- Email: [email protected]
Reliability of Patient History in Determining Pregnancy Status
Research Forum Abstracts perform pelvic exams on this patient population than male residents. In addition, male physicians were more likely to see younger patients within our study population, although race was not selected for. Further study is necessary to determine the effect of this difference on patient care and outcomes, as well as to measure the impact of this variation on equality of education.
198
Ruptured Ectopic Pregnancy Diagnosed in the Emergency Department
Korn CS, Hollinger M, Henderson SO, Keck School of Medicine of the University of Southern California, Los Angeles, CA
Backround: Despite early recognition of ectopic pregnancy with the increase in both the usage of ultrasound in the ED and management on an outpatient basis, cases of rupture still exist. Study Objectives: To describe our experience with all patients receiving an ED discharge diagnosis of ruptured ectopic pregnancy (REP). Methods: This was a retrospective chart review of all ED discharge diagnosis of REP in a Level 1 trauma center from 1996-2003. Data included abdominal pain, vaginal bleeding, initial and ED vital signs, initial and subsequent hematocrits, and final disposition. Results: Fifty-six female patients were identified and all charts were available for review. On presentation, 55/56 (98%) patients were experiencing abdominal pain and 33/56 (59%) had vaginal bleeding. Initially, tachycardia (HRO100) occurred in 23/56 (41%) patients, where as, bradycardia (HR\60) occurred in only 1 patient. During the ED course, the patients with tachycardia increased to 33/56 (59%). Twenty eight (50%) patients were hypotensive (BP\ 90) on arrival, which throughout the ED course of treatment remained consistent. Signs of hypovolemic shock (hypotension and tachycardia) occurred only in 15/56 (27%). The initial mean hematocrit level was 31%, ranging from 13-41% (normal 38.5-46). Throughout the ED course, 41/56 (73%) patients sustained a decrease in their hematocrit level, mean 3-points (range 0-14 percentage points). The most frequent decrease (mode) was 0,1, 2 (7 cases each). All 56 patients were discharged directly to the operating room. Conclusion: The majority of patients that where diagnosed with REP while in the ED arrived experiencing abdominal pain and vaginal bleeding. Hypovolemic shock (hypotension and tachycardia) occurred in only 27% of the cases and only one patient had bradycardia despite the fact that both can result from intraabdominal hemorrhage. Hematocrit levels decreased by a mean of 3-points in the majority of patients during their ED course and all required surgical intervention.
199
Should Emergency Physicians Sit or Stand? It Does Not Much Matter
Gambarota M, Eberhardt M, Melanson S, Deitrick D, St Lukes Hospital, Bethlehem, PA
Study Objectives: It is often taught that patients prefer their physicians to be seated, but there are few data to support this contention in emergency care. The purpose of this prospective randomized clinical trial was to investigate the validity of this widely accepted belief, using as our primary endpoint overall patient satisfaction with medical care provided by the physician. Other endpoints included patient perception of time spent with physician and patient perception of total time spent in the emergency department (ED). Methods: A convenience sample of 73 fast track patients presenting to our community hospital ED with an annual census of 55,000 visits, were randomized to a seated (SEAT) or a standing (STAND) group. The physicians for patients in SEAT were instructed to remain in a seated position while obtaining the patient history and discussing results and treatment but were permitted to stand during the physical exam. Physicians in the STAND group were instructed to stand during the entire patient encounter. At the time of discharge, a research assistant presented the patient with a six-question survey asking them to rate aspects of their physician encounter on a five-point Likert scale as well as a Visual Analogue Scale (VAS). They were also asked to estimate the total time their physician spent with them and the total time spent in the ED. Results: The 73 patients had a mean age of 26 years and were evenly matched by sex. On all measures of patient satisfaction, there was no difference between the SEAT and the STAND groups (4.6G0.6 for both groups, p=0.61). This was confirmed by the VAS satisfaction scores (SEAT 85.0G22.5 vs STAND 89.4G17.7, p=0.36). The actual mean time spent by physicians in SEAT group was 7.2G4.0 min, compared with 5.7G3.0 min in STAND group (p=0.06). Perception of the
S56 Annals of Emergency Medicine
time spent as reported by patients was not different (SEAT 10.8G8.4 min vs STAND 8.6G4.5 min, p=0.19). Although patients in the SEAT group had a total ED time that was similar to those in the STAND group (73.4 min vs 84.8 min, p=0.85), the patients in the SEAT group overestimated their total ED stay while the STAND group was very accurate in their assessment (127.3 min vs 91.0 min, p=0.09). Conclusion: There was no difference in patient satisfaction with physician care regardless of whether physicians sat or stood during the patient encounter.
200
Reliability of Patient History in Determining Pregnancy Status
Strote J, Chen G, Holmer W, University of Washington Medical Center, Seattle, WA
Study Objectives: Pregnancy tests are often performed routinely for reproductive age female emergency department patients. One major reason is a perception that patients are unreliable in predicting their pregnancy status. We hypothesized that patients could reliably predict their not being pregnant. Methods: The study used a prospective cross-sectional design in an urban, academic emergency department from January 19 through May 19, 2004. All patients for whom a pregnancy test was ordered were asked about their sexual and menstrual history as well as an additional question: ‘‘Is there any chance you could be pregnant?’’ Patients with already documented pregnancies were excluded. Likelihood ratios (LRs) of a positive pregnancy test for each question asked were calculated. Results: 474 patients had pregnancy tests performed that met inclusion criteria. Eleven (2.3%) tests were positive. Among patients who said that there was no chance they could be pregnant (337), one test (0.3%) was positive (LR 0.13, 95% CI 0.020.81). No tests were positive among patients who stated they were not sexually active; other questions about sexual and menstrual history had high negative predictive values, consistent with the low overall pregnancy rate, but LRs did not meet significance cutoffs. All pregnancies occurred in patients with gastrointestinal or genitourinary chief complaints, which comprised only 56% of the presentations for which tests were ordered. Conclusion: In certain populations, self-assessment may be useful as a predictor of a patient not being pregnant. Further study is required to determine whether selfassessment could be safely and beneficially used in the emergency department to decrease pregnancy testing.
201
The Impact of Cocaine Use in Patients with New Onset Congestive Heart Failure
Yursik B, Mills LD, Mills TJ, Tulane University School of Medicine, New Orleans, LA; Louisiana State University Health Science Center at New Orleans, New Orleans, LA
Objective: The objective of this study is to describe the difference in disease severity between patients with new onset congestive heart failure (CHF) who use cocaine and those who do not use cocaine. Methods: IRB approval was obtained. This study was conducted in a county hospital that serves and inner city population. All patients 18 years of age and older diagnosed with new onset CHF in the Emergency Department were prospectively enrolled in the study. Demographic data, drug use, and medical history was collected. Patients were followed to determine the presence of concurrent acute myocardial infarction (AMI) and length of stay in the hospital. Echocardiography was used to assess cardiac function. The patients were divided into 2 groups, those patients who used cocaine and those who did not. Fischer’s exact tests, with statistical significance defined as p \ 0.05, were performed to define significant differences between the 2 groups. Results: Ninety-six patients were enrolled. Eighty-eight percent (n=84) of patients were Black, 9.3% (n=10) Caucasian, 1% (n=1) Indian, 1% (n=1) Hispanic. There were no differences in demographic data between the 2 groups. Cocaine users were more likely to report a visit for the same symptoms in the past month than non-cocaine users (RR, 3.91; 95% CI, 2.15-5.64; p=0.00). Cocaine users were more likely to have left ventricular hypokinesis (RR, 1.97; 95% CI, 1.2-2.39; p=0.03). Cocaine users had longer lengths of stay than non-cocaine users by 2.84 days (95% CI 0.47-5.21; p=0.02). There was no difference among the 2 groups in the presence of AMI. Conclusion: In a population of patients with new onset CHF, there are statistical differences between patients who use cocaine and those who do not. Cocaine users are more likely to make multiple visits for the same complaints, to have a longer length of stay in the hospital, and to have left ventricular hypokinesis.
Volume 46, no. 3 : September 2005
198
Ruptured Ectopic Pregnancy Diagnosed in the Emergency Department
Korn CS, Hollinger M, Henderson SO, Keck School of Medicine of the University of Southern California, Los Angeles, CA
Backround: Despite early recognition of ectopic pregnancy with the increase in both the usage of ultrasound in the ED and management on an outpatient basis, cases of rupture still exist. Study Objectives: To describe our experience with all patients receiving an ED discharge diagnosis of ruptured ectopic pregnancy (REP). Methods: This was a retrospective chart review of all ED discharge diagnosis of REP in a Level 1 trauma center from 1996-2003. Data included abdominal pain, vaginal bleeding, initial and ED vital signs, initial and subsequent hematocrits, and final disposition. Results: Fifty-six female patients were identified and all charts were available for review. On presentation, 55/56 (98%) patients were experiencing abdominal pain and 33/56 (59%) had vaginal bleeding. Initially, tachycardia (HRO100) occurred in 23/56 (41%) patients, where as, bradycardia (HR\60) occurred in only 1 patient. During the ED course, the patients with tachycardia increased to 33/56 (59%). Twenty eight (50%) patients were hypotensive (BP\ 90) on arrival, which throughout the ED course of treatment remained consistent. Signs of hypovolemic shock (hypotension and tachycardia) occurred only in 15/56 (27%). The initial mean hematocrit level was 31%, ranging from 13-41% (normal 38.5-46). Throughout the ED course, 41/56 (73%) patients sustained a decrease in their hematocrit level, mean 3-points (range 0-14 percentage points). The most frequent decrease (mode) was 0,1, 2 (7 cases each). All 56 patients were discharged directly to the operating room. Conclusion: The majority of patients that where diagnosed with REP while in the ED arrived experiencing abdominal pain and vaginal bleeding. Hypovolemic shock (hypotension and tachycardia) occurred in only 27% of the cases and only one patient had bradycardia despite the fact that both can result from intraabdominal hemorrhage. Hematocrit levels decreased by a mean of 3-points in the majority of patients during their ED course and all required surgical intervention.
199
Should Emergency Physicians Sit or Stand? It Does Not Much Matter
Gambarota M, Eberhardt M, Melanson S, Deitrick D, St Lukes Hospital, Bethlehem, PA
Study Objectives: It is often taught that patients prefer their physicians to be seated, but there are few data to support this contention in emergency care. The purpose of this prospective randomized clinical trial was to investigate the validity of this widely accepted belief, using as our primary endpoint overall patient satisfaction with medical care provided by the physician. Other endpoints included patient perception of time spent with physician and patient perception of total time spent in the emergency department (ED). Methods: A convenience sample of 73 fast track patients presenting to our community hospital ED with an annual census of 55,000 visits, were randomized to a seated (SEAT) or a standing (STAND) group. The physicians for patients in SEAT were instructed to remain in a seated position while obtaining the patient history and discussing results and treatment but were permitted to stand during the physical exam. Physicians in the STAND group were instructed to stand during the entire patient encounter. At the time of discharge, a research assistant presented the patient with a six-question survey asking them to rate aspects of their physician encounter on a five-point Likert scale as well as a Visual Analogue Scale (VAS). They were also asked to estimate the total time their physician spent with them and the total time spent in the ED. Results: The 73 patients had a mean age of 26 years and were evenly matched by sex. On all measures of patient satisfaction, there was no difference between the SEAT and the STAND groups (4.6G0.6 for both groups, p=0.61). This was confirmed by the VAS satisfaction scores (SEAT 85.0G22.5 vs STAND 89.4G17.7, p=0.36). The actual mean time spent by physicians in SEAT group was 7.2G4.0 min, compared with 5.7G3.0 min in STAND group (p=0.06). Perception of the
S56 Annals of Emergency Medicine
time spent as reported by patients was not different (SEAT 10.8G8.4 min vs STAND 8.6G4.5 min, p=0.19). Although patients in the SEAT group had a total ED time that was similar to those in the STAND group (73.4 min vs 84.8 min, p=0.85), the patients in the SEAT group overestimated their total ED stay while the STAND group was very accurate in their assessment (127.3 min vs 91.0 min, p=0.09). Conclusion: There was no difference in patient satisfaction with physician care regardless of whether physicians sat or stood during the patient encounter.
200
Reliability of Patient History in Determining Pregnancy Status
Strote J, Chen G, Holmer W, University of Washington Medical Center, Seattle, WA
Study Objectives: Pregnancy tests are often performed routinely for reproductive age female emergency department patients. One major reason is a perception that patients are unreliable in predicting their pregnancy status. We hypothesized that patients could reliably predict their not being pregnant. Methods: The study used a prospective cross-sectional design in an urban, academic emergency department from January 19 through May 19, 2004. All patients for whom a pregnancy test was ordered were asked about their sexual and menstrual history as well as an additional question: ‘‘Is there any chance you could be pregnant?’’ Patients with already documented pregnancies were excluded. Likelihood ratios (LRs) of a positive pregnancy test for each question asked were calculated. Results: 474 patients had pregnancy tests performed that met inclusion criteria. Eleven (2.3%) tests were positive. Among patients who said that there was no chance they could be pregnant (337), one test (0.3%) was positive (LR 0.13, 95% CI 0.020.81). No tests were positive among patients who stated they were not sexually active; other questions about sexual and menstrual history had high negative predictive values, consistent with the low overall pregnancy rate, but LRs did not meet significance cutoffs. All pregnancies occurred in patients with gastrointestinal or genitourinary chief complaints, which comprised only 56% of the presentations for which tests were ordered. Conclusion: In certain populations, self-assessment may be useful as a predictor of a patient not being pregnant. Further study is required to determine whether selfassessment could be safely and beneficially used in the emergency department to decrease pregnancy testing.
201
The Impact of Cocaine Use in Patients with New Onset Congestive Heart Failure
Yursik B, Mills LD, Mills TJ, Tulane University School of Medicine, New Orleans, LA; Louisiana State University Health Science Center at New Orleans, New Orleans, LA
Objective: The objective of this study is to describe the difference in disease severity between patients with new onset congestive heart failure (CHF) who use cocaine and those who do not use cocaine. Methods: IRB approval was obtained. This study was conducted in a county hospital that serves and inner city population. All patients 18 years of age and older diagnosed with new onset CHF in the Emergency Department were prospectively enrolled in the study. Demographic data, drug use, and medical history was collected. Patients were followed to determine the presence of concurrent acute myocardial infarction (AMI) and length of stay in the hospital. Echocardiography was used to assess cardiac function. The patients were divided into 2 groups, those patients who used cocaine and those who did not. Fischer’s exact tests, with statistical significance defined as p \ 0.05, were performed to define significant differences between the 2 groups. Results: Ninety-six patients were enrolled. Eighty-eight percent (n=84) of patients were Black, 9.3% (n=10) Caucasian, 1% (n=1) Indian, 1% (n=1) Hispanic. There were no differences in demographic data between the 2 groups. Cocaine users were more likely to report a visit for the same symptoms in the past month than non-cocaine users (RR, 3.91; 95% CI, 2.15-5.64; p=0.00). Cocaine users were more likely to have left ventricular hypokinesis (RR, 1.97; 95% CI, 1.2-2.39; p=0.03). Cocaine users had longer lengths of stay than non-cocaine users by 2.84 days (95% CI 0.47-5.21; p=0.02). There was no difference among the 2 groups in the presence of AMI. Conclusion: In a population of patients with new onset CHF, there are statistical differences between patients who use cocaine and those who do not. Cocaine users are more likely to make multiple visits for the same complaints, to have a longer length of stay in the hospital, and to have left ventricular hypokinesis.
Volume 46, no. 3 : September 2005