Cardiology electrocardiogram overreads rarely influence patient care outcome.

OBJECTIVE: The value of electrocardiogram (ECG) overreads of emergency department (ED) tracings have been questioned in the literature. This review was designed to assess the validity of this criticism. METHODS: In this university teaching hospital ED, following the normal quality assurance protocol, each abnormal ECG is reviewed the following day against the corresponding chart; and if the official reading from cardiology is discordant from the initial clinical one, the patient and/or their physician is contacted. If necessary, the patient is instructed to return to the ED or to their private physician's office. This study is a retrospective review of those ECG overreads for a 21-month period, as well as a summary of those patients who required follow-up care. RESULTS: There were 38,490 patients seen with ECGs performed during the study interval. Of these, 16,011 were discharged and 22,479 were admitted from a total patient volume of 117,407. Of those 16,011 patients discharged, follow-up was deemed necessary in 22 patients whose official readings were discordant from the interpretation of the original clinician. Three patients were lost to follow-up (no phone, no address). Review of the tracings and patient/physician follow-up of the 19 remaining patients resulted in a significant change of therapy in 2 patients (admission). The remainder of the abnormal tracings were deemed, after patient or private physician follow-up, to be not significant or to mandate no change in management. CONCLUSION: Official cardiology overreads seldom affect the clinical outcome of patient care delivered in the ED setting.

Randomized trial of bilevel versus continuous positive airway pressure for acute pulmonary edema.

BACKGROUND: Studies have shown different clinical outcomes of noninvasive positive pressure ventilation (NPPV) from those of continuous positive airway pressure (CPAP). OBJECTIVE: We evaluated whether bilevel positive airway pressure (BPAP) more rapidly improves dyspnea, ventilation, and acidemia without increasing the myocardial infarction (MI) rate compared to continuous positive pressure ventilation (CPAP) in patients with acute cardiogenic pulmonary edema (APE). METHODS: Patients with APE were randomized to either BPAP or CPAP. Vital signs and dyspnea scores were recorded at baseline, 30 min, 1 h, and 3 h. Blood gases were obtained at baseline, 30 min, and 1 h. Patients were monitored for MI, endotracheal intubation (ETI), lengths of stay (LOS), and hospital mortality. RESULTS: Fourteen patients received CPAP and 13 received BPAP. The two groups were similar at baseline (ejection fraction, dyspnea, vital signs, acidemia/oxygenation) and received similar medical treatment. At 30 min, PaO2:FIO2 was improved in the BPAP group compared to baseline (283 vs. 132, p < 0.05) and the CPAP group (283 vs. 189, p < 0.05). Thirty-minute dyspnea scores were lower in the BPAP group compared to the CPAP group (p = 0.05). Fewer BPAP patients required intensive care unit (ICU) admission (38% vs. 92%, p < 0.05). There were no differences between groups in MI or ETI rate, LOS, or mortality. CONCLUSIONS: Compared to CPAP to treat APE, BPAP more rapidly improves oxygenation and dyspnea scores, and reduces the need for ICU admission. Further, BPAP does not increase MI rate compared to CPAP.

Time to first antibiotics for pneumonia is not associated with in-hospital mortality.

BACKGROUND: Time to first antibiotic (TTFA) is postulated to impact pneumonia mortality. The Joint Commission/Centers for Medicare and Medicaid Services national quality standards previously indicated that TTFA should be <6 h (modified from <4 h when the study was initiated, now eliminated as a time measure entirely). OBJECTIVE: The purpose of this article was to determine whether TTFA is associated with inpatient mortality. METHODS: The records of 444 consecutive patients admitted with pneumonia at a single institution were retrospectively reviewed for a correlation between TTFA and inpatient complications, including death. Statistical significance was set at p < 0.01 due to multiple comparisons. RESULTS: Patients whose TTFA was <4 h had more complications (27% vs. 3%; p < 0.01) including death, intensive care unit admission, and intubation. These patients were judged sicker on arrival (median Emergency Severity Index 2 vs. 3; p < 0.001) and were more likely to be triaged to a critical care bed (36% vs. 5%; p < 0.001). Shortness of breath was the only presenting factor that was more frequent in the TTFA <4-h group (61% vs. 16%; p < 0.01). CONCLUSIONS: Shorter TTFA is not associated with improved inpatient mortality. TTFA should not be considered to be a marker of quality of care but rather a reflection of patient disease severity.

Implementing a collaborative protocol in a sepsis intervention program: lessons learned.

The objective of this prospective cohort study was to see the effect of the implementation of a Sepsis Intervention Program on the standard processes of patient care using a collaborative approach between the Emergency Department (ED) and Medical Intensive Care Unit (MICU). This was performed in a large urban tertiary-care hospital, with no previous experience utilizing a specific intervention program as routine care for septic shock and which has services and resources commonly available in most hospitals. The study included 106 patients who presented to the ED with severe sepsis or septic shock. Eighty-seven of those patients met the inclusion criteria for complete data analysis. The ED and MICU staff underwent a 3-month training period followed by implementation of a protocol for sepsis intervention program over 6 months. In the first 6 months of the program's implementation, 106 patients were admitted to the ED with severe sepsis and septic shock. During this time, the ED attempted to initiate the sepsis intervention protocol in 76% of the 87 septic patients who met the inclusion criteria. This was assessed by documentation of a central venous catheter insertion for continuous SvO(2) monitoring in a patient with sepsis or septic shock. However, only 48% of the eligible patients completed the early goal-directed therapy (EGDT) protocol. Our data showed that the in-hospital mortality rate was 30.5% for the 87 septic shock patients with a mean APACHE II score of 29. This was very similar to a landmark study of EGDT (30.5% mortality with mean APACHE II of 21.5). Data collected on processes of care showed improvements in time to fluid administration, central venous access insertion, antibiotic administration, vasopressor administration, and time to MICU transfer from ED arrival in our patients enrolled in the protocol versus those who were not. Further review of our performance data showed that processes of care improved steadily the longer the protocol was in effect, although this was not statistically significant. There was no improvement in secondary outcomes, including total length of hospital stay, MICU days, and mortality. Implementation of a sepsis intervention program as a standard of care in a typical hospital protocol leads to improvements in processes of care. However, despite a collaborative approach, the sepsis intervention program was underutilized with only 48% of the patients completing the sepsis intervention protocol.

Effect of oral contrast for abdominal computed tomography on emergency department length of stay.

Computed tomography of the abdomen and/or pelvis (CTAP) is frequently used in the emergency department (ED) allowing diagnosis of a variety of conditions, but requiring a prolonged period of preparation. To determine whether not requiring oral contrast for CTAP reduces ED length of stay (LOS). Retrospective cohort of adult patients visiting an academic ED over 13 weeks around a radiology protocol change. Before the change, many CTAPs required oral contrast; thereafter, oral contrast was not required. LOS was compared before and after the change among all adult ED patients. Among patients undergoing CTAP, adjusted LOS and time to CTAP were compared using multivariate linear regression. 20,464 adult ED visits occurred over the study period, including 1,806 where a CTAP was performed. Oral contrast usage decreased from 42.5% of CTAP to 12.2% (difference 30.3%, 95% confidence interval 38.7% to 46.3%). There was no change in LOS among all ED visits. Among ED visits where a CTAP was performed, median time to CTAP decreased by 27 min and median LOS decreased by 30 min. Adjusted LOS decreased from 324 min (312-337) to 297 min (285-309). Not routinely requiring oral contrast for CTAP in the ED is associated with a half-hour reduction in LOS among all patients undergoing CTAP.

Non-invasive pulse CO-oximetry screening in the emergency department identifies occult carbon monoxide toxicity.

As carbon monoxide (CO) toxicity may present with non-specific signs and symptoms and without history of exposure, screening for CO toxicity may identify occult cases. The objective of this study was to determine whether non-invasive screening for CO exposure could be performed in all patients presenting to a high-volume urban emergency department (ED) and would identify patients with unsuspected CO toxicity. A study of adult patients, who presented to the ED for any complaint, prospectively screened for carboxyhemoglobin concentration by a pulse CO-oximeter (SpCO). ED triage staff recorded SpCO on the patient's chart at triage. Data, including SpCO and vital signs, were recorded in a database by two trained research assistants. When available, carboxyhemoglobin concentration obtained by venous blood was also included in the data set. There were 14,438 patients who presented to the ED and were entered in the study. Data from 10,856 (75%) patients receiving screening for SpCO were analyzed. Patients were 44 +/- 19 years old and 51% female; 32% of the patients smoked. The mean SpCO was 5.17% +/- 3.78% among smokers and 2.90% +/- 2.76% among non-smokers. During the study period, 11 patients with presenting signs and symptoms not consistent with CO toxicity were identified through SpCO screening. Screening for CO toxicity using a non-invasive pulse CO-oximeter can be conducted even in a busy tertiary center ED and identify patients with occult CO toxicity.

Altered levels and molecular forms of granzyme k in plasma from septic patients.

Granzyme K (GrK) is a member of a highly conserved group of potent serine proteases specifically found in the secretory granules of cytotoxic T lymphocytes and natural killer cells. Based on the report indicating that inter-alpha inhibitor proteins are the physiological inhibitors of GrK and on previous findings that showed a significant decrease in plasma inter-alpha inhibitor proteins in patients with sepsis, it was our aim to determine whether increased levels of uninhibited GrK would contribute to the development of sepsis. To test this hypothesis, a competitive enzyme-linked immunosorbent assay system was developed; and the levels of GrK were measured in plasma samples obtained from healthy controls and 2 sets of patients with sepsis: patients admitted to the emergency department with a putative diagnosis of sepsis and patients with severe sepsis enrolled in a clinical trial. In addition, the molecular form(s) of GrK present in these samples was analyzed by Western blot. The levels of GrK were significantly increased in emergency department patients compared with healthy controls and significantly decreased in patients with severe sepsis enrolled in a clinical trial compared with healthy controls. GrK was detected as high-molecular-weight protein complexes in healthy controls but as complexes of lower molecular weight in the septic patients. The decrease in complex size correlated with the appearance of a band at 26 kDa similar to the size of free GrK. Our results indicate that plasma levels of GrK could serve as a useful diagnostic marker to stage sepsis, permitting better classification of septic patients and enabling targeting of specific treatments, and may play a functional role in the development of sepsis.

Peer review and feedback can modify pain treatment patterns for emergency department patients with fractures.

Consecutive fracture patients presenting to an adult (AED) or pediatric trauma center (PED) or a community teaching hospital (CED) were reviewed for treatment. Physicians received individual and group feedback. Data were dichotomized by age, gender, race and insurance status. Logistic regression analysis modeled variables approaching statistical significance. A total of 1454 patients participated in the study. The aggregate initial treatment rate was 54%, with no subgroup differences. Significant improvements were seen in all sites/subgroups; the final aggregate treatment rate was 84% (P < .001). PED and CED patients were less likely to receive treatment than AED patients (odds ratios = 0.49, 0.68). After feedback, whites were treated more often than were non-whites (84% vs 71%, P < .0001); CED alone did not show this pattern (odds ratios = AED 4.14, PED 2.67, CED1.28). Patients at all sites received improved pain treatment in association with directed feedback. Race and treatment site were significant factors.

False-negative chest radiographs in emergency department diagnosis of pneumonia.

BACKGROUND: Emergency department (ED) patients frequently undergo chest x-ray (CXR) to evaluate for pneumonia. The rate of false-negative CXR in patients with pneumonia is unclear. OBJECTIVES: Identify patients admitted with pneumonia who were diagnosed by CT despite nondiagnostic CXR. METHODS: Retrospective analysis of quality improvement data on adult ED patients admitted with pneumonia over 21 months. Primary outcome was percent of patients diagnosed by CT despite normal CXR. Patients were classified as CXR-diagnosed if they had CXR and no CT, or if antibiotics were ordered after CXR and before CT. CT-based diagnosis was indicated by administration of antibiotics only after CT was completed. RESULTS: 49 patients (11.4%) were diagnosed by CT (p<0.001). These patients were younger (p<0.001) and more often complained of chest pain (p<0.001). CONCLUSIONS: Patients with pneumonia may present with normal or nondiagnostic CXR, although false negatives may be less common than previously reported.

A cost-efficiency analysis to increase clinician staffing in an academic emergency department.

PURPOSE: To develop a software-based model to determine which combination of attendings working with/without residents and/or midlevel providers (MLP) was most cost-efficient for incremental staffing in an academic emergency department (ED). METHOD: A decision tree model using standard decision analysis software was created to compare different staffing configurations for the Rhode Island Hospital ED. The productivity, salary, and working hour data of different staffing configurations were determined using data from the ED, reported productivity data, and assumptions based on the authors' experience. Attending physician productivity alone was assumed to be 2.1 patients per hour, and each additional resident and/or MLP was assumed to add smaller net productivity gains (the first one adds 0.75 patients/hour; the second, 0.5 patients/hour; the third, 0.33 patients/hour). Resident and MLP productivity were assumed to be equivalent in the base case and varied during subsequent analysis. Noneconomic variables were not included in the model. RESULTS: The lowest base case cost option is to pair one attending with one resident; all other approaches are more expensive. The difference between most options is less than $5/patient. Only at extremes of variables do overall choices differ. CONCLUSIONS: Incrementally staffing an academic ED with a ratio of one attending per resident achieves the lowest cost, but other models are minimally more expensive. The model allows an ED administrator to determine the costs of different models.

Finding needles in a haystack: a case series of carbon monoxide poisoning detected using new technology in the emergency department.

INTRODUCTION: The diagnosis of carbon monoxide poisoning can be difficult because the symptoms are nonspecific and may mimic other illnesses. If carbon monoxide poisoning is suspected, the standard test at this time is venous or arterial carboxyhemoglobin levels. A new device, the Rad-57 pulse CO-oximeter (Masimo Inc.), can measure carboxyhemoglobin levels non-invasively at emergency department triage. METHODS: The pulse CO-oximeter was utilized in our emergency department triage to measure carboxyhemoglobin levels on all patients. A retrospective chart review was then conducted to identify all patients with elevated levels. CASE SERIES: Out of an estimated 74,880 patients who had their SpCO measured and documented at triage, seven patients who presented with vague complaints were diagnosed with occult carbon monoxide poisoning. Their diagnosis was facilitated by the non-invasive pulse CO-oximeter, which measured their carboxyhemoglobin levels when the standard vital signs were also documented at triage. CONCLUSIONS: The non-invasive pulse CO-oximeter could be a major triage tool for identifying unsuspected carbon monoxide poisoning among patients with nonspecific symptoms.

Advanced medical simulation applications for emergency medicine microsystems evaluation and training.

Participants in the 2008 Academic Emergency Medicine Consensus Conference "The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise" morning workshop session on developing systems expertise were tasked with evaluating best applications of simulation techniques and technologies to small-scale systems in emergency medicine (EM). We collaborated to achieve several objectives: 1) describe relevant theories and terminology for discussion of health care systems and medical simulation, 2) review prior and ongoing efforts employing systems thinking and simulation programs in general medical sectors and acute care medicine, 3) develop a framework for discussion of systems thinking for EM, and 4) explore the rational application of advanced medical simulation methods to a defined framework of EM microsystems (EMMs) to promote a "quality-by-design" approach. This article details the materials compiled and questions raised during the consensus process, and the resulting simulation application framework, with proposed solutions as well as their limitations for EM systems education and improvement.

Portable advanced medical simulation for new emergency department testing and orientation.

OBJECTIVES: Efforts to mitigate unexpected problems during transition of an active emergency department (ED) to a new physical plant are imperative to ensure effective health care delivery and patient safety. The authors used advanced medical simulation (SIM) to evaluate the capacity of a new ED for emergent resuscitative processes and assist facility orientation before opening day. METHODS: Operational readiness testing and orientation to the new ED of a large academic center were arranged through a Transportable Enhanced Simulation Technologies for Pre-Implementation Limited Operations Testing (TESTPILOT) project. Using a portable life-sized computerized manikin, the project required participants to perform assorted patient care interventions on-site. Cardiac arrest, multitrauma, uroseptic shock, and pediatric toxicology scenarios elicited the dynamics of real-life ED activities. Debriefings and surveys assessed participants' perceptions of the new facility's clinical readiness and identified areas needing administrative attention. Subjective utility of SIM orientation was compared with that of standard facility orientation. RESULTS: Fourteen ED clinicians and five SIM facilitators participated over two sessions. The new facility received mean (+/- SD) and median five-point Likert scale scores of 4.4 (+/- 0.8) and 5 for ability of clinical staff to perform resuscitations. The respective scores for ability of simulated scenarios to prepare staff for new ED function were 4.6 (+/- 0.5) and 5, compared with 4.2 (+/- 1.0) and 4 for non-SIM orientation (p = 0.22; not significant). Problems with equipment location, inadequate procedural surfaces, and insufficient orientation were discovered and rapidly corrected. CONCLUSIONS: Transportable SIM was used to evaluate the clinical functions of a new ED. Significant operational issues identified by participants were corrected before opening of the facility. Limited comparison did not reveal SIM enhancement of orientation.