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What does “risk of MI” mean to the emergency physician? results of an observational study
RESEARCH FORUM ABSTRACTS
initial pH class. A 2-way analysis of variance was done with each parameter as the dependent variable and pH class and disposition as independent variables. InterQual criteria for ICU admission were used to assess likely disposition from a routine ED visit. The difference in disposition was the basis for cost analysis. Results: Fifteen of 61 patients were admitted to the ICU after initial high-severity ED management including all 7 with serum pH less than or equal to 7.00, 5 of 10 with pH less than or equal to 7.10, 2 of 17 with pH less than or equal to 7.20, and 1 of 27 with pH greater than or equal to 7.21. Factors that had a statistically significant effect on disposition were initial pH and HCO-3; glucose levels did not. There was no significant difference in ED stay between ICU and floor admission. One patient with pH less than 7.00 died of sepsis in the ICU. All others were discharged from the hospital. Mean stay in ICU was 2 days. Fifty-six of the 61 patients met InterQual criteria for ICU admission; 41 of these were diverted to a regular floor after aggressive management in the ED without adverse effect on outcome. Conclusion: We estimate a reduction in charges of $65,600 for care of these 61 patients.
328
Evaluation of Physical Examination in Determining the Outcomes of Ultrasoundfor Deep Vein Thrombosis
Chan L, Reilly KM/Albany Medical College, Albany, NY Study objective: To evaluate the ability of physical examination to determine the results of ultrasound (US) for deep vein thrombosis (DVT). Methods: Our tertiary care emergency department has an annual census of 59,000 with a diverse racial and socioeconomic population. This was a retrospective chart review of ED patients who underwent US to diagnose DVT. Charts were identified by the radiology computer system. Age, sex, and the presence or absence of the following physical examination findings were recorded: extremity edema, vein distention, extremity tenderness to palpation, extremity erythema, extremity warmth, calf pain on passive dorsiflexion of the toe, and palpable cord. The outcomes of the US study were recorded as well. Charts were excluded if the US results could not differentiate between chronic and acute DVT. The physical examination was considered positive if any one or more of the physical signs were present. The sensitivity and specificity of physical examination for DVT by US diagnosis were calculated. Positive and negative predictive values of physical examination to predict the results of US for DVT were also calculated. The odds ratio was determined as well. Results: The charts of 186 patients were reviewed. Thirteen charts were excluded because of US inability to determine between acute and chronic DVT. One hundred seventy-three charts (67 males and 106 females) were evaluated. The mean age was 55.0_+18.9 years. Ultrasound diagnosed 43 cases of acute DVT and ruled out 130 cases of DVT. Physical examination had a sensitivity of 95% (95% confidence interval [CI] 92% to 98%); specificity of 31% (95% CI 24% to 38%); positive predictive value of 31% (95% CI 24% to 38%); and negative predictive value of 95% (95% CI 92% to 98%). The odds ratio was 9.11. Conclusion: A negative physical examination was reliable and predictive of a negative US result for DVT. Presence of physical examination findings was not reliable or predictive of US results for DVT.
329
Patient Preferences Regarding Pain Medication in the Emergency Department
Beel TL, Mitchiner JC, FraderiksenS. McCormick J/St. Joseph Mercy Hospital, Ann Arbor, MI Previous studies have shown that pain control in the emergency department is inadequate. Study objectives: To determine the proportion of ED patients with acute fractures who want pain medication, the level of pain present on ED admission and desired at ED discharge, and the manner in which these patients want pain medication given. Methods: A convenience sample of 107 adults with acute long-bone fractures seen in a community hospital ED completed a brief 8-item pain questionnaire. Patients with head injury, multiple trauma, fractures more than 6 hours old, questionable fractures, prehospital pain control, evidence of intoxication, or inability to answer questions were excluded. The questionnaire asked patients to score their pain level on ED admission and the level of pain desired at discharge on a 10O-mm visual analog scale, and to answer 6 questions.
S 84
Results: Eighty-eight percent of the patients wanted pain medication given in the ED, and 77% actually received it. Sixty-nine percent were comfortable with a nurse administering pain medication before being seen by a physician. Preferred routes were as follows: intravenous 40% orally 34%, intramuscular 20%. Seventy percent wanted pain control without being sedated, and 25% wanted complete pain relief even if sedation was necessary to achieve it. Sixty percent of patients were either slightly concerned or not concerned about potential medication side effects. Conclusion: More than 8 of L0 patients with acute fractures want pain medication given while in the ED, and 7 of 10 would accept pain medication administered by a nurse before physician evaluation.
330
What Does "Risk of Mr" Mean to the Emergency Physician? Results of an Observational Study
Feldman J, Wallace E, Betty C, Mitchell P, Fish S/Boston Medical Center, Boston University School of Medicine, Boston, MA Previous research has demonstrated that non-emergency physicians' estimates of risk varied widely and that the estimates of risk correlated positively with testing decisions. Study objective: To determine the emergency physician variability in the quantification of 4 categories of estimated probability of myocardial infarction (MI), and to determine the relationship between estimated probability of MI and disposition decisions. Methods: We performed an observational study using a questionnaire given to all emergency medicine faculty at an urban Level I trauma center with an established emergency medicine residency program. The instrument required study subjects to define a range of probability of MI for a 4-group risk classification (very low, low, medium, high) and to determine the appropriate ED disposition based on the estimated probability of MI (home, telemetry/chest pain unit [CPUI, coronary care unit [CCU]). We recorded gender and years of emergency medicine experience for all subjects. Years of experience were dichotomized as less than or equal to 5 years (junior) and more than 5 years (senior). Means and SDs were calculated for the cut points between each risk category. We evaluated the effect of gender and experience on risk cut points and triage cut points with a t test (2-sided, ~=.05). The very low risk cut point was compared with estimated MI risk for discharge home. Results: All 24 physicians responded. Of these, 5 (21%) were female; 12 (50%) were seniors in terms of experience. Each cut point for risk classification demonstrated substantial variability: very low to low 3.5%_+2.7%; low to medium 12.1%_+7.9%; medium to high 48.9%_+23.5%. The mean estimated probability of MI that would support direct ED discharge to home was 2.3%_+3.0%; to CCU 45.2%_+28.7%. We found that female gender was associated with higher risk cut points (very low to low mean 6.2% versus 2.8%, P=.009; low to medium mean 17.2% versus 10.8% P=.ll) and MI estimate for discharge to home (4.5% versus 1.9%, P=.08), whereas years of experience was not associated with lower risk probability cut points (/:'>.07 for all cut points). Fourteen physicians indicated a lower threshold for home discharge than their very low to low cut point, whereas 3 indicated a higher acceptable MI risk for home discharge. Conclusion: Emergency physicians demonstrate great variability when assigning absolute numerical values to commonly used risk categories of estimated probability of MI. Women tended to have higher cut points for very low and low risk of MI categories and higher estimated MI risk for discharge to home. Further research is required to determine the effect of physician risk estimates on testing and triage for patients with possible acute cardiac ischemia.
31 the Inhaled Corticosteroidsin Acute Asthma:A Systematic Review of Literature Edmonds ML, CamargoCA Jr, Pollack CA Jr, Rowe BH/University of Nberta, Edmonton,Alberta, Canada; Massachusetts 6eneral Hospital, Boston, MA; Maricopa Medical Center, Phoenix,AZ Study objectives: The use of inhaled corticosteroids in asthma is increasing; however, their benefit in the acute setting is unclear. This systematic review was designed to determine the benefit of inhaled corticosteroids for acute asthma in the emergency department. Methods: Randomized controlled trials (RCTs) were identified using the Cochrane Collaboration's Airways Review Group database, hand searching, bibliographies, pharmaceutical company, and author contact. Studies in which an inhaled corticosteroid was compared with placebo or any corticosteroid were considered. Relevance, inclusion, and study quality were assessed independently by 2 reviewers. Results: From 396 identified references, 7 were included. Six of the trials were
ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER1999, PART 2
initial pH class. A 2-way analysis of variance was done with each parameter as the dependent variable and pH class and disposition as independent variables. InterQual criteria for ICU admission were used to assess likely disposition from a routine ED visit. The difference in disposition was the basis for cost analysis. Results: Fifteen of 61 patients were admitted to the ICU after initial high-severity ED management including all 7 with serum pH less than or equal to 7.00, 5 of 10 with pH less than or equal to 7.10, 2 of 17 with pH less than or equal to 7.20, and 1 of 27 with pH greater than or equal to 7.21. Factors that had a statistically significant effect on disposition were initial pH and HCO-3; glucose levels did not. There was no significant difference in ED stay between ICU and floor admission. One patient with pH less than 7.00 died of sepsis in the ICU. All others were discharged from the hospital. Mean stay in ICU was 2 days. Fifty-six of the 61 patients met InterQual criteria for ICU admission; 41 of these were diverted to a regular floor after aggressive management in the ED without adverse effect on outcome. Conclusion: We estimate a reduction in charges of $65,600 for care of these 61 patients.
328
Evaluation of Physical Examination in Determining the Outcomes of Ultrasoundfor Deep Vein Thrombosis
Chan L, Reilly KM/Albany Medical College, Albany, NY Study objective: To evaluate the ability of physical examination to determine the results of ultrasound (US) for deep vein thrombosis (DVT). Methods: Our tertiary care emergency department has an annual census of 59,000 with a diverse racial and socioeconomic population. This was a retrospective chart review of ED patients who underwent US to diagnose DVT. Charts were identified by the radiology computer system. Age, sex, and the presence or absence of the following physical examination findings were recorded: extremity edema, vein distention, extremity tenderness to palpation, extremity erythema, extremity warmth, calf pain on passive dorsiflexion of the toe, and palpable cord. The outcomes of the US study were recorded as well. Charts were excluded if the US results could not differentiate between chronic and acute DVT. The physical examination was considered positive if any one or more of the physical signs were present. The sensitivity and specificity of physical examination for DVT by US diagnosis were calculated. Positive and negative predictive values of physical examination to predict the results of US for DVT were also calculated. The odds ratio was determined as well. Results: The charts of 186 patients were reviewed. Thirteen charts were excluded because of US inability to determine between acute and chronic DVT. One hundred seventy-three charts (67 males and 106 females) were evaluated. The mean age was 55.0_+18.9 years. Ultrasound diagnosed 43 cases of acute DVT and ruled out 130 cases of DVT. Physical examination had a sensitivity of 95% (95% confidence interval [CI] 92% to 98%); specificity of 31% (95% CI 24% to 38%); positive predictive value of 31% (95% CI 24% to 38%); and negative predictive value of 95% (95% CI 92% to 98%). The odds ratio was 9.11. Conclusion: A negative physical examination was reliable and predictive of a negative US result for DVT. Presence of physical examination findings was not reliable or predictive of US results for DVT.
329
Patient Preferences Regarding Pain Medication in the Emergency Department
Beel TL, Mitchiner JC, FraderiksenS. McCormick J/St. Joseph Mercy Hospital, Ann Arbor, MI Previous studies have shown that pain control in the emergency department is inadequate. Study objectives: To determine the proportion of ED patients with acute fractures who want pain medication, the level of pain present on ED admission and desired at ED discharge, and the manner in which these patients want pain medication given. Methods: A convenience sample of 107 adults with acute long-bone fractures seen in a community hospital ED completed a brief 8-item pain questionnaire. Patients with head injury, multiple trauma, fractures more than 6 hours old, questionable fractures, prehospital pain control, evidence of intoxication, or inability to answer questions were excluded. The questionnaire asked patients to score their pain level on ED admission and the level of pain desired at discharge on a 10O-mm visual analog scale, and to answer 6 questions.
S 84
Results: Eighty-eight percent of the patients wanted pain medication given in the ED, and 77% actually received it. Sixty-nine percent were comfortable with a nurse administering pain medication before being seen by a physician. Preferred routes were as follows: intravenous 40% orally 34%, intramuscular 20%. Seventy percent wanted pain control without being sedated, and 25% wanted complete pain relief even if sedation was necessary to achieve it. Sixty percent of patients were either slightly concerned or not concerned about potential medication side effects. Conclusion: More than 8 of L0 patients with acute fractures want pain medication given while in the ED, and 7 of 10 would accept pain medication administered by a nurse before physician evaluation.
330
What Does "Risk of Mr" Mean to the Emergency Physician? Results of an Observational Study
Feldman J, Wallace E, Betty C, Mitchell P, Fish S/Boston Medical Center, Boston University School of Medicine, Boston, MA Previous research has demonstrated that non-emergency physicians' estimates of risk varied widely and that the estimates of risk correlated positively with testing decisions. Study objective: To determine the emergency physician variability in the quantification of 4 categories of estimated probability of myocardial infarction (MI), and to determine the relationship between estimated probability of MI and disposition decisions. Methods: We performed an observational study using a questionnaire given to all emergency medicine faculty at an urban Level I trauma center with an established emergency medicine residency program. The instrument required study subjects to define a range of probability of MI for a 4-group risk classification (very low, low, medium, high) and to determine the appropriate ED disposition based on the estimated probability of MI (home, telemetry/chest pain unit [CPUI, coronary care unit [CCU]). We recorded gender and years of emergency medicine experience for all subjects. Years of experience were dichotomized as less than or equal to 5 years (junior) and more than 5 years (senior). Means and SDs were calculated for the cut points between each risk category. We evaluated the effect of gender and experience on risk cut points and triage cut points with a t test (2-sided, ~=.05). The very low risk cut point was compared with estimated MI risk for discharge home. Results: All 24 physicians responded. Of these, 5 (21%) were female; 12 (50%) were seniors in terms of experience. Each cut point for risk classification demonstrated substantial variability: very low to low 3.5%_+2.7%; low to medium 12.1%_+7.9%; medium to high 48.9%_+23.5%. The mean estimated probability of MI that would support direct ED discharge to home was 2.3%_+3.0%; to CCU 45.2%_+28.7%. We found that female gender was associated with higher risk cut points (very low to low mean 6.2% versus 2.8%, P=.009; low to medium mean 17.2% versus 10.8% P=.ll) and MI estimate for discharge to home (4.5% versus 1.9%, P=.08), whereas years of experience was not associated with lower risk probability cut points (/:'>.07 for all cut points). Fourteen physicians indicated a lower threshold for home discharge than their very low to low cut point, whereas 3 indicated a higher acceptable MI risk for home discharge. Conclusion: Emergency physicians demonstrate great variability when assigning absolute numerical values to commonly used risk categories of estimated probability of MI. Women tended to have higher cut points for very low and low risk of MI categories and higher estimated MI risk for discharge to home. Further research is required to determine the effect of physician risk estimates on testing and triage for patients with possible acute cardiac ischemia.
31 the Inhaled Corticosteroidsin Acute Asthma:A Systematic Review of Literature Edmonds ML, CamargoCA Jr, Pollack CA Jr, Rowe BH/University of Nberta, Edmonton,Alberta, Canada; Massachusetts 6eneral Hospital, Boston, MA; Maricopa Medical Center, Phoenix,AZ Study objectives: The use of inhaled corticosteroids in asthma is increasing; however, their benefit in the acute setting is unclear. This systematic review was designed to determine the benefit of inhaled corticosteroids for acute asthma in the emergency department. Methods: Randomized controlled trials (RCTs) were identified using the Cochrane Collaboration's Airways Review Group database, hand searching, bibliographies, pharmaceutical company, and author contact. Studies in which an inhaled corticosteroid was compared with placebo or any corticosteroid were considered. Relevance, inclusion, and study quality were assessed independently by 2 reviewers. Results: From 396 identified references, 7 were included. Six of the trials were
ANNALS OF EMERGENCY MEDICINE 34:4 OCTOBER1999, PART 2