CAEP/ACMU 2000 Scientific Abstracts: 40-43

CAEP Abstracts

CJEM 2001;2(3):169-187

040 ED-Based Parenteral Antibiotic Therapy: An Emerging Treatment Strategy for Cellulitis.
Murray HE, Tourigny P. Queen's University, Kingston, Ont.

OBJECTIVE: Patients in Canadian EDs with cellulitis are now often treated with outpatient parenteral antibiotic therapy (OPAT) delivered through the ED instead of hospital admission. This change in practice has not been previously documented. The goal of this study was to quantify the numbers and types of patients receiving OPAT.
METHODS: This retrospective cohort was performed in a tertiary referral centre. Charts from all 1998 ED patient visits with a discharge diagnosis of skin infection were reviewed. Analyses included descriptive statistics with 95% CIs, univariate and multivariate associations. RESULTS: 778 charts were reviewed and 488 patients were included. Study patients had the following diagnoses: cellulitis (42.4%), abscess (34.2%), wound infection (17.8%) and erysipelas (5.5%). 167 patients (34.2%) were treated with ED based OPAT. 57 patients (11.7%) were referred for subspecialty consultation and 33(6.8%) were admitted. Of the patients treated with OPAT, 120 (71.9%) were managed by the ED physicians alone. These patients had 427 ED visits, with a mean 3.2 visits per patient (95% CI, 2.9­3.6). Univariate predictors of OPAT (p < 0.05) were previous antibiotic treatment, immunocompromise, history of fever, chills or vomiting, lymphangitis, fever in ED and absence of pus. Multivariate predictors of OPAT were fever in ED (OR 3.95; 95% CI, 1.6­9.8), previous antibiotics (OR 2.73; 95% CI, 1.5­5.0) and lymphangitis (OR 2.58; 95% CI, 1.4­4.8). CONCLUSIONS: ED based OPAT for skin infections is an emerging phenomenon in Canada. Further study is needed to determine the cost-effectiveness of this treatment strategy.
Key words: cellulitis, outpatient, cost-effectiveness

041 Identification of HIV and Hepatitis C Infected Patients in a Northern Urban Emergency Department. Rowe BH, Mashinter L, Joffe M, Mackey D, Preiksaitis Y, Houston S. University of Alberta, Edmonton, Alta.

OBJECTIVES: Transmission of blood borne pathogens like HIV and Hepatitis C (HC) from patients is a potential risk for all emergency department staff. However, data regarding disclosure of these infections in the ED setting remains sparse. This anonymous unlinked study examined HIV and HC disclosure in a Canadian urban ED sample.
METHODS: Patients aged 15­54 were included if they presented to one of 2 EDs and had a CBC drawn. Left over blood was collected and serotested for HIV and HC. The list of study patients was cross-referenced against local lab and clinic databases of known HIV and HC seropositive patients prior to unlinking and serotesting. ED records of known seropositives were reviewed for evidence of patient HIV or HC disclosure. RESULTS: A total of 3,057 adult cases were identified from 06/99­07/99. Overall, 39 (1.3%) patients had proven HIV infection and 302 (9.8%) had proven HC infection. More patients (32 [82%]) with HIV were previously known to the laboratory or to ID clinics/physicians compared to patients with HC (p < 0.001). Patients with HIV more commonly disclosed their infection in some way (24[75%]) in the ED than did those who had HC (p = 0.02). Only 130 (43%) patients were known to have HC infection. CONCLUSIONS: Most HIV patients are aware of their infection and disclose this to health providers in the ED. However, HC is a much more common infection, and more than half of these patients are unaware of their illness. Moreover, since few HC patients disclose their disease to the ED staff, the transmission risk posed by unknown HC positive patients is considerable for health workers.
Key words: hepatitis C, HIV, transmission, seropositive

042 Do Injection Drug Users Have Different Medication Requirements in Procedural Sedation?
Grafstein E, Innes G, Roland K. St. Paul's Hospital, Vancouver, BC.

BACKGROUND: Injection drug users (IDUs) may require increased sedation medications that put them at higher risk of adverse events (AE) during procedural sedation. OBJECTIVES: To compare mean dose, medication choices, AE and ED length of stay (LOS) for IDUs.
METHODS: A retrospective survey of patients receiving procedural sedation in an inner city Canadian ED from January 1997 to October 1999. During procedural sedation, all patients have a standard sedation form completed that documents drug administration, vital signs and patient outcomes. We reviewed 539 consecutive patients who underwent procedural sedation and excluded 38 patients whose IDU status was uncertain. RESULTS: 166 patients were IDUs and 335 were non-IDUs (n = 501). 92.6% (315) of the non-IDUs received midazolam/fentanyl, 3.6% (8) received thiopental, 1% (4) received ketamine, and 2.4% (8) received other medications. 71% (118) of the IDU group received midazolam/fentanyl, 23% (38) received ketamine, and 6.6% (11) received thiopental. The commonest procedures in IDUs were I&D of cutaneous abscesses (73%) and shoulder relocation (13%); and in non-IDUs shoulder relocation (30%) and Colles' fracture reduction (28%).

Median LOS was 94 minutes (IQR 70­135) for non-IDU patients and 102 minutes (IQR 69.3­165) for IDUs. No arrhythmias, deaths, or intubations occurred in either group. CONCLUSIONS: IDUs require more medications for procedural sedation and have slightly longer ED LOS. IDUs have no appreciable increased risks of adverse events than non-IDU patients.

Key words: procedural sedation, complications, intravenous drug use

043 The Canadian Activase for Stroke Effectiveness Study (CASES).
043 The Canadian Activase for Stroke Effectiveness Study (CASES).

BACKGROUND: Therapy for acute stroke using rtPA was approved in Canada in February 1999. The Canadian Activase for Stroke Effectiveness Study Group was formed to study the use of rtPA in Canada in a 2 year post-marketing study. PURPOSE: To prospectively assess the safety of rtPA in the Canadian context and to examine whether the efficacy of rtPA for acute stroke, demonstrated in randomized trials, can be translated into effectiveness in clinical practice across Canada.
METHODS: The CASES group is a multi-stakeholder collaboration involving the Canadian Stroke Consortium (CSC), the Heart & Stroke Foundation of Canada, Hoffman­LaRoche Canada and physicians across the country. Canadian centres were registered and recruitment is ongoing. Patient information is being collected prospectively and evaluated in a blinded fashion. Each centre has been asked to have study protocol approved by the local research ethics board. Demographics, stroke risk factors, blood pressure, biochemistry, hematology, and CT scans are being collected. NIH stroke scores and modified Rankin scores are being collected. Outcomes will be monitored at discharge and at 3 months.

RESULTS:

CONCLUSIONS: CASES is an ongoing prospective evaluation of the effectiveness of rtPA in acute stroke. The symptomatic hemorrhage rate is 4.0%, and other 90-day outcomes are commensurate with those observed in randomized trials.

Key words: stroke, thrombolysis, tissue plasminogen activator