- Email: [email protected]
Bedside cardiac markers and the emergency evaluation of chest pain
RESEARCH FORUM ABSTRACTS
i aware that each is respectively a risk factor for CAD, but were not more aware of risk factors in general. Conclusion: Baseline levels of knowledge about CAD risk factors are low in this ED-based population. There are significant differences in knowledge among races.
1 t J; Chest Demographics, Descriptions, Diagnosis, and Disposition of 1,677 Pain Patients in an Indigent Acute Care Hospital Henderson SO, OstrzegaE, GennaT, Matayoshi D, Alcocer L/Los Angeles County-Universityof Southern California Medical Center, Los Angeles, CA Traditionally, descriptive studies of chest pain focus on sentinel events, such as myocardial infarction. In addition, chest pain in the African-American and white population has been well described, whereas the indigent and immigrant population has been largely ignored. Our facility is a Level I trauma center serving a muhicuhural urban community. Although our community is 70% Hispanic, our hospital also sees many other immigrant populations A disproportionate number of patients are indigent and less than 5% have private insurance. Study objective: To evaluate the demographics, presentation, diagnosis, and final disposition of this underreported, primarily Hispanic, socioeconomically depressed, urban population of patients with the chief complaint of chest pain. Methods: We conducted a retrospective case review of all emergency department patients with chief complaint of chest pain from January 1 through June 30, 1998 Data included patient demographics and chief compiaint, cardiac risk factors, first ECG, first troponin (TnI), intoxicant history and levels, final diagnosis, and disposition from the ED. Results: There were 1,677 patients with the chief complaint of chest pain; 885 (53%) were men. The mean age was 53 years (range E2 to 93 years). Fifty-five percent of patients were Hispanic, 25% African-American, 10% white, 8% Asian, and 2% other; 41.9% of patients were from the United States and 29.2% from Mexico with more than 48 other countries of origin represented. A total of 1,165 (70%) of the patients presented with the classical precordial description (left-sided, substerna], and so on) of chest pain. Of the 1,677 patients, 52% had hypertension, 20.5% had a family history of heart disease, 24.2% were diabetic. 37.6% had a past cardiac history, 36% used tobacco. 16% of those tested used cocaine, and 14.2% had known cholesterolemia. Two hundred thirty-six (15.6%) of the patients were discharged directly home. Of the 1,419 (84.4% of the total patients) patients who were admitted to the hospital. 697 (42% of those admitted) went to the chest pain unit, 405 (24%) went to the 1CU/coronary care unit, 285 (17%) went to a routine medical unit and 22 (0.5%) died in the ED. The final diagnosis for this cohort included 4.5% acute myocardial infarctions, 1.4% cardiac arrests, 35.5% with atypical chest pain with no cardiac etiology found, 11.0% with congestive heart failure, 6.3% with unstable angina, 4.0% with pleuritic chest pain, 8.1% with dysrhythmias, 0.7% with endocarditis or pericarditis, and 25.7% of the patients had other final diagnosis. By race, Asians had the highest incidence of myocardial infarctions at 6.35%, compared with 2.53% in African-Americans, 4 7 6 % in whites, and 4.38% in Hispanics Conclusion: Our Hispanic population had similar chest pain, nsk factors, and chief complaints as other populations. Smoking and hypertension rates were higher and the average age was relatively low. For acute myocardial infarction, Hispanics had a higher incidence than African-Americans but similar to whites.
414 Evidence of Myocardial Complement Activation Following Hemorrhagic Shock and Resuscitation Craig K, Washington RA, HuangO. YoungerJG. Lucchesi BR/Oniversit'r of Michigan Medical Center, Ann Arbor. MI Evidence supporting myocardial malfunction after hemorrhagic shock and resuscitation has been limited and controversial. Complement has been shown to play a role in the in vatro and in vivo myocardial isehemia reperfusion (IR) injury, model. Similarly, complement activation may occur during hemorrhagic shock and resusCitation and contribute to cardiac dysfunction. Study objectives: This investigation measured cardiac performance after hemorrhage and examined cardiac tissue for histologic evidence of injm3". Methods: A fixed-pressure model of hemorrhage was performed on New Zealand White rabbits to a mean arterial pressure of 35 to 40 mm Hg for 1 hour. After 3 hours of resuscitation with shed blood and normal saline, rabbit hearts were placed on a Langendorff apparatus, paced, and perfused with warmed, oxygenated modified Krebs-Henseleit buffer at a constant flow. Cardiac performance was gauged by coronary perfusion pressure (CPP), left ventricular end-diastolic pressure (LVEDP), and left
OCTOBER 1999, PART 2 34:4 ANNALS OF EMERGENCY MEDICINE
venmcular developed pressure (LVDP). After Langendorlt perfusion, cardiac tissue was analyzed histologically by (1) hematoxyfin-eosin (H&E) staining, (2) proptdium iodide (P1) staining to assess cell vmbifity, or (3) immunohistochemistry for membrane attack complex (MAC). Results: There was no statistically significant difference between the hemorrhage and control groups in regard to CPP (P= 60). and LVEDP (P=.63). Hemorrhage and resuscitation resulted in a significantly lower LVDP (48+7, 6 mm Hg) versus control (77+16 mm Hg; P=.01). Review of H&E slides suggested a greater degree of myocardial damage in the hemorrhage group versus control as evidenced by increased capillap/engorgement, interstitial edema, and loss of nuclei. PI uptake appeared more diffuse in the hemorrhage group compared with the controls, with the former also positive for MAC. Conclusion: Changes in cardiac function induced by hemorrhagic shock and resuscitation is associated with histologac evidence of myocardial injury and complement activation
415
o,,.,o.,,.s...,.
Who Are Evaluated for Acute Cardiac Ischemic Syndromes
NagorneyJT, Brown OF. Chae CU, ChangY, CranmerHH. ChungWG, Ban L, FisherJ, Grossman SA. Jang IK. Lewandrowski I(B, O'ConnorME. Tedrow U/MassachusettsGeneral Hospital, Harvard Medical School.Boston, MA Stud)" objective: Most research on predictors of acute cardiac ischemic syndromes (ACIS) focus only on patients who present to the emergency department with chest pain We attempted to measure the frequency of ED presentations of all patients thought by clinicians to need an evaluation for ACIS. Methods: This was a prospective descnptive study design using a close-ended ACIS questionnaire The study included all patients 30 years or older with symptoms less than or equal to 48 hours who were admitted for a routine "rule out myocardial infarction" protocol or who were discharged home from the ED with the plan for an outpatient AC1S evaluation (usually an exercise tolerance test). Results: Among the first 100 patients enrolled in the study, 64% were male. The median age was 61 years (interquarrile range 49 to 71). Seventy patients (70%, 95% confidence interval [CI] 61% to 79%) presented with substerual or left chest pain: 29 (29%, 95% Cl 20% to 38%) wathout radiation, 25 (25%, 95% CI 16% to 34%) with radiation to the left arm/shoulder or neck/jaw, or both. Thirty patients (30%, 95% C[ 21% to 39%) presented with non-chest pain as their chief complaint: shortness of breath/dyspnea on exertion 9, syncope/presyncope/weakness 6, palpitation~arrhythmia 6, pain (non
1= U
Bedside Cardiac Markers and the Emergency Evaluation of Chest Pain
Henderson SO. Chan KM. GennaT, Alcocer L. Conforto A/Los Angeles County-Universityof Southern California Medical Center. Los Angeles. CA Study objective: To evaluate the efficacy of bedside cardiac markers in the initial evaluation of patients presenting with chest pain and without ECG evidence of an acute myocardial infarction in the setting of a 24-hour coronary triage unit (CTU). Methods: This was a prospective study approved by the institutional review board. All patients admitted to the CTU (18 to 65 ),ears, onset of chest pain within 72 hours, no active chest pain, no acute ST-/T-wave ECG changes) were consented and enrolled. A bedside tropontn I (Tnl) assay (Spectral lnc) was performed (positive cutoff more than 1.5 ng/mL), as well as a Tnl in the central core laboratory' (batched to run every 4 hours). Agreement between the 2 specimen results was recorded, as well as time savings that would have resulted had the bedside test been used in isolation. Results: Ninety-eight patients were enrolled. The bedside Tnl had a specificity of 98% (95% confidence interval [Cl] 89 to 100) and a sensiti~aty of 50% (95% C[ 9 to 99). Time sa~ings that would have occurred had the bedside Tnl been used in isolation were 216 minutes (3.6 hours). Although there was concordance of 97% between the 2 moth-
S 105
RESEARCH FORUM A B S T R A C T S
ods, the use of a bedside qualitative test in isolation would have resulted in a delay in diagnosis of 12 hours in 1 patient and misdiagnosis in 2 patients compared with the central laboratory value. Conclusion: Bedside TnI testing in the low-risk chest pain patient is an alternative method of ruling out myocardial infarct. Benefits from the bedside tests include time savings in the form of shorter stays in a CTU or ED. Risks include false-negative results and delayed diagnosis if the first TnI falls below the manufacturer cutoff.
417 forTypes,Emergency Benefits, and Follow-up of Social Worker Consultations Department Patients OlshakerJ, Green Y, Jerrard D/University of Maryland Medical Center, Baltimore, MD Study objective: To study types, benefits, and follow-up of emergency department social worker (SW) consultations. Methods: This was a prospective observational study of all SW consultations in an urban university adult ED over a 4-month period. Data were collected on patient age, sex, reason for ED visit, reason and outcome of SW consult, and agreement to and results of 2-month tdephone follow-up. Results: Eighty-sbx patients were seen by the SW during the study period. SW consults were initiated by physicians in 36 (42%) cases, nurses 21 (25%), patients 15 (17%), and by the SW 14 (16%). Most common reasons for ED visits were illness 52 (60%), injury 15 (17%), and domestic violence 6 (7%). Most common reasons for SW consults were inability to afford prescriptions 45 (52%), social crisis counseling 6 (7%), domestic violence counseling 6 (7%), and shelter placement 5 (6%). Forty-three patients (96%) were successfully helped to fill prescriptions. Twenty-eight (33%) patients agreed to 2-month follow-up; 15 were reached. All remembered the SW consultations and believed the interaction was helpful initially. Eleven felt the SW consultation brought benefits 2 months later, the most common reason being the acquisition of regular pharmacy assistance benefits. Conclusion: SW consultations are helpful to many ED patients, although telephone follow-up is difficuh to attain on most patients.
18
Focused Abdominal Sonography for Trauma: Evaluation of a Half-Day Curriculum
Mandavia DP, Bistrain J, Chan L, Chan D/Los Angeles County-University of Southern California Medical Center, Los Angeles, CA; University of California-San Diego Medical Center, San Diego, CA Study objectives: Bedside ultrasound (US) by emergency physicians and surgeons is rapidly being integrated into trauma care yet minimum training requirements for competency have not been well defined or tested. This study evaluated image interpretation after a 4-hour trauma US course. Methods: A standardized trauma US curriculum based on Society for Academic Emergency Medicine (SAEM) guidelines was administered to emergency physicians and surgeons over 4 hours. Lectures with syllabus material and videotapes were used to cover the fundamentals of trauma US over 2 hours. The following standard views were taught: Morison's pouch, splenorenal recess, paracolic gutters, suprapubic views, and the subcostal view of the heart. Subsequently each student received 2 hours of hands-on US instruction using normal models and peritoneal dialysis models as positive controls. At the beginning and end of this curriculum, participants received 12 trauma US images for interpretation including positive, negative, and nondiagnostic scans. Mean changes in scores were calculated using the paired t test. Results: A total of 44 emergency physicians and surgeons underwent standardized training and testing. From a maximum score of 12, the mean pretest score was 5.52_+3.01 and the mean posttest score was 9.25_+1.43 (P<.00L). The mean of changes was 3.73_+2.55 (95% confidence interval 2.95 to 4.51). Conclusion: A standardized 4-hour trauma US course significantly improves the ability of emergency physicians and surgeons to interpret US images. Further prospective studies need to evaluate this curriculum in the clinical setting.
10 Developing a New Model for Transmitting Advance Directives ;J From Long-Term Care Facilities to Emergency Departments Pauls MA, Singer PA, Dubinsky I/Joint Centre for Bioethics, University of Toronto, The Toronto Hospital, Ontario, Canada Study objectives: To identify and describe health care providers' ideal model for transmitting a patient's treatment preferences from long-term care facilities to emergency departments.
$ 1 O6
Methods: This qualitative study used semistructured focus group interviews and content analysis. Emergency medicine, emergency medical services, and long4erm care providers were asked to describe their experiences with the transfer of long-term care residents to EDs and to identify barriers that prevent residents' treatment wishes from being transferred with them. Participants were then asked to describe their ideal model for transferring residents' treatment wishes. The interviews were transcribed and a grounded theory methodology was used to identify key themes. All compatible themes were incorporated into a single model. Participants were recruited from the teaching hospitals that are affiliated with the Joint Centre for Bioethics at the University of Toronto, the Toronto Ambulance Service, and long-term care facilities that transfer patients to the EDs of these hospitals. Thirty-five participants were recruited from 5 health care provider groups: emergency nurses, emergency physicians, paramedics, long-term care nurses, and long-term care physicians. Results: Participants believed a general, less specific directive was preferable to a highly detailed one because of concerns that patients may make poorly informed choices, or may make choices that have unintended effects if the directive is too detailed. All focus groups agreed that information about resuscitation and advance care planning should be provided to patients and families as early as possible, either before or at the time of admission to a long-term care facility. It should be done in a sensitive manner, using different methods such as videos and booklets, and with little pressure to make an immediate decision. The documentation of residents' decisions should be standardized, prepared well in advance of time of transfer, and easily accesstbk. Conclusion: Our participants emphasized the importance of education and discussion rather than a specific transfer form. To improve the transmission of residents' treatment wishes from long-term care facilities to EDs, greater efforts should be made to educate residents and families about resuscitation and advance care planning. These efforts should begin as early as possible, even before the time of admission to a longterm care facility.
420
DirectNurseTriageto a Respiraton/TherapistDoes Not Decrease Time to Treatment of Patients Presenting With Dyspnea
O'Connell J, Drescher MJ, Hartman J, Smally AJ, PerezA/Hartford Hospital, University of Connecticut School of Medicine, Hartford, CT Study objective: Recently Gotdberg et al described the positive effect of a nursedriven critical pathway on resource utilization in the emergency department. We undertook this study to assess the effectiveness of a protocol allowing respiratory therapists (RT) to evaluate and treat select patients, in decreasing patient waiting time to treatment with bronchodilators. Methods: Exemption from review was received from the institutional review board. The setting was an urban teaching hospital with a census of approximately 65,000 adult patients annually. A protocol by which patients meeting criteria would be treated with bronchodflators by RTs before physician evaluation. The study design is a prospective before and after study in which a convenience sample of patients were evaluated in the 2 months before the intervention (n=150) and in the 2 months after the intervention (n=117). Inclusion criteria were patients older than age 16, presenting with dyspnea, with stable vital signs, history of chronic obstructive pulmonary disease or asthma, no history of chest pain, or 3 of the following: increased work of breathing, peak flow less than 50% of predicted or personal best, severe cough, or history of mucociliary clearance problem. Exclusion criteria included unstable vital signs, patient with chest pain, or clinical congestive heart failure. Time until seen by the RT and time until first treatment was received was recorded by the RT caring for the patient. Results: The mean time from triage to RT evaluation in the preprotocol group was 27 minutes and for the postprotocol group was 22.7 minutes. The mean time to first bronchodilator treatment was 32 minutes for the preprotocoI and 26 minutes for the postprotocol group. Conclusion: Instituting a protocol whereby RTs initiated treatment before physician evaluation of the patient did not achieve a clinically significant decrease in time to treatment of stable patients with difficulty in breathing. This finding reinforces the need to assess the effectiveness of treatment protocols such as this after their implementation. Our intention was to enroll a consecutive sample of patients meeting criteria, but do not have a method to measure compliance by the RT on duty and therefore do not know the characteristics of patients who were not enrolled. An additional limitation is our inability to generalize our findings to other institutions where time to physician evaluation, availability of RT support, nurse to patient ratio, and patient cen-
ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER 1999, PART 2
i aware that each is respectively a risk factor for CAD, but were not more aware of risk factors in general. Conclusion: Baseline levels of knowledge about CAD risk factors are low in this ED-based population. There are significant differences in knowledge among races.
1 t J; Chest Demographics, Descriptions, Diagnosis, and Disposition of 1,677 Pain Patients in an Indigent Acute Care Hospital Henderson SO, OstrzegaE, GennaT, Matayoshi D, Alcocer L/Los Angeles County-Universityof Southern California Medical Center, Los Angeles, CA Traditionally, descriptive studies of chest pain focus on sentinel events, such as myocardial infarction. In addition, chest pain in the African-American and white population has been well described, whereas the indigent and immigrant population has been largely ignored. Our facility is a Level I trauma center serving a muhicuhural urban community. Although our community is 70% Hispanic, our hospital also sees many other immigrant populations A disproportionate number of patients are indigent and less than 5% have private insurance. Study objective: To evaluate the demographics, presentation, diagnosis, and final disposition of this underreported, primarily Hispanic, socioeconomically depressed, urban population of patients with the chief complaint of chest pain. Methods: We conducted a retrospective case review of all emergency department patients with chief complaint of chest pain from January 1 through June 30, 1998 Data included patient demographics and chief compiaint, cardiac risk factors, first ECG, first troponin (TnI), intoxicant history and levels, final diagnosis, and disposition from the ED. Results: There were 1,677 patients with the chief complaint of chest pain; 885 (53%) were men. The mean age was 53 years (range E2 to 93 years). Fifty-five percent of patients were Hispanic, 25% African-American, 10% white, 8% Asian, and 2% other; 41.9% of patients were from the United States and 29.2% from Mexico with more than 48 other countries of origin represented. A total of 1,165 (70%) of the patients presented with the classical precordial description (left-sided, substerna], and so on) of chest pain. Of the 1,677 patients, 52% had hypertension, 20.5% had a family history of heart disease, 24.2% were diabetic. 37.6% had a past cardiac history, 36% used tobacco. 16% of those tested used cocaine, and 14.2% had known cholesterolemia. Two hundred thirty-six (15.6%) of the patients were discharged directly home. Of the 1,419 (84.4% of the total patients) patients who were admitted to the hospital. 697 (42% of those admitted) went to the chest pain unit, 405 (24%) went to the 1CU/coronary care unit, 285 (17%) went to a routine medical unit and 22 (0.5%) died in the ED. The final diagnosis for this cohort included 4.5% acute myocardial infarctions, 1.4% cardiac arrests, 35.5% with atypical chest pain with no cardiac etiology found, 11.0% with congestive heart failure, 6.3% with unstable angina, 4.0% with pleuritic chest pain, 8.1% with dysrhythmias, 0.7% with endocarditis or pericarditis, and 25.7% of the patients had other final diagnosis. By race, Asians had the highest incidence of myocardial infarctions at 6.35%, compared with 2.53% in African-Americans, 4 7 6 % in whites, and 4.38% in Hispanics Conclusion: Our Hispanic population had similar chest pain, nsk factors, and chief complaints as other populations. Smoking and hypertension rates were higher and the average age was relatively low. For acute myocardial infarction, Hispanics had a higher incidence than African-Americans but similar to whites.
414 Evidence of Myocardial Complement Activation Following Hemorrhagic Shock and Resuscitation Craig K, Washington RA, HuangO. YoungerJG. Lucchesi BR/Oniversit'r of Michigan Medical Center, Ann Arbor. MI Evidence supporting myocardial malfunction after hemorrhagic shock and resuscitation has been limited and controversial. Complement has been shown to play a role in the in vatro and in vivo myocardial isehemia reperfusion (IR) injury, model. Similarly, complement activation may occur during hemorrhagic shock and resusCitation and contribute to cardiac dysfunction. Study objectives: This investigation measured cardiac performance after hemorrhage and examined cardiac tissue for histologic evidence of injm3". Methods: A fixed-pressure model of hemorrhage was performed on New Zealand White rabbits to a mean arterial pressure of 35 to 40 mm Hg for 1 hour. After 3 hours of resuscitation with shed blood and normal saline, rabbit hearts were placed on a Langendorff apparatus, paced, and perfused with warmed, oxygenated modified Krebs-Henseleit buffer at a constant flow. Cardiac performance was gauged by coronary perfusion pressure (CPP), left ventricular end-diastolic pressure (LVEDP), and left
OCTOBER 1999, PART 2 34:4 ANNALS OF EMERGENCY MEDICINE
venmcular developed pressure (LVDP). After Langendorlt perfusion, cardiac tissue was analyzed histologically by (1) hematoxyfin-eosin (H&E) staining, (2) proptdium iodide (P1) staining to assess cell vmbifity, or (3) immunohistochemistry for membrane attack complex (MAC). Results: There was no statistically significant difference between the hemorrhage and control groups in regard to CPP (P= 60). and LVEDP (P=.63). Hemorrhage and resuscitation resulted in a significantly lower LVDP (48+7, 6 mm Hg) versus control (77+16 mm Hg; P=.01). Review of H&E slides suggested a greater degree of myocardial damage in the hemorrhage group versus control as evidenced by increased capillap/engorgement, interstitial edema, and loss of nuclei. PI uptake appeared more diffuse in the hemorrhage group compared with the controls, with the former also positive for MAC. Conclusion: Changes in cardiac function induced by hemorrhagic shock and resuscitation is associated with histologac evidence of myocardial injury and complement activation
415
o,,.,o.,,.s...,.
Who Are Evaluated for Acute Cardiac Ischemic Syndromes
NagorneyJT, Brown OF. Chae CU, ChangY, CranmerHH. ChungWG, Ban L, FisherJ, Grossman SA. Jang IK. Lewandrowski I(B, O'ConnorME. Tedrow U/MassachusettsGeneral Hospital, Harvard Medical School.Boston, MA Stud)" objective: Most research on predictors of acute cardiac ischemic syndromes (ACIS) focus only on patients who present to the emergency department with chest pain We attempted to measure the frequency of ED presentations of all patients thought by clinicians to need an evaluation for ACIS. Methods: This was a prospective descnptive study design using a close-ended ACIS questionnaire The study included all patients 30 years or older with symptoms less than or equal to 48 hours who were admitted for a routine "rule out myocardial infarction" protocol or who were discharged home from the ED with the plan for an outpatient AC1S evaluation (usually an exercise tolerance test). Results: Among the first 100 patients enrolled in the study, 64% were male. The median age was 61 years (interquarrile range 49 to 71). Seventy patients (70%, 95% confidence interval [CI] 61% to 79%) presented with substerual or left chest pain: 29 (29%, 95% Cl 20% to 38%) wathout radiation, 25 (25%, 95% CI 16% to 34%) with radiation to the left arm/shoulder or neck/jaw, or both. Thirty patients (30%, 95% C[ 21% to 39%) presented with non-chest pain as their chief complaint: shortness of breath/dyspnea on exertion 9, syncope/presyncope/weakness 6, palpitation~arrhythmia 6, pain (non
1= U
Bedside Cardiac Markers and the Emergency Evaluation of Chest Pain
Henderson SO. Chan KM. GennaT, Alcocer L. Conforto A/Los Angeles County-Universityof Southern California Medical Center. Los Angeles. CA Study objective: To evaluate the efficacy of bedside cardiac markers in the initial evaluation of patients presenting with chest pain and without ECG evidence of an acute myocardial infarction in the setting of a 24-hour coronary triage unit (CTU). Methods: This was a prospective study approved by the institutional review board. All patients admitted to the CTU (18 to 65 ),ears, onset of chest pain within 72 hours, no active chest pain, no acute ST-/T-wave ECG changes) were consented and enrolled. A bedside tropontn I (Tnl) assay (Spectral lnc) was performed (positive cutoff more than 1.5 ng/mL), as well as a Tnl in the central core laboratory' (batched to run every 4 hours). Agreement between the 2 specimen results was recorded, as well as time savings that would have resulted had the bedside test been used in isolation. Results: Ninety-eight patients were enrolled. The bedside Tnl had a specificity of 98% (95% confidence interval [Cl] 89 to 100) and a sensiti~aty of 50% (95% C[ 9 to 99). Time sa~ings that would have occurred had the bedside Tnl been used in isolation were 216 minutes (3.6 hours). Although there was concordance of 97% between the 2 moth-
S 105
RESEARCH FORUM A B S T R A C T S
ods, the use of a bedside qualitative test in isolation would have resulted in a delay in diagnosis of 12 hours in 1 patient and misdiagnosis in 2 patients compared with the central laboratory value. Conclusion: Bedside TnI testing in the low-risk chest pain patient is an alternative method of ruling out myocardial infarct. Benefits from the bedside tests include time savings in the form of shorter stays in a CTU or ED. Risks include false-negative results and delayed diagnosis if the first TnI falls below the manufacturer cutoff.
417 forTypes,Emergency Benefits, and Follow-up of Social Worker Consultations Department Patients OlshakerJ, Green Y, Jerrard D/University of Maryland Medical Center, Baltimore, MD Study objective: To study types, benefits, and follow-up of emergency department social worker (SW) consultations. Methods: This was a prospective observational study of all SW consultations in an urban university adult ED over a 4-month period. Data were collected on patient age, sex, reason for ED visit, reason and outcome of SW consult, and agreement to and results of 2-month tdephone follow-up. Results: Eighty-sbx patients were seen by the SW during the study period. SW consults were initiated by physicians in 36 (42%) cases, nurses 21 (25%), patients 15 (17%), and by the SW 14 (16%). Most common reasons for ED visits were illness 52 (60%), injury 15 (17%), and domestic violence 6 (7%). Most common reasons for SW consults were inability to afford prescriptions 45 (52%), social crisis counseling 6 (7%), domestic violence counseling 6 (7%), and shelter placement 5 (6%). Forty-three patients (96%) were successfully helped to fill prescriptions. Twenty-eight (33%) patients agreed to 2-month follow-up; 15 were reached. All remembered the SW consultations and believed the interaction was helpful initially. Eleven felt the SW consultation brought benefits 2 months later, the most common reason being the acquisition of regular pharmacy assistance benefits. Conclusion: SW consultations are helpful to many ED patients, although telephone follow-up is difficuh to attain on most patients.
18
Focused Abdominal Sonography for Trauma: Evaluation of a Half-Day Curriculum
Mandavia DP, Bistrain J, Chan L, Chan D/Los Angeles County-University of Southern California Medical Center, Los Angeles, CA; University of California-San Diego Medical Center, San Diego, CA Study objectives: Bedside ultrasound (US) by emergency physicians and surgeons is rapidly being integrated into trauma care yet minimum training requirements for competency have not been well defined or tested. This study evaluated image interpretation after a 4-hour trauma US course. Methods: A standardized trauma US curriculum based on Society for Academic Emergency Medicine (SAEM) guidelines was administered to emergency physicians and surgeons over 4 hours. Lectures with syllabus material and videotapes were used to cover the fundamentals of trauma US over 2 hours. The following standard views were taught: Morison's pouch, splenorenal recess, paracolic gutters, suprapubic views, and the subcostal view of the heart. Subsequently each student received 2 hours of hands-on US instruction using normal models and peritoneal dialysis models as positive controls. At the beginning and end of this curriculum, participants received 12 trauma US images for interpretation including positive, negative, and nondiagnostic scans. Mean changes in scores were calculated using the paired t test. Results: A total of 44 emergency physicians and surgeons underwent standardized training and testing. From a maximum score of 12, the mean pretest score was 5.52_+3.01 and the mean posttest score was 9.25_+1.43 (P<.00L). The mean of changes was 3.73_+2.55 (95% confidence interval 2.95 to 4.51). Conclusion: A standardized 4-hour trauma US course significantly improves the ability of emergency physicians and surgeons to interpret US images. Further prospective studies need to evaluate this curriculum in the clinical setting.
10 Developing a New Model for Transmitting Advance Directives ;J From Long-Term Care Facilities to Emergency Departments Pauls MA, Singer PA, Dubinsky I/Joint Centre for Bioethics, University of Toronto, The Toronto Hospital, Ontario, Canada Study objectives: To identify and describe health care providers' ideal model for transmitting a patient's treatment preferences from long-term care facilities to emergency departments.
$ 1 O6
Methods: This qualitative study used semistructured focus group interviews and content analysis. Emergency medicine, emergency medical services, and long4erm care providers were asked to describe their experiences with the transfer of long-term care residents to EDs and to identify barriers that prevent residents' treatment wishes from being transferred with them. Participants were then asked to describe their ideal model for transferring residents' treatment wishes. The interviews were transcribed and a grounded theory methodology was used to identify key themes. All compatible themes were incorporated into a single model. Participants were recruited from the teaching hospitals that are affiliated with the Joint Centre for Bioethics at the University of Toronto, the Toronto Ambulance Service, and long-term care facilities that transfer patients to the EDs of these hospitals. Thirty-five participants were recruited from 5 health care provider groups: emergency nurses, emergency physicians, paramedics, long-term care nurses, and long-term care physicians. Results: Participants believed a general, less specific directive was preferable to a highly detailed one because of concerns that patients may make poorly informed choices, or may make choices that have unintended effects if the directive is too detailed. All focus groups agreed that information about resuscitation and advance care planning should be provided to patients and families as early as possible, either before or at the time of admission to a long-term care facility. It should be done in a sensitive manner, using different methods such as videos and booklets, and with little pressure to make an immediate decision. The documentation of residents' decisions should be standardized, prepared well in advance of time of transfer, and easily accesstbk. Conclusion: Our participants emphasized the importance of education and discussion rather than a specific transfer form. To improve the transmission of residents' treatment wishes from long-term care facilities to EDs, greater efforts should be made to educate residents and families about resuscitation and advance care planning. These efforts should begin as early as possible, even before the time of admission to a longterm care facility.
420
DirectNurseTriageto a Respiraton/TherapistDoes Not Decrease Time to Treatment of Patients Presenting With Dyspnea
O'Connell J, Drescher MJ, Hartman J, Smally AJ, PerezA/Hartford Hospital, University of Connecticut School of Medicine, Hartford, CT Study objective: Recently Gotdberg et al described the positive effect of a nursedriven critical pathway on resource utilization in the emergency department. We undertook this study to assess the effectiveness of a protocol allowing respiratory therapists (RT) to evaluate and treat select patients, in decreasing patient waiting time to treatment with bronchodilators. Methods: Exemption from review was received from the institutional review board. The setting was an urban teaching hospital with a census of approximately 65,000 adult patients annually. A protocol by which patients meeting criteria would be treated with bronchodflators by RTs before physician evaluation. The study design is a prospective before and after study in which a convenience sample of patients were evaluated in the 2 months before the intervention (n=150) and in the 2 months after the intervention (n=117). Inclusion criteria were patients older than age 16, presenting with dyspnea, with stable vital signs, history of chronic obstructive pulmonary disease or asthma, no history of chest pain, or 3 of the following: increased work of breathing, peak flow less than 50% of predicted or personal best, severe cough, or history of mucociliary clearance problem. Exclusion criteria included unstable vital signs, patient with chest pain, or clinical congestive heart failure. Time until seen by the RT and time until first treatment was received was recorded by the RT caring for the patient. Results: The mean time from triage to RT evaluation in the preprotocol group was 27 minutes and for the postprotocol group was 22.7 minutes. The mean time to first bronchodilator treatment was 32 minutes for the preprotocoI and 26 minutes for the postprotocol group. Conclusion: Instituting a protocol whereby RTs initiated treatment before physician evaluation of the patient did not achieve a clinically significant decrease in time to treatment of stable patients with difficulty in breathing. This finding reinforces the need to assess the effectiveness of treatment protocols such as this after their implementation. Our intention was to enroll a consecutive sample of patients meeting criteria, but do not have a method to measure compliance by the RT on duty and therefore do not know the characteristics of patients who were not enrolled. An additional limitation is our inability to generalize our findings to other institutions where time to physician evaluation, availability of RT support, nurse to patient ratio, and patient cen-
ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER 1999, PART 2