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Emergency department management and resource utilization in patients with Do-Not-Resuscitate orders
RESEARCH FORUM ABSTRACTS
self-reported degree of visual impairment and test their ability to read a standardized consent form. Methods: We performed an institutional review board–approved, prospective cohort study of a convenience sample of patients in the ED of a tertiary care, community-based hospital with an annual census of 60,000 patients. Data were collected between September 15, 2002, and April 1, 2004. Inclusion criteria were English-speaking patients older than 65 years who are clinically stable, able to accurately complete a verbal questionnaire, and able to give verbal consent. All patients with chief complaints related to vision were excluded from the study. All patients had a brief visual acuity screening examination with the Snellen eye chart and were asked to read a standardized consent form. Descriptive statistics were used for data analysis. Results: Five hundred seventeen patients were included in the study. Among them, 58% (302/517) of patients admitted problems with vision; 91% (473/517) of patients stated they could read a newspaper, but only 67% (346/517) of patients could read the consent form. In patients aged 85 years and older, 61% (60/98) admitted problems with vision, 59% (58/98) could not read a consent form, 43% (42/98) lived alone, and 41% (40/98) stated that they can drive a car. Conclusion: In this study, we found that a large percentage of our elderly patients state they can read but cannot when challenged because of visual impairment, which suggests that other interventions are necessary to improve the dissemination of information to a vulnerable subsegment of our population.
228
Emergency Department Management and Resource Utilization in Patients With Do-Not-Resuscitate Orders
Gee C, Bundschuh M, Clinton R, Duldner JE/Case School of Medicine, Cleveland, OH; Akron General Medical Center, Akron, OH Study objectives: The advent of the ‘‘do-not-resuscitate’’ (DNR) clause has brought with it comfort, anxiety, and sometimes anguish for patients, families, and health care providers. To date, there is no information in the emergency care literature describing practice patterns and treatment of patients with DNR orders. The objective of this study is to determine whether there is a difference in the emergency department (ED) treatment or cost of care in patients with ‘‘DNR comfort care’’ orders compared with patients with ‘‘DNR general medical care’’ or patients without DNR orders. Methods: A retrospective, matched pair, case-control design was used. Medical records for all patients residing in extended care facilities evaluated in the ED in 2002 were reviewed. After confirmation of ‘‘DNR comfort care’’ status, variables of interest were abstracted. Controls were matched on ED International Classification of Diseases, Ninth Revision diagnosis code, sex, age, and clinical acuity. Results: Review of 3,176 records resulted in 48 potential DNR–comfort care cases. A total of 26 patients could be appropriately matched. There was no significant difference in the age between DNR–comfort care and DNR–general medical care groups (85.8 versus 81.5 years, respectively; P=.11). Sex and racial distributions were the same for both DNR groups. As expected, an ambulance was used to transport more than 85% of patients but did not differ according to DNR status (P=.12). There was no difference in ordering CBC count, metabolic panel, or urinalyses (P[.24). No difference in use of cranial or abdominal computed tomography was found (P[.32). ED disposition and type of nursing unit on admission did not differ (P[.61). Although the average hospital cost in DNR– comfort care patients was lower ($8,323.29 versus $15,332.58), it did not reach statistical significance (P=.10). Conclusion: In this small, single-center sample, there was no difference in the ED treatment, resource utilization, or cost of care between DNR–comfort care and DNR–general medical care patients.
229
Community-Acquired Pneumonia in Older Persons at the Emergency Department
Ferrer C, Coma E, Gomez M, Ayuso A/Fundacio Sanitaria d’lgualada, Igualada, Spain; Hospital Sant Pau, Barcelona, Spain; Hospital d’Olot, Olot, Spain; Clinica Plato, Barcelona, Spain
S 7 0
Study objectives: We evaluate the clinical presentation and outcomes at 30 days among elderly patients with community-acquired pneumonia (CAP) presenting to the emergency department (ED) Methods: This was a multicenter prospective study in a 14 Hospitalary ED of Catalunya, Spain, and the Principality of Andorra from January 20 to July 1, 2003. All patients aged 18 years or older admitted through the ED with a diagnosis of CAP were eligible for the study. Patients constituted 2 groups: (1) group I: younger than 65 years; (2) group II: 65 years or older. The diagnosis of CAP required the following: (1) new pulmonary infiltrate on chest radiograph; (2) clinical evidence suggestive of pneumonia, with presence of at least 2 of the following: temperature 38°C or greater, cough, purulent sputum, pleuritic chest pain, dyspnea, and confusion. Patients were excluded if they had an immunosuppressive illness, hospitalization in the past 14 days, or an alternative diagnosis. Data were collected for demographic information, triage time, previous or current antibiotic administration, time to antibiotic administration, initial antibiotic regimen, and clinical outcome at 30 days. The Sant Pau Ethic’s Committee approved the study. Data were analyzed using SPSS software. Results: One thousand thirty-four patients were entered into the study. One hundred were eliminated for alternative diagnosis or immunosuppression. The mean age was 65.33 years (range 18 to 99 years, SD 19.82), and 62% of patients were older than 65 years. There was a predominance of incidence among men in subgroup II (58%, 65%, P=.060). Older patients had more comorbid conditions. In group II, only 58% had received an influenza vaccination. The clinical presentation in elderly patients was characterized by fewer symptoms; dyspnea was the symptom most differentiated into 2 groups (34%, 71%, P\.001). In the physical examination, we detected a statistically significant difference above the scores of the PSI: FR 30 or greater (11% versus 31%, P\.001), FC 125 or greater (9% versus 5%, P=.039), Tas (2%, 1%, P=.128), temperature less than 35°C or 40°C or greater (1%, 0,2%, P=.072). In group II the mean Barthel’s index was 92 (SD 24). There were no significant differences above the results of laboratory tests except for the urea (13%, 41%, P\.001). We detected statistically significant differences about the PSI distribution: 71.2% of group II and 6% of group I was class IV to V (P\.001). There were no statistically significant differences above the initial empiric antimicrobial treatment after admission to the hospital (levofloxacin, amoxicillineclavulanate). The mean time to administration of first dose of antibiotics was 4 hours 9 minutes (SD 3 hours) in group I and 4 hours 5 minutes (SD 3 hours) in group II (P=.0067). The rate of hospitalization was 40% in group I and 82% in group II. At 30 days, the mortality was significantly higher in older persons (1% versus 9%, P\.001). Conclusion: Older patients have a proper CAP profile, but the clinical management was similar to that of a young patient. Older patients have a higher mortality rate than young patients. It is necessary to reinforce measures to prevent CAP in older people.
230
Electrocardiographic Intervals in Nonagenarians: What Are the ‘‘Normals’’?
Vedula KC, Varadachari CJ, Vukov LF, Decker WW, Stead LG/University of Minnesota, Minneapolis, MN; Mayo Clinic, Rochester, MN Study objectives: We determine whether standard ECG intervals, based largely on population data from middle-aged men, are applicable to the elderly, particularly those older than 90 years. Methods: The medical records of all patients aged 90 years and older presenting to our institution for health maintenance examinations in 2002 were examined. Data on rhythm, QTc, QRS, and PR intervals was collected. The presence of coronary artery disease, including history of myocardial infarction, valvulopathy, or presence of pacemaker, was also recorded. A prolonged QTc interval was defined as 440 ms or greater. A prolonged QRS interval was defined as 100 ms or greater. A prolonged PR interval was defined as 200 ms or greater. All patients in the mentioned cohort were captured; there were no missing records. Results: Of the 60 total patients, 35 had an ECG performed as part of their routine medical examination. Fourteen of the 35 patients had a history of coronary artery disease (CAD) as defined above, whereas 21 patients had no such history. The mean PR, QRS, and QTc intervals are summarized in Table 1. The presence of pronged intervals is summarized in Table 2 according to intervals defined in the methods.
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004
self-reported degree of visual impairment and test their ability to read a standardized consent form. Methods: We performed an institutional review board–approved, prospective cohort study of a convenience sample of patients in the ED of a tertiary care, community-based hospital with an annual census of 60,000 patients. Data were collected between September 15, 2002, and April 1, 2004. Inclusion criteria were English-speaking patients older than 65 years who are clinically stable, able to accurately complete a verbal questionnaire, and able to give verbal consent. All patients with chief complaints related to vision were excluded from the study. All patients had a brief visual acuity screening examination with the Snellen eye chart and were asked to read a standardized consent form. Descriptive statistics were used for data analysis. Results: Five hundred seventeen patients were included in the study. Among them, 58% (302/517) of patients admitted problems with vision; 91% (473/517) of patients stated they could read a newspaper, but only 67% (346/517) of patients could read the consent form. In patients aged 85 years and older, 61% (60/98) admitted problems with vision, 59% (58/98) could not read a consent form, 43% (42/98) lived alone, and 41% (40/98) stated that they can drive a car. Conclusion: In this study, we found that a large percentage of our elderly patients state they can read but cannot when challenged because of visual impairment, which suggests that other interventions are necessary to improve the dissemination of information to a vulnerable subsegment of our population.
228
Emergency Department Management and Resource Utilization in Patients With Do-Not-Resuscitate Orders
Gee C, Bundschuh M, Clinton R, Duldner JE/Case School of Medicine, Cleveland, OH; Akron General Medical Center, Akron, OH Study objectives: The advent of the ‘‘do-not-resuscitate’’ (DNR) clause has brought with it comfort, anxiety, and sometimes anguish for patients, families, and health care providers. To date, there is no information in the emergency care literature describing practice patterns and treatment of patients with DNR orders. The objective of this study is to determine whether there is a difference in the emergency department (ED) treatment or cost of care in patients with ‘‘DNR comfort care’’ orders compared with patients with ‘‘DNR general medical care’’ or patients without DNR orders. Methods: A retrospective, matched pair, case-control design was used. Medical records for all patients residing in extended care facilities evaluated in the ED in 2002 were reviewed. After confirmation of ‘‘DNR comfort care’’ status, variables of interest were abstracted. Controls were matched on ED International Classification of Diseases, Ninth Revision diagnosis code, sex, age, and clinical acuity. Results: Review of 3,176 records resulted in 48 potential DNR–comfort care cases. A total of 26 patients could be appropriately matched. There was no significant difference in the age between DNR–comfort care and DNR–general medical care groups (85.8 versus 81.5 years, respectively; P=.11). Sex and racial distributions were the same for both DNR groups. As expected, an ambulance was used to transport more than 85% of patients but did not differ according to DNR status (P=.12). There was no difference in ordering CBC count, metabolic panel, or urinalyses (P[.24). No difference in use of cranial or abdominal computed tomography was found (P[.32). ED disposition and type of nursing unit on admission did not differ (P[.61). Although the average hospital cost in DNR– comfort care patients was lower ($8,323.29 versus $15,332.58), it did not reach statistical significance (P=.10). Conclusion: In this small, single-center sample, there was no difference in the ED treatment, resource utilization, or cost of care between DNR–comfort care and DNR–general medical care patients.
229
Community-Acquired Pneumonia in Older Persons at the Emergency Department
Ferrer C, Coma E, Gomez M, Ayuso A/Fundacio Sanitaria d’lgualada, Igualada, Spain; Hospital Sant Pau, Barcelona, Spain; Hospital d’Olot, Olot, Spain; Clinica Plato, Barcelona, Spain
S 7 0
Study objectives: We evaluate the clinical presentation and outcomes at 30 days among elderly patients with community-acquired pneumonia (CAP) presenting to the emergency department (ED) Methods: This was a multicenter prospective study in a 14 Hospitalary ED of Catalunya, Spain, and the Principality of Andorra from January 20 to July 1, 2003. All patients aged 18 years or older admitted through the ED with a diagnosis of CAP were eligible for the study. Patients constituted 2 groups: (1) group I: younger than 65 years; (2) group II: 65 years or older. The diagnosis of CAP required the following: (1) new pulmonary infiltrate on chest radiograph; (2) clinical evidence suggestive of pneumonia, with presence of at least 2 of the following: temperature 38°C or greater, cough, purulent sputum, pleuritic chest pain, dyspnea, and confusion. Patients were excluded if they had an immunosuppressive illness, hospitalization in the past 14 days, or an alternative diagnosis. Data were collected for demographic information, triage time, previous or current antibiotic administration, time to antibiotic administration, initial antibiotic regimen, and clinical outcome at 30 days. The Sant Pau Ethic’s Committee approved the study. Data were analyzed using SPSS software. Results: One thousand thirty-four patients were entered into the study. One hundred were eliminated for alternative diagnosis or immunosuppression. The mean age was 65.33 years (range 18 to 99 years, SD 19.82), and 62% of patients were older than 65 years. There was a predominance of incidence among men in subgroup II (58%, 65%, P=.060). Older patients had more comorbid conditions. In group II, only 58% had received an influenza vaccination. The clinical presentation in elderly patients was characterized by fewer symptoms; dyspnea was the symptom most differentiated into 2 groups (34%, 71%, P\.001). In the physical examination, we detected a statistically significant difference above the scores of the PSI: FR 30 or greater (11% versus 31%, P\.001), FC 125 or greater (9% versus 5%, P=.039), Tas (2%, 1%, P=.128), temperature less than 35°C or 40°C or greater (1%, 0,2%, P=.072). In group II the mean Barthel’s index was 92 (SD 24). There were no significant differences above the results of laboratory tests except for the urea (13%, 41%, P\.001). We detected statistically significant differences about the PSI distribution: 71.2% of group II and 6% of group I was class IV to V (P\.001). There were no statistically significant differences above the initial empiric antimicrobial treatment after admission to the hospital (levofloxacin, amoxicillineclavulanate). The mean time to administration of first dose of antibiotics was 4 hours 9 minutes (SD 3 hours) in group I and 4 hours 5 minutes (SD 3 hours) in group II (P=.0067). The rate of hospitalization was 40% in group I and 82% in group II. At 30 days, the mortality was significantly higher in older persons (1% versus 9%, P\.001). Conclusion: Older patients have a proper CAP profile, but the clinical management was similar to that of a young patient. Older patients have a higher mortality rate than young patients. It is necessary to reinforce measures to prevent CAP in older people.
230
Electrocardiographic Intervals in Nonagenarians: What Are the ‘‘Normals’’?
Vedula KC, Varadachari CJ, Vukov LF, Decker WW, Stead LG/University of Minnesota, Minneapolis, MN; Mayo Clinic, Rochester, MN Study objectives: We determine whether standard ECG intervals, based largely on population data from middle-aged men, are applicable to the elderly, particularly those older than 90 years. Methods: The medical records of all patients aged 90 years and older presenting to our institution for health maintenance examinations in 2002 were examined. Data on rhythm, QTc, QRS, and PR intervals was collected. The presence of coronary artery disease, including history of myocardial infarction, valvulopathy, or presence of pacemaker, was also recorded. A prolonged QTc interval was defined as 440 ms or greater. A prolonged QRS interval was defined as 100 ms or greater. A prolonged PR interval was defined as 200 ms or greater. All patients in the mentioned cohort were captured; there were no missing records. Results: Of the 60 total patients, 35 had an ECG performed as part of their routine medical examination. Fourteen of the 35 patients had a history of coronary artery disease (CAD) as defined above, whereas 21 patients had no such history. The mean PR, QRS, and QTc intervals are summarized in Table 1. The presence of pronged intervals is summarized in Table 2 according to intervals defined in the methods.
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004