Advance directives. Effect of type of directive on physicians' therapeutic decisions.

BACKGROUND: Despite growing support for advance directives, there are few data validating their utility. We conducted this study to determine if the type of advance directive influences physicians' willingness to withhold specific therapies and if physicians are equally willing to withhold these therapies. METHODS: The 444 full-time faculty of the department of medicine of a university medical center were presented with patient scenarios and accompanying advance directives in three separate surveys that were mailed. They were asked if they would withhold each of 12 specific therapies based on their interpretation of the advance directive. Three types of advance directives were studied: general statement, therapy specific, and therapy specific combined with designation of a proxy and prior patient-physician discussion. RESULTS: The mean proportion of all 12 therapies that were withheld varied by type of advance directive: general-statement advance directive, 55%; therapy-specific advance directive, 71%; and therapy-specific advance directive with proxy and prior patient-physician discussion, 83%. Respondents were more likely to withhold cardiopulmonary resuscitation when given a therapy-specific advance directive vs general-statement advance directive, 84% vs 73%, respectively. With a therapy-specific advance directive that was supported by a proxy and prior patient-physician discussion, 100% of physicians were willing to withhold cardiopulmonary resuscitation. With the therapy-specific advance directive that was supported by proxy and prior patient-physician discussion, physicians were not equally willing to withhold all therapies, ie, mechanically assisted ventilation, 98%; intravenous fluids, 82%; antibiotics, 80%; simple tests, 70%; and pain medications, 13%. CONCLUSIONS: Detailed advance directives with a supportive proxy, coupled with physician-patient discussion, furnish the most reliable medical directives. Even with such directives, physicians are more likely to withhold life-saving therapies than simple tests, treatments, and pain medications.

Effect of antibiotic therapy and etiologic microorganism on the risk of bacterial meningitis in children with occult bacteremia.

OBJECTIVE: To quantify the effect of antibiotic therapy on the probability of subsequent bacterial meningitis in children with fever without source treated as outpatients. DESIGN: Bayesian meta-analyses. REPORTS INCLUDED: All reports of the organism-specific prevalence of occult bacteremia in children with fever without source treated as outpatients, and the organism-specific prevalence of subsequent meningitis in children with occult bacteremia initially treated as outpatients stratified by type of antibiotic therapy. RESULTS: The mean probabilities of subsequent meningitis in children with occult bacteremia were 9.8%, 8.2%, and 0.3% in the no antibiotic, oral antibiotic, and parenteral antibiotic therapy groups, respectively. All cases of bacterial meningitis in children with occult bacteremia treated with oral antibiotics were due to Haemophilus influenzae. There were no cases of culture-positive bacterial meningitis in 139 bacteremic children treated with ceftriaxone (mean probability, 0.3%; 95% confidence interval, 0.0% to 1.5%). The mean probabilities of bacterial meningitis in a child with fever without source treated as an outpatient without antibiotics were: Streptococcus pneumoniae, 0.21%; and H influenzae, 0.06%. CONCLUSIONS: Antibiotic therapy is effective in preventing meningitis in children at risk of occult bacteremia.

The role of antibiotics, immunizations, and adenoviruses in pertussis.

Sixty-five patients with pertussis were identified by a clinical criterion, and Bordetella pertussis was isolated from 75% of these patients or their symptomatic household contacts. Negative nasopharyngeal cultures were usually associated with either a history of antibiotic therapy with erythromycin or tetracycline (two of three patients), two or more diphtheria and tetanus toxoids with pertussis (DTP) vaccines (six of eight patients), or both (two of three patients). Erythromycin therapy resulted in the elimination of B. pertussis from the nasopharynx in 2 to 7 days (mean, 3.6 days) compared with 7 to 17 or more days (mean, greater than 12 days) in patients treated with no antibiotics, but had no effect on the duration or severity of illness as judged by length of hospitalization. Adenoviruses were recovered from five of 44 patients cultured. Four of these isolates were from throat swabs obtained early in the illness and the remaining isolate was from one of 33 repeated viral cultures obtained two to three weeks later; B. pertussis was also isolated from these five patients. Paired serum samples were obtained from only two of these patients. Neither demonstrated a fourfold rise in adenoviral complement-fixing antibodies. Therefore, in these patients, adenoviral isolation may have been secondary to reactivation of a latent viral infection by infection with B. pertussis.

DTP-associated reactions: an analysis by injection site, manufacturer, prior reactions, and dose.

Local and less serious systemic reactions are frequent following immunization with diphtheria-tetanus-pertussis (DTP) vaccine. The effects of injection site, manufacturer, previous reactions, and dosage reduction upon subsequent reactions to DTP immunization were investigated. Local reactions, notably pain and swelling, were less common when the immunization was given in the buttocks than in the thigh. No injection site was consistently associated with lower systemic reaction rates. There was no significant difference in the rate of more serious reactions by vaccine manufacturer. Differences in rates of less serious reactions by manufacturer were observed but seemed to be related to vaccine lot differences rather than the specific vaccines. In a subset of 772 children, in whom data regarding sequential reactions were available, it was noted that all three reactions investigated--local redness, temperature greater than or equal to 39 degrees C, and persistent crying longer than one-half hour--were two to three times more frequent on a subsequent immunization when present on a prior vaccination than if not present on a prior vaccination than if not present previously. One hundred children received a half dose of DTP vaccine because of a less serious reaction associated with prior immunization. In all instances, they had significantly less serious local reactions as well as notable differences in temperature, drowsiness, and persistent crying.

Nature and rates of adverse reactions associated with DTP and DT immunizations in infants and children.

In 784 DT and 15,752 DTP immunizations given to children 0 to 6 years of age who were prospectively studied for reactions occurring within 48 hours following immunization, minor reactions were significantly more frequent following DTP vaccine. The ratio of reaction rates associated with DTP and DT immunizations (DTP/DT) for selected local and systemic reactions was as follows: local redness, 37.4%/7.6%; local swelling, 40.7%/7.6%; pain, 50.9%/9.9%; fever, 31.5%/14.9%; drowsiness, 31.5%/14.9%; fretfulness, 53.4%/22.6%; vomiting, 6.2%/2.6%; anorexia, 20.9%/7.0% and persistent crying, 3.1%/0.7%. Following DTP immunization nine children developed convulsions and nine developed hypotonic hyporesponsive episodes. No sequelae were detected following these reactions.

Infants and children with convulsions and hypotonic-hyporesponsive episodes following diphtheria-tetanus-pertussis immunization: follow-up evaluation.

In a prior prospective study, we evaluated the nature and rates of adverse reactions occurring within 48 hours following 15,752 diphtheria-tetanus-pertussis (DTP) immunizations. Nine children had convulsions, and nine had hypotonic-hyporesponsive episodes. After an interval of 6 to 7 years, we were successful in contacting the families of 16 of these children to determine whether any had evidence of neurologic impairment too subtle to have been detected at the time of initial evaluation. All 16 were considered normal by their parents and were doing well in school. A complete neurologic and psychometric evaluation was performed on 13 of these children. No child had significant neurologic deficit, although four had minor neurologic abnormalities. Psychometric testing revealed normal performance IQ scores (104.3 +/- 15.8) but low verbal IQ scores (91.8 +/- 18.4); however, these lower verbal IQ scores can be explained by the proportion of Hispanic and bilingual children in this sample. Therefore, there is no evidence that any of these 16 children have any serious neurologic damage as a result of a convulsion or a hypotonic-hyporesponsive episode temporally associated with a prior diphtheria-tetanus-pertussis immunization.

Immunologic response to early and routine DTP immunization in infants.

The effect of early immunization, prior to discharge from the newborn nursery, on subsequent immunity as determined by enzyme-linked immunosorbent assay (ELISA) immunoglobulin (Ig) M and IgG antibody titers to filamentous hemagglutinin and lymphocytosis-promoting toxin (LPT) of Bordetella pertussis and by standard pertussis agglutinin titers was investigated. Eighteen infants received routine diphtheria-tetanus-pertussis (DTP) immunization at 2, 4, and 6 months of age; 17 other infants received routine immunization and an additional DTP immunization in the newborn nursery. Antibody was determined on samples of cord blood and whole blood obtained at 4, 6, and 9 months of age. IgM anti-filamentus hemagglutinin was significantly higher at 4 and 6 months of age in the group that received early immunization (P less than .05). There was no significant difference in IgM anti-LPT, IgG anti-filamentus hemagglutinin, IgG anti-LPT, or pertussis agglutinin antibodies. Six control infants had high cord IgG anti-LPT titers. These six infants had significantly lower antibody titers to LPT at 6 and 9 months of age when compared with control with control infants with lower cord titers. Thirteen infants in the early immunization group with lower cord IgG anti-LPT titers achieved significantly lower titers at 9 months of age than the 12 comparable infants in the control group.

Prognostic significance of field response in out-of-hospital ventricular fibrillation.

We reviewed 94 cases of prehospital ventricular fibrillation (VF) to determine aspects of field response that predicted outcome. Only one of 37 patients (3 percent) failing to achieve rhythms other than VF or asystole after the first two defibrillations survived to hospital discharge compared to nine of 57 (16 percent) achieving organized rhythms by this point (p less than 0.05). None of 56 patients failing to achieve pulses prior to transport survived to hospital discharge compared to ten of 38 achieving field pulses (p less than 0.01). However, survival to discharge was not significantly different between patients who developed pulses immediately with their rhythms (5 of 17, 29 percent) and those who were defibrillated into pulseless rhythms but later developed pulses in the field (five of 21, 24 percent). Thus, for prehospital VF, the best field response identifies potential survivors prior to hospital arrival. In addition, the frequent occurrence and potentially favorable outcome of an initially pulseless rhythm necessitates reevaluation of current therapy.

Effect of routine emergency department triage pulse oximetry screening on medical management.

PURPOSE: To determine the utility of routine triage pulse oximetry screening in emergency department (ED) patients. DESIGN: Prospective study using pulse oximetry to measure oxygen saturation of ED patients at triage. Saturation values were disclosed to physicians only after they completed medical evaluations and were ready to discharge or admit each patient. We measured changes in medical management initiated after disclosure of pulse oximetry values. SETTING AND PARTICIPANTS: The study included 14,059 consecutive patients presenting to triage at a university ED. MEASUREMENTS: Changes in select diagnostic tests: chest radiography, CBC count, spirometry, arterial blood gases, pulse oximetry, and ventilation-perfusion scans; treatments: antibiotics, beta-agonists, supplemental oxygen; and hospital admission and final diagnoses that occurred after disclosure of triage pulse oximetry values. RESULTS: Of 1,175 patients having triage pulse oximetry values less than 95%, physicians ordered repeat pulse oximetry on 159 (13.5%), additional chest radiography on 5.4%, CBC count on 3.1%, arterial blood gases on 2.9%, spirometry on 0.9%, and ventilation-perfusion scans on 0.3%. Physicians ordered 178 new therapies on 134 patients (11.4%), including supplemental oxygen for 6.5%, antibiotics for 3.9%, and beta-agonists for 1.8%. Thirty-five patients (3.0%) initially scheduled for hospital discharge were subsequently admitted. Physicians changed or added diagnoses in 77 patients (6.6%). CONCLUSIONS: Providing physicians with routine triage pulse oximetry measurements resulted in significant changes in medical treatment of these patients.

Management of the febrile child: a survey of pediatric and emergency medicine residency directors.

We conducted a survey to determine whether there is uniformity in the training of residents regarding the management of febrile children. One hundred forty-three (62%) of 231 pediatric and 39 (53%) of the 73 emergency medicine residency directors responded. There was no uniformity in the definition of a fever. Ninety-nine percent of the pediatric and 82% of the emergency medicine residency directors teach that all febrile infants less than 4 weeks of age should be hospitalized (P less than 0.0001). Forty-six percent of residency directors teach that a lumbar puncture should be performed for all children less than 12 months of age with their first febrile convulsion. Thirty percent of pediatric and 62% of emergency medicine residency directors teach that a blood culture should be obtained from a child with fever without source who is younger than 24 months of age (P less than 0.0005). Nonspecific tests are taught to be used to determine which febrile child should have a blood culture as follows: white blood cell count, 50%; differential, 20%; erythrocyte sedimentation rate, 13%; and C-reactive protein, 2%. There was little uniformity of teaching regarding the approach to the febrile child and there were significant differences in training by specialty.

Outcomes of bacterial meningitis in children: a meta-analysis.

We abstracted the results of all English language reports of the outcomes of bacterial meningitis published after 1955. We used hierarchical Bayesian meta-analysis to determine the overall and organism-specific frequencies of death and persistent neurologic sequelae in children 2 months to 19 years of age. A total of 4920 children with acute bacterial meningitis were included in 45 reports that met the inclusion criteria. Children described in the 19 reports of prospectively enrolled cohorts from developed countries had lower mortality (4.8% vs. 8.1%) and were more likely to have no sequelae (82.5% vs. 73.9%). In these 19 studies 1602 children were evaluated for at least 1 sequela after hospital discharge. The mean probabilities of these sequelae were: deafness, 10.5%; bilateral severe or profound deafness, 5.1%; mental retardation, 4.2%; spasticity and/or paresis, 3.5%; seizure disorder, 4.2%; and no detectable sequelae, 83.6%. Mean probabilities of outcomes varied significantly by etiologic bacteria, e.g. mortality: Haemophilus influenzae, 3.8%; Neisseria meningitis, 7.5%; Streptococcus pneumoniae, 15.3%.

Analyses of adverse reactions to diphtheria and tetanus toxoids and pertussis vaccine by vaccine lot, endotoxin content, pertussis vaccine potency and percentage of mouse weight gain.

We investigated the rates of local and systemic reactions following 9920 diphtheria-tetanus toxoids-pertussis immunizations from 25 lots of commercially available, United States-licensed diphtheria-tetanus toxoids-pertussis adsorbed vaccines from four manufacturers as a function of vaccine lot, endotoxin content, pertussis vaccine potency and percent of mouse weight gain. There were significant differences between the rates of reactions by lot for all local and systemic reactions except convulsions and hypotonic hyporesponsive episodes. For these latter reactions there were insufficient cases for analyses. P was less than 0.0001 for local reactions, fever, drowsiness, fretfulness, anorexia and screaming and 0.017 for vomiting. No single lot was associated with the highest or lowest rate of reactions for more than 3 of the 11 reactions. There was a significant positive association of endotoxin unit (EU) content and the percent of vaccine recipients who developed fever (P = 0.004). Fever increased in frequency from 20.6% of children immunized with vaccine lots that contained 2500 EU to 55.1% of children immunized with vaccine lots containing 40,000 EU. There were significant positive associations of all local reactions and pertussis vaccine potency (P = 0.0004), and percent of mouse weight gain (P less than 0.0001). There was also a positive association of percent mouse weight gain and persistent screaming (P = 0.001). However, for the majority of reactions there was no clinically meaningful associations between reaction rates and the biological properties of the vaccine studied.

Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age.

OBJECTIVE: The authors have shown that clinical guidelines embedded in an electronic medical record improved the quality, while lowering the cost, of care for health care workers who incurred occupational exposures to body fluid. They seek to determine whether this system has similar effects on the emergency department care of young children with febrile illness. DESIGN: Off-on-off, interrupted time series with intent-to-treat analysis. SETTING: University hospital emergency department. SUBJECTS: 830 febrile children less than 3 years of age and the physicians who treated them. INTERVENTIONS: Implementation of an electronic medical record that provides real-time advice regarding the content of the history and physical examination and recommendations regarding laboratory testing, treatment, diagnosis, and disposition. MEASUREMENTS: Documentation of essential items in the medical record and after-care instructions; compliance with guidelines regarding testing, treatment, and diagnosis; charges. RESULTS: The computer was used in 64 percent of eligible cases. Mean percentage documentation of 21 essential history and physical examination items increased from 80 percent during the baseline period to 92 percent in the intervention phase (13 percent increase; 95 percent CI, 10-15 percent). Mean percentage documentation of ten items in the after-care instructions increased from 48 percent at baseline to 81 percent during the intervention phase (33 percent increase; 95 percent confidence interval, 28-38 percent). All documentation decreased to baseline when the computer system was removed. There were no demonstrable improvements in appropriateness of care, nor was there evidence that appropriateness worsened. Mean charges were not changed by the intervention. CONCLUSION: The intervention markedly improved documentation, had little effect on the appropriateness of the process of care, and had no effect on charges. Results for the febrile child module differ from those for the module for occupational blood and body fluid exposure (a more focused and straightforward medical condition), underscoring the need for implementation methods to be tailored to specific clinical complaints.

A comparison of pulse oximetry and respiratory rate in patient screening.

OBJECTIVE: To examine how well respiratory rate correlates with arterial oxygen saturation status as measured by pulse oximetry, and determine whether respiratory rate measurements detect oxygen desaturation reliably. METHODS: Respiratory rate (RR) and oxygen saturation (SaO2) were measured prospectively on 12,096 consecutive adult emergency department triage patients at a university medical center. Respiratory rate was measured by counting ausculated breath sounds for 1 min. Pulse oximetry was used to measure SaO2. Measurements were analysed by age (with one group for 18-19 year olds, groups for every 10 yr from age 20 to age 60, and groups for every 5 yr for subsequent ages). Pearson correlation coefficients were calculated for each age group as well as the weighted average coefficient. Cases having oxygen saturation below 90% were examined to determine how frequently they exhibited increased RR (increased RRs were defined as any rate in the upper five percentile by age. RESULTS: Correlation coefficients ranged from 0.379 to -0.465 with a weighted mean of -0.160. Coefficients for ages 18 through 70 years (representing 10,740 patients) all had magnitude < 0.252. Overall, only 33% of subjects with oxygen saturation below 90% exhibited increased RR. CONCLUSIONS: Respiratory rate measurements correlate poorly with oxygen saturation measurements and do not screen reliably for desaturation. Patients with low SaO2 do not usually exhibit increased RR. Similarly, increased RR is unlikely to reflect desaturation.

Serratia arthritis in heroin users.

Septic arthritis due to Serratia species was seen in four users of intravenous heroin. In all cases, the organism was cultured from joint aspirates. Both the clinical presentation and the involvement of the sacro-iliac and knee joints were notably similar to the Pseudomonas septic arthritis encountered in other heroin users. All four patients responded satisfactorily to therapy although one had a residual flexion contracture of the knee. Twelve previously reported cases of Serratia arthritis are reviewed.

A survey of nonphysician medical screening examinations in academic emergency medicine.

OBJECTIVES: To determine the proportions of U.S. emergency medicine (EM) residency programs that use nonphysicians to perform medical screening examinations (MSEs) in lieu of a physician evaluation. METHODS: This was a cross-sectional observational study consisting of a mail survey of the 109 base hospitals of accredited U.S. EM residency programs. Follow-up letters were sent twice to nonrespondents. Questions regarding ED demographics, the performance and structure of MSEs by physicians and nonphysicians, and the exact nature and purpose of such examinations were included. RESULTS: Ninety of 109 (83%) programs responded. Eighty-seven of the 90 programs (97%) perform MSEs on all patients presenting to the ED prior to discharge. Thirty-seven percent (33/90) perform nonphysician MSEs (NPMSEs) at least some of the time. Fifty percent (16/32) refer patients to an outside facility based on the result of the screening, and in 32% of cases the patient is not offered the choice of an ED evaluation. Seventy percent (19/27) at times refer patients, including uninsured patients, to a same-day clinic within their hospital system. Seven of 27 (26%) programs performing NPMSEs reported occasional adverse events, defined as two to 11 per year. Eight of 22 (36%) reported poorer clinical outcomes than expected from ED care as a result of the NPMSE, and 18 of 25 (72%) reported some degree of patient dissatisfaction. Two programs reported death as a result of NPMSEs. CONCLUSIONS: The use of NPMSEs is common and is frequently used as a basis for referring patients away from the ED without a physician examination. Using NPMSEs may be associated with adverse events, including patient dissatisfaction, morbidity, and possibly, mortality.

Effect of a practice guideline on the process of emergency department care of falls in elder patients.

OBJECTIVE: To determine the effect of a practice guideline on the process of ED care in a health maintenance organization. METHODS: A prepost-intervention comparison with a one-year pre-intervention phase followed by a one-year post-educational intervention phase was used to study the effect of the guideline on ED care. Emergency physicians and nurses were provided the details of the guideline during a two-week interval between the two periods. RESULTS: During the two years of the study, 1,140 pre-intervention and 759 post-intervention patients met study eligibility criteria. More patients were diagnosed as having had falls due to loss of consciousness, stroke, and seizures during the post-intervention period (pre-intervention 3.8% vs post-intervention 8.4%, p < 0.001). There was a significant improvement in documentation of six of ten history items: cause of fall (64.5% vs 72.9%), location of fall (54.7% vs 60.5%), ability to get up unassisted (5.4% vs 12.5%), long lie after fall (1.5% vs 10.1%), prescription medications (79.0% vs 92.2%), and Pneumovax immunization status (20.8% vs 43.0%); and two of the four physical examination items: visual acuity (1.5% vs 3.2%) and the "get up and go test" (1.3% vs 11.2%). Prescribing of calcium and vitamin D increased from 0% to 6.6%. CONCLUSIONS: The educational intervention to the practice guideline for the ED management of falls in elders led to small but significant improvements in the documentation of selected history and physical examination items and the prescribing of calcium and vitamin D, and to a greater consideration of the causes of falls.

Effect of a practice guideline for emergency department care of falls in elder patients on subsequent falls and hospitalizations for injuries.

OBJECTIVE: To determine the effect of a practice guideline for the ED management of falls in community-dwelling elders on selected health outcomes. METHODS: The experimental design was a prepost-intervention comparison with one-year pre- and post-intervention phases. The guideline was presented to emergency physicians and nurses during a two-week interval between these two periods. The intervention also included health information provided to the subjects and a one-time educational intervention directed at primary care providers. The number of falls in the year following the ED visit was determined by telephone interview. The number of hospitalizations for falls was determined from the HMO database of all health care encounters. RESULTS: 1,899 patients were eligible for the study; 1,140 pre-intervention and 759 post-intervention patients. Of these, 1,504 (79%) were interviewed by telephone 12 to 15 months after their initial ED visits. Eighteen percent of the pre-intervention and 21% of the post-intervention subjects reported at least one fall in the 12 months following their ED visits (p = 0.162). The rate of falls per 100 patient years was 36.2 in both groups. Three percent of both groups were hospitalized at least once for a fall in the year following their ED visits. One percent in each group were hospitalized for a hip fracture. CONCLUSIONS: The attempted implementation of a practice guideline for the ED management of falls in community-dwelling elders did not result in a reduction in total falls, or in hospitalizations for falls, injuries, or fractures.

Pulse oximetry as a fifth vital sign in emergency geriatric assessment.

OBJECTIVE: To determine the utility of pulse oximetry as a routine fifth vital sign in emergency geriatric assessment. METHODS: Prospective study using pulse oximetry to measure O2 saturation in geriatric patients presenting to ED triage. Saturation values were disclosed to clinicians only after they had completed medical evaluations and were ready to release or admit each patient. The authors measured changes in medical management and diagnoses initiated after the disclosure of pulse oximetry values. The study included 1,963 consecutive adults aged > or = 65 years presenting to triage at a university ED. Measurements included changes in select diagnostic tests: chest radiography, complete blood count (CBC), spirometry, arterial blood gases (ABGs), pulse oximetry, and ventilation-perfusion scans; treatments: antibiotics, beta-agonists, and supplemental O2; and hospital admission and final diagnoses that occurred after complete ED evaluation when physicians were informed of triage pulse oximetry values. RESULTS: 397 (20.2%) geriatric patients had triage pulse oximetry values <95%. Physicians ordered repeat oximetry for 51 patients, additional chest radiography for 23, CBC for 16, ABGs for 15, spirometry for 5, and ventilation-perfusion scans for none. Physicians ordered 49 new therapies for 44 patients, including antibiotics for 14, supplemental O2 for 29, and beta-agonists for 6. Nine patients initially scheduled for ED release were subsequently admitted to the hospital. Physicians changed or added diagnoses for 27 patients. CONCLUSIONS: Using pulse oximetry as a routine fifth vital sign resulted in important changes in the diagnoses and treatments of a small proportion of emergency geriatric patients.

Management of infants and children 3 to 36 months of age with fever without source.

The evidence and guidelines presented in this article are meant to assist clinicians who manage children with FWS. However, physicians may choose to individualize therapy based on unique clinical circumstances or to adopt a variation of these guidelines based on a different interpretation of the evidence concerning these issues. No guidelines can eliminate all risk nor confine antibiotic treatment only to children likely to have occult bacteremia. The optimal management strategy reduces risk to a minimum at a reasonable cost and can be used in most practice settings.