Lit Bits: Oct 29, 2008

From the recent medical literature...

1. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke

Hacke W, et al. N Engl J Med. 2008;359:1317-1329.

Background: Intravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke, but its efficacy and safety when administered more than 3 hours after the onset of symptoms have not been established. We tested the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke.

Methods: After exclusion of patients with a brain hemorrhage or major infarction, as detected on a computed tomographic scan, we randomly assigned patients with acute ischemic stroke in a 1:1 double-blind fashion to receive treatment with intravenous alteplase (0.9 mg per kilogram of body weight) or placebo. The primary end point was disability at 90 days, dichotomized as a favorable outcome (a score of 0 or 1 on the modified Rankin scale, which has a range of 0 to 6, with 0 indicating no symptoms at all and 6 indicating death) or an unfavorable outcome (a score of 2 to 6 on the modified Rankin scale). The secondary end point was a global outcome analysis of four neurologic and disability scores combined. Safety end points included death, symptomatic intracranial hemorrhage, and other serious adverse events.

Results: We enrolled a total of 821 patients in the study and randomly assigned 418 to the alteplase group and 403 to the placebo group. The median time for the administration of alteplase was 3 hours 59 minutes. More patients had a favorable outcome with alteplase than with placebo (52.4% vs. 45.2%; odds ratio, 1.34; 95% confidence interval [CI], 1.02 to 1.76; P=0.04). In the global analysis, the outcome was also improved with alteplase as compared with placebo (odds ratio, 1.28; 95% CI, 1.00 to 1.65; P less than 0.05). The incidence of intracranial hemorrhage was higher with alteplase than with placebo (for any intracranial hemorrhage, 27.0% vs. 17.6%; P=0.001; for symptomatic intracranial hemorrhage, 2.4% vs. 0.2%; P=0.008). Mortality did not differ significantly between the alteplase and placebo groups (7.7% and 8.4%, respectively; P=0.68). There was no significant difference in the rate of other serious adverse events.

Conclusions: As compared with placebo, intravenous alteplase administered between 3 and 4.5 hours after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke; alteplase was more frequently associated with symptomatic intracranial hemorrhage.

Related Medscape Articles:

ECASS 3: Thrombolysis Beneficial Up to 4.5 Hours After Acute Ischemic Stroke

A Long, Difficult Path

In an editorial accompanying the article, Patrick Lyden, MD, from the University of California, San Diego, points out that the results of ECASS 3, like the National Institute for Neurological Disorders and Stroke trial that established the efficacy of tPA in stroke treatment, was robust across multiple endpoints, and showed efficacy for treatment despite an increased rate of hemorrhage. Based on this, he writes, "one cannot help wondering why thrombolytic therapy has travelled such a long, difficult path to wider clinical use."

The inclusion and exclusion criteria for ECASS 3 were broad, and in general, patients who present with an acute stroke will qualify for treatment, he writes. When collected properly, the evidence consistently shows that one-third of patients with stroke come to an emergency department within the appropriate time window and satisfy the criteria for thrombolytic therapy, Dr. Lyden writes.

"The frequently quoted statistic that only 4% of all patients with stroke receive rt-PA [recombinant tissue plasminogen activator] must be viewed as an important indictment of our health care system and of the field of neurology in particular," he asserts. "The patients are coming in but we are not."

Policies and procedures should be instituted to ensure that patients are promptly identified and treated, quality outcome data must be used to select and designate treatment centers of excellence for patients with acute stroke, and patients should be diverted to these centers, Dr. Lyden concludes. "The public expects no less, and given the past decade of distortion of the NINDS [National Institute for Neurological Disorders and Stroke] study findings and delay in implementing thrombolytic therapy for acute stroke, we have not a minute to lose."

Full-text of this Medscape article: http://www.medscape.com/viewarticle/581053

ECASS 3 Gets a Warm Welcome From the Stroke Community

Joseph Broderick, MD, from the University of Cincinnati, in Ohio, and a primary investigator of the National Institute of Neurological Disorders and Stroke (NINDS) trial that first established efficacy of tPA in stroke, told Medscape Neurology & Neurosurgery that, in his view, the ECASS 3 results are the most important to the field of stroke treatment since the NINDS results were published some 13 years ago.

However, like the ECASS 3 researchers and others, he too is concerned that physicians will take more time if they think they have it. "Unfortunately with physicians, sometimes the more time you have, the more you kind of drag your feet or you want to do another test, and what I worry about is that people will be treated later when it's clear that this is a very time-dependent therapy."

“What I worry about is that people will be treated later, and it's clear that this is a very time-dependent therapy.”

He said the efficacy in ECASS 3 was similar to that seen in the NINDS trial, although he noted that the ECASS 3 population was a much less severely affected group. "I think their median [National Institutes of Health Stroke Scale] NIHSS score was 9 to 10 as opposed to 14 in the NINDS trial, which is a big difference," he said. "That's why their mortality is extraordinarily low, around 8%, whereas in the [NINDS] trial, the mortality with placebo was 21% and with tPA it was 17%, so you're talking about half the mortality rate, but that reflects the lesser severity of the strokes."

The findings, then, do not provide information on the patients excluded from the trial, Dr. Broderick said. Still, he added, "It's just a great event that builds upon the positive momentum. I still think reperfusion is what it's all about, but reperfusion within a certain time window."

During his presentation, Dr. Hacke acknowledged this limitation for the generalizability of their results but pointed out that the inclusion criteria for the ECASS 3 study were identical to the labeling of tPA for Europe, except for the time window. "So we were not responsible as the investigators that the age limit ended at 80. We were also not responsible that there was exclusion of patients who had had a prior stroke and were diabetic, but that's what we had to do."

Full-text of Medscape article: http://www.medscape.com/viewarticle/581353

2. Study Dispels Some Myths about Uninsured Patients Presenting to ED

By Anthony J. Brown, MD. NEW YORK (Reuters Health) Oct 21 - Contrary to what many people believe, uninsured patients are not a primary cause of the overcrowding that is seen in US emergency departments (EDs), new research indicates. By contrast, the assumption that increasing numbers of uninsured patients are presenting to EDs is, in fact, true.

"There is a commonly held belief that uninsured patients abuse the ED, coming in for 'non-urgent' complaints, are overwhelming the system. This is simply not true," lead author Dr. Manya F. Newton told Reuters Health. "Crowding in the ED is highly multifactorial (this includes an increased amount of ED use by everyone, fewer EDs, fewer inpatient beds, and many other problems). People without insurance tend to use the ED less than any other group and when they present they tend to be sicker/more acutely ill."

Dr. Newton, a researcher with the University of Michigan, Ann Arbor, noted that "this is the first paper to critically examine unsupported statements in the peer reviewed literature concerning uninsured patients in the ED and compare these statements to the current data on the subject."

In searching MEDLINE from 1950 through September 19, 2008, the research team identified 127 studies that looked at the medical and surgical care of uninsured adult patients in emergency settings. Assumptions identified in these studies were then tested against supporting data in various data sets and in peer-reviewed literature.

Overall, 53 studies had one or more assumptions (mean = 3) about uninsured ED patients, according to the report in the Journal of the American Medical Association for October 22/29.

The assumptions that increasing numbers of uninsured patients are presenting to the ED and that uninsured patients lack access to primary care were both found to be accurate. Likewise, the belief that ED care is more expensive than office-based care for both uninsured and insured patients was also true.

Unsupported assumptions include the beliefs that uninsured patients are the main cause of ED overcrowding, uninsured ED patients have less acute conditions than insured patients, and that uninsured patients use the ED mostly for convenience.

"We have a crisis in the ED and we have a crisis with the uninsured, but it is crucial that we do not assume that the latter is causing the former," Dr. Newton emphasized. "If we attempt to solve ED overcrowding by creating policies based on inaccurate assumptions, common knowledge, or what 'everybody knows,' we will waste limited resources, fail to address the root causes of the problem, and potentially increase the barriers to care faced by 47 million uninsured Americans."

JAMA 2008;300:1914-1924.

3. Antibiotic-Associated Adverse Events Often Require Emergency Care

Laurie Barclay, MD. October 17, 2008 — Antibiotic-associated adverse events, particularly allergic reactions, lead to many emergency department visits, according to the results of a study reported in the September 15 issue of Clinical Infectious Diseases.

"Drug-related adverse events are an underappreciated consequence of antibiotic use, and the national magnitude and scope of these events have not been studied," write Nadine Shehab, from the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, and colleagues. "Our objective was to estimate and compare the numbers and rates of emergency department (ED) visits for drug-related adverse events associated with systemic antibiotics in the United States by drug class, individual drug, and event type."

Using data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project from 2004 to 2006, the investigators analyzed drug-related adverse events. These were linked with outpatient prescriptions identified from national sample surveys of ambulatory care practices, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey from 2004 to 2005.

On the basis of 6614 cases thus identified, the investigators estimated that the annual rate of visits to US EDs for adverse events related to systemic antibiotics was 142,505 visits (95% confidence interval [CI], 116,506 - 168,504 visits). Among all ED visits for drug-related adverse events, antibiotics were thought to be causally related in 19.3%.

Allergic reactions were most often implicated in ED visits for antibiotic-associated adverse events (78.7% of visits; 95% CI, 75.3% - 82.1% of visits). The most common culprits regarding allergic reactions were penicillins (36.9% of visits; 95% CI, 34.7% - 39.2% of visits) and cephalosporins (12.2%; 95% CI, 10.9% - 13.5%).

Of frequently prescribed antibiotics, sulfonamides and clindamycin were linked to the highest rate of ED visits (18.9 ED visits per 10,000 outpatient prescription visits [95% CI, 13.1 - 24.7 ED visits per 10,000 outpatient prescription visits] and 18.5 ED visits per 10,000 outpatient prescription visits [95% CI, 12.1 - 25.0 ED visits per 10,000 outpatient prescription visits], respectively).

Sulfonamides were linked to a significantly higher rate of moderate to severe allergic reactions vs all other antibiotic classes (4.3% [95% CI, 2.9% - 5.8%] vs 1.9% [95% CI, 1.5% - 2.3%]). Compared with all other antibiotic classes, sulfonamides and fluoroquinolones were linked to a significantly higher rate of neurologic or psychiatric complaints and/or findings (1.4% [95% CI, 1.0% - 1.7%] vs. 0.5% [95% CI, 0.4% - 0.6%]).

"Antibiotic-associated adverse events lead to many ED visits, and allergic reactions are the most common events," the study authors write. "Minimizing unnecessary antibiotic use by even a small percentage could significantly reduce the immediate and direct risks of drug-related adverse events in individual patients."

Limitations of this study include focus on drug-related adverse events diagnosed in EDs, with failure to include all antibiotic-associated adverse events; inability to account for unreported events and events identified in clinicians' offices or other healthcare settings; difficulty in detecting rare and less well-recognized events and events with subacute onset; analysis of drug-related adverse event conditions and outcomes limited to cases in which only drugs from a single antibiotic class were implicated in the adverse event; and inclusion only of events that were attributed to antibiotics and not to other types of drugs.

"Communicating the risks of antibiotic-associated adverse events can become an important strategy in efforts to promote judicious antibiotic use," the study authors conclude.

In an accompanying editorial, Jeffrey A. Linder, from Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, notes that antibiotic prescription by US clinicians greatly exceeds guidelines recommendations.

"The decision and discussion about antibiotic prescribing should focus on benefits and risks for the individual patient," Dr. Linder writes. "For most acute respiratory tract infections, antimicrobial resistance is irrelevant. For an individual patient, the risks are greater than the benefits, and the discussion should stop there."

The CDC supported this study.

Clin Infect Dis. 2008;47:735-743, 744-746.

4. Subdissociative-dose Ketamine versus Fentanyl for Analgesia during Propofol Procedural Sedation: A Randomized Clinical Trial

Messenger DW, et al. Acad Emerg Med. 2008;15:1–10.

Objectives: The authors sought to compare the safety and efficacy of subdissociative-dose ketamine versus fentanyl as adjunct analgesics for emergency department (ED) procedural sedation and analgesia (PSA) with propofol.

Methods: This double-blind, randomized trial enrolled American Society of Anesthesiology (ASA) Class I or II ED patients, aged 14–65 years, requiring PSA for orthopedic reduction or abscess drainage. Subjects received 0.3 mg/kg ketamine or 1.5 μg/kg fentanyl intravenously (IV), followed by IV propofol titrated to deep sedation. Supplemental oxygen was not routinely administered. The primary outcomes were the frequency and severity of cardiorespiratory events and interventions, rated using a composite intrasedation event rating scale. Secondary outcomes included the frequency of specific scale component events, propofol doses required to achieve and maintain sedation, times to sedation and recovery, and physician and patient satisfaction.

Results: Sixty-three patients were enrolled. Of patients who received fentanyl, 26/31 (83.9%) had an intrasedation event versus 15/32 (46.9%) of those who received ketamine. Events prospectively rated as moderate or severe were seen in 16/31 (51.6%) of fentanyl subjects versus 7/32 (21.9%) of ketamine subjects. Patients receiving fentanyl had 5.1 (95% confidence interval [CI] = 1.9 to 13.6; p less than 0.001) times the odds of having a more serious intrasedation event rating than patients receiving ketamine. There were no significant differences in secondary outcomes, apart from higher propofol doses in the ketamine arm.

Conclusions: Subdissociative-dose ketamine is safer than fentanyl for ED PSA with propofol and appears to have similar efficacy.

5. The Effect of Clinical Experience on the Error Rate of Emergency Physicians

Berk WA, et al. Ann Emerg Med. 2008;52:497-501.

Study objective
We assess the effect of emergency physicians' clinical experience on the propensity to commit a patient care error.

Methods
Seven years of data from a single emergency department's peer review activities were reviewed for all patient care errors made by emergency physicians. Emergency physician clinical experience was defined as years since completion of residency training during the year each error was made. A repeated-measures log-linear model was constructed that predicted error count and the rate of errors over time, with a correction for number of patients treated by each physician.

Results
Of 829 cases reviewed during 7 years, there were 374 emergency physician errors identified. Mean emergency physician experience was 8.1±8.6 years. Emergency physicians with experience of 1.5 years or more were less likely to make an error (relative risk [RR]=0.66; 95% confidence interval [CI] 0.48 to 0.91) than those who were less experienced. Errors were not associated with emergency physician age (RR=1.01; 95% CI 0.99 to 1.03) or sex (RR=1.29; 95% CI 0.93 to 1.79).

Conclusion
Emergency physicians with less than 1.5 years of clinical experience may be more likely to commit errors than more experienced emergency physicians.

6. Prediction of Outcome in Subarachnoid Hemorrhage

In predicting risks for vasospasm, delayed infarction, and poor outcome after aneurysmal subarachnoid hemorrhage, the modified Fisher scale has advantages over the traditional Fisher scale.

After aneurysm rupture, the amount of blood in the subarachnoid cisterns on the initial CT scan predicts the risk for vasospasm. Clinicians have traditionally estimated this risk via a scale described by C.M. Fisher and colleagues in 1980. In initial studies, two newer scales — the Claassen and modified Fisher scales — had improved prognostic yield. The modified Fisher scale incorporates any intraventricular hemorrhage (IVH); the Claassen scale incorporates bilateral IVH. In this retrospective, single-center study, investigators compared the prognostic performance of the three scales in 237 consecutive patients with aneurysmal subarachnoid hemorrhage.

Compared with the traditional Fisher scale, the newer scales had more-linear associations with risks for symptomatic vasospasm and for delayed radiologic infarctions. The newer scales also had better interobserver agreement. Scores on the modified Fisher scale, unlike on the other two, were associated incrementally with risk for poor functional outcome at 6 weeks. Presence of IVH was not associated significantly with symptomatic vasospasm or with delayed infarction but did predict worse functional outcome.

Comment: The two newer radiologic scales modify the traditional Fisher scale by combining the amount of subarachnoid hemorrhage and the presence of IVH in their grading systems. Thus, they achieve more-linear and more-accurate associations with vasospasm risk. In this study population, IVH was so common (nearly 70% of cases) that the study might have been underpowered to detect a stronger association between IVH and vasospasm. Nonetheless, the new scales performed better than did the traditional Fisher scale. Moreover, these findings highlight that the scales predict functional prognosis, although they were designed to assess the risk for vasospasm only. Overall, the modified Fisher scale appears to offer the best prognostic performance.

— Alejandro Rabinstein, MD. Published in Journal Watch Neurology October 28, 2008. Citation:
Kramer AH et al. J Neurosurg 2008 Aug; 109:199.

7. Child Abuse Often Overlooked in Emergency Department

October 28, 2008 (Chicago, Illinois) — At least one third of children diagnosed with abuse had at least 1 visit to the emergency department before diagnosis, according to a new study.

The results were presented here at the American College of Emergency Physicians 2008 Scientific Assembly.

This is among the first studies looking at emergency-department use before the diagnosis of child abuse. Child abuse is often overlooked in the emergency department, according to the researchers from Oregon Health & Science University, in Portland. The researchers have been taking a close look at people who use emergency departments frequently.

In this study, administrative data were gathered on patients younger than 18 years who visited 23 Oregon emergency departments between February 2001 to August 2005. The hospitals ranged from small rural facilities to urban medical centers. When patients were diagnosed with abuse, demographic characteristics, the number of visits before the diagnosis, and the type of injuries were noted. Of the 286,066 pediatric patients, 399 were diagnosed with abuse.

Of those diagnosed as having experienced child abuse, 53% were girls, and 20% were infants (younger than 1 year), 15% were toddlers (1 to 2 years), 14% were preschool age (3 to 5 years), 24% were school age (6 to 12 years), and 28% were teenagers (13 to 17 years). Of the infants diagnosed with abuse, 49% had previous visits for injury. Of the overall injuries, 70% were to the head, face, and neck.

"I was not surprised by the overall number of visits for abuse, but I was surprised by the number of previous visits by these patients for which abuse was not a recorded diagnosis," lead author Esther K. Choo, MD, told Medscape Emergency Medicine. She is a clinical instructor and research fellow at the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University. "Thirty percent of children eventually diagnosed with child abuse did not have the diagnosis recorded until at least their second visit, and 7% had 3 or more visits before receiving the diagnosis of abuse."

"This study highlights the importance of screening for and identifying in the chart suspicious or confirmed child abuse," said Paula Oldeg, MD, clinical instructor in emergency medicine at Rush Medical College and attending physician in the emergency department of West Suburban Medical Center, in Oak Park, Illinois, who attended the presentation. "Based on the results of this study, it seems that if these patients are identified, appropriate referrals can be made," and further abuse might be prevented, she said.

Dr. Choo pointed out that emergency-department visits might be a missed opportunity, especially for identifying abuse in infants. The study also indicates that once child abuse is recognized, repeat emergency-department visits are unlikely.

As a result of the study, Dr. Choo believes that, although individual physicians should maintain constant vigilance about abuse, they cannot fix the problem alone. Policy makers need to consider the resources in the healthcare system that can best assist clinicians in detecting and addressing family violence, she said.

The study was funded by the National Heart, Lung, and Blood Institute, the Robert Wood Johnson Foundation, and the Oregon Office for Health Policy and Research.

American College of Emergency Physicians (ACEP) 2008 Scientific Assembly: Abstract 113. Presented October 27, 2008.

8. Images in Emergency Medicine

a. Man with Progressive Dyspnea

http://www.annemergmed.com/article/S0196-0644(08)00558-1/fulltext

b. Infant with Vomiting and Weight Loss

http://www.annemergmed.com/article/S0196-0644(08)00598-2/fulltext

9. Kaiser Study Finds that Use of a Fan During Sleep Reduces Risk of SIDS

The theory is that the moving air dispels the carbon dioxide buildup that can occur when the expelled breath air isn't moving away from the baby's face.

Coleman-Phox K, et al. Arch Pediatr Adolesc Med. 2008;162:963-968

Objective: To examine the relation between room ventilation during sleep and risk of sudden infant death syndrome (SIDS).

Design: Population-based case-control study.

Setting: Eleven California counties.

Participants: Mothers of 185 infants with a confirmed SIDS diagnosis and 312 randomly selected infants matched on county of residence, maternal race/ethnicity, and age.

Intervention: Fan use and open window during sleep.

Main Outcome Measure: Risk of SIDS.

Results: Fan use during sleep was associated with a 72% reduction in SIDS risk (adjusted odds ratio [AOR], 0.28; 95% confidence interval [CI], 0.10-0.77). The reduction in SIDS risk seemed more pronounced in adverse sleep environments. For example, fan use in warmer room temperatures was associated with a greater reduction in SIDS risk (AOR, 0.06; 95% CI, 0.01-0.52) compared with cooler room temperatures (0.77; 0.22-2.73). Similarly, the reduction associated with fan use was greater in infants placed in the prone or side sleep position (AOR, 0.14; 95% CI, 0.03-0.55) vs supine (0.84; 0.21-3.39). Fan use was associated with a greater reduction in SIDS risk in infants who shared a bed with an individual other than their parents (AOR, 0.15; 95% CI, 0.01-1.85) vs with a parent (0.40; 0.03-4.68). Finally, fan use was associated with reduced SIDS risk in infants not using pacifiers (AOR, 0.22; 95% CI, 0.07-0.69) but not in pacifier users (1.99; 0.16-24.4). Some differences in the effect of fan use on SIDS risk did not reach statistical significance.

Conclusion: Fan use may be an effective intervention for further decreasing SIDS risk in infants in adverse sleep environments.

10. Three Hours of Follow-Up Is Sufficient for Asymptomatic Penetrating Thoracic Trauma

Plain films at 6 hours did not detect any pneumothoraces or hemothoraces that were not seen at presentation or at 3 hours.

Penetrating thoracic trauma is termed "asymptomatic" if the patient has no symptoms, signs, or radiographic findings of intrathoracic injury, but delayed pneumothorax or hemothorax occurs in about 3% of such patients and usually necessitates tube thoracostomy. Patients with asymptomatic thoracic penetrating trauma usually are observed and undergo repeat chest radiography after 6 hours. However, findings from two studies suggest that 3 hours is sufficient for follow-up (Surg Gynecol Obstet 1992; 175:249).

In a prospective study, researchers compared chest radiography findings at 3 and 6 hours after presentation in patients who presented to a single emergency department within 2 hours after asymptomatic penetrating thoracic trauma (anatomic boundaries of injury: clavicles and base of the neck, superiorly; inferior costal margin and iliac crests, inferiorly). Supine anteroposterior chest radiographs were obtained at presentation, and upright posterioanterior and lateral chest radiographs were obtained at 3 and 6 hours. Patients with worrisome clinical or laboratory findings or findings of pneumothorax or hemothorax on the initial radiograph were excluded.

Of 100 patients who met inclusion criteria, 75% were men, 75% had stab wounds, and 25% had gunshot wounds. The average ED stay was 8.8 hours. Two patients had findings of pneumothorax on the 3-hour film; both patients underwent tube thoracostomy. No new cases of pneumothorax or hemothorax were detected on the 6-hour films. Patient charges, including the cost of radiographs and continuous pulse oximetry monitoring, were US$2802 for the 3-hour observation period and $4521 for the 6-hour period.

Comment: In the three studies published to date (including this study) that compared chest radiography findings at 3 and 6 hours, 8 of the combined total of 304 patients (2.6%) developed pneumothoraces within 3 hours, and no patients developed pneumothoraces or hemothoraces within the next 3 hours. The inherent value of a 3-hour follow-up chest radiography policy is that the stay is shortened, thereby relieving ED overcrowding, and associated healthcare costs are reduced considerably. Moreover, this approach limits radiation exposure, a matter of increasing concern. Some authors have advocated for the use of chest computed tomography (CT) at presentation, with immediate discharge if the scan is negative. However, that approach is a poor alternative because thoracic CT transmits 8 mSv of ionizing radiation — an amount that is 400 times the radiation dose of a two-view chest radiograph and is equivalent to 3 years of background radiation in the U.S. Finally, the evolving role of ED ultrasound, such as the extended FAST examination, and its ability to identify pneumothorax remain to be determined.

— John A. Marx, MD, FAAEM, FACEP. Published in Journal Watch Emergency Medicine October 10, 2008. Citation: Seamon MJ et al. J Trauma 2008 Sep; 65:549.

11. Surprise, Surprise: ED Crowding Adversely Affects Patient Satisfaction

Dissatisfaction lasts throughout entire hospital stay.

Pines JM, et al. Acad Emerg Med. 2008;15:825–831.

Objectives: The objective was to study the association between factors related to emergency department (ED) crowding and patient satisfaction.

Methods: The authors performed a retrospective cohort study of all patients admitted through the ED who completed Press-Ganey patient satisfaction surveys over a 2-year period at a single academic center. Ordinal and binary logistic regression was used to study the association between validated ED crowding factors (such as hallway placement, waiting times, and boarding times) and patient satisfaction with both ED care and assessment of satisfaction with the overall hospitalization.

Results: A total of 1,501 hospitalizations for 1,469 patients were studied. ED hallway use was broadly predictive of a lower likelihood of recommending the ED to others, lower overall ED satisfaction, and lower overall satisfaction with the hospitalization (p less than 0.05). Prolonged ED boarding times and prolonged treatment times were also predictive of lower ED satisfaction and lower satisfaction with the overall hospitalization (p less than 0.05). Measures of ED crowding and ED waiting times predicted ED satisfaction (p less than 0.05), but were not predictive of satisfaction with the overall hospitalization.

Conclusions: A poor ED service experience as measured by ED hallway use and prolonged boarding time after admission are adversely associated with ED satisfaction and predict lower satisfaction with the entire hospitalization. Efforts to decrease ED boarding and crowding might improve patient satisfaction.

12. In ‘Sweetie’ and ‘Dear,’ a Hurt for the Elderly

Heidi Schumann for The New York Times. October 6, 2008. Professionals call it elderspeak, the sweetly belittling form of address that has always rankled older people: the doctor who talks to their child rather than to them about their health; the store clerk who assumes that an older person does not know how to work a computer, or needs to be addressed slowly or in a loud voice. Then there are those who address any elderly person as “dear.”

“People think they’re being nice,” said Elvira Nagle, 83, of Dublin, Calif., “but when I hear it, it raises my hackles.”

Now studies are finding that the insults can have health consequences, especially if people mutely accept the attitudes behind them, said Becca Levy, an associate professor of epidemiology and psychology at Yale University, who studies the health effects of such messages on elderly people.

“Those little insults can lead to more negative images of aging,” Dr. Levy said. “And those who have more negative images of aging have worse functional health over time, including lower rates of survival.”

In a long-term survey of 660 people over age 50 in a small Ohio town, published in 2002, Dr. Levy and her fellow researchers found that those who had positive perceptions of aging lived an average of 7.5 years longer, a bigger increase than that associated with exercising or not smoking. The findings held up even when the researchers controlled for differences in the participants’ health conditions.

In her forthcoming study, Dr. Levy found that older people exposed to negative images of aging, including words like “forgetful,” “feeble” and “shaky,” performed significantly worse on memory and balance tests; in previous experiments, they also showed higher levels of stress.

Despite such research, the worst offenders are often health care workers, said Kristine Williams, a nurse gerontologist and associate professor at the University of Kansas School of Nursing.

To study the effects of elderspeak on people with mild to moderate dementia, Dr. Williams and a team of researchers videotaped interactions in a nursing home between 20 residents and staff members. They found that when nurses used phrases like “good girl” or “How are we feeling?” patients were more aggressive and less cooperative or receptive to care. If addressed as infants, some showed their irritation by grimacing, screaming or refusing to do what staff members asked of them.

The researchers, who will publish their findings in The American Journal of Alzheimer’s Disease and Other Dementias, concluded that elderspeak sent a message that the patient was incompetent and “begins a negative downward spiral for older persons, who react with decreased self-esteem, depression, withdrawal and the assumption of dependent behaviors.”

Dr. Williams said health care workers often thought that using words like “dear” or “sweetie” conveyed that they cared and made them easier to understand. “But they don’t realize the implications,” she said, “that it’s also giving messages to older adults that they’re incompetent.”

“The main task for a person with Alzheimer’s is to maintain a sense of self or personhood,” Dr. Williams said. “If you know you’re losing your cognitive abilities and trying to maintain your personhood, and someone talks to you like a baby, it’s upsetting to you.”

She added that patients who reacted aggressively against elderspeak might receive less care.

For people without cognitive problems, elderspeak can sometimes make them livid. When Sarah Plummer’s pharmacy changed her monthly prescription for cancer drugs from a vial to a contraption she could not open, she said, the pharmacist explained that the packaging was intended to help her remember her daily dose.

“I exploded,” Ms. Plummer wrote to a New York Times blog, The New Old Age, which asked readers about how they were treated in their daily life.

“Who says I don’t take my medicine as prescribed?” wrote Ms. Plummer, 61, who lives in Champaign, Ill. “I am alive right now because I take these pills! What am I supposed to do? Hold it with vice grips and cut it with a hack saw?’”

She added, “I believed my dignity and integrity were being assaulted.”

Full-text: http://www.nytimes.com/2008/10/07/us/07aging.html

13. Early Goal-Directed Therapy for Sepsis: Show Me the Data!

A meta-analysis of randomized sepsis trials showed mortality benefit with early goal-directed therapy.

The validity of various aspects of early goal-directed therapy (EGDT) for patients with severe sepsis and septic shock has been challenged in non–peer-reviewed publications. Researchers conducted a meta-analysis of randomized controlled trials in adult patients with sepsis; eligible trials described the resuscitative protocol used to achieve predetermined hemodynamic endpoints and included control groups of patients who received standard care. The primary endpoint in the meta-analysis was mortality. Assessment of trial quality included evaluation of diagnostic criteria for patient selection and internal validity.

Of 903 reports identified in a comprehensive search, 29 were chosen for complete manuscript review, and 9 (involving a total of 1001 patients) were eligible for inclusion in the final analysis. Overall, mortality was significantly lower in patients who received resuscitation directed by quantitative endpoints than in those who received standard care (odds ratio, 0.64; 95% confidence interval, 0.43–0.96). Analysis of predefined subgroups of patients who received endpoint-directed resuscitation early (6 studies) demonstrated lower mortality with this procedure (OR, 0.50; 95% CI, 0.37–0.69). However, no mortality benefit resulted from late (more than 24 hours) resuscitation (OR, 1.16; 95% CI, 0.60–2.22). The results remained consistent in sensitivity analyses. Because the early endpoint-based resuscitation strategy had such a clear effect on mortality, the investigators performed a post hoc sensitivity analysis to determine whether any specific study had a disproportionate influence on the overall results; as each study was excluded and data from the remaining studies were reanalyzed, the significant mortality benefit of early goal-directed resuscitation remained consistent.

Comment: This meta-analysis showed a dramatic mortality benefit from early resuscitation that was targeted to achieve specified physiologic goals. The authors conclude that the data strongly support the Surviving Sepsis Campaign recommendations for EGDT in septic patients. Large multicenter studies evaluating the benefits of EGDT, including various individual components, currently are under way or nearing completion. Until those results are available, clinicians resuscitating patients with sepsis syndrome are well advised to embrace the principles of EGDT, which are supported by more than 14 peer-reviewed publications.

— Tiffany M. Osborn, MD. Published in Journal Watch EM October 3, 2008. Citation:
Jones AE et al. Crit Care Med 2008 Oct; 36:2734.

14. Olanzapine versus Droperidol for the Treatment of Primary Headache in the ED

It’s a tie.

Hill CH, at al. Acad Emerg Med. 2008;15:806–811.
Objectives: The objective was to determine if there is a difference in pain relief or frequency and severity of side effects in emergency department (ED) patients with primary headache treated with either intramuscular (IM) olanzapine or IM droperidol.

Methods: This was a prospective, randomized nonblinded clinical trial of adult ED patients undergoing treatment for suspected primary headache. Consenting patients were randomized to receive either droperidol 5 mg IM or olanzapine 10 mg IM. Prior to receiving treatment, patients were asked to complete a 100-mm visual analog scale (VAS) describing their pain and a 4-point verbal rating scale (VRS) describing their pain as none, mild, moderate, or severe. Patients also completed a 100-mm VAS describing their level of nausea. Pain and nausea measurements were repeated 30 and 60 minutes after medication administration. Patients also completed the Barnes Akathisia Scale (BAS) 30 and 60 minutes after medication administration. Descriptive statistics were used as appropriate. Pain relief was compared both in terms of the decrease in VAS scores and in the proportion of patients who reported moderate or severe pain whose report later changed to mild or no pain.

Results: One-hundred patients were enrolled; 13 were withdrawn before administration of the study medication, 8 in the droperidol group and 5 in the olanzapine group, leaving 87 patients for analysis. Forty-two patients received droperidol and 45 received olanzapine. In the droperidol group, 35/40 (87.5%) patients who had reported moderate or severe pain at baseline reported mild or no pain at 60 minutes. In the olanzapine group, 38/44 (86.4%) reported this change (p = 0.89). The mean percent change from baseline VAS pain score at 60 minutes was −37% (95% CI = −84% to 11%) for droperidol and −37% (95% CI = −64% to 10%) for olanzapine (p = 0.30). The mean percent change from baseline for the VAS nausea score was −59% (95% CI = −70% to −47%) for droperidol and −64% (95% CI = −77% to −51%) for olanzapine (p = 0.83). There was no difference in any report of akathisia by the BAS between the groups (p = 0.63).

Conclusions: Both olanzapine and droperidol are effective treatments for primary headaches in the ED. No significant differences were found between the medications in terms of pain relief, antiemetic effect, or akathisia. Olanzapine may be used to treat primary headache and it is an effective alternative to droperidol.

15. Morphine analgesia in patients with acute appendicitis: a randomised double-blind clinical trial (again)

Amoli HA, et al. Emerg Med J 2008;25:586-589.

Background: The administration of analgesics to patients with acute abdominal pain due to acute appendicitis is controversial. A study was undertaken to assess the analgesic effect of morphine in patients with acute appendicitis.

Methods: A randomised double-blind clinical trial was conducted in Sina hospital, a general teaching hospital, from January 2004 to March 2005. Patients scheduled for appendectomy were randomised to receive 0.1 mg/kg morphine sulfate or saline (0.9%) to a maximum dose of 10 mg over a 5 min period. Patients were examined by surgeons not involved in their care before and after drug administration and their pain intensity and signs were recorded at each visit. The physicians were also asked to indicate their own treatment plan. The main outcome measures were pain intensity using a visual analogue scale (VAS) and signs of acute appendicitis. A favourable reduction in VAS score was defined as a change of greater than 13 mm.

Results: Of the 71 patients enrolled in the study, 35 were allocated to receive morphine and 36 to receive placebo. One patient left the hospital before receiving morphine. No significant differences were seen between the two groups with regard to age, sex and initial VAS score. A more favourable change in VAS score was reported in the morphine group with a significantly greater reduction in the median VAS score than in the placebo group. Morphine administration did not cause significant changes in patients’ signs or in the physicians’ plans or diagnoses. No adverse events were seen in either group.

Conclusion: Morphine can reduce pain in patients with acute appendicitis without affecting diagnostic accuracy.

16. Procedures Can Be Learned on the Web: A Randomized Study of Ultrasound-guided Vascular Access Training

Chenkin J, et al. Acad Emerg Med. 2008;15:949–954.

Objectives: Web-based learning has several potential advantages over lectures, such as anytime–anywhere access, rich multimedia, and nonlinear navigation. While known to be an effective method for learning facts, few studies have examined the effectiveness of Web-based formats for learning procedural skills. The authors sought to determine whether a Web-based tutorial is at least as effective as a didactic lecture for learning ultrasound-guided vascular access (UGVA).

Methods: Participating staff emergency physicians (EPs) and junior emergency medicine (EM) residents with no UGVA experience completed a precourse test and were randomized to either a Web-based or a didactic group. The Web-based group was instructed to use an online tutorial and the didactic group attended a lecture. Participants then practiced on simulators and live models without any further instruction. Following a rest period, participants completed a four-station objective structured clinical examination (OSCE), a written examination, and a postcourse questionnaire. Examination results were compared using a noninferiority data analysis with a 10% margin of difference.

Results: Twenty-one residents and EPs participated in the study. There were no significant differences in mean OSCE scores (absolute difference = −2.8%; 95% confidence interval [CI] = −9.3% to 3.8%) or written test scores (absolute difference = −1.4%; 95% CI = −7.8% to 5.0%) between the Web group and the didactic group. Both groups demonstrated similar improvements in written test scores (26.1% vs. 25.8%; p = 0.95). Ninety-one percent (10/11) of the Web group and 80% (8/10) of the didactic group participants found the teaching format to be effective (p = 0.59).

Conclusions: Our Web-based tutorial was at least as effective as a traditional didactic lecture for teaching the knowledge and skills essential for UGVA. Participants expressed high satisfaction with this teaching technology. Web-based teaching may be a useful alternative to didactic teaching for learning procedural skills.

17. When to Suspect Abuse in Children with Fractures

Results of a meta-analysis suggest that about 70% of rib fractures and 50% of humeral fractures result from abuse.

Kemp AM, et al. BMJ 2008;337:a1518

Introduction

Skeletal fractures are diagnosed in up to a third of children who have been investigated for physical abuse. The fractures are often occult, and they occur in infants and toddlers who cannot give a causal explanation. Children who have been physically abused represent a small proportion of the total number of childhood fractures. Most children who sustain fractures do so from falls, motor vehicle crashes, or other non-abusive trauma. In addition, a small group of children are more susceptible to fractures owing to underlying conditions that contribute to bone fragility. All health professionals who see children should be able to recognise the characteristics of fractures resulting from abuse and initiate child protection investigations where necessary, to prevent further injury that could be fatal. In reality, the possibility of child abuse is often overlooked in clinical practice.

We systematically reviewed the published world literature to answer the question "what features differentiate fractures resulting from abuse from those sustained from other causes?" We aimed to identify indicators that can help clinicians to identify cases of suspected child abuse when a child presents with a fracture for which the cause cannot be confirmed. We explore the strengths and limitations of the current evidence base and make recommendations for future research in this field. We anticipate that this review will enable the development of evidence based clinical guidelines. It will also contribute to the knowledge and understanding of the scientific evidence that expert medical witnesses are expected to have to support their opinion in the family and criminal courts.

Excerpt from Abstract

Results: In total, 32 studies were included. Fractures resulting from abuse were recorded throughout the skeletal system, most commonly in infants (<1 year) and toddlers (between 1 and 3 years old). Multiple fractures were more common in cases of abuse. Once major trauma was excluded, rib fractures had the highest probability for abuse (0.71, 95% confidence interval 0.42 to 0.91). The probability of abuse given a humeral fracture lay between 0.48 (0.06 to 0.94) and 0.54 (0.20 to 0.88), depending on the definition of abuse used. Analysis of fracture type showed that supracondylar humeral fractures were less likely to be inflicted. For femoral fractures, the probability was between 0.28 (0.15 to 0.44) and 0.43 (0.32 to 0.54), depending on the definition of abuse used, and the developmental stage of the child was an important discriminator. The probability for skull fractures was 0.30 (0.19 to 0.46); the most common fractures in abuse and non-abuse were linear fractures. Insufficient comparative studies were available to allow calculation of a probability of abuse for other fracture types.

Conclusion: When infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive cause. During the assessment of individual fractures, the site, fracture type, and developmental stage of the child can help to determine the likelihood of abuse. The number of high quality comparative research studies in this field is limited, and further prospective epidemiology is indicated.

Full-text (free): http://www.bmj.com/cgi/content/full/337/oct02_1/a1518

18. Is Hospital Admission and Observation Required after a Normal Abdominal Computed Tomography Scan in Children with Blunt Abdominal Trauma?

No. Send them home.

Awasthi S, et al. (UC Davis). Acad Emerg Med. 2008;15:895–899.

Objectives: The objective was to determine if hospital admission of children with blunt abdominal trauma for observation of possible intraabdominal injury (IAI) is necessary after a normal abdominal computed tomography (CT) scan in the emergency department (ED).

Methods: The authors conducted a prospective observational cohort study of children less than 18 years of age with blunt abdominal trauma who underwent an abdominal CT scan in the ED. Abdominal CT scans were obtained with intravenous contrast but no oral contrast. The decision to hospitalize the patient was made by the attending emergency physician (EP) with the trauma or pediatric surgery teams. An abnormal abdominal CT scan was defined by the presence of any visualized IAI or findings suggestive of possible IAI (e.g., intraperitoneal fluid without solid organ injury). Patients were followed to determine if IAI was later diagnosed and the need for acute therapeutic intervention if IAI was present.

Results: A total of 1,295 patients underwent abdominal CT, and 1,085 (84%) patients had normal abdominal CT scans in the ED and make up the study population. Seven-hundred thirty-seven (68%) were hospitalized, and 348 were discharged to home. None of the 348 patients discharged home and 2 of the 737 hospitalized patients were identified with an IAI after a normal initial abdominal CT. The IAIs in patients with normal initial CT scans included a 10-year-old with a mesenteric hematoma and serosal tear at laparotomy and a 10-year-old with a perinephric hematoma on repeat CT. Neither underwent specific therapy. The negative predictive value (NPV) of a normal abdominal CT scan for IAI was 99.8% (95% confidence interval [CI] = 99.3% to 100%).

Conclusions: Children with blunt abdominal trauma and a normal abdominal CT scan in the ED are at very low risk of having a subsequently diagnosed IAI and are very unlikely to require a therapeutic intervention. Hospitalization of children for evaluation of possible undiagnosed IAI after a normal abdominal CT scan has a low yield and is generally unnecessary.

19. Is Traditional Reading of the Bedside Chest Radiograph Appropriate To Detect Intraatrial Central Venous Catheter Position?

Wirsing M, et al. Chest. 2008;134:527-533.

Background: Traditionally, the positioning of central venous catheters (CVCs) outside the right atrium (RA) in patients receiving intensive care is determined by surrogate landmarks on bedside chest radiographs (CXRs). The validity of this method was examined by comparing readings of radiologists with the results of transesophageal echocardiography (TEE).

Methods: Prospective study at university hospital. Two hundred thirteen adults scheduled for cardiothoracic surgery were randomized to right or left internal jugular vein catheterization under ECG guidance. One senior radiologist and two radiologists in training independently read the CXRs, and determined whether the CVC tip ended in the RA and measured the vertical distance from the CVC tip to the carina (TC-distance).

Results: Two hundred twelve CVC tips could be identified by TEE. Only left-sided CVCs (n = 5) ended in the upper RA (2.4%). Three of those patients were shorter than 160 cm. Specificity was 94% for senior radiologist, 44% for the first radiologist in training, and 60% for the second radiologist in training. The TC-distance of intraatrial catheters was 39, 55, 59, 80, and 83 mm, respectively. Thus, a TC-distance 55 mm ensured extraatrial tip position in four of five intraatrial CVCs (80%, p = 0.002). The TC-distance of extraatrial catheters ranged from – 26 to 102 mm.

Conclusions: Reading of a bedside CXR alone is not very accurate to identify intraatrial CVC tip position. TC-distance is a helpful marker, and its specificity is as good as that of an experienced radiologist if a cutoff value of 55 mm is chosen.

20. Empiric Antibiotic Therapy for Sepsis Patients: Monotherapy With β-Lactam or β-Lactam Plus an Aminoglycoside?

Sinert R, et al. Ann Emerg Med. 2008;557-560.

Objective
The objective of this review is to examine the efficacy of monotherapy with β-lactam antibiotics versus the standard β-lactam-aminoglycoside antibiotic combination in treatment of sepsis, with regard to all-cause mortality and an estimation of the rate of adverse effects with each treatment.

Conclusions
The authors concluded that in sepsis patients there is no difference in overall mortality between monotherapy or combination therapy. The addition of an aminoglycoside only increased the risk of nephrotoxicity. The authors concluded that a broad-spectrum antibiotic β-lactam required less modification than a narrow-spectrum β-lactam with aminoglycoside combination. No specific infection or disease was identified in which the addition of an aminoglycoside to a broad-spectrum β-lactam antibiotic therapy provided an advantage.

Lit Bits. Oct 5, 2008

From the recent medical literature...



1. Evaluation of a "Triple Rule-Out" Coronary CT Angiography Protocol: Use of 64-Section CT in Low-to-Moderate Risk ED Patients Suspected of Having ACS

Takakuwa KM, et al. Radiology 2008;248:438-446.

Purpose: To determine whether coronary computed tomographic (CT) angiography "triple rule-out" evaluation of emergency department (ED) patients presenting with symptoms suggestive of acute coronary syndrome (ACS) can help identify a subset of patients who can be discharged without adverse clinical outcomes within 30 days.

Materials and Methods: This protocol was approved by the university institutional review board. Each patient provided written informed consent prior to inclusion. Coronary CT angiography was performed in 201 consecutive low-to-moderate risk ACS patients. A triple rule-out protocol was used to evaluate for coronary disease, pulmonary embolism, aortic dissection, and other thoracic disease. Four patients were excluded because of technical problems. The remaining subjects underwent a 30-day follow-up.

Results: A disease process other than coronary atherosclerosis that explained the presenting symptoms was diagnosed in 22 (11%) of 197 patients. Clinically important noncoronary diagnoses that did not explain patient symptoms were identified in 27 (14%) of 197 additional patients. With respect to coronary artery disease, 10 patients had severe disease (greater than 70% stenosis), 12 had moderate disease (50%–70% stenosis), 46 had mild disease (up to 50% stenosis), and 129 had no disease. No further diagnostic testing was performed in 133 (76%) of 175 of patients with no to mild coronary disease. At 30-day follow-up, the negative predictive value of coronary CT angiography with no more than mild disease was 99.4%. There were no adverse outcomes at 30 days.

Conclusion: Triple rule-out coronary CT angiography evaluation of low-to-moderate risk ACS patients presenting to the ED provided a noncoronary diagnosis that explained the presenting complaint in 11% of patients, suggested the presence of significant moderate-to-severe coronary disease in 11% (22 of 197) of patients, and precluded additional diagnostic cardiac testing in the majority of patients with no adverse outcomes at 30-day follow-up.

2. ER top 5: a few thoughts on why I (generally) love my job

Murray H. CJEM 2008;10:396-7.

5. The colleagues
4. The team
3. The variety
2. The cool equipment
1. Making a difference

Full-text: http://caep.ca/template.asp?id=f462cc763d9f4b11bc930deaf26045c5

3. Prochlorperazine vs. Promethazine for Headache Treatment in the Emergency Department: A Randomized Controlled Trial

Callan JE, et al. J Emerg Med. 2008;35:247-253.

Headache is a very common medical complaint. Four to six percent of the population will have a debilitating headache in their lifetime; and 1–2% of all Emergency Department (ED) visits involve patients with headaches. Although promethazine is used frequently, it has never been studied as a single-agent treatment in undifferentiated headache. We hypothesized that promethazine would be superior to prochlorperazine in the treatment of headache.

We conducted a prospective, double-blinded, randomized, controlled trial on patients presenting to our ED between May and August 2005 with a chief complaint of headache. Each subject was randomized to receive either intravenous promethazine 25 mg or prochlorperazine 10 mg, and graded the intensity of their headache on serial 100-mm visual analog scales (VAS). Patients with dystonic reactions or akathisia were treated with diphenhydramine. Adequate pain relief was defined as an absolute decrease in VAS score of 25 mm. After discharge from the ED, patients were queried regarding the recurrence of headache symptoms, the need for additional pain medications, and the occurrence of any side effects since discharge.

Thirty-five patients were enrolled in each group. Both drugs were shown to be effective in treatment of headaches. Prochlorperazine provided a faster rate of pain resolution and less drowsiness when compared to promethazine. Both medications were individually effective as abortive therapy for headache.

Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathisia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.

4. A Prospective, Randomized Trial of an ED Observation Unit for Acute Onset Atrial Fibrillation

Decker WW, et al. Ann Emerg Med. 2008;52:322-328.

Study objective
An emergency department (ED) observation unit protocol for the management of acute onset atrial fibrillation is compared with routine hospital admission and management.

Methods
Adult patients presenting to the ED with atrial fibrillation of less than 48 hours' duration without hemodynamic instability or other comorbid conditions requiring hospitalization were enrolled. Participants were randomized to either ED observation unit care or routine inpatient care. The ED observation unit protocol included pulse rate control, cardiac monitoring, reassessment, and electrical cardioversion if atrial fibrillation persisted. Patients who reverted to sinus rhythm were discharged with a cardiology follow-up within 3 days, whereas those still in atrial fibrillation were admitted. All cases were followed up for 6 months and adverse events recorded.

Results
Of the 153 patients, 75 were randomized to the ED observation unit and 78 to routine inhospital care. Eighty-five percent of ED observation unit patients converted to sinus rhythm versus 73% in the routine care group (difference 12%; 95% confidence interval [CI] −1% to 25%]; P=.06). The median length of stay was 10.1 versus 25.2 hours (difference 15.1 hours; 95% CI 11.2 to 19.6; P less than .001) for ED observation unit and inhospital care respectively. Nine ED observation unit patients required inpatient admission. Eleven percent of the ED observation unit group had recurrence of atrial fibrillation during follow-up versus 10% of the routine inpatient care group (difference 1%; 95% CI −9% to 11%; P=.93). There was no significant difference between the groups in the frequency of hospitalization or the number of tests, and the number of adverse events during follow-up was similar in the 2 groups.

Conclusion
An ED observation unit protocol that includes electrical cardioversion is a feasible alternative to routine hospital admission for acute onset of atrial fibrillation and results in a shorter initial length of stay.

5. Regulator says hospitals need strict heparin rules

September 24, 2008. By LINDSEY TANNER, AP Medical Writer.CHICAGO - A regulatory group told hospitals Wednesday to adopt strict measures to prevent errors involving blood thinners including heparin — mistakes that have been made nearly 60,000 times and led to dozens of deaths in recent years.

The Joint Commission issued a safety alert saying hospitals need to adopt prevention measures that could include bar-coding technology for medicines or computerized drug orders. It advised hospitals to more closely monitor patients on these drugs and make sure that adult-strength heparin is stored nowhere near children's units.

The alert said 28 deaths are among 32 reports of drug errors involving blood thinners that it received between 1997 and last year.

"We know that there are many more (deaths) and ... that's the reason for issuing this alert," said Dr. Mark Chassin, president of the Oakbrook Terrace, Ill.-based commission.

Recent errors include accidental life-threatening heparin overdoses given to actor Dennis Quaid's newborn twins at a Los Angeles hospital last November. In July, 14 babies received accidental heparin overdoses at a hospital in Corpus Christi, Texas.

Commission investigators will make unannounced visits to make sure hospitals are adopting strict measures to prevent blood thinner errors, and those who fail to do so could see their accreditation revoked, Chassin said

The commission is a private group that sets hospital standards and accredits most of the nation's hospitals. Accreditation brings prestige and federal dollars.

A total of 59,316 medication errors involving blood thinners were reported between 2001 and 2006 to a database run by U.S. Pharmacopeia, a group that sets drug standards, the alert said. Nearly 3 percent, or roughly 1,700, resulted in patient harm or death, the commission said.

Blood thinners are particularly tricky to use because too much can cause hard-to-control bleeding internally and from every body opening; too little can result in life-threatening blood clots, Chassin said.

Heparin is usually given intravenously. Warfarin, another blood thinner cited in the alert, is available in pills patients can take at home but can cause bad reactions when mixed with other medicines.

The recommendations "absolutely" will make a difference and hospitals will pay attention, said James Conway, senior vice president of the nonprofit Institute for Healthcare Improvement in Cambridge, Mass.

6. CT Continues to Miss Hollow Viscus Injury

Free fluid without organ injury on CT scan might be a harbinger of hollow viscus pathology.

Diagnosis of Blunt Intestinal and Mesenteric Injury in the Era of Multidetector CT Technology--Are Results Better?

Ekeh AP, et al. J Trauma. 2008;65:354-359.

Background: Blunt Bowel and Mesenteric injuries (BBMI) can present diagnostic difficulties and are occasionally recognized in a delayed fashion. Most studies evaluating these injuries predate multidetector Computerized Tomography (CT) scan technology. We set out to analyze whether the current era of multislice CT scanning has led to changes in the incidence of missed injuries in BBMI or altered the patterns of diagnosis.

Methods: All patients with blunt small and large intestinal injury as well as mesenteric lacerations, recognized in the operating room (OR) between November 2000 and December 2006 were identified from the trauma registry. A 4 slice helical multidetector CT scanner was in use for abdominal CT scans during the first portion of the study (November 2000-July 2005) whereas a 16 slice scanner was in use in the second portion (July 2005-December 2006). Rectal injuries and serosal tears were excluded.

Results: Eighty-two patients were identified with BBMI. Twenty-five patients went directly to the OR for laparotomy after a positive Diagnostic Peritoneal Lavage, a positive Focused Abdominal Sonogram or other injury. Of the 57 patients who underwent CT, findings indicating possible BBMI were present in 46 patients (80.7%). These included free fluid without solid organ injury (50.9%), free air (10.5%), active mesenteric bleeding (10.5%), and bowel swelling (5.3%). Eleven patients (19.3%) had delayed bowel or mesenteric injury recognition with the diagnosis ultimately made by repeat CT or in the OR (range, 1-10 days).

Conclusion: Missed injuries remain common in BBMI even in the current era of multislice CT scanners. Free fluid w/o solid organ injury, though not specific, continues to be an important finding. Adjuncts to CT continue to be necessary for the optimal diagnosis of bowel injuries.

7. Pediatric myth: fever and petechiae

Klinkhammer MD, et al. CJEM 2008;10:479-82.

A child presenting with petechiae and fever is assumed to have meningococcemia or another form of bacterial sepsis and therefore to require antibiotics, blood cultures, cerebrospinal fluid analysis and hospital admission.

A review of the literature challenges this statement and suggests that a child presenting with purpura (or petechiae), an ill appearance and delayed capillary refill time or hypotension should be admitted and treated for meningococcal disease without delay.

Conversely, a child with a petechial rash, which is confined to the distribution of the superior vena cava, is unlikely to have meningococcal disease. Outpatient therapy in this context is appropriate.

In other children, a reasonable approach would be to draw blood for culture and C-reactive protein (CRP) while administering antibiotics. If the CRP is normal, these children could be discharged to follow-up in 1 day, whereas children with CRP values greater than 6 mg/L would be admitted.

Full-text (free): http://caep.ca/template.asp?id=721926f66fc14a5d866d45c12f403cf1

8. Who Needs a Blood Culture? A Prospectively Derived and Validated Prediction Rule

Shapiro NI, et al. J Emerg Med. 2008;35:255-264

The study objective was to derive and validate a clinical decision rule for obtaining blood cultures in Emergency Department (ED) patients with suspected infection. This was a prospective, observational cohort study of consecutive adult ED patients with blood cultures obtained. The study ran from February 1, 2000 through February 1, 2001.

Patients were randomly assigned to derivation (2/3) or validation (1/3) sets. The outcome was “true bacteremia.” Features of the history, co-morbid illness, physical examination, and laboratory testing were used to create a clinical decision rule. Among 3901 patients, 3730 (96%) were enrolled with 305 (8.2%) episodes of true bacteremia. A decision rule was created with “major criteria” defined as: temperature above 39.5°C (103.0°F), indwelling vascular catheter, or clinical suspicion of endocarditis. “Minor criteria” were: temperature 38.3–39.4°C (101–102.9°F), age over 65 years, chills, vomiting, hypotension (systolic blood pressure below 90 mm Hg), neutrophil% greater than 80, white blood cell count over 18 k, bands more than 5%, platelets less than 150 k, and creatinine above 2.0.

A blood culture is indicated by the rule if at least one major criterion or two minor criteria are present. Otherwise, patients are classified as “low risk” and cultures may be omitted. Only 4 (0.6%) low-risk patients in the derivation set and 3 (0.9%) low-risk patients in the validation set had positive cultures. The sensitivity was 98% (95% confidence interval [CI] 96–100%) (derivation) and 97% (95% CI 94–100%) (validation). We developed and validated a promising clinical decision rule for predicting bacteremia in patients with suspected infection

9. Electrocardiographic Criteria for Detecting AMI in Patients With Left BBB: A Meta-analysis

Tabas JA, et al. Ann Emerg Med. 2008;52: 329-336.e1

Study objective
Numerous investigators have evaluated the ECG algorithm described by Sgarbossa et al to predict acute myocardial infarction in the presence of left bundle branch block and have arrived at divergent conclusions. To clarify the utility of the Sgarbossa ECG algorithm, we perform a systematic review and meta-analysis of these trials.

Methods
A structured search was applied to MEDLINE and Scopus databases, beginning with the year that the algorithm was derived (1996). Two reviewers independently screened citations, assessed for method quality, and extracted data (individual study characteristics, screening performance, and interobserver agreement) with a standardized extraction tool. We assessed qualifying studies for heterogeneity and generated summary estimates for the sensitivity, specificity, and positive and negative likelihood ratios with fixed-effect models.

Results
We identified 11 studies with 2,100 patients that met criteria for at least 1 component of the analysis. Ten studies with 1,614 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 3. These yielded a summary sensitivity of 20% (95% confidence interval [CI] 18% to 23%), specificity of 98% (95% CI 97% to 99%), a positive likelihood ratio of 7.9 (95% CI 4.5 to 13.8), and a negative likelihood ratio of 0.8 (95% CI 0.8 to 0.9). The summary diagnostic odds ratio revealed homogeneity. Seven studies with 1,213 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 2. These yielded sensitivities ranging from 20% to 79% and specificities ranging from 61% to 100%. Positive likelihood ratios ranged from 0.7 to 6.6 and negative likelihood ratios ranged from 0.2 to 1.1. The summary diagnostic odds ratio revealed heterogeneity. Intra- and interobserver agreement was substantial. Sensitivity analysis using the highest-quality studies yielded similar results.

Conclusion
A Sgarbossa ECG algorithm score of greater than or equal to 3, representing greater than or equal to 1 mm of concordant ST elevation or greater than or equal to 1 mm ST depression in leads V1 to V3, is useful for diagnosing acute myocardial infarction in patients who present with left bundle branch block on ECG. The scoring system demonstrates good to excellent overall interobserver variability. A score of 2, representing 5 mm or more of discordant ST deviation, demonstrated ineffective positive likelihood ratios. A Sgarbossa ECG algorithm score of 0 is not useful in excluding acute myocardial infarction.

Full-text (free): http://www.annemergmed.com/article/S0196-0644(07)01857-4/fulltext

10. Poor Sign-Outs = Worse Outcomes and Wasted Time

A prospective observational study reveals that inadequate sign-outs are common and have a negative effect on patient care.

Horwitz LI, et al. Arch Intern Med. 2008;168:1755-1760.

Background: In case reports, transfers in the care of patients among health care providers have been linked to adverse events. However, little is known about the nature and frequency of these transfer-related problems.

Methods: We conducted a prospective audiotape study of 12 days of "sign-out" of clinical information among 8 internal medicine house-staff teams. Each day, postcall and night-float interns were asked to identify any sign-out–related problems occurring during the coverage period and to identify the associated sign-out inadequacies. We verified reported sign-out inadequacies by reviewing each corresponding oral and written sign-out. We then developed a taxonomy of types of errors and their consequences through an iterative coding process.

Results: Sign-out sessions (N = 88) included 503 patient sign-outs. A total of 184 patients were signed out twice in the same night. Thus, there were 319 unique patient-days in the data set. We interviewed intern recipients of 84 of 88 sign-out sessions (95%) about sign-out–related problems. Postcall interns identified 24 sign-out–related problems for which we could verify sign-out inadequacies. Five patients suffered delays in diagnosis or treatment, resulting in 1 intensive care unit transfer, and 4 patients had near misses. In addition, house staff experienced 15 inefficiencies or redundancies in work. Sign-outs omitted key information, such as the patient's clinical condition, recent or scheduled events, tasks to complete, anticipatory guidance, and a specific plan of action and rationale for assigned tasks.

Conclusion: Omission of key information during sign-out can have important adverse consequences for patients and health care providers.

11. Five Images (with case descriptions) in EM from the Annals

a. Right-eye Swelling

http://www.annemergmed.com/article/S0196-0644(07)01951-8/fulltext

b. Proptosis of Left Eye

http://www.annemergmed.com/article/S0196-0644(07)01803-3/fulltext

c. Shortness of Breath and Chest Pain in Two Females

http://www.annemergmed.com/article/S0196-0644(08)00487-3/fulltext

d. Infant with Vomiting and Diarrhea

http://www.annemergmed.com/article/S0196-0644(08)00801-9/fulltext

e. Eye Pain and Double Vision

http://www.annemergmed.com/article/S0196-0644(07)01955-5/fulltext

12. Out-of-hospital cardiac arrest: Location is all

September 23, 2008. Lisa Nainggolan. Seattle, WA and Ann Arbor, MI - A new analysis of out-of-hospital cardiac arrest (OHCA) in 10 areas in North America has found a fivefold difference in survival rates [1]. Dr Graham Nichol (University of Washington, Seattle) and colleagues from the Resuscitation Outcomes Consortium (ROC) report their results in the September 24, 2008 issue of the Journal of the American Medical Association.

Nichol et al say more research is needed to understand why there is such variation but note that their study demonstrates that cardiac arrest is a treatable condition. "If survival after OHCA treated by emergency medical services [EMS] could be increased throughout North America from the study average of 7.9% to the maximum observed rate of 16.3%, an estimated 15 000 premature deaths would be prevented each year," they point out.

In a related paper in the same issue [2], Dr Comilla Sasson (University of Michigan, Ann Arbor) and colleagues say that to try to improve outcomes, attention should be focused on those patients most likely to survive OHCA, and they suggest certain rules should be adopted by EMS to decide when it is futile to continue resuscitation.

If survival after OHCA treated by EMS could be increased . . . from the study average . . . to the maximum observed rate, an estimated 15,000 premature deaths would be prevented each year. In an accompanying editorial [3], Drs Arthur B Sanders (University of Arizona Health Sciences Center, Tucson) and Karl B Kern (University of Arizona, Tucson) say that OHCA "has a dismal prognosis in many communities, [and] the magnitude of the problem in the US and Canada is such that even small improvements in survival translate into thousands of lives saved."

The study by Nichol et al illustrates that there is much room for improvement in the treatment of OHCA, they say, but they argue that applying rigid termination-of-resuscitation (TOR) criteria—as suggested by Sasson et al—is not necessarily the answer. Nichol agrees, telling heartwire: "Our point is more that there is a wide variation in care, so EMS agencies in [more poorly performing] cities need to try to improve their outcomes, rather than not resuscitating."

Location is all: 3% survive in Alabama compared with 16% in Seattle

In their prospective, observational ROC study, Nichol et al set out to determine whether cardiac-arrest incidence and outcome differed across geographic regions and included data on all OHCAs at seven US and three Canadian sites from May 2006 to April 30, 2007, followed up to hospital discharge and including data available as of June 28, 2008. The 10 sites were: Alabama; Dallas, TX; Iowa; Milwaukee, WI; Ottawa, ON; Pittsburgh, PA; Portland, OR; Seattle, WA; Toronto, ON; and Vancouver, BC.

Among the 10 sites, with a total population of 21.4 million, there were 20,520 cardiac arrests assessed by EMS personnel. Resuscitation was attempted in 11 898 cases (58.0% of the total); 2729 (22.9% of those treated) had initial rhythm of ventricular fibrillation (VF) or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator (AED), but just 954 (4.6%) were discharged alive. Among those in whom resuscitation was attempted, 7.9% of all patients with cardiac arrest and 21% of those with VF survived to hospital discharge.

But there was huge variation in survival rates across the sites, ranging from 3.0% in Alabama to 16.3% in Seattle, the best-performing region for cardiac-arrest survival rates. For VF survival, the figures were 7.7% in Alabama and 39.9% in Seattle. Median survival for cardiac arrest was 8.4% and for VF 22%.

"These findings have implications for prehospital emergency care. The fivefold variation in survival after EMS-treated cardiac arrest and fivefold variation in survival after ventricular fibrillation demonstrate that cardiac arrest is a treatable condition," they write.

Nichol told heartwire: "We are doing further work to understand why these differences occur, but it's probably for several reasons, including differences in patient risk, community response, and EMS response. The key point is for every city to monitor outcomes and try to improve them."

The editorialists agree: "It is time to work to overcome barriers in each community, devote appropriate resources, and optimize survival of all patients so that location by city becomes a minor factor in survival of cardiac arrest."

The remainder of the article: http://www.theheart.org/article/907113.do

13. Adding More Beds to the ED or Reducing Admitted Patient Boarding Times: Which Has a More Significant Influence on Emergency Department Congestion?

Khare RK, et al. Ann Emerg Med. 2008;52:in press as of Sept 29

Study objective
We evaluate a computer simulation model designed to assess the effect on emergency department (ED) length of stay of varying the number of ED beds or altering the interval of admitted patient departure from the ED.

Methods
We created a computer simulation model (Med Model) based on institutional data and augmented by expert estimates and assumptions. We evaluated simulations of increasing the number of ED beds, increasing the admitted patient departure and increasing ED census, analyzing potential effects on overall ED length of stay. Multiple sensitivity analyses tested the robustness of the results to changes in model assumptions and institutional data.

Results
With a constant ED departure rate at the base case and increasing ED beds, there is an increase in mean length of stay from 240 to 247 minutes (95% confidence interval [CI] 0.8 to 12.6 minutes). When keeping the number of beds constant at the base case and increasing the rate at which admitted patients depart the ED to their inpatient bed, the mean overall ED length of stay decreases from 240 to 218 minutes (95% CI 16.8 to 26.2 minutes). With a 15% increase in daily census, the trends are similar to the base case results. The sensitivity analyses reveal that despite a wide range of inputs, there are no differences from the base case.

Conclusion
Our computer simulation modeled that improving the rate at which admitted patients depart the ED produced an improvement in overall ED length of stay, whereas increasing the number of ED beds did not.

14. A Comparison of Observed Versus Documented Physician Assessment and Treatment of Pain: The Physician Record Does Not Reflect the Reality

Chisholm CD, et al. Ann Emerg Med. 2008;52:383-389.

Study objective
The Joint Commission requires “appropriate assessment” of patients presenting with painful conditions. Compliance is usually assessed through retrospective chart analysis. We investigate the discrepancy between observed physician pain assessment and that subsequently documented in the medical record.

Methods
This was an observational study using a trained investigator watching bedside interactions of emergency physicians. Using a priori definitions, the investigator recorded whether the patient volunteered the presence of pain, physician inquiry about pain, attempts to quantify the pain, treatment offered/rendered, and any assessment of the response to therapy. An independent investigator subsequently assessed the patient's chart for documentation of pain assessment, therapy rendered, and response to treatment. Children younger than 5 years and patients with major trauma, altered mental status, or nontraumatic chest pain were excluded. The institutional review board approved the protocol, the physicians agreed to participate in an “ergonomic study” without knowing the exact nature of data collection, and patients released their records.

Results
The investigator observed 209 patient encounters. Physicians acknowledged the patients' pain 98.1% of the time but documented its presence in 91.7%. Physicians attempted to quantify the patient's pain in 61.5% of encounters but documented that attempt in only 38.9%. Treatment was offered in 79.9% and recorded in 31.7% of charts. When treatment was offered, the patient's response to the therapy was recorded only 28% of the time.

Conclusion
Physicians almost always assess and treat patient pain but infrequently record those efforts. The patient's chart is a poor surrogate marker for pain assessment and care by emergency physicians and may not be suitable for use as a compliance assessment tool. Research methodology using retrospective chart analysis may be affected by this phenomenon, suggesting the potential for underestimation of patient pain assessment and treatment by emergency physicians.

Full-text (free): http://www.annemergmed.com/article/PIIS0196064408000310/fulltext

15. Ovarian Hyperstimulation Syndrome: A Potentially Fatal Complication of Early Pregnancy

Madill JJ, et al. J Emerg Med. 2008;35:283-286.

We present the case of a patient who presented to the Emergency Department (ED) 48 h after successful in vitro fertilization with abdominal pain, hypotension, and free fluid on an ED-focused abdominal sonogram for trauma study. This presentation is typical of Ovarian Hyperstimulation Syndrome (OHSS), a diagnosis that may be unfamiliar to many Emergency Physicians. With the increasing frequency of in vitro fertilization procedures, this disease process is becoming more common. Numerous complications can occur with OHSS, including third-space fluid accumulation, hemoconcentration, renal failure, and thromboembolic phenomena. Vigilance is required as these patients are at increased risk of ovarian torsion, ovarian rupture with internal hemorrhage, ectopic pregnancy, and infection. This case report provides an overview of clinical features and emergent management of OHSS.

16. Does a waiting room video about what to expect during an ED visit improve patient satisfaction?

Papa L, et al. CJEM 2008;10:347-54

Objective: We created an instructional waiting room video that explained what patients should expect during their emergency department (ED) visit and sought to determine whether preparing patients using this video would 1) improve satisfaction, 2) decrease perceived waiting room times and 3) increase calls to an outpatient referral line in an ambulatory population.

Methods: This serial cross-sectional study took place over a period of 2 months before (control) and 2 months after the introduction of an educational waiting room video that described a typical patient visit to our ED. We enrolled a convenience sample of adult patients or parents of pediatric patients who were triaged to the ED waiting room; a research assistant distributed and collected the surveys as patients were being discharged after treatment. Subjects were excluded if they were admitted. The primary outcome was overall satisfaction measured on a 5-point Likert scale, and secondary outcomes included perceived waiting room time, and the number of outpatient referral-line calls.

Results: There were 1132 subjects surveyed: 551 prevideo and 581 postvideo. The mean age was 38 years (standard deviation [SD] 18), 61% were female and the mean ED length of stay was 5.9 hours (SD 3.6). Satisfaction scores were significantly higher postvideo, with 65% of participants ranking their visit as either "excellent" or "very good", compared with 58.1% in the prevideo group (p = 0.019); however, perceived waiting room time was not significantly different between the groups (p = 0.24). Patient calls to our specialty outpatient clinic referral line increased from 1.5 per month (95% confidence interval [CI] 0.58-2.42) to 4.5 per month (95% CI 1.19-7.18) (p = 0.032). After adjusting for possible covariates, the most significant determinants of overall satisfaction were perceived waiting room time (odds ratio [OR] 0.41, 95% CI 0.34-0.48) and having seen the ED waiting room video (OR 1.41, 95% CI 1.06-1.86).

Conclusion: Preparing patients for their ED experience by describing the ED process of care through a waiting room video can improve ED patient satisfaction and the knowledge of outpatient clinic resources in an ambulatory population. Future studies should research the implementation of this educational intervention in a randomized fashion.

Full-text: http://caep.ca/template.asp?id=33082a7e5f5d48e797bb5746646f0d61

17. Regionalization of Care for ST-Segment Elevation Myocardial Infarction: Is It Too Soon?

Pottenger BC, et al. Ann Emerg Med. 2008;52:in press as of Sept 29

Interest in regionalization of the care of acute ST-segment elevation myocardial infarction (STEMI) has gained momentum recently. Optimal treatment of STEMI involves balancing time to treatment and reperfusion options. Primary percutaneous coronary intervention, when performed in a timely fashion, has been shown to be more effective than fibrinolysis. However, numerous practical barriers prevent many STEMI patients from receiving primary percutaneous coronary intervention. In an effort to increase beneficial primary percutaneous coronary intervention administration to STEMI patients, health care leaders have proposed regionalized STEMI care networks with advanced emergency medical services (EMS) involvement. Constructing regionalized STEMI networks presents a policy challenge because this shift in STEMI care would require changes in current EMS and emergency medicine practices.

Therefore, we present various perspectives and issues that decision-makers and system organizers must address properly before deciding whether to adopt this new model of care. Reorganizing STEMI care in a manner analogous to how trauma and stroke care are currently triaged and treated appeals intuitively; however, given the absence of evidence that STEMI regionalization actually improves patient outcomes and is cost-effective, more research is needed to determine whether STEMI regionalization is an efficient model for providing evidence-based care. The concept of STEMI regionalization represents an effort to inform policy according to evidence-based medicine, but real-world quality, geospatial, financial, cost, business, resource, and practice barriers present obstacles to implementing this concept efficiently and effectively.

18. A Randomized Trial of Diphenhydramine as Prophylaxis Against Metoclopramide-Induced Akathisia in Nauseated ED Patients

Friedman BW, et al. Ann Emerg Med. 2008;52:in press as of Sept 29

Study objective
Akathisia, an adverse effect observed at times after administration of parenteral metoclopramide, is an unpleasant symptom complex characterized by restlessness and agitation. Some try to limit the development of akathisia by coadministering diphenhydramine when using parenteral metoclopramide. The goal of this investigation is to determine whether concomitant administration of diphenhydramine 25 mg decreased the rate of development of akathisia after administration of 10 mg or 20 mg of intravenous metoclopramide.

Methods
This was a randomized, double-blind, factorial design trial. Patients who presented to our emergency department with a primary or secondary chief complaint of nausea were randomized to one of the following 4 groups: (1) metoclopramide 10 mg+diphenhydramine 25 mg; (2) metoclopramide 10 mg+placebo; (3) metoclopramide 20 mg+diphenhydramine 25 mg; (4) metoclopramide 20 mg+placebo. The medications were inserted into a 50-mL bag of normal saline solution and administered as an intravenous drip during 15 minutes. Primary outcome was development of akathisia within 60 minutes of medication administration, as measured by blinded assessors using a short akathisia instrument, or use of rescue medication for treatment of akathisia by blinded clinical staff. Patients were also asked at baseline and 30 minutes later whether they felt restless.

Results
Two hundred eighty-nine patients were randomized and 286 patients were included in the final analysis. Within 1 hour of medication administration, 17 of 143 patients randomized to diphenhydramine (12%; 95% confidence interval [CI] 8% to 18%) and 17 of 143 (12%; 95% CI 8% to 18%) randomized to placebo developed akathisia (95% CI for difference of 0%: –8% to 8%). Thirteen of 143 patients randomized to metoclopramide 10 mg (9%; 95% CI 5% to 15%) and 21 of 143 randomized to metoclopramide 20 mg (15%; 95% CI 10% to 22%) developed akathisia (95% CI for difference of 6%: –2% to 14%). In those administered prophylactic diphenhydramine, odds of akathisia relative to placebo were 1.0 (95% CI 0.5 to 2.0). Odds of akathisia in those administered 20 mg of metoclopramide relative to the 10-mg dose were 1.7 (95% CI 0.8 to 3.6). Among patients who received 20 mg of metoclopramide, subjective restlessness was reported by 7 of 72 (9.7%) patients who received diphenhydramine and 14 of 71 (19.7%) patients who received placebo (95% CI for difference of 10%: –2% to 22%).

Conclusion
Routine prophylaxis with diphenhydramine to prevent akathisia is unwarranted when intravenous metoclopramide is administered over 15 minutes. For patients administered 20 mg of metoclopramide, prophylactic diphenhydramine may decrease subjective restlessness.

19. Elderly Patients May Be Less Likely to be Taken to a Trauma Center by EMS Personnel

Laurie Barclay, MD. August 24, 2008 — Emergency medical services (EMS) providers may be less likely to transport elderly patients to a trauma center, according to the results of a retrospective analysis reported in the August issue of Archives of Surgery.

"Evidence-based clinical practice guidelines strongly recommend that elderly trauma patients be treated as aggressively as non-elderly patients," write David C. Chang, PhD, MPH, MBA, from the Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues. "However, some studies have suggested that age bias may still exist in trauma care, even in the prehospital phase of that care."

The goal of this study was to assess whether age bias is a factor in triage errors. A retrospective analysis of 10 years of prospectively collected data (from 1995 to 2004) in the statewide Maryland Ambulance Information System was performed, followed by surveys of EMS personnel at regional EMS conferences and of trauma center personnel at level 1 trauma centers.

Trauma patients were defined as those who met criteria of the American College of Surgeons for physiology, injury, and/or mechanism and who were subjectively declared by EMS personnel to be priority 1 status (requiring immediate attention). The primary endpoint was undertriage, defined as failure to transport trauma patients to a state-designated trauma center.

Among 26,565 trauma patients identified by registry analysis, the undertriage rate was higher in patients aged 65 years or older than in younger patients (49.9% vs 17.8%; P less than .001). Multivariate analysis revealed that being age 50 years was also associated with a decrease in trauma center transports (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.57 – 0.77), with an even more marked decrease at age 70 years (OR, 0.45; 95% CI, 0.39 – 0.53) in comparison with patients aged younger than 50 years.

Among 166 respondents (127 EMS personnel and 32 medical personnel, with 7 respondents refusing to identify their training background) who completed the follow-up surveys, the leading 3 factors responsible for this undertriage were given as insufficient training for managing elderly patients (25.3%), lack of familiarity with the protocol (12%), and possible age bias (13.4%).

"Even when trauma is recognized and acknowledged by EMS, providers are consistently less likely to consider transporting elderly patients to a trauma center," the study authors write. "Unconscious age bias, in both EMS in the field and receiving trauma center personnel, was identified as a possible cause."

Limitations of this study include unknown effect of this undertriage on patient outcomes and unsuccessful attempt to link the EMS data to Maryland hospital discharge data.

"The problem of age bias raised in this study may negate efforts to improve clinical care for elderly trauma patients within trauma centers if the system as a whole does not function properly and deliver patients appropriately to needed resources," the authors write. "It may be helpful to highlight the literature that now suggests that elderly trauma patients do, in fact, return to productive lives after their injury, which can eliminate the perception of futility of care that may be used consciously or subconsciously to justify age bias."

Chang DC, et al. Arch Surg. 2008;143:776–781.

20. The prognostic factors of hypotension after rapid sequence intubation

Lin C, et al. Amer J Emerg Med. 2008;26:845-851.

Background
Rapid sequence intubation (RSI) has achieved high success and low complication rate in the ED. However, hypotension after RSI does occur. This study aimed to identify the prognostic factors of hypotension after RSI.

Methods
This study identified patients who needed emergency airway management and then divided them into 2 groups. Patients in the first group were the hypotension group, whose systolic blood pressure (SBP) was found to be greater than 90 mm Hg before RSI but less than 90 mm Hg after RSI. Patients in the second group were deemed as the control group whose pre-SBP and post-SBP were greater than 90 mm Hg. The following variables were measured in the study: age, sex, body weight, patients' underlying disease and ongoing disease, the initial vital signs, and laboratory tests. A prognostic model with multiple logistic regression was established based on significant findings from univariate analysis.

Results
A total of 149 patients were recruited from the ED in this study, with 28 patients in the hypotension group and 121 patients in the control group. After univariate analysis, there were 6 factors identified as significant findings including chronic obstructive pulmonary disease, sepsis, albumin, lidocaine, low body weight (below 55 kg), and preintubation blood pressure of less than 140 mm Hg. Multiple logistic regression has demonstrated that patients' underlying diseases, anthropometric parameters, and drug medications were factors related to postintubation hypotension among ED patients.

Conclusions
Clinical practitioners in the ED should take a patient's predisposing factors into serious consideration before emergency intubation while a preplanned strategy is made.

21. Adenosine in the treatment of supraventricular tachycardia: 5 years of experience (2002-2006)

Riccardi A, et al. Amer J Emerg Med. 2008;26:879-882.

We report a retrospective analysis of 5 years of adenosine use in our emergency department (2002-2006). We treated 454 patients with an intravenous bolus of adenosine. The cohort was made up of 40.7% men and 59.3% women, with mean age of 47.32 years, mean heart rate of 162.48 beats per minute. Among them, 73% responded immediately to the 6-mg dose, 15% responded after the second 12-mg dose, and 11% responded to a further 12-mg dose, whereas 11% were unresponsive. We observed minor side effects in a high percentage of patients (ie, chest tightness 83%, flushing 39.4%, sense of impending death 7%). Only 1 major adverse effect was recorded, that is, administering 12 mg of adenosine induced a marked acceleration in the ventricular rate of a patient with an undiagnosed atrial flutter, caused by induction of atrioventricular conduction (1:1). Our results confirm that when patients are appropriately selected, adenosine is probably the best available drug to treat paroxysmal supraventricular tachycardias, especially in emergency situations.