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Lumbar puncture in the emergency department: Complications and theri costs
RESEARCH FORUM ABSTRACTS
Study objectives: To determine whether ED assessments of stable patients with GIH can predict those who will require hospital admission (HA) versus CDU care. Methods: We conducted a retrospective observational study conducted by performing chart reviews of patients treated for GIH in the ED/CDU at an urban tertiary care facility from 1996-1998. Historical (demographics, comorbidities, alcohol use, medications, previous GIH) and ED data (initial vital signs, orthostasis, laboratory, ED therapies) were obtained. Subjects were grouped according to final CDU disposition (HA versus discharge) and collected variables analyzed for their ability to predict the need for HA. Results: The ED/CDU records of 215 patients were reviewed. Forty-eight patients (29%) required HA, whereas i67 (71%) were discharged from the CDU. Four variables significantly predicted admission (Table). Location of hemorrhage, use of alcohol or nonsteroidal antiinflammatory drugs, other comorbidities, initial vital signs, and other ED therapies did not have a predictive power for HA. Conclusion: Advanced age, low hemoglobin level, need for blood transfusion, and presence of orthostasis help predict which ED patients with stable GIH may not be candidates for CDU pathway management. Other historical data and ED managements are not predictive of CDU outcome. Prospective trials are needed to better stratify stable GIHs as to appropriate disposition to the CDU or inpatient unit.
published studies documenting the frequency of PDPH, or any other complications, in patients receiving LP in the emergency department. The goal of this study is to (1) determine the incidence of the complications of LP, including PDPH, in patients receiving diagnostic LP in the ED, and (2) determine the financial burden of the complications of LP. Methods: This is a retrospective, chart review study of consecutive patients who received diagnostic LP in an urban trauma center in calendar years 1996 and 1997. Patients who were admitted to the hospital after LP were excluded from the study. The medical records of patients who were discharged after their LP were reviewed for retum visits to the ED for complications related to LP. Results: Of the 488 patients included in the study, 44 returned to the ED, for a total of 54 visits, with a complication related to LP. The overall incidence of PDPH was 8.0%. No statistically significant differences between the patients developing PDPH and sex or race were present in this study. However, age approached significance at the P=.06 level. The average additional cost per visit for patients returning to the ED with an LP complication was $950. Conclusion: With only 5 exceptions, PDPH comprised the majority of complications of LP. The 8.0% incidence of PDPH is concerning; however, no clear causal or associative factors emerged. The cost of the additional visit for treatment of LP complications was significant, nearly doubling the cost of care. A prospective study is required to clarify the true incidence and possible risk factors of PDPH.
Table, abstract 400.
403 AnNonverifiableEmergenCYPainDepartment Protocolfor Management of
Age (y) HA Discharge Pvalue
67.3+13.6 56.1+19.3 <.001
Initial Hemoglobin (g/dL)
0rthostasis (%)
Blood Transfusion (%)
10.7+2.2 12.3+_2.6 <.001
60.0 34.7 .02
34.0 13.3 .001
01 "Medical Clearance" in the Psychiatric Patient Presentingto the Emergency Department: Is It Necessary? Korn CS, Currier G, HendersonS0/Los Angeles County-University Southern California Medical Center, Los Angeles, CA Study objective: To evaluate the necessity for comprehensive "medical clearance" (history/physical/laboratory/radiography) in patients presenting to the emergency department with isolated psychiatric complaints. Methods: We conducted a retrospective chart review over a 5-month period of all patients 16 years or older requiring a psychiatric evaluation for new or established psychiatric complaints before their discharge from the ED. Data included patient age, sex, initial complaint, past medical and psychiatric history, laboratory and chest radiography results, and final disposition. The number of patients that could have been referred to a psychiatric unit after a history and physical and without additional laboratory or radiographic studies was determined. Results: Two hundred twelve patients met the criteria and 100% of the charts were available for review. Eighty (38%) patients presented with isolated psychiatric complaints coupled with a documented psychiatric history. All received a comprehensive "medical clearance" in the ED followed by a psychiatric consultation. None of the patients had positive screening laboratory or radiographic results. All were discharged home or to the psychiatric ED. The remaining 132 (62%) patients presented to the ED with medically based chief complaints or medical history requiring further medical evaluation in the ED before disposition. Conclusion: The initial complaints of the patients in our study directly correlated with the need for laboratory and radiographic "medical clearance" in the ED. Patients with a primary psychiatric complaint coupled with a documented psychiatric history may be referred to psychiatric services without the use of ancillary testing in the ED.
402 and Lumbar Their Puncture Costs in the Emergency Department: Complications Sternfeld D, Trott A/University of Cincinnati College of Medicine, Cincinnati, OH Study objective: Postdural puncture headache (PDPH) is a common complication of lumbar puncture (LP), with a reported incidence of 5% to 40~163 depending primarily on the study population and technique of dural puncture. However, there are no
S 1 02
Schuckman H, Gaffney P, Wilber ST, 6erson LW, Blanda M, Powell C/Summa Health System, Northeastern Ohio Universities College of Medicine, Akron, OH Substance-abusmg persons may attempt to obtain drugs by presenting to emergency departments with nonverifiable pain (NVP). NVP is subjective, relying on the patient's history to determine its presence and severity. Study objective: To describe findings from our protocol for NVP management. This prospective, observational study was conducted at 2 university-affiliated community teaching hospital EDs (89,000 visits per year). Methods: Criteria for protocol inclusion are NVP patients unwilling or unable to take nonnarcotic analgesics for whom controlled drugs are considered. Patients enrolled from August 1, 1997, to May 31, 1998, were included. The study intervention was for emergency physicians to identify patients and obtain written informed consent, self-reported drug use in the past 30 days, and a urine drug screen (UDS). Data are presented as means and proportions with 95% confidence intervals (CIs). Results: Seventeen (68%; 95% C1 47% to 85%) of 25 attending physicians used the protocol on 148 patients. Seventy-seven (53%; 95% CI 44% to 60%) of 148 patients were male, 112 (76%; 95% CI 68% to 73%) of 148 were white and mean age was 40 years (95% CI 38 to 41). Forty-six (31%; 95% CI 24% to 39%) of 148 patients complained of backache, 31 (21%; 95% CI L5% to 28%) of 148 headache, and 18 (12%; 95% C1 7% to 17%) of 148 toothache. Thirteen patients refused consent. One hundred fifty-seven screens were done on 134 remaining patients; 105 (67%; 95% CI 59% to 74%) of 134 patients claimed narcotic use, 32 (20%; 95% CI 14% to 27%) of 134 benzodiazepines, 11 (7%; 95% CI 4% to 12%) of 134 marijuana (THC), and 3 (2%; 95% CI 0.4% to 5%) of 134 cocaine. Unclaimed drugs were found in 55 (35%; 95% CI 27% to 43%) of 134 UDS. including narcotics in 33 (60%; 95% C146% to 73%) of 55, cocaine in 16 (29%; 95% CI 18% to 43%) of 55, butalbital in 9 (16%, 95% CI 8% to 29%) of 55, benzodiazepines in 7 (13%, 95% C1 5% to 24%) of 55, and marijuana in 4 (2.5%, 95% CI 0.7% to 6.4%) of 55. Conclusion: This ED protocol identified prescription and illegal drug use and detected unclaimed drugs in patients with NVP. lts use allows drug discussions, intervention if needed, and aids in the management of NVP.
404
EmergencyPhysician Management of Musculoskeletal Low Back Pain: Are We Following Published Guidelines?
Velendzas D, Weiner A/University of Connecticut Medical Center, Farmington, CT Study objectives: In 1994, the Agency for Health Care Policy and Research (AHCPR) published guidelines for the initial evaluation and management of patients with musculoskeletal low back pain (MSLBP). This study looks at the compliance of the emergency medicine practitioner with the AHCPR guidelines. Methods: Patients evaluated for MSLBP in our university-based emergency department, between June 1, 1998, and October 31, i998, were identified retrospectively by their International Classification of Diseases-ninth revision (ICD-9) code. Patients were
ANNALS OF EMERGENCY MEDICINE
34:4 OCTOBER 1999, PART 2
Study objectives: To determine whether ED assessments of stable patients with GIH can predict those who will require hospital admission (HA) versus CDU care. Methods: We conducted a retrospective observational study conducted by performing chart reviews of patients treated for GIH in the ED/CDU at an urban tertiary care facility from 1996-1998. Historical (demographics, comorbidities, alcohol use, medications, previous GIH) and ED data (initial vital signs, orthostasis, laboratory, ED therapies) were obtained. Subjects were grouped according to final CDU disposition (HA versus discharge) and collected variables analyzed for their ability to predict the need for HA. Results: The ED/CDU records of 215 patients were reviewed. Forty-eight patients (29%) required HA, whereas i67 (71%) were discharged from the CDU. Four variables significantly predicted admission (Table). Location of hemorrhage, use of alcohol or nonsteroidal antiinflammatory drugs, other comorbidities, initial vital signs, and other ED therapies did not have a predictive power for HA. Conclusion: Advanced age, low hemoglobin level, need for blood transfusion, and presence of orthostasis help predict which ED patients with stable GIH may not be candidates for CDU pathway management. Other historical data and ED managements are not predictive of CDU outcome. Prospective trials are needed to better stratify stable GIHs as to appropriate disposition to the CDU or inpatient unit.
published studies documenting the frequency of PDPH, or any other complications, in patients receiving LP in the emergency department. The goal of this study is to (1) determine the incidence of the complications of LP, including PDPH, in patients receiving diagnostic LP in the ED, and (2) determine the financial burden of the complications of LP. Methods: This is a retrospective, chart review study of consecutive patients who received diagnostic LP in an urban trauma center in calendar years 1996 and 1997. Patients who were admitted to the hospital after LP were excluded from the study. The medical records of patients who were discharged after their LP were reviewed for retum visits to the ED for complications related to LP. Results: Of the 488 patients included in the study, 44 returned to the ED, for a total of 54 visits, with a complication related to LP. The overall incidence of PDPH was 8.0%. No statistically significant differences between the patients developing PDPH and sex or race were present in this study. However, age approached significance at the P=.06 level. The average additional cost per visit for patients returning to the ED with an LP complication was $950. Conclusion: With only 5 exceptions, PDPH comprised the majority of complications of LP. The 8.0% incidence of PDPH is concerning; however, no clear causal or associative factors emerged. The cost of the additional visit for treatment of LP complications was significant, nearly doubling the cost of care. A prospective study is required to clarify the true incidence and possible risk factors of PDPH.
Table, abstract 400.
403 AnNonverifiableEmergenCYPainDepartment Protocolfor Management of
Age (y) HA Discharge Pvalue
67.3+13.6 56.1+19.3 <.001
Initial Hemoglobin (g/dL)
0rthostasis (%)
Blood Transfusion (%)
10.7+2.2 12.3+_2.6 <.001
60.0 34.7 .02
34.0 13.3 .001
01 "Medical Clearance" in the Psychiatric Patient Presentingto the Emergency Department: Is It Necessary? Korn CS, Currier G, HendersonS0/Los Angeles County-University Southern California Medical Center, Los Angeles, CA Study objective: To evaluate the necessity for comprehensive "medical clearance" (history/physical/laboratory/radiography) in patients presenting to the emergency department with isolated psychiatric complaints. Methods: We conducted a retrospective chart review over a 5-month period of all patients 16 years or older requiring a psychiatric evaluation for new or established psychiatric complaints before their discharge from the ED. Data included patient age, sex, initial complaint, past medical and psychiatric history, laboratory and chest radiography results, and final disposition. The number of patients that could have been referred to a psychiatric unit after a history and physical and without additional laboratory or radiographic studies was determined. Results: Two hundred twelve patients met the criteria and 100% of the charts were available for review. Eighty (38%) patients presented with isolated psychiatric complaints coupled with a documented psychiatric history. All received a comprehensive "medical clearance" in the ED followed by a psychiatric consultation. None of the patients had positive screening laboratory or radiographic results. All were discharged home or to the psychiatric ED. The remaining 132 (62%) patients presented to the ED with medically based chief complaints or medical history requiring further medical evaluation in the ED before disposition. Conclusion: The initial complaints of the patients in our study directly correlated with the need for laboratory and radiographic "medical clearance" in the ED. Patients with a primary psychiatric complaint coupled with a documented psychiatric history may be referred to psychiatric services without the use of ancillary testing in the ED.
402 and Lumbar Their Puncture Costs in the Emergency Department: Complications Sternfeld D, Trott A/University of Cincinnati College of Medicine, Cincinnati, OH Study objective: Postdural puncture headache (PDPH) is a common complication of lumbar puncture (LP), with a reported incidence of 5% to 40~163 depending primarily on the study population and technique of dural puncture. However, there are no
S 1 02
Schuckman H, Gaffney P, Wilber ST, 6erson LW, Blanda M, Powell C/Summa Health System, Northeastern Ohio Universities College of Medicine, Akron, OH Substance-abusmg persons may attempt to obtain drugs by presenting to emergency departments with nonverifiable pain (NVP). NVP is subjective, relying on the patient's history to determine its presence and severity. Study objective: To describe findings from our protocol for NVP management. This prospective, observational study was conducted at 2 university-affiliated community teaching hospital EDs (89,000 visits per year). Methods: Criteria for protocol inclusion are NVP patients unwilling or unable to take nonnarcotic analgesics for whom controlled drugs are considered. Patients enrolled from August 1, 1997, to May 31, 1998, were included. The study intervention was for emergency physicians to identify patients and obtain written informed consent, self-reported drug use in the past 30 days, and a urine drug screen (UDS). Data are presented as means and proportions with 95% confidence intervals (CIs). Results: Seventeen (68%; 95% C1 47% to 85%) of 25 attending physicians used the protocol on 148 patients. Seventy-seven (53%; 95% CI 44% to 60%) of 148 patients were male, 112 (76%; 95% CI 68% to 73%) of 148 were white and mean age was 40 years (95% CI 38 to 41). Forty-six (31%; 95% CI 24% to 39%) of 148 patients complained of backache, 31 (21%; 95% CI L5% to 28%) of 148 headache, and 18 (12%; 95% C1 7% to 17%) of 148 toothache. Thirteen patients refused consent. One hundred fifty-seven screens were done on 134 remaining patients; 105 (67%; 95% CI 59% to 74%) of 134 patients claimed narcotic use, 32 (20%; 95% CI 14% to 27%) of 134 benzodiazepines, 11 (7%; 95% CI 4% to 12%) of 134 marijuana (THC), and 3 (2%; 95% CI 0.4% to 5%) of 134 cocaine. Unclaimed drugs were found in 55 (35%; 95% CI 27% to 43%) of 134 UDS. including narcotics in 33 (60%; 95% C146% to 73%) of 55, cocaine in 16 (29%; 95% CI 18% to 43%) of 55, butalbital in 9 (16%, 95% CI 8% to 29%) of 55, benzodiazepines in 7 (13%, 95% C1 5% to 24%) of 55, and marijuana in 4 (2.5%, 95% CI 0.7% to 6.4%) of 55. Conclusion: This ED protocol identified prescription and illegal drug use and detected unclaimed drugs in patients with NVP. lts use allows drug discussions, intervention if needed, and aids in the management of NVP.
404
EmergencyPhysician Management of Musculoskeletal Low Back Pain: Are We Following Published Guidelines?
Velendzas D, Weiner A/University of Connecticut Medical Center, Farmington, CT Study objectives: In 1994, the Agency for Health Care Policy and Research (AHCPR) published guidelines for the initial evaluation and management of patients with musculoskeletal low back pain (MSLBP). This study looks at the compliance of the emergency medicine practitioner with the AHCPR guidelines. Methods: Patients evaluated for MSLBP in our university-based emergency department, between June 1, 1998, and October 31, i998, were identified retrospectively by their International Classification of Diseases-ninth revision (ICD-9) code. Patients were
ANNALS OF EMERGENCY MEDICINE
34:4 OCTOBER 1999, PART 2