CAEP/ACMU 2000 Scientific Abstracts: 26-28

CAEP Abstracts

CJEM 2001;2(3):169-187

026 Mortality and Thrombolysis Time Intervals with Prehospital 12-Lead Electrocardiogram and Advance Emergency Department Notification: A Meta-Analysis.
Morrison LJ, Brooks S, Sawadsky BV, McDonald AC, Verbeek PR. Division of Prehospital Care, Sunnybrook & Women's Health Sciences Centre, University of Toronto, Toronto Ambulance Service, Toronto, Ont.

OBJECTIVE: All randomized, historical and concurrent controlled trials of EMS care in suspected acute myocardial infarction (AMI), comparing all-cause mortality (ACM) or thrombolysis time intervals with prehospital 12-lead electrocardiogram (PHECG) and advance emergency department (ED) notification to standard EMS care, were systematically reviewed and analyzed.
METHODS: The Cochrane search strategy was used to search MEDLINE (85­99), EMBASE (80­99), Current Contents (93­99), Dissertation Abstracts (81­99), and Index of Scientific and Technical Proceedings (91­98). Bibliographies of texts and journals were hand searched. The search for unpublished studies included the NIH Web site, Medical Editors Trial Amnesty, industry and primary authors. Two authors independently reviewed 1283 citations. Weighted kappa for selection: Titles 0.61 (SE 0.045); Abstracts 0.63 (SE 0.051); Articles 0.79 (SE 0.146). Two authors blinded to title, author and journal, independently abstracted data. Two different authors, blinded as above, independently assessed study quality using a validated scale by Detsky and Naylor (range 0.2­0.59/1.0). The ICC for random raters was 0.84 (95% CI 0.09­0.98). RESULTS: ACM at 42 days was only reported in one study using a historical control (treatment group (TG) 6/71, control group (CG) 20/128, OR 0.499, 95% CI 0.17­1.4, NNT 14, p = 0.22, 29% power). The weighted pooled mean on-scene time interval was similar in both groups (TG 20.83 mins SD 12.28, CG 20.47 mins SD 11.34, p = 0.6735, 10% difference, 84% power). The weighted pooled mean door-to-needle interval was decreased in the TG by 60.7 mins (TG 35.16 mins, SD 11.24, CG 95.83 mins, SD 43.85, p < 0.01). CONCLUSION: There is inadequate data to determine the effect of PHECG with advance ED notification on all-cause mortality in AMI. The significant pooled effect on relevant time intervals should be interpreted with caution due to the overall low study quality and the comparison of different control groups.
Key words: emergency medical services, electrocardiogram, myocardial infarction

027 Determinants of the Risk of Violence in the Emergency Department: Implications for Triage.
Oster A, Bernbaum S, Patten S. Faculty of Medicine, University of Calgary, Calgary, Alta.

OBJECTIVES: To identify the clinical correlates of Emergency Department (ED) violent behaviour in patients presenting to a Psychiatric Emergency Service (PES).
METHODS: We analysed data from an electronic PES database covering a 4-year period to April 1998. The database included demographic and clinical data for all patients seen in the service. The PES was physically located in a general hospital ED. RESULTS: 10,582 patient presentations were recorded. Violence was defined as physically or verbally aggressive or assaultive behaviour. Correlates of violence were identified. Patients with a moderate to high score (>26) on the American Psychiatric Association's DSM-IV Global Assessment of Functioning (GAF) scale were violent 5.5% of the time while in the ED. Patients with a GAF <26 had a frequency of violence (FOV) of 17.8% (RR = 3.24, CI 2.50­4.18). Patients with a GAF >26 who also had a history of violence, had a FOV of 15.9% (RR = 2.89, CI 2.39­3.50). Patients with a GAF >26 who had schizophrenia (or a psychotic disorder not otherwise specified) had a FOV of 9.3% (RR = 1.69, CI 1.35­2.12). Patients with a GAF >26 with psychosis and a history of violence, had a FOV of 23.4% (RR = 4.25, CI 3.01­6.01). Patients with a GAF <26 and a history of violence, had a FOV of 35.0% (RR = 6.37, CI 3.77­10.75). Patients with a GAF <26 with psychosis, had a FOV of 23.7% (RR = 4.31, CI 2.86­6.50). Patients with a GAF <26, psychosis and a history of violence, had a FOV of 45.5% (RR = 8.26, CI 3.45­19.74). CONCLUSIONS: Prevention of violence in the ED involves identifying those patients at highest risk and implementing appropriate safeguards and preventive strategies. Our data suggest that patients with a history of violence, those who are severely ill (reflected in a low GAF score) and those with psychotic symptoms are at highest risk. The cumulative impact of these predictors is additive.
Key words: violence, emergency department

028 Adolescent Psychosocial Documentation in the Emergency Department: Testing of an Intervention.
van Amstel LL, Lafleur D, Blake KD. Dalhousie University, Department of Pediatrics and , IWK Grace Health Centre, Halifax, NS.

The emergency department (ED) is the only health contact for many adolescents and could therefore serve as a route for identifying psychosocial concerns. The topics of Home,Education, Alcohol, Drugs,Smoking andSex (HEADSS) are important areas of inquiry when interviewing adolescents. OBJECTIVES: To determine the effectiveness of a HEADSS stamp at improving adolescent psychosocial documentation in the ED chart.
METHODS: An interventional study of ED chart psychosocial documentation was conducted which compared a control period to a period with the HEADSS stamp on the chart. Presenting complaints were recorded and psychosocial documentation in the ED chart was compared between the two periods. Historical information from past medical records was also gathered.
RESULTS: 153 adolescents (M = 79, F = 74; mean age = 14.1 ± 0.90 years) were seen during the HEADSS period. Documentation of the HEADSS topics ranged from 8%­12% whereas the preceding control period (n = 153, M = 85, F = 67; mean age = 14.2 ± 0.90 years) ranged from 0%­7%. During the HEADSS period, ED physicians were more likely to document whether the topics of Education (p = 0.015), Alcohol (p = 0.02) and Smoking (p = 0.001) were addressed as well as whether the patient was interviewed alone (p = 0.0001). Physicians were also more likely to report detailed psychosocial assessment (>4/6 topics addressed; p = 0.003) and to refer to a crisis worker or specialist (p = 0.048) during the HEADSS period.
CONCLUSIONS: The HEADSS stamp is useful in prompting adolescent psychosocial documentation in the ED chart. Routine placement of HEADSS in adolescent ED charts could serve to facilitate psychosocial screening of adolescents.
Key words:adolescent health, documentation