dL, OR 1.93 (95% CI 1.07-3.49); age ⬎ 75 years, OR 1.75 (95% CI 1.01 to 3.03). Conclusion: Albumin ⬍ 2.5, lactate ⬎2.5, creatinine ⬎1.5, CRP⬎8.5 and age ⬎75 were associated with 28-day inpatient mortality. Limitations included: lack of a consecutive series of all eligible patients, incomplete medical record retrieval, and lack of follow-up data on discharged patients. Future sepsis research should focus on validating and incorporating these factors in different settings.
S54 Annals of Emergency Medicine
41
Seroprevalence of HSV-2 Infection Among an Urban Emergency Department Patient Population
Kraus CK, Shahan JB, Hsieh Y, Rothman RE, Oliver A, Gamiel J, Laeyendecker O, Quinn TC, Kelen GD/Johns Hopkins University, Baltimore, MD
Study Objectives: The prevalence of HIV and other sexually transmitted infections (STIs) among patients presenting to urban EDs remains high. Genital herpes caused by HSV-2 is a common infection in the US. Although often asymptomatic, HSV-2 infection is associated with a 2 to 4 fold increased risk of HIV infection and can have significant morbidity, especially in immunocompromised patients, pregnant patients, and neonates. Our study measures the seroprevalence of HSV-2 in patients presenting to an urban, academic ED. Methods: The study site is an urban, academic ED with an annual census of approximately 60,000 visits and is a regional tertiary care center that also serves the local population of socio-economically disadvantaged, minority patients with known high rates of STIs. Using an IRB-approved identity-unlinked methodology, we conducted an 8 week (Jun-Aug 2007) cross-sectional study of all adult ED patients (ages ⱖ18 years) with excess sera available. Research assistants interviewed patients for risk factors for STIs and other bloodborne pathogens. Demographic and clinical data were collected from charts, electronic medical records, and administrative databases. Excess blood specimens were obtained from the ED satellite and central hospital lab. Laboratory analysis of HSV-2 antibody assay were subsequently linked to the deidentified data. Results: Of 8,943 adult visits to the ED during the study period, 5,685 (64%) unique subjects were interviewed by study staff and 3,762 (66% of enrolled) had excess blood specimens available for serologic testing. Enrolled subjects were older (mean 44.5 ⫹/⫺ 16.5 years v. 40.7 ⫹/⫺ 15.6 years, p⬍0.05), but no other significant demographic differences existed. HSV-2 antibodies were detected in 1,928 subjects (51%), with significantly higher rates in females (61%) and those ages ⱖ35 years (p⬍0.05). HSV-2 seropositives were slightly older than seronegatives (HSV2(⫹): 48.1⫾15.3 years v. HSV-2(⫺): 44.8⫾17.9 years, p⬍0.05). There were no significant differences between race, triage level, or disposition between the two groups. A total of 222 (5.9%) subjects were co-infected with HSV-2 and HIV. There were 1,706 (45%) HSV(⫹) only, 58 (1.5%) HIV(⫹) only, and 1,776 (47%) seronegative for both HIV and HSV-2. Males and those ages 35-54 years had significantly (p⬍0.05) higher rates of co-infection, but race, triage level and disposition were not significant factors for co-infection. Conclusions: Our results are the first epidemiologic description of HSV-2 prevalence among ED patients. HSV-2 infection in our population (51%) is higher than in the general population of the US (⬇20%), but is consistent with prevalence data from other populations with high burdens of STIs, injection drug use, and HIV. Additionally, our results mimic the national trend of decreased HSV-2 infections among younger (ages ⬍35 years) patients.
42
Cost-Effectiveness of Emergency Department Penicillin Skin Testing to Guide Antibiotic Treatment of Odontogenic Infections
Raja AS, Moellman JJ, Schauer DP, Eckman MH, Lindsell CJ, Bernstein JA, Collins SP/Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Department of Internal Medicine, Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH; Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati, Cincinnati, OH
Study Objective: Odontogenic infections present commonly in the emergency department (ED) setting. The combination of penicillin (PCN) and metronidazole effectively treats these infections but patient-reported PCN allergy often requires substitution with clindamycin, a more expensive medication associated with potentially serious side effects. Previously, we reported that patients presenting to the ED with a history of PCN allergy had a 91.3% false-positive rate of self-reported PCN allergy confirmed by PCN skin testing. Although PCN skin testing was demonstrated to be feasible in the ED setting it was unclear whether this procedure would be cost-effective to use routinely. The objective of this study was to determine the cost-effectiveness of ED-based PCN skin testing in patients with odontogenic infections who reported a PCN allergy. Methods: A decision analytic model was constructed that evaluates the costeffectiveness of two possible strategies in patients with odontogenic infections who self-report a PCN allergy: 1) skin testing using PCN major and minor determinants
Volume , . : October
Research Forum Abstracts and antibiotic treatment guided by the results; and 2) empiric treatment with clindamycin. The 2007 Medicare costs and National Physician Fee Schedule were used to capture ED and hospital costs, including those associated with complications and death. All analyses were conducted using Decision Maker® software. Results: In our base case analysis PCN skin testing is the dominant strategy, being both more effective and less costly. Sensitivity analysis demonstrates PCN skin testing continues to have a marginal cost-effectiveness ratio less than $50,000 per quality adjusted life year until the cost of skin testing increases to more than $657.10 per patient. Similarly an increase in the percentage of patients with true PCN allergy above 47.7%, a PCN anaphylaxis rate above 82.5%, an anaphylaxis mortality rate above 12.6%, or an increase in the cost of a course of PCN and metronidazole to greater than $723.37 would each independently increase the cost of the PCN skin testing strategy above a willingness to pay threshold of $50,000 per quality adjusted life year. Conclusion: PCN skin testing for ED patients presenting with odontogenic infections and self-reported PCN allergy is more effective and less costly than treating empirically with clindamycin. Although the marginal cost-effectiveness of skin testing increases as the prevalence of PCN allergy, the percentage of allergic patients who have true anaphylaxis, and the costs of PCN/metronidazole and the skin test rise, the cost-effectiveness ratio remains less than $50,000 per quality adjusted life year for all clinically reasonable values of these parameters.
43
Implementation of a Sepsis Quality Intitiative in a Community Hospital and its Impact on Morbidity and Mortality in Septic Shock
Gunaga S, Kella V, Walker J, Nedzlek C, Pensler M/Henry Ford Wyandotte Hospital, Wyandotte, MI
Study Objective: The 2008 Surviving Sepsis Campaign guidelines emphasize the importance of early identification and early goal-directed therapy (EGDT) in patients with severe sepsis and septic shock. While these recommendations have shown outcome benefit in larger hospitals, the generalizability and reproducibility of these findings to the community setting remains a question. We sought to determine whether a joint emergency department (ED) and intensive care unit (ICU) septic shock quality initiative would decrease in-hospital mortality, mechanical ventilation requirements, and vasopressor use in patients presenting to the ED with septic shock. Methods: Septic shock was defined as a suspected or confirmed source of infection in the presence of hypotension requiring vasopressor support or a blood lactate concentration ⬎ 4 mmol per liter. In phase I, a retrospective chart review was conducted on all adult patients identified with septic shock in the ED of a 320 bed community-based teaching hospital. The phase I patients were extracted from the medical records between January 1st, 2006 and April 30th, 2007. In phase II, patients were prospectively followed after the implementation of an ED-based EGDT protocol and a septic shock ICU admission bundle took effect on May 1st, 2007. All septic shock patients in phase I were defined as the historical control group, and all patients in phase II were defined as the treatment group. Charts were reviewed by trained medical student abstractors who were blinded to study questions, using a health system-wide sepsis database. Results: During the 2 year review period, 146 septic shock patients were identified. 98 of these patients made up the phase I group, and 48 patients made up the phase II group. Baseline characteristics between the two groups were similar, with average APACHE II scores of 20 ⫹ 4 in the phase I group and 19 ⫹ 4 in the phase II group. In-hospital mortality was 23% in the phase II group, as compared to 38 percent in the phase I group (P ⫽ 0.06). The patients in the phase II group had a reduction in mechanical ventilation during the first 6 hours of care (31% vs. 45%, P ⫽ 0.07) and from 6 to 72 hours (29% vs. 46%, P ⫽ 0.06) when compared to the patients in the phase I group. The need for vasopressor support in the phase II group was significantly decreased during the interval of 0 to 6 hours (44% vs. 69%, P ⫽ 0.004) as well as from 6 to 24 hours (44% vs. 63%, P ⫽ 0.03), and reduced at 24 to 72 hours (17% vs. 36%, P ⫽ 0.08) when compared with the patients in the phase I group. Conclusion: Implementation of a collaborative ED and ICU based EGDT protocol and ICU septic shock admission bundle is both feasible and beneficial with
Volume , . : October
respect to outcomes and health care resource consumption in a community-based hospital. This study confirms that ED care significantly impacts outcomes in severe sepsis and septic shock patients.
44
Transitioning from Paper to Electronic Documentation in an Urban Emergency Department: Effect on Provider Efficiency
Malhotra MK, Roberts D, Goyal N, Vallee PA, Nagarwala J, Rolland L, Martin GB/Henry Ford Hospital, Detroit, MI
Background: Electronic systems for documentation in the emergency department (ED) have been aggressively promoted and are being used widely. However, there has been no objective study of their impact on the delivery of patient care. Study Objectives: To quantify the impact on patient care efficiency as a result of changing from a paper template system to an electronic physician documentation system in the ED. Methods: This was a prospective, observational study conducted at an urban Level 1 trauma center which forms the main teaching hospital for an emergency medicine (EM) 1-3 residency program. A checklist of tasks routinely performed by EM residents in the ED was created by the authors. Data was collected by a thirdparty observer who recorded the current task being performed by each resident physician at 20-second intervals for the length of the shift. The first set of data was collected while the paper template system (T-System, Inc. ©) was still in use. The second set of data was collected immediately following implementation of the electronic documentation system (EmSTAT Physician Documentation ©). The final set of data was collected one month later. Each set represented five days of data collection with observations carried out for one shift on each of those days. Results: EM senior residents were observed throughout a 10-hour shift on fifteen different days and approximately 20,000 data samples were generated. The total time related to documentation was compared for the three collection periods. The percentage of time spent on documentation while using the paper template system was 22.5%. In the period immediately following the transition to the electronic documentation system, the time spent on documentation increased to 29%. One month later, the percentage of time spent on documentation was found to be 28.1%. Conclusion: Based on these observations, we conclude that the transition to electronic medical documentation in the ED has an adverse effect on patient care efficiency. After one month of use, the percentage of time spent on documentation remained markedly increased over times noted during use of paper templates. Further long-term studies should be completed to see if practitioners become more proficient in using an electronic documentation system over time.
45
Computerized Recruiting for Clinical Research in the Emergency Department
Kashyap R, Herasevich V, Afessa B, Gajic O, Stead L, Decker W, Smith V/Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: Patient recruitment in timely manner is critical for the success of prospective studies, particularly in the emergency department (ED), where it often depends on immediate identification of eligible patients. We report use of a real-time Automated Notification System (ANS) to identify potential patients for a clinical research protocol at the time of ED registration on the basis of information routinely collected; we hypothesize that the ANS improves the patient recruitments. Methods: We performed a comparison of patient recruitments before and after the ANS implementation over a period of 2 years. The first 12 months (Sept.2005Aug. 2006) of study recruitments were done on the basis of e-mail and phone calls from nurses and physicians or direct manual screening. The second 12 months (Sept.2006-Aug. 2007) of the study a computer system generated a pager alert, every time systolic blood pressure (SBP) of an ED patient recorded less than 90 mm Hg. After this pager alert, patients were approached for inclusion criteria assessment and recruitment, if study criteria were met. Results: In the 12 months before use of the automated notification system, the investigator enrolled 23 patients out of 64647 patients seen in ED. During 12 months of using the automated notification system, the investigator was paged by the automated notification system 180 times Monday - Friday (8 AM-4 PM) resulting in 48 enrolled patients out of 66202 patients seen in The ED, which is significantly higher than during the previous period (48/66202 versus 23/64647, p⫽ 0.006). Conclusion:The automated notification system is a more efficient and effective tool in the recruitment of patients for research studies in the ED. Use requires online linked registration, a database, and paging systems.
Annals of Emergency Medicine S55
40
Factors Predictive of 28-Day In-Patient Mortality Among Adult Emergency Department Patients Admitted for Suspected Infection
Berger T, Green JP, Garg N, Bhar A, Radeos MS/New York Hospital Queens, Flushing, NY
Study Objectives: To determine demographic and clinical data of adult patients screened in the emergency department (ED) for suspicion of sepsis associated with 28-day inpatient mortality. Methods: Design: Prospective observational cohort. Setting: urban teaching hospital (90,000 annual visits). Inclusion criteria: Adult patients with emergency physician suspicion for infection screened for severe sepsis or septic shock (SS/SS) and admitted during a 6-month period (2/2007-7/2007). Exclusion criteria: patients not screened for SS/SS and patients discharged home from the ED. Data Collection: All patients screened were prospectively identified. Vital signs, laboratory data, demographics, length of hospital stay and 28-day inpatient mortality were collected. Patients discharged from the hospital prior to 28 days were considered survivors. Univariate analysis was performed using chi-square and Mann-Whitney U test as appropriate. Factors significantly associated with mortality on univariate analysis were included in logistic regression to determine factors associated with 28-day mortality. Results: 931 unique patients were identified during the 6-month study period. 854 (92%) were admitted to the hospital with records available for 714 (84%); median age 78 (IQR 65-86); 51.8% female; mean SIRS score 2.16⫾1.15. 96 (11.4% [95% CI 9.28 to 13.6%]) patients died in hospital within 28 days. Factors associated with 28-day inpatient mortality on logistic regression included serum albumin ⬍ 2.5 g/dL, OR 7.73 (95% CI 4.41 to 13.57); serum lactate ⬎ 2.5 mmol/L, OR 2.76 (95% CI 1.63 to 4.72); serum creatinine⬎1.5 mg/dL, OR 2.18 (95% CI 1.25 to 3.79); serum CRP ⬎ 8.5 mg/dL, OR 1.93 (95% CI 1.07-3.49); age ⬎ 75 years, OR 1.75 (95% CI 1.01 to 3.03). Conclusion: Albumin ⬍ 2.5, lactate ⬎2.5, creatinine ⬎1.5, CRP⬎8.5 and age ⬎75 were associated with 28-day inpatient mortality. Limitations included: lack of a consecutive series of all eligible patients, incomplete medical record retrieval, and lack of follow-up data on discharged patients. Future sepsis research should focus on validating and incorporating these factors in different settings.
S54 Annals of Emergency Medicine
41
Seroprevalence of HSV-2 Infection Among an Urban Emergency Department Patient Population
Kraus CK, Shahan JB, Hsieh Y, Rothman RE, Oliver A, Gamiel J, Laeyendecker O, Quinn TC, Kelen GD/Johns Hopkins University, Baltimore, MD
Study Objectives: The prevalence of HIV and other sexually transmitted infections (STIs) among patients presenting to urban EDs remains high. Genital herpes caused by HSV-2 is a common infection in the US. Although often asymptomatic, HSV-2 infection is associated with a 2 to 4 fold increased risk of HIV infection and can have significant morbidity, especially in immunocompromised patients, pregnant patients, and neonates. Our study measures the seroprevalence of HSV-2 in patients presenting to an urban, academic ED. Methods: The study site is an urban, academic ED with an annual census of approximately 60,000 visits and is a regional tertiary care center that also serves the local population of socio-economically disadvantaged, minority patients with known high rates of STIs. Using an IRB-approved identity-unlinked methodology, we conducted an 8 week (Jun-Aug 2007) cross-sectional study of all adult ED patients (ages ⱖ18 years) with excess sera available. Research assistants interviewed patients for risk factors for STIs and other bloodborne pathogens. Demographic and clinical data were collected from charts, electronic medical records, and administrative databases. Excess blood specimens were obtained from the ED satellite and central hospital lab. Laboratory analysis of HSV-2 antibody assay were subsequently linked to the deidentified data. Results: Of 8,943 adult visits to the ED during the study period, 5,685 (64%) unique subjects were interviewed by study staff and 3,762 (66% of enrolled) had excess blood specimens available for serologic testing. Enrolled subjects were older (mean 44.5 ⫹/⫺ 16.5 years v. 40.7 ⫹/⫺ 15.6 years, p⬍0.05), but no other significant demographic differences existed. HSV-2 antibodies were detected in 1,928 subjects (51%), with significantly higher rates in females (61%) and those ages ⱖ35 years (p⬍0.05). HSV-2 seropositives were slightly older than seronegatives (HSV2(⫹): 48.1⫾15.3 years v. HSV-2(⫺): 44.8⫾17.9 years, p⬍0.05). There were no significant differences between race, triage level, or disposition between the two groups. A total of 222 (5.9%) subjects were co-infected with HSV-2 and HIV. There were 1,706 (45%) HSV(⫹) only, 58 (1.5%) HIV(⫹) only, and 1,776 (47%) seronegative for both HIV and HSV-2. Males and those ages 35-54 years had significantly (p⬍0.05) higher rates of co-infection, but race, triage level and disposition were not significant factors for co-infection. Conclusions: Our results are the first epidemiologic description of HSV-2 prevalence among ED patients. HSV-2 infection in our population (51%) is higher than in the general population of the US (⬇20%), but is consistent with prevalence data from other populations with high burdens of STIs, injection drug use, and HIV. Additionally, our results mimic the national trend of decreased HSV-2 infections among younger (ages ⬍35 years) patients.
42
Cost-Effectiveness of Emergency Department Penicillin Skin Testing to Guide Antibiotic Treatment of Odontogenic Infections
Raja AS, Moellman JJ, Schauer DP, Eckman MH, Lindsell CJ, Bernstein JA, Collins SP/Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Department of Internal Medicine, Division of General Internal Medicine and the Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH; Department of Internal Medicine, Division of Immunology/Allergy Section, University of Cincinnati, Cincinnati, OH
Study Objective: Odontogenic infections present commonly in the emergency department (ED) setting. The combination of penicillin (PCN) and metronidazole effectively treats these infections but patient-reported PCN allergy often requires substitution with clindamycin, a more expensive medication associated with potentially serious side effects. Previously, we reported that patients presenting to the ED with a history of PCN allergy had a 91.3% false-positive rate of self-reported PCN allergy confirmed by PCN skin testing. Although PCN skin testing was demonstrated to be feasible in the ED setting it was unclear whether this procedure would be cost-effective to use routinely. The objective of this study was to determine the cost-effectiveness of ED-based PCN skin testing in patients with odontogenic infections who reported a PCN allergy. Methods: A decision analytic model was constructed that evaluates the costeffectiveness of two possible strategies in patients with odontogenic infections who self-report a PCN allergy: 1) skin testing using PCN major and minor determinants
Volume , . : October
Research Forum Abstracts and antibiotic treatment guided by the results; and 2) empiric treatment with clindamycin. The 2007 Medicare costs and National Physician Fee Schedule were used to capture ED and hospital costs, including those associated with complications and death. All analyses were conducted using Decision Maker® software. Results: In our base case analysis PCN skin testing is the dominant strategy, being both more effective and less costly. Sensitivity analysis demonstrates PCN skin testing continues to have a marginal cost-effectiveness ratio less than $50,000 per quality adjusted life year until the cost of skin testing increases to more than $657.10 per patient. Similarly an increase in the percentage of patients with true PCN allergy above 47.7%, a PCN anaphylaxis rate above 82.5%, an anaphylaxis mortality rate above 12.6%, or an increase in the cost of a course of PCN and metronidazole to greater than $723.37 would each independently increase the cost of the PCN skin testing strategy above a willingness to pay threshold of $50,000 per quality adjusted life year. Conclusion: PCN skin testing for ED patients presenting with odontogenic infections and self-reported PCN allergy is more effective and less costly than treating empirically with clindamycin. Although the marginal cost-effectiveness of skin testing increases as the prevalence of PCN allergy, the percentage of allergic patients who have true anaphylaxis, and the costs of PCN/metronidazole and the skin test rise, the cost-effectiveness ratio remains less than $50,000 per quality adjusted life year for all clinically reasonable values of these parameters.
43
Implementation of a Sepsis Quality Intitiative in a Community Hospital and its Impact on Morbidity and Mortality in Septic Shock
Gunaga S, Kella V, Walker J, Nedzlek C, Pensler M/Henry Ford Wyandotte Hospital, Wyandotte, MI
Study Objective: The 2008 Surviving Sepsis Campaign guidelines emphasize the importance of early identification and early goal-directed therapy (EGDT) in patients with severe sepsis and septic shock. While these recommendations have shown outcome benefit in larger hospitals, the generalizability and reproducibility of these findings to the community setting remains a question. We sought to determine whether a joint emergency department (ED) and intensive care unit (ICU) septic shock quality initiative would decrease in-hospital mortality, mechanical ventilation requirements, and vasopressor use in patients presenting to the ED with septic shock. Methods: Septic shock was defined as a suspected or confirmed source of infection in the presence of hypotension requiring vasopressor support or a blood lactate concentration ⬎ 4 mmol per liter. In phase I, a retrospective chart review was conducted on all adult patients identified with septic shock in the ED of a 320 bed community-based teaching hospital. The phase I patients were extracted from the medical records between January 1st, 2006 and April 30th, 2007. In phase II, patients were prospectively followed after the implementation of an ED-based EGDT protocol and a septic shock ICU admission bundle took effect on May 1st, 2007. All septic shock patients in phase I were defined as the historical control group, and all patients in phase II were defined as the treatment group. Charts were reviewed by trained medical student abstractors who were blinded to study questions, using a health system-wide sepsis database. Results: During the 2 year review period, 146 septic shock patients were identified. 98 of these patients made up the phase I group, and 48 patients made up the phase II group. Baseline characteristics between the two groups were similar, with average APACHE II scores of 20 ⫹ 4 in the phase I group and 19 ⫹ 4 in the phase II group. In-hospital mortality was 23% in the phase II group, as compared to 38 percent in the phase I group (P ⫽ 0.06). The patients in the phase II group had a reduction in mechanical ventilation during the first 6 hours of care (31% vs. 45%, P ⫽ 0.07) and from 6 to 72 hours (29% vs. 46%, P ⫽ 0.06) when compared to the patients in the phase I group. The need for vasopressor support in the phase II group was significantly decreased during the interval of 0 to 6 hours (44% vs. 69%, P ⫽ 0.004) as well as from 6 to 24 hours (44% vs. 63%, P ⫽ 0.03), and reduced at 24 to 72 hours (17% vs. 36%, P ⫽ 0.08) when compared with the patients in the phase I group. Conclusion: Implementation of a collaborative ED and ICU based EGDT protocol and ICU septic shock admission bundle is both feasible and beneficial with
Volume , . : October
respect to outcomes and health care resource consumption in a community-based hospital. This study confirms that ED care significantly impacts outcomes in severe sepsis and septic shock patients.
44
Transitioning from Paper to Electronic Documentation in an Urban Emergency Department: Effect on Provider Efficiency
Malhotra MK, Roberts D, Goyal N, Vallee PA, Nagarwala J, Rolland L, Martin GB/Henry Ford Hospital, Detroit, MI
Background: Electronic systems for documentation in the emergency department (ED) have been aggressively promoted and are being used widely. However, there has been no objective study of their impact on the delivery of patient care. Study Objectives: To quantify the impact on patient care efficiency as a result of changing from a paper template system to an electronic physician documentation system in the ED. Methods: This was a prospective, observational study conducted at an urban Level 1 trauma center which forms the main teaching hospital for an emergency medicine (EM) 1-3 residency program. A checklist of tasks routinely performed by EM residents in the ED was created by the authors. Data was collected by a thirdparty observer who recorded the current task being performed by each resident physician at 20-second intervals for the length of the shift. The first set of data was collected while the paper template system (T-System, Inc. ©) was still in use. The second set of data was collected immediately following implementation of the electronic documentation system (EmSTAT Physician Documentation ©). The final set of data was collected one month later. Each set represented five days of data collection with observations carried out for one shift on each of those days. Results: EM senior residents were observed throughout a 10-hour shift on fifteen different days and approximately 20,000 data samples were generated. The total time related to documentation was compared for the three collection periods. The percentage of time spent on documentation while using the paper template system was 22.5%. In the period immediately following the transition to the electronic documentation system, the time spent on documentation increased to 29%. One month later, the percentage of time spent on documentation was found to be 28.1%. Conclusion: Based on these observations, we conclude that the transition to electronic medical documentation in the ED has an adverse effect on patient care efficiency. After one month of use, the percentage of time spent on documentation remained markedly increased over times noted during use of paper templates. Further long-term studies should be completed to see if practitioners become more proficient in using an electronic documentation system over time.
45
Computerized Recruiting for Clinical Research in the Emergency Department
Kashyap R, Herasevich V, Afessa B, Gajic O, Stead L, Decker W, Smith V/Mayo Clinic College of Medicine, Rochester, MN
Study Objectives: Patient recruitment in timely manner is critical for the success of prospective studies, particularly in the emergency department (ED), where it often depends on immediate identification of eligible patients. We report use of a real-time Automated Notification System (ANS) to identify potential patients for a clinical research protocol at the time of ED registration on the basis of information routinely collected; we hypothesize that the ANS improves the patient recruitments. Methods: We performed a comparison of patient recruitments before and after the ANS implementation over a period of 2 years. The first 12 months (Sept.2005Aug. 2006) of study recruitments were done on the basis of e-mail and phone calls from nurses and physicians or direct manual screening. The second 12 months (Sept.2006-Aug. 2007) of the study a computer system generated a pager alert, every time systolic blood pressure (SBP) of an ED patient recorded less than 90 mm Hg. After this pager alert, patients were approached for inclusion criteria assessment and recruitment, if study criteria were met. Results: In the 12 months before use of the automated notification system, the investigator enrolled 23 patients out of 64647 patients seen in ED. During 12 months of using the automated notification system, the investigator was paged by the automated notification system 180 times Monday - Friday (8 AM-4 PM) resulting in 48 enrolled patients out of 66202 patients seen in The ED, which is significantly higher than during the previous period (48/66202 versus 23/64647, p⫽ 0.006). Conclusion:The automated notification system is a more efficient and effective tool in the recruitment of patients for research studies in the ED. Use requires online linked registration, a database, and paging systems.
Annals of Emergency Medicine S55