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Emergency Department Referral Bias in Cerebral Hemorrhage
Research Forum Abstracts We examine the utilization of emergency CT/CTA (CT angiography) and MRI scanning in patients presenting to the ED with neurologic complaints. Methods: Chart review of consecutive patients who underwent head CT/CTA and brain MRI ordered by EP over a 6 month period in a urban,tertiary care ED with an annual volume of 76,000. All studies were read by board certified neuroradiologists. Presenting symptoms/imaging indications, physical exam, radiology data were collected. Discharge diagnosis was utilized to classify neurologic conditions. Chi square analysis was used for comparisons. Results: 456 patients were eligible for the study. Mean age was 62.2 (range 18-98) and 47% were male. 213 patients underwent CT/CTA only, while 242 had CT/CTA/MRI studies. Final diagnosis (Dx) in the CT/CTA only group included: intracranial hemorrhage(ICH) 69 (32%), stroke 37 (17%), head/neck trauma 36 (17%), headache (HA) 19 (9%). Final Dx in patients undergoing CT/CTA/MRI included: stroke 164 (68%), ICH 23 (10%), HA 10 (4%), head/neck trauma 9 (4%). MRI scans were ordered more frequently in patients with final diagnosis of stroke (p\.01), while CT/CTA only were ordered more frequently in patients with head/neck trauma (p\.01) or ICH (p\.01). CT/CTA without MRI was more likely to be ordered than CT/CTA with MRI in patients presenting with: HA 98 (46%) vs 65 (27%) (p\.01), coma 41 (19%) vs 14 (6%) p\.01). CT/CTA with MRI scanning was more likely utilized in patients with lateralizing neurologic complaints 157 (65%) than CT/CTA w/o MRI 60 (28%) (p\.01). There was no difference in MRI ordering rates for patients presenting with seizure or a change in mental status. Conclusion: Presenting symptoms and Dx influence EP’s decision to add MRI to their workup. Studying utilization is an important initial step towards defining indications for ordering urgent ED MRI scanning, and in particular, it’s relationship to CT/CTA.
EMF-4
Emergency Department Referral Bias in Cerebral Hemorrhage
Clinton R, Karam A, Rashi S, Duldner JE, CWRU School of Medicine, Akron; Akron General Medical Center/NEOUCOM, Akron; Akron General Medical Center/ NEOUCOM, CWRU School of Medicine, Akron
Objectives: Intracerebral and subarachnoid hemorrhages are serious neurological emergencies that require urgent care. In subarachnoid hemorrhage (SAH) improved outcomes were found if patients were transferred to a referral center. Similar data for intracerebral hemorrhage (ICH) does not exist. The larger question concerns why some patients are transferred and others are not. This study evaluates predictors of transfer from two community emergency departments (ED) in patients presenting with cerebral hemorrhage. Methods: Design. A retrospective chart review of all patients presenting with a primary ED diagnosis (CT or lumbar puncture) of either SAH or ICH. Setting. Two community EDs over a 7 year period (1997-2004). Pertinent ED data was collected as well as inpatient data on patients not transferred. Results: A total of 159 patients were studied, 90 (56.6%) patients from one ED and 69 (43.4%) from the second ED. There was a significant difference in the ethnicity between ED’s, with one ED having only caucasion patients. Age for ICH patients was higher (75.2 v. 56.3 years, p\0.03) than in SAH patients, but it did not differ between ED’s (p=0.16). Sixty-four percent arrived via EMS and greater than 75% within 12 hours of ictus. Early arrival was more likely in ICH patients (p = 0.027) Patients were more likely to be transferred if they had an SAH (OR = 3.3, CI 1.39-7.75). In transferred patients significant predictors favoring transfer include type of hemorrhage, if they were intubated in the ED, use of warfarin and Glasgow coma scale. Time of symptom onset, mode of arrival, initial ED, and seizure activity did not affect transfer. Conclusion: There does exist a bias in the referral patterns of patients who present with cerebral hemorrhage to community EDs. Further study is necessary to evaluate benefit of transfer, outcome and establishing ED transfer guidelines.
228
Propofol for Procedural Sedation in a Community Emergency Department
Charles M, McGinnis HD, Wehner P, Marshall University School of Medicine, Huntington, WV; Wake Forest University School of Medicine, Winston-Salem, NC
Study Objectives: Investigate the incidence of complications in procedural sedation with propofol by emergency physicians in a community emergency department.
S64 Annals of Emergency Medicine
Methods: Core data and complications were prospectively collected for the initial 4500 patients (age 9 months to 92 years) who received procedural sedation with propofol by our eleven emergency physicians. Propofol was titrated IV by the physician until the desired level of sedation was obtained, usually level III or level IV. Patients were given propofol in a titrated dose at the discretion of the emergency physician until the desired level of sedation was obtained. The drug was given without regard to time of last oral intake. Vital signs and pulse oximetry were recorded during the procedure and until recovery. Case data and complications were recorded into a database. Hypotension (SBP \ 90 mmHg or age appropriate decrease in children), hypoxemia (pulse oximetry \ 90%), respiratory depression requiring assisted ventilation or intubation, aspiration, airway obstruction, or anesthesia consultations were considered complications. Results: Over the study period, patients received propofol for orthopedic reduction (40%), lumbar puncture (21%), incision and drainage of abscess (17%), laceration repair (14%), chest tube insertion (5%), and other indications (3%). Mean total dose of propofol was 183 mg (range, 20 to 600 mg). Patient ages ranged from 9 months to 92 years of age. 85% of patients were ASA class I, 11% were ASA Class II, and 4% were ASA Class III. Transient hypotension occurred in 3% of patients. In all cases, the hypotension responded quickly to fluid bolus and did not recur. Transient hypoxia developed in 3% of patients. In the majority of these cases, the hypoxia resolved with simple airway repositioning. Twenty-seven patients required assisted ventilation by bag-valve-mask for less than 1 minute. No patient required intubation, aspirated, suffered airway obstruction, or required anesthesia consultation. Conclusion: Propofol is safe and effective for sedation during procedures carried out by emergency physicians. The rapid onset of action and short half-life allow for safe, early discharge. All patients were awake and alert in 2 to 37 minutes and those of sufficient age reported total amnesia and very high patient satisfaction. Of specific note, the emergency physicians administered propofol without regard to time of last oral intake with zero incidence of aspiration.
229
Documenting Pain Intensity: Distortions in the Electronic Medical Record
DeSandre PL, Todd KH, Bowers W, Lera L, Nachat A, Dreisinger N, Weisburd S, Pain and Emergency Medicine Institute, Department of Emergency Medicine, Beth Israel Medical Center, New York, NY
Study Objectives: Electronic medical records (EMRs) can improve efficiency and reduce error in the ED. This study compares the documentation of ED pain intensity using an EMR with pain assessments from direct patient interview. Methods: We conducted a prospective, observational cohort study in an urban teaching ED serving 65,000 annually. This ED uses a commercially available EMR. After written, informed consent, ED patients 8 and older with complaints of moderate to severe pain (pain NRSO3) underwent structured interviews conducted by trained research assistants prior to discharge home. Subjects were enrolled during ten 8-hour shifts over 2 two-week periods. All shifts of the 24 hour cycle were represented. Interviewers recorded patient pain intensity on ED arrival and discharge using an 11-point NRS. Investigators also abstracted pain assessments at arrival and discharge from the EMR. The EMR allowed entry of an 11-point NRS pain assessment at ED arrival; however, a required ‘‘pain at discharge’’ response field offered a limited number of narrative choices for pain assessment. Results: 99 subjects entered the study. The EMR indicated NRS pain assessments on arrival for 72 of these 99 subjects. Results for arrival NRS pain assessments were similar for both the EMR and direct interview (means 6.7 vs. 7.5, medians 7 vs. 8, Spearman correlation coefficient 0.7). Discharge assessments were obtained in both the EMR and direct interview for all 99 subjects. A number of disparities were noted between these two sets of observations. For 54 subjects reported in the EMR to be ‘‘pain-free’’ at the time of discharge, pain assessed by direct interview indicated a mean pain intensity of 4.2 (median 4, IQR 3-6, range 0-10). Only 6 of these 54 subjects (11%) indicated pain scores of zero and 12 subjects (22%) indicated severe pain intensity (NRSO6). For 29 subjects reported to be ‘‘tolerating pain at present,’’ direct interviews revealed mean pain scores in the moderate to severe range with a mean of 5.6 (median 6, IQR 5-7, range 0-10). Of the remaining 16 subjects, 14 were reported as ‘‘given Rx with follow-up’’ (mean 6.3, median 6.5, IQR 5-8, range 0-10) and 2 were reported as ‘‘baby/child appears comfortable.’’ Conclusion: EMRs have great potential to improve validity of documentation, but human factors encouraging invalid data entry should be investigated and addressed. Our study demonstrates that EMRs incorporating standardized scoring systems such as the NRS, encourage greater validity in pain assessment than forced-choice systems using text descriptors. EMR systems should
Volume 46, no. 3 : September 2005
EMF-4
Emergency Department Referral Bias in Cerebral Hemorrhage
Clinton R, Karam A, Rashi S, Duldner JE, CWRU School of Medicine, Akron; Akron General Medical Center/NEOUCOM, Akron; Akron General Medical Center/ NEOUCOM, CWRU School of Medicine, Akron
Objectives: Intracerebral and subarachnoid hemorrhages are serious neurological emergencies that require urgent care. In subarachnoid hemorrhage (SAH) improved outcomes were found if patients were transferred to a referral center. Similar data for intracerebral hemorrhage (ICH) does not exist. The larger question concerns why some patients are transferred and others are not. This study evaluates predictors of transfer from two community emergency departments (ED) in patients presenting with cerebral hemorrhage. Methods: Design. A retrospective chart review of all patients presenting with a primary ED diagnosis (CT or lumbar puncture) of either SAH or ICH. Setting. Two community EDs over a 7 year period (1997-2004). Pertinent ED data was collected as well as inpatient data on patients not transferred. Results: A total of 159 patients were studied, 90 (56.6%) patients from one ED and 69 (43.4%) from the second ED. There was a significant difference in the ethnicity between ED’s, with one ED having only caucasion patients. Age for ICH patients was higher (75.2 v. 56.3 years, p\0.03) than in SAH patients, but it did not differ between ED’s (p=0.16). Sixty-four percent arrived via EMS and greater than 75% within 12 hours of ictus. Early arrival was more likely in ICH patients (p = 0.027) Patients were more likely to be transferred if they had an SAH (OR = 3.3, CI 1.39-7.75). In transferred patients significant predictors favoring transfer include type of hemorrhage, if they were intubated in the ED, use of warfarin and Glasgow coma scale. Time of symptom onset, mode of arrival, initial ED, and seizure activity did not affect transfer. Conclusion: There does exist a bias in the referral patterns of patients who present with cerebral hemorrhage to community EDs. Further study is necessary to evaluate benefit of transfer, outcome and establishing ED transfer guidelines.
228
Propofol for Procedural Sedation in a Community Emergency Department
Charles M, McGinnis HD, Wehner P, Marshall University School of Medicine, Huntington, WV; Wake Forest University School of Medicine, Winston-Salem, NC
Study Objectives: Investigate the incidence of complications in procedural sedation with propofol by emergency physicians in a community emergency department.
S64 Annals of Emergency Medicine
Methods: Core data and complications were prospectively collected for the initial 4500 patients (age 9 months to 92 years) who received procedural sedation with propofol by our eleven emergency physicians. Propofol was titrated IV by the physician until the desired level of sedation was obtained, usually level III or level IV. Patients were given propofol in a titrated dose at the discretion of the emergency physician until the desired level of sedation was obtained. The drug was given without regard to time of last oral intake. Vital signs and pulse oximetry were recorded during the procedure and until recovery. Case data and complications were recorded into a database. Hypotension (SBP \ 90 mmHg or age appropriate decrease in children), hypoxemia (pulse oximetry \ 90%), respiratory depression requiring assisted ventilation or intubation, aspiration, airway obstruction, or anesthesia consultations were considered complications. Results: Over the study period, patients received propofol for orthopedic reduction (40%), lumbar puncture (21%), incision and drainage of abscess (17%), laceration repair (14%), chest tube insertion (5%), and other indications (3%). Mean total dose of propofol was 183 mg (range, 20 to 600 mg). Patient ages ranged from 9 months to 92 years of age. 85% of patients were ASA class I, 11% were ASA Class II, and 4% were ASA Class III. Transient hypotension occurred in 3% of patients. In all cases, the hypotension responded quickly to fluid bolus and did not recur. Transient hypoxia developed in 3% of patients. In the majority of these cases, the hypoxia resolved with simple airway repositioning. Twenty-seven patients required assisted ventilation by bag-valve-mask for less than 1 minute. No patient required intubation, aspirated, suffered airway obstruction, or required anesthesia consultation. Conclusion: Propofol is safe and effective for sedation during procedures carried out by emergency physicians. The rapid onset of action and short half-life allow for safe, early discharge. All patients were awake and alert in 2 to 37 minutes and those of sufficient age reported total amnesia and very high patient satisfaction. Of specific note, the emergency physicians administered propofol without regard to time of last oral intake with zero incidence of aspiration.
229
Documenting Pain Intensity: Distortions in the Electronic Medical Record
DeSandre PL, Todd KH, Bowers W, Lera L, Nachat A, Dreisinger N, Weisburd S, Pain and Emergency Medicine Institute, Department of Emergency Medicine, Beth Israel Medical Center, New York, NY
Study Objectives: Electronic medical records (EMRs) can improve efficiency and reduce error in the ED. This study compares the documentation of ED pain intensity using an EMR with pain assessments from direct patient interview. Methods: We conducted a prospective, observational cohort study in an urban teaching ED serving 65,000 annually. This ED uses a commercially available EMR. After written, informed consent, ED patients 8 and older with complaints of moderate to severe pain (pain NRSO3) underwent structured interviews conducted by trained research assistants prior to discharge home. Subjects were enrolled during ten 8-hour shifts over 2 two-week periods. All shifts of the 24 hour cycle were represented. Interviewers recorded patient pain intensity on ED arrival and discharge using an 11-point NRS. Investigators also abstracted pain assessments at arrival and discharge from the EMR. The EMR allowed entry of an 11-point NRS pain assessment at ED arrival; however, a required ‘‘pain at discharge’’ response field offered a limited number of narrative choices for pain assessment. Results: 99 subjects entered the study. The EMR indicated NRS pain assessments on arrival for 72 of these 99 subjects. Results for arrival NRS pain assessments were similar for both the EMR and direct interview (means 6.7 vs. 7.5, medians 7 vs. 8, Spearman correlation coefficient 0.7). Discharge assessments were obtained in both the EMR and direct interview for all 99 subjects. A number of disparities were noted between these two sets of observations. For 54 subjects reported in the EMR to be ‘‘pain-free’’ at the time of discharge, pain assessed by direct interview indicated a mean pain intensity of 4.2 (median 4, IQR 3-6, range 0-10). Only 6 of these 54 subjects (11%) indicated pain scores of zero and 12 subjects (22%) indicated severe pain intensity (NRSO6). For 29 subjects reported to be ‘‘tolerating pain at present,’’ direct interviews revealed mean pain scores in the moderate to severe range with a mean of 5.6 (median 6, IQR 5-7, range 0-10). Of the remaining 16 subjects, 14 were reported as ‘‘given Rx with follow-up’’ (mean 6.3, median 6.5, IQR 5-8, range 0-10) and 2 were reported as ‘‘baby/child appears comfortable.’’ Conclusion: EMRs have great potential to improve validity of documentation, but human factors encouraging invalid data entry should be investigated and addressed. Our study demonstrates that EMRs incorporating standardized scoring systems such as the NRS, encourage greater validity in pain assessment than forced-choice systems using text descriptors. EMR systems should
Volume 46, no. 3 : September 2005