- Email: [email protected]
85: Reliability of Point-of-Care Hemoglobin Testing in the Emergency Department
ICEM 2008 Scientific Abstract Program Conclusions: The new computerized database model and prototype software for Emergency Based of Thai Pediatric Injury Surveillance System are essential for pediatric injury surveillance and holistic approach for the injury management and prevention in Thailand. The decision support system (DSS), PTS is a useful tool for the management of pediatric injury at the emergency department. The future online registration model for pediatric injury surveillance survey in Thailand is promising.
85
Reliability of Point-of-Care Hemoglobin Testing in the Emergency Department
Luber S, de Give D, Roppolo L, Todd C, Sharda R, Patyrak S, Byrne D, Pepe P/ UT Southwestern Medical Center, Dallas, TX; Baylor University Medical Center, Dallas, TX; Texas A&M, College Station, TX
Study Objectives: Point-of-care tests for hemoglobin, using capillary blood sampling from fingertips (POC-Hgb), are now performed routinely to screen emergency department (ED) patients with anemia of various etiologies. Although POC-Hgb values may often guide clinical decisionmaking, independently conducted, prospective studies, evaluating the accuracy of such tests, have been lacking in the ED patient population. The purpose of this study was to perform a head-to-head comparison of ED-based POC-Hgb measurements versus venous blood samples that are quantified in the hospital central laboratory (Lab-Hgb). Methods: Using a convenience population over a two-month period from a large, public, urban hospital ED, enrollees were those for whom both POC-Hgb (Hemocue®) and Lab-Hgb (Sysmex America XE-2100®) measurements were obtained. Using customary techniques, venous samples for Lab-Hgb were obtained either by a nurse, patient care technician or phlebotomist and POC-Hgb fingertip capillary samples were obtained, immediately analyzed, and recorded by the provider. By design, so that the results could be assessed within the context of routine practices, investigators did not dictate sampling techniques or intervene in either specimen collections or analyses. Results: Of the 75 patients enrolled, the average age was 48.8 years (range 19-79): 51% were men and 42% were Caucasian, 33% African American, 20% Hispanic. Mean POC-Hgb values were 10.4 g/dl ⫾3.34 (range, 3-17.2 g/dl). Mean Lab-Hgb was 10.78 g/dl ⫾ 3.17 (range, 3.5-17.7 g/dl). The mean difference (bias) between POC-Hgb and Lab-Hgb values was ⫺0.383 g/dl with a standard deviation of 0.917 g/dl. However, the 95% Limits of Agreement calculation was ⫺2.179 to 1.414 g/dl and, 32% of the time, POC-Hgb either overestimated or underestimated Lab-Hgb more than 1 g/dl, with underestimations ⬎ 1 g/dl occurring in nearly a quarter (24%) of the total cases. Larger differences ( ⬎ 2g/dl) occurred in 5.3%. While appreciating the limitations in sample size, retrospective reviews of the cases with discrepancies did not indicate any definitive correlations (e.g., trauma, hypovolemia, fever, hypotension) or any likely impact on the clinical decisionmaking. Conclusion: In an urban ED population, POC-Hgb measurements generally were accurate for the majority of cases, but, overall, they tended to be lower than laboratory-measured values and they differed from those laboratory values more than 1 g/dl in nearly a third of cases. In almost every case, these differences probably would have been acceptable from a clinical perspective. However, recognizing the sample size constraints and the fact that ⬎ 2 g/dl discrepancies can occur, providers should still remain aware of the limitations of these bedside tests when making relevant therapeutic decisions.
86
The Use of Geographic Information Systems Technology to Analyze the Relationship Between Geographic Location and Out-of-Hospital Travel Time in the Developing World: A Pilot Study
Amitai A, Merino D, Chuluundorj O, Jambaa T, Saandar N/Brown University, Pawtucket, RI; University of Colorado, Denver, CO; Khon Kaen University, Khon Kaen, Thailand; Maternity Hospital, Ulaan Baatar, Mongolia
Study Objectives: Geographic Information Systems (GIS) technology has been used extensively in the developed world to optimise emergency medical systems. This pilot study evaluated the use of GIS technology in a developing world urban trauma center to assess the geographic distribution of time delays in patient arrival. METHODS: Using ArcView 9.2 software (ESRI, Redlands CA), QuickBird satellite imagery (DigitalGlobe Co, Longmont, CO) and urban survey data (MonMap Co, Ltd, Mongolia), a digital map of Ulaan Baatar and its suburbs was constructed, including major streets and landmarks. Over a continuous 2-week period, all consenting trauma cases presenting at the Ulaan Baatar Trauma Hospital, the single source of trauma care in the city, were enrolled. The geographic locations of their
Volume , . : April
traumatic events were plotted on the digital map and data collected including their age, sex, mechanism of injury, time of injury, mode of travel to the hospital, time of arrival to the hospital, and severity of injury. Absolute distances from the trauma sites to the Trauma Hospital were calculated using ArcToolbox software. Travel times were color coded and plotted on the digital map. Using STATA 10 software (College Station, Texas) a quadratic fit model was used to assess the relationship between travel distance and transit time. Results: A total of 1,360 patients were enrolled in the study. 1,145 (84.2%) provided geographic locations for their injuries that fell within our digital map area. The mean distance between trauma locations and the Trauma Hospital was 4.0 kilometers, a figure that remained constant over all severities of injury. No association was found between travel distance and transit time, but transit time was found to vary significantly with time of day, with the longest transit times occurring in the afternoon and early evening. Transit times varied significantly by means of transportation: ambulance patients arrived after an average of 180 minutes, patients arriving by private vehicles after 263 minutes, and taxi delivered patients after 320 minutes. Conclusion: This pilot study demonstrates the feasibility of utilizing GIS in the developing world to map and analyze the distribution of trauma. Contrary to expectations, within the geographic area of our study, there was no significant relationship demonstrated between location and time to hospital arrival, though time of day did appear a significant determinant. Given that late afternoon and early evening are the times of greatest utilization of the Mongolian out-of-hospital care system, we speculate that prolonged out-of-hospital travel time in our setting are more likely due to the overloaded emergency and private transportation systems.
87
A Continuous Quality Improvement Approach to Patient Record Documentation Compliance in an Academic Emergency Department
Jalili M/University of Tehran, Tehran, Iran (Islamic Republic of)
Study Objectives: To determine whether continuous quality improvement (CQI) methodology could improve and maintain patient record documentation compliance by emergency medicine residents in an academic emergency department (ED). Methods: A minimum set of documentation requirements was first determined by an expert panel based on their clinical and legal significance. This included documentation of the patient history and physical findings, as well as the results of laboratory and imaging tests, clinical procedures, and initial and final diagnosis. All notes were supposed to be signed in an eligible way and the exact date and time of them recorded. Baseline compliance data were collected and shared with staff during a formal educational session. Minimum documentation requirements were made clear. A Documentation Improvement Taskforce monitored outcomes. Each month of the study period, a total of 300 records were reviewed by a member of the taskforce. This record sample was stratified proportionally to represent the different types of records for different categories of patients, namely fast track patients, shortstay patients, and admitted patients. The following indicators were monitored: admission note, reporting of lab and imaging results, notes on procedures, complete discharge note, correct and precise recording of date and time for all elements of documentation. Individualized results were provided to residents on a monthly basis and in a confidential way. The overall results for the whole department were, however, disclosed for them in public. Results: During the six-month study period, compliance rates increased from 60 to 98% (p-value⬍ .05). The positive change for various residents ranged from 39 to 76 %. The most marked improvement among different elements of documentation was seen with time of the first physician visit. The degree of improvement for different types of patient records was 70, 58, and 64 % for fast track outpatients, short-stay patients, and admitted patients, respectively. Conclusion: In our ED, we have demonstrated that the application of CQI methodology, combined with the individualized feedback, resulted in sustained and acceptable improvement in mandatory documentation compliance by residents. Key elements for success included uniform supervision strategy, the timely reporting of individualized feedback to the stakeholders, and the leadership of a committed and respected member of the faculty. This study supports the growing body of evidence that CQI is an effective tool for improving ED operational systems.
Annals of Emergency Medicine 497
85
Reliability of Point-of-Care Hemoglobin Testing in the Emergency Department
Luber S, de Give D, Roppolo L, Todd C, Sharda R, Patyrak S, Byrne D, Pepe P/ UT Southwestern Medical Center, Dallas, TX; Baylor University Medical Center, Dallas, TX; Texas A&M, College Station, TX
Study Objectives: Point-of-care tests for hemoglobin, using capillary blood sampling from fingertips (POC-Hgb), are now performed routinely to screen emergency department (ED) patients with anemia of various etiologies. Although POC-Hgb values may often guide clinical decisionmaking, independently conducted, prospective studies, evaluating the accuracy of such tests, have been lacking in the ED patient population. The purpose of this study was to perform a head-to-head comparison of ED-based POC-Hgb measurements versus venous blood samples that are quantified in the hospital central laboratory (Lab-Hgb). Methods: Using a convenience population over a two-month period from a large, public, urban hospital ED, enrollees were those for whom both POC-Hgb (Hemocue®) and Lab-Hgb (Sysmex America XE-2100®) measurements were obtained. Using customary techniques, venous samples for Lab-Hgb were obtained either by a nurse, patient care technician or phlebotomist and POC-Hgb fingertip capillary samples were obtained, immediately analyzed, and recorded by the provider. By design, so that the results could be assessed within the context of routine practices, investigators did not dictate sampling techniques or intervene in either specimen collections or analyses. Results: Of the 75 patients enrolled, the average age was 48.8 years (range 19-79): 51% were men and 42% were Caucasian, 33% African American, 20% Hispanic. Mean POC-Hgb values were 10.4 g/dl ⫾3.34 (range, 3-17.2 g/dl). Mean Lab-Hgb was 10.78 g/dl ⫾ 3.17 (range, 3.5-17.7 g/dl). The mean difference (bias) between POC-Hgb and Lab-Hgb values was ⫺0.383 g/dl with a standard deviation of 0.917 g/dl. However, the 95% Limits of Agreement calculation was ⫺2.179 to 1.414 g/dl and, 32% of the time, POC-Hgb either overestimated or underestimated Lab-Hgb more than 1 g/dl, with underestimations ⬎ 1 g/dl occurring in nearly a quarter (24%) of the total cases. Larger differences ( ⬎ 2g/dl) occurred in 5.3%. While appreciating the limitations in sample size, retrospective reviews of the cases with discrepancies did not indicate any definitive correlations (e.g., trauma, hypovolemia, fever, hypotension) or any likely impact on the clinical decisionmaking. Conclusion: In an urban ED population, POC-Hgb measurements generally were accurate for the majority of cases, but, overall, they tended to be lower than laboratory-measured values and they differed from those laboratory values more than 1 g/dl in nearly a third of cases. In almost every case, these differences probably would have been acceptable from a clinical perspective. However, recognizing the sample size constraints and the fact that ⬎ 2 g/dl discrepancies can occur, providers should still remain aware of the limitations of these bedside tests when making relevant therapeutic decisions.
86
The Use of Geographic Information Systems Technology to Analyze the Relationship Between Geographic Location and Out-of-Hospital Travel Time in the Developing World: A Pilot Study
Amitai A, Merino D, Chuluundorj O, Jambaa T, Saandar N/Brown University, Pawtucket, RI; University of Colorado, Denver, CO; Khon Kaen University, Khon Kaen, Thailand; Maternity Hospital, Ulaan Baatar, Mongolia
Study Objectives: Geographic Information Systems (GIS) technology has been used extensively in the developed world to optimise emergency medical systems. This pilot study evaluated the use of GIS technology in a developing world urban trauma center to assess the geographic distribution of time delays in patient arrival. METHODS: Using ArcView 9.2 software (ESRI, Redlands CA), QuickBird satellite imagery (DigitalGlobe Co, Longmont, CO) and urban survey data (MonMap Co, Ltd, Mongolia), a digital map of Ulaan Baatar and its suburbs was constructed, including major streets and landmarks. Over a continuous 2-week period, all consenting trauma cases presenting at the Ulaan Baatar Trauma Hospital, the single source of trauma care in the city, were enrolled. The geographic locations of their
Volume , . : April
traumatic events were plotted on the digital map and data collected including their age, sex, mechanism of injury, time of injury, mode of travel to the hospital, time of arrival to the hospital, and severity of injury. Absolute distances from the trauma sites to the Trauma Hospital were calculated using ArcToolbox software. Travel times were color coded and plotted on the digital map. Using STATA 10 software (College Station, Texas) a quadratic fit model was used to assess the relationship between travel distance and transit time. Results: A total of 1,360 patients were enrolled in the study. 1,145 (84.2%) provided geographic locations for their injuries that fell within our digital map area. The mean distance between trauma locations and the Trauma Hospital was 4.0 kilometers, a figure that remained constant over all severities of injury. No association was found between travel distance and transit time, but transit time was found to vary significantly with time of day, with the longest transit times occurring in the afternoon and early evening. Transit times varied significantly by means of transportation: ambulance patients arrived after an average of 180 minutes, patients arriving by private vehicles after 263 minutes, and taxi delivered patients after 320 minutes. Conclusion: This pilot study demonstrates the feasibility of utilizing GIS in the developing world to map and analyze the distribution of trauma. Contrary to expectations, within the geographic area of our study, there was no significant relationship demonstrated between location and time to hospital arrival, though time of day did appear a significant determinant. Given that late afternoon and early evening are the times of greatest utilization of the Mongolian out-of-hospital care system, we speculate that prolonged out-of-hospital travel time in our setting are more likely due to the overloaded emergency and private transportation systems.
87
A Continuous Quality Improvement Approach to Patient Record Documentation Compliance in an Academic Emergency Department
Jalili M/University of Tehran, Tehran, Iran (Islamic Republic of)
Study Objectives: To determine whether continuous quality improvement (CQI) methodology could improve and maintain patient record documentation compliance by emergency medicine residents in an academic emergency department (ED). Methods: A minimum set of documentation requirements was first determined by an expert panel based on their clinical and legal significance. This included documentation of the patient history and physical findings, as well as the results of laboratory and imaging tests, clinical procedures, and initial and final diagnosis. All notes were supposed to be signed in an eligible way and the exact date and time of them recorded. Baseline compliance data were collected and shared with staff during a formal educational session. Minimum documentation requirements were made clear. A Documentation Improvement Taskforce monitored outcomes. Each month of the study period, a total of 300 records were reviewed by a member of the taskforce. This record sample was stratified proportionally to represent the different types of records for different categories of patients, namely fast track patients, shortstay patients, and admitted patients. The following indicators were monitored: admission note, reporting of lab and imaging results, notes on procedures, complete discharge note, correct and precise recording of date and time for all elements of documentation. Individualized results were provided to residents on a monthly basis and in a confidential way. The overall results for the whole department were, however, disclosed for them in public. Results: During the six-month study period, compliance rates increased from 60 to 98% (p-value⬍ .05). The positive change for various residents ranged from 39 to 76 %. The most marked improvement among different elements of documentation was seen with time of the first physician visit. The degree of improvement for different types of patient records was 70, 58, and 64 % for fast track outpatients, short-stay patients, and admitted patients, respectively. Conclusion: In our ED, we have demonstrated that the application of CQI methodology, combined with the individualized feedback, resulted in sustained and acceptable improvement in mandatory documentation compliance by residents. Key elements for success included uniform supervision strategy, the timely reporting of individualized feedback to the stakeholders, and the leadership of a committed and respected member of the faculty. This study supports the growing body of evidence that CQI is an effective tool for improving ED operational systems.
Annals of Emergency Medicine 497