- Email: [email protected]
Decisions in chest pain: how often do they change after the initial evaluation?
RESEARCH FORUM ABSTRACTS
self-report. A univariate analysis was performed to determine whether any of the traditional risk factors were significant predictors of physical examination findings or evidence of CHF on chest radiograph. Any significant variables were entered into a multivariate analysis for each endpoint. Descriptive statistics were used, including x2 testing; odds ratios (ORs) and 95% confidence intervals (CIs) are given. Results: CHF was diagnosed in 537 patients who met study criteria. Of these patients, the presence of rales was documented in 67% (176/537), S3 2% (10/537), JVD 11% (61/537), and CHF on chest radiograph in 51% (165/321). History of hypertension was a significant multivariate predictor of CHF on chest radiograph. There were no predictors of the presence of an S3. History of CHF and renal insufficiency were predictors of JVD on physical examination. Only age was predictive of the presence of rales (Table). Conclusion: The presence of physical examination and chest radiograph findings of CHF are unreliable in identifying these patients in the ED. In addition, traditional risk factors for CHF have limited influence on predicting the occurrence of such findings.
Table, abstract 325.
CHF on chest radiograph Hypertension Renal insufficiency JVD History of CHF Renal insufficiency Rales Age >60 y Renal insufficiency
326
Univariate Analysis, OR (95% CI)
Multivariate Analysis, OR (95% CI)
1.8 (1.3–2.9) 1.6 (1.0–2.6)
1.7 (1.1–2.7) 1.5 (0.9–3.6)
2.2 (1.2–4.1) 1.9 (1.1–3.2)
2.1 (1.2–4.1) 1.9 (1.1–3.2)
2.5 (2.7–2.7) 1.5 (1.0–2.1)
2.4 (1.7–3.6) 1.4 (0.9–2.0)
Aspirin Therapy in Patients Who Presented to an Academic Emergency Department With Chest Pain: Race, Sex, and Age Effects
Takakuwa KM, Shofer FS, Hollander JE/New York Hospital of Queens, Flushing, NY; University of Pennsylvania, Philadelphia, PA Study objectives: We determine whether aspirin therapy was differentially administered according to race, sex, or age in patients who presented to an urban academic emergency department (ED) with chest pain. Our hypothesis is that there will be no differences. Methods: This was a prospective cohort study of all patients aged 24 years or older who presented to our ED between July 1999 and March 2002 with chest pain. Structured data collection included demographics, laboratory test data, treatment provided, and 30-day follow-up. Patients were divided into 3 groups according to 30-day final diagnosis: acute myocardial infarction (AMI), unstable angina (USA), and all others (non–acute coronary syndrome [ACS] chest pain). Data were analyzed using x2 and t tests for categorical and continuous data, respectively. Results: Four thousand four hundred seventy patients were studied (men [41%]; black [70%], white [26%], and other race [4%]; age 52.2615.8 years). A total of 2,498 patients (56%) received aspirin therapy. Three hundred nineteen patients (7%) had an AMI, and 544 patients (12%) had USA. The majority, 3,607 (81%), had a non-ACS chest pain diagnosis. Aspirin therapy differed by race, sex, age, and final diagnosis. Patients who received aspirin were more likely to be white (60% versus black 55% versus other 50%, P=.002), men (61% versus women 52%, P\.0001), older (56 versus 48 years, P\.0001), or have an ACS diagnosis (82% versus nonACS chest pain 50%, P\.0001). When aspirin therapy was examined by final diagnosis, there were no differences in race, sex, and age for AMI or USA (P[.05 for all). There were significant sex and age differences for non-ACS chest pain patients: men had higher aspirin therapy compared with women (53% versus 48%, P\.0001),
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
and older patients had higher aspirin therapy compared with younger patients (54.4 versus 46.8, P\.0001). No racial differences in non-ACS chest pain patients were found. Conclusion: There was an overall race, sex, and age difference: white, male, and older patients had higher rates of aspirin therapy. However, these effects can be explained by higher rates of aspirin administered to older men with non-ACS chest pain. We found no race, sex, or age differences in aspirin therapy for patients who had time-sensitive AMI or USA.
327
Impact of Nesiritide Infusion on Acute Decompensated Heart Failure in an Urban Hospital Emergency Department
Nazeer SR, Miller AH, Brickner B, Yancy C/University of Texas Southwestern Medical School, Dallas, TX Study objectives: Decompensated congestive heart failure (CHF) is a major cause of emergency department (ED) visits and resource utilization. It has previously been demonstrated that patients treated in an urban ED for acute decompensated heart failure (ADHF) have a 60% rate of recidivism to the ED, with admission to the hospital. Recent data suggest that treatment with natriuretic peptides may decrease admission rates by 50% in a general hospital population. We determine whether intravenous natriuretic peptides for ADHF will affect ED disposition at the index visit and decrease the rate of recidivism for a high-risk urban population. Methods: This is an institutional review board–approved, randomized, doubleblinded, placebo-controlled trial of nesiritide versus placebo in addition to a standard treatment algorithm for ADHF. Adult patients ($18 years) presenting to the ED with a history of CHF, symptoms of dyspnea at rest or minimal exertion, and physical and laboratory evidence of volume overload are eligible. Patients are randomized to receive intravenous nesiritide or placebo for 8 hours, in addition to standard therapy, which includes intravenous furosemide, as well as oxygen and antihypertensive medication, if necessary. Physician assessment occurs at 0, 3, and 8 hours for symptoms, adequate diuresis, and readiness for discharge. All patients have echocardiograms completed within 72 hours of presentation. Significant adverse events are noted, and endpoints are followed up by telephone or in person at 1 week. Hospital records will be reviewed at 30 days and 90 days for return visits to the ED, readmissions, or death. Results: The initial 21 patients included 15 men (71%) and 6 women (29%). Black patients composed the majority at 12 patients (57%). Six patients were white (29%) and 3 Hispanic (14%). The average age of patients currently enrolled is 56 years, with a range of 25 to 93 years. Primary outcome measures are hospitalization or discharge from the ED after treatment, level of care to which the patient is transferred from the ED, and return visits to the ED within 30 days. Secondary outcome measures are return visit to the ED, hospitalization, or death within 90 days. As a separate focus, we will track the occurrence of systolic (left ventricular ejection fraction \0.40) and diastolic (left ventricular ejection fraction [0.40) dysfunction in patients with decompensated heart failure within an urban population. This study is powered to determine a 20% treatment effect at 85% power with an a of 0.05 for a sample size of 150 patients. Conclusion: If the results are positive, the treatment of ADHF in an urban population at high risk for repeated ED visits for heart failure will be greatly improved, with a reduction in morbidity and a decrease in resource utilization.
328
Decisions in Chest Pain: How Often Do They Change After the Initial Evaluation?
Martin KR, Giles BK, Mullis SA, Schaffer JT/Indiana University, Indianapolis, IN; Methodist Emergency Medicine and Trauma Center, Indianapolis, IN; Methodist Research Institute, Indianapolis, IN Study objectives: We determine to what extent decisions in chest pain change from initial emergency department (ED) patient encounter to final ED diagnosis, disposition, and treatment. Methods: We designed a prospective, observational study of a convenience sample of chest pain patients triaged to the critical care area of an urban ED. Patients were excluded if they were diagnosed with ST-segment elevation myocardial in farction. Physician decisions about these patients were studied. The physicians involved in the study were attending emergency physicians and upper-level
S 1 0 1
RESEARCH FORUM ABSTRACTS
emergency medicine residents who staff 100% of cases with an attending emergency physician. Physicians were surveyed after initial patient evaluation. This initial evaluation was defined as initial medical history and physical examination and reading of the ECG. The survey elicited initial ‘‘working’’ diagnosis, treatment, and disposition. The treating physician was again surveyed after final ED decisions and disposition were made. The second survey elicited the same information as the first survey about decisions. The second survey also asked the treating physicians to cite the factors that led to changes in their decisions. The surveys were then compared, and decision changes were noted as upgrades or downgrades. Changes in decisions were correlated with cardiac marker results and physician-cited factors that led to those decision changes. Results: Of 83 physician/patient interactions studied, 20 (24%) had an upgrade in management, 24 (29%) a downgrade, and 39 (47%) had no change. Seventy-six patients had negative cardiac markers. Of the patients with negative markers, 14 (18%) had an upgrade, 24(32%) had a downgrade, and 37 (49%) had no change in decisions. The most common factor cited by the treating physician as affecting decisions was change in patient status (N=34, 41%). The second most common factor cited was cardiac marker results (N=30, 36%). From these 30 interactions, 4 had positive markers, all of which had an upgrade in management; 26 had negative markers. Of these 26, 6 were upgraded and 8 were downgraded; 12 had no change in management, even though the physician stated that the marker results affected their decisions. Finally, from these 30 interactions in which cardiac markers were cited as affecting decisions, 9 patients had negative markers and duration less than 6 hours. Follow-up was available for 81 of the 83 patients. No significant correlation between changes in decision and outcomes was found. Conclusion: Nearly 50% of chest pain management decisions did not change after the initial evaluation. Physicians may inappropriately rely on initial cardiac marker results in determining the etiology of a patient’s chest pain.
329
Key Factors in Out-of-Hospital Intubation Suggested for Further Training
Kryder GD, Jang TB, Tan D/Washington University School of Medicine, St. Louis, MO Study objectives: We identify key factors affecting out-of-hospital intubation attempts. Methods: This was a retrospective review of consecutive patients transported by the primary ambulance service of a large Midwestern city. Patients were identified as requiring emergency intubation if they were newly unresponsive without a gag reflex, unresponsive with persistent pulse oximetry below 90%, or having a respiratory rate less than 10 breaths/min or greater than 30 breaths/min with persistent pulse oximetry below 90%. Analysis was done using a multiple regression model. Results: From March 2003 to June 2003, 386 transported patients required emergency intubation. Intubation was attempted in 42 (11%) patients and successful in 10 (24%, 95% confidence interval [CI] 11% to 37%), which is consistent with previous studies. Using a multiple regression model, 3 factors were identified that were associated with failure to attempt intubation when indicated: Glasgow Coma Scale (GCS) score of 9 or greater (odds ratio [OR] 18.2, 95% CI 6.5 to 29.9), failure to obtain intravenous access (OR 1.8, 95% CI 0.9 to 2.7), and performing bag-valvemask or positive pressure ventilation (PPV) (OR 50.4, 95% CI 12.8 to 88.0). Although PPV is a temporizing measure, it does not provide a definitive airway. Whether or not it should preclude out-of-hospital intubation should be addressed prospectively, especially because more than 50% of patients had persistent pulse oximetry between 80% and 90% despite PPV. Out-of-hospital personnel may benefit from further training in optimal techniques for PPV. Likewise, although advanced trauma life support protocols use GCS score as an indication for intubation, it may not be the best indication of the need for intubation, because many patients had GCS score greater than 9 but were in respiratory failure, which suggests an area for further education. Finally, the ability to establish intravenous access was a weak but persistent factor affecting intubation attempts and may be an important area for ongoing training. Conclusion: GCS score of 9 or greater, the ability to obtain intravenous access, and performing PPV were 3 factors affecting intubation attempts and may be important areas for the further training of out-of-hospital personnel.
S 1 0 2
330
Trauma Diversion Within a Tiered Emergency Department Closure Policy
Sidani RS, Gibbons MP, Brickman KR, Moomey PR, Lindstrom DA/Medical College of Ohio, Toledo, OH; Lucas County Emergency Medical Services, Toledo, OH Study objectives: Emergency department (ED) closures impart a considerable strain on community and hospital trauma resources. Trauma and nontrauma ambulance transports alike play a significant role in the diversion of trauma patients. Policies to address these issues and appropriately direct patients to adequate facilities are necessary for the timely management of the most critical cases. This retrospective study evaluates the role of a trauma bypass designation in reducing out-of-hospital emergency medical services (EMS) diversion of trauma patients within a tiered ED closure policy. Methods: We evaluated data about ED closures from 1997 through 2003, incorporating 3 Level I trauma centers and 10 county-operated EMS Life Squads. A tiered ED closure policy was introduced in Lucas County, OH, in May 2000 to address a progressive problem with EMS diversions. Before this new system, all hospital EDs were either open or completely closed to EMS traffic, which included all traumas. The tiered protocol provides various closure options, including basic life support bypass, advanced life support (ALS) bypass, and trauma bypass, leaving hospitals the ability to be open to select EMS transports. The trauma bypass designation allows the ED to be closed to trauma but open to all other patients. ALS bypass, however, diverts all EMS transports, including trauma victims, to the next closest appropriate facility. During this period, data were collected pertaining to Level I trauma center closures and subsequent patient diversions throughout Lucas County. Results: After the introduction of the tiered ED closure policy, trauma-only closure hours increased slightly from 291.79 in 2001 to 330.77 (13%) in 2003. ALS closure hours, however, decreased dramatically within the same period, from 999.81 in 2001 to 273.13 (73%) in 2003. This policy resulted in a significant decrease in overall ED closures to trauma patients, from 1,291.60 hours in 2001 to 603.90 (53%) hours in 2003. Conclusion: A trauma bypass designation within a tiered ED closure policy increases the capability of a Level I trauma center to continue receiving EMS transports in the event that trauma resources are unavailable. Furthermore, the tiered system itself decreases ALS bypass hours in these 3 hospitals, thus reducing the trauma closures indirectly by reallocating resources.
331
Impact of the San Diego County Firestorm on Emergency Medical Services
Vilke GM, Murrin PA, Marcotte A, Upledger RL/University of California–San Diego, San Diego, CA; San Diego County Emergency Medical Services, San Diego, CA Study objectives: In October 2003, San Diego County experienced the worst firestorm in recent history. The fires and the associated poor air quality directly affected many citizens in the county. This study assessed the impact patients with fire-related complaints had on the emergency medical services (EMS) system. Once the fire emergency was declared, EMS worked with local media to inform the citizenry of the potential effects of poor air quality, especially on chronically ill populations. The media broadcast preventive measures to avert related health issues and advised chronically ill patients to contact their primary care physicians to keep emergency departments (EDs) and out-of-hospital services available. Methods: This was a retrospective review of an out-of-hospital database for patients with fire-related complaints. San Diego County has an urban, suburban, rural, and remote resident population of approximately 3 million and covers 4,300 square miles. During the firestorm, fire consumed approximately 400,000 acres, or 15% of the county land mass; 2,455 residences; more than 750 outbuildings and businesses; and 14 lives. All patients evaluated by advanced life support ambulance personnel after accessing 911 for direct fire-related complaints from October 26, 2003, through November 3, 2003, were included. The out-of-hospital patient database was searched for all patients with a complaint that was directly related to the fires. Medical records were abstracted for data, including demographics, medical issues, treatments rendered, and disposition status. Results: Advanced life support providers for fire-related complaints evaluated 138 patients. The majority of calls were for nonchronic respiratory complaints. Other complaints included burns, trauma associated with evacuation or firefighting, eye
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004
self-report. A univariate analysis was performed to determine whether any of the traditional risk factors were significant predictors of physical examination findings or evidence of CHF on chest radiograph. Any significant variables were entered into a multivariate analysis for each endpoint. Descriptive statistics were used, including x2 testing; odds ratios (ORs) and 95% confidence intervals (CIs) are given. Results: CHF was diagnosed in 537 patients who met study criteria. Of these patients, the presence of rales was documented in 67% (176/537), S3 2% (10/537), JVD 11% (61/537), and CHF on chest radiograph in 51% (165/321). History of hypertension was a significant multivariate predictor of CHF on chest radiograph. There were no predictors of the presence of an S3. History of CHF and renal insufficiency were predictors of JVD on physical examination. Only age was predictive of the presence of rales (Table). Conclusion: The presence of physical examination and chest radiograph findings of CHF are unreliable in identifying these patients in the ED. In addition, traditional risk factors for CHF have limited influence on predicting the occurrence of such findings.
Table, abstract 325.
CHF on chest radiograph Hypertension Renal insufficiency JVD History of CHF Renal insufficiency Rales Age >60 y Renal insufficiency
326
Univariate Analysis, OR (95% CI)
Multivariate Analysis, OR (95% CI)
1.8 (1.3–2.9) 1.6 (1.0–2.6)
1.7 (1.1–2.7) 1.5 (0.9–3.6)
2.2 (1.2–4.1) 1.9 (1.1–3.2)
2.1 (1.2–4.1) 1.9 (1.1–3.2)
2.5 (2.7–2.7) 1.5 (1.0–2.1)
2.4 (1.7–3.6) 1.4 (0.9–2.0)
Aspirin Therapy in Patients Who Presented to an Academic Emergency Department With Chest Pain: Race, Sex, and Age Effects
Takakuwa KM, Shofer FS, Hollander JE/New York Hospital of Queens, Flushing, NY; University of Pennsylvania, Philadelphia, PA Study objectives: We determine whether aspirin therapy was differentially administered according to race, sex, or age in patients who presented to an urban academic emergency department (ED) with chest pain. Our hypothesis is that there will be no differences. Methods: This was a prospective cohort study of all patients aged 24 years or older who presented to our ED between July 1999 and March 2002 with chest pain. Structured data collection included demographics, laboratory test data, treatment provided, and 30-day follow-up. Patients were divided into 3 groups according to 30-day final diagnosis: acute myocardial infarction (AMI), unstable angina (USA), and all others (non–acute coronary syndrome [ACS] chest pain). Data were analyzed using x2 and t tests for categorical and continuous data, respectively. Results: Four thousand four hundred seventy patients were studied (men [41%]; black [70%], white [26%], and other race [4%]; age 52.2615.8 years). A total of 2,498 patients (56%) received aspirin therapy. Three hundred nineteen patients (7%) had an AMI, and 544 patients (12%) had USA. The majority, 3,607 (81%), had a non-ACS chest pain diagnosis. Aspirin therapy differed by race, sex, age, and final diagnosis. Patients who received aspirin were more likely to be white (60% versus black 55% versus other 50%, P=.002), men (61% versus women 52%, P\.0001), older (56 versus 48 years, P\.0001), or have an ACS diagnosis (82% versus nonACS chest pain 50%, P\.0001). When aspirin therapy was examined by final diagnosis, there were no differences in race, sex, and age for AMI or USA (P[.05 for all). There were significant sex and age differences for non-ACS chest pain patients: men had higher aspirin therapy compared with women (53% versus 48%, P\.0001),
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
and older patients had higher aspirin therapy compared with younger patients (54.4 versus 46.8, P\.0001). No racial differences in non-ACS chest pain patients were found. Conclusion: There was an overall race, sex, and age difference: white, male, and older patients had higher rates of aspirin therapy. However, these effects can be explained by higher rates of aspirin administered to older men with non-ACS chest pain. We found no race, sex, or age differences in aspirin therapy for patients who had time-sensitive AMI or USA.
327
Impact of Nesiritide Infusion on Acute Decompensated Heart Failure in an Urban Hospital Emergency Department
Nazeer SR, Miller AH, Brickner B, Yancy C/University of Texas Southwestern Medical School, Dallas, TX Study objectives: Decompensated congestive heart failure (CHF) is a major cause of emergency department (ED) visits and resource utilization. It has previously been demonstrated that patients treated in an urban ED for acute decompensated heart failure (ADHF) have a 60% rate of recidivism to the ED, with admission to the hospital. Recent data suggest that treatment with natriuretic peptides may decrease admission rates by 50% in a general hospital population. We determine whether intravenous natriuretic peptides for ADHF will affect ED disposition at the index visit and decrease the rate of recidivism for a high-risk urban population. Methods: This is an institutional review board–approved, randomized, doubleblinded, placebo-controlled trial of nesiritide versus placebo in addition to a standard treatment algorithm for ADHF. Adult patients ($18 years) presenting to the ED with a history of CHF, symptoms of dyspnea at rest or minimal exertion, and physical and laboratory evidence of volume overload are eligible. Patients are randomized to receive intravenous nesiritide or placebo for 8 hours, in addition to standard therapy, which includes intravenous furosemide, as well as oxygen and antihypertensive medication, if necessary. Physician assessment occurs at 0, 3, and 8 hours for symptoms, adequate diuresis, and readiness for discharge. All patients have echocardiograms completed within 72 hours of presentation. Significant adverse events are noted, and endpoints are followed up by telephone or in person at 1 week. Hospital records will be reviewed at 30 days and 90 days for return visits to the ED, readmissions, or death. Results: The initial 21 patients included 15 men (71%) and 6 women (29%). Black patients composed the majority at 12 patients (57%). Six patients were white (29%) and 3 Hispanic (14%). The average age of patients currently enrolled is 56 years, with a range of 25 to 93 years. Primary outcome measures are hospitalization or discharge from the ED after treatment, level of care to which the patient is transferred from the ED, and return visits to the ED within 30 days. Secondary outcome measures are return visit to the ED, hospitalization, or death within 90 days. As a separate focus, we will track the occurrence of systolic (left ventricular ejection fraction \0.40) and diastolic (left ventricular ejection fraction [0.40) dysfunction in patients with decompensated heart failure within an urban population. This study is powered to determine a 20% treatment effect at 85% power with an a of 0.05 for a sample size of 150 patients. Conclusion: If the results are positive, the treatment of ADHF in an urban population at high risk for repeated ED visits for heart failure will be greatly improved, with a reduction in morbidity and a decrease in resource utilization.
328
Decisions in Chest Pain: How Often Do They Change After the Initial Evaluation?
Martin KR, Giles BK, Mullis SA, Schaffer JT/Indiana University, Indianapolis, IN; Methodist Emergency Medicine and Trauma Center, Indianapolis, IN; Methodist Research Institute, Indianapolis, IN Study objectives: We determine to what extent decisions in chest pain change from initial emergency department (ED) patient encounter to final ED diagnosis, disposition, and treatment. Methods: We designed a prospective, observational study of a convenience sample of chest pain patients triaged to the critical care area of an urban ED. Patients were excluded if they were diagnosed with ST-segment elevation myocardial in farction. Physician decisions about these patients were studied. The physicians involved in the study were attending emergency physicians and upper-level
S 1 0 1
RESEARCH FORUM ABSTRACTS
emergency medicine residents who staff 100% of cases with an attending emergency physician. Physicians were surveyed after initial patient evaluation. This initial evaluation was defined as initial medical history and physical examination and reading of the ECG. The survey elicited initial ‘‘working’’ diagnosis, treatment, and disposition. The treating physician was again surveyed after final ED decisions and disposition were made. The second survey elicited the same information as the first survey about decisions. The second survey also asked the treating physicians to cite the factors that led to changes in their decisions. The surveys were then compared, and decision changes were noted as upgrades or downgrades. Changes in decisions were correlated with cardiac marker results and physician-cited factors that led to those decision changes. Results: Of 83 physician/patient interactions studied, 20 (24%) had an upgrade in management, 24 (29%) a downgrade, and 39 (47%) had no change. Seventy-six patients had negative cardiac markers. Of the patients with negative markers, 14 (18%) had an upgrade, 24(32%) had a downgrade, and 37 (49%) had no change in decisions. The most common factor cited by the treating physician as affecting decisions was change in patient status (N=34, 41%). The second most common factor cited was cardiac marker results (N=30, 36%). From these 30 interactions, 4 had positive markers, all of which had an upgrade in management; 26 had negative markers. Of these 26, 6 were upgraded and 8 were downgraded; 12 had no change in management, even though the physician stated that the marker results affected their decisions. Finally, from these 30 interactions in which cardiac markers were cited as affecting decisions, 9 patients had negative markers and duration less than 6 hours. Follow-up was available for 81 of the 83 patients. No significant correlation between changes in decision and outcomes was found. Conclusion: Nearly 50% of chest pain management decisions did not change after the initial evaluation. Physicians may inappropriately rely on initial cardiac marker results in determining the etiology of a patient’s chest pain.
329
Key Factors in Out-of-Hospital Intubation Suggested for Further Training
Kryder GD, Jang TB, Tan D/Washington University School of Medicine, St. Louis, MO Study objectives: We identify key factors affecting out-of-hospital intubation attempts. Methods: This was a retrospective review of consecutive patients transported by the primary ambulance service of a large Midwestern city. Patients were identified as requiring emergency intubation if they were newly unresponsive without a gag reflex, unresponsive with persistent pulse oximetry below 90%, or having a respiratory rate less than 10 breaths/min or greater than 30 breaths/min with persistent pulse oximetry below 90%. Analysis was done using a multiple regression model. Results: From March 2003 to June 2003, 386 transported patients required emergency intubation. Intubation was attempted in 42 (11%) patients and successful in 10 (24%, 95% confidence interval [CI] 11% to 37%), which is consistent with previous studies. Using a multiple regression model, 3 factors were identified that were associated with failure to attempt intubation when indicated: Glasgow Coma Scale (GCS) score of 9 or greater (odds ratio [OR] 18.2, 95% CI 6.5 to 29.9), failure to obtain intravenous access (OR 1.8, 95% CI 0.9 to 2.7), and performing bag-valvemask or positive pressure ventilation (PPV) (OR 50.4, 95% CI 12.8 to 88.0). Although PPV is a temporizing measure, it does not provide a definitive airway. Whether or not it should preclude out-of-hospital intubation should be addressed prospectively, especially because more than 50% of patients had persistent pulse oximetry between 80% and 90% despite PPV. Out-of-hospital personnel may benefit from further training in optimal techniques for PPV. Likewise, although advanced trauma life support protocols use GCS score as an indication for intubation, it may not be the best indication of the need for intubation, because many patients had GCS score greater than 9 but were in respiratory failure, which suggests an area for further education. Finally, the ability to establish intravenous access was a weak but persistent factor affecting intubation attempts and may be an important area for ongoing training. Conclusion: GCS score of 9 or greater, the ability to obtain intravenous access, and performing PPV were 3 factors affecting intubation attempts and may be important areas for the further training of out-of-hospital personnel.
S 1 0 2
330
Trauma Diversion Within a Tiered Emergency Department Closure Policy
Sidani RS, Gibbons MP, Brickman KR, Moomey PR, Lindstrom DA/Medical College of Ohio, Toledo, OH; Lucas County Emergency Medical Services, Toledo, OH Study objectives: Emergency department (ED) closures impart a considerable strain on community and hospital trauma resources. Trauma and nontrauma ambulance transports alike play a significant role in the diversion of trauma patients. Policies to address these issues and appropriately direct patients to adequate facilities are necessary for the timely management of the most critical cases. This retrospective study evaluates the role of a trauma bypass designation in reducing out-of-hospital emergency medical services (EMS) diversion of trauma patients within a tiered ED closure policy. Methods: We evaluated data about ED closures from 1997 through 2003, incorporating 3 Level I trauma centers and 10 county-operated EMS Life Squads. A tiered ED closure policy was introduced in Lucas County, OH, in May 2000 to address a progressive problem with EMS diversions. Before this new system, all hospital EDs were either open or completely closed to EMS traffic, which included all traumas. The tiered protocol provides various closure options, including basic life support bypass, advanced life support (ALS) bypass, and trauma bypass, leaving hospitals the ability to be open to select EMS transports. The trauma bypass designation allows the ED to be closed to trauma but open to all other patients. ALS bypass, however, diverts all EMS transports, including trauma victims, to the next closest appropriate facility. During this period, data were collected pertaining to Level I trauma center closures and subsequent patient diversions throughout Lucas County. Results: After the introduction of the tiered ED closure policy, trauma-only closure hours increased slightly from 291.79 in 2001 to 330.77 (13%) in 2003. ALS closure hours, however, decreased dramatically within the same period, from 999.81 in 2001 to 273.13 (73%) in 2003. This policy resulted in a significant decrease in overall ED closures to trauma patients, from 1,291.60 hours in 2001 to 603.90 (53%) hours in 2003. Conclusion: A trauma bypass designation within a tiered ED closure policy increases the capability of a Level I trauma center to continue receiving EMS transports in the event that trauma resources are unavailable. Furthermore, the tiered system itself decreases ALS bypass hours in these 3 hospitals, thus reducing the trauma closures indirectly by reallocating resources.
331
Impact of the San Diego County Firestorm on Emergency Medical Services
Vilke GM, Murrin PA, Marcotte A, Upledger RL/University of California–San Diego, San Diego, CA; San Diego County Emergency Medical Services, San Diego, CA Study objectives: In October 2003, San Diego County experienced the worst firestorm in recent history. The fires and the associated poor air quality directly affected many citizens in the county. This study assessed the impact patients with fire-related complaints had on the emergency medical services (EMS) system. Once the fire emergency was declared, EMS worked with local media to inform the citizenry of the potential effects of poor air quality, especially on chronically ill populations. The media broadcast preventive measures to avert related health issues and advised chronically ill patients to contact their primary care physicians to keep emergency departments (EDs) and out-of-hospital services available. Methods: This was a retrospective review of an out-of-hospital database for patients with fire-related complaints. San Diego County has an urban, suburban, rural, and remote resident population of approximately 3 million and covers 4,300 square miles. During the firestorm, fire consumed approximately 400,000 acres, or 15% of the county land mass; 2,455 residences; more than 750 outbuildings and businesses; and 14 lives. All patients evaluated by advanced life support ambulance personnel after accessing 911 for direct fire-related complaints from October 26, 2003, through November 3, 2003, were included. The out-of-hospital patient database was searched for all patients with a complaint that was directly related to the fires. Medical records were abstracted for data, including demographics, medical issues, treatments rendered, and disposition status. Results: Advanced life support providers for fire-related complaints evaluated 138 patients. The majority of calls were for nonchronic respiratory complaints. Other complaints included burns, trauma associated with evacuation or firefighting, eye
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004