CAEP/ACMU 2000 Scientific Abstracts: 44-47

CAEP Abstracts

CJEM 2001;2(3):169-187

044 Platelet Hyperactivity and Platelet/Leukocyte Interactions Associated with Ischemic Cerebrovascular Disease.
Holroyd BR, Rowe BH, Saddiqui M, Folk D, Etches WS, Shuaib A, Stewart MW. University of Alberta, Edmonton, Alta.

BACKGROUND: Platelets (plt) play an important role in thrombus formation in transient ischemic attacks (TIA) and strokes (CVA). This study was designed to examine plt function and other cellular interactions in TIA and CVA patients.
METHODS: A convenience sample of adult (>18 years) cases (acute TIAs/CVAs) and controls (age and gender matched) were enrolled in this prospective laboratory study after informed consent was obtained. Plt function (adhesion and aggregation) and white blood cell (WBC)-plt interactions were rapidly determined using a modification of a previously validated technique based on plt binding to immobilized von Willebrand factor (VWF) (Br J Haem 1997;97:321). RESULTS: Samples from 15 cases and 8 ED controls were available for analysis. Mean age was 71.1 years (SD = 11.6), 16 of 23 (70%) were male, and 9 (60%) of the cases were already receiving anti-platelet agents. Age, gender, plt, hemoglobin, and WBC counts were similar between the groups (p > 0.05). Plt hyper-function was identified in 13 (87%) cases compared to only 2 (25%) controls (p = 0.006). WBC-plt interactions were observed in 5 (33%) cases compared to only 1 (13%) controls (p = 0.36). Overall, only 1 (4%) of the patients had wbc-plt interactions without plt hyperactivity. CONCLUSIONS: Plt hyper-function and plt/wbc binding are commonly identified in ED patients who present with TIA/CVA, irrespective of their previous anti-platelet therapy. These data suggest an association between thrombosis and the inflammatory response in this patient group. These results identify a unique opportunity to diagnose and manage acute ischemic cerebrovascular diseases.
Key words: stroke, transient ischemic attack, platelet function

045 Physician Charting in the Emergency Department: Does a Change in Chart Format Result in Improved Documentation?
Bijlsma JJ, Mcleod KI, Abu-Laban RB. Vancouver General Hospital, Vancouver, BC.

OBJECTIVES: Documentation is an important aspect of patient care. In November 1997, a new chart, which included numerous labeled fields to facilitate and encourage documentation, was introduced in the Vancouver General Hospital emergency department. We sought to determine whether this change in chart format resulted in an improvement in emergency physician documentation for an a priori derived item list.
METHODS: A retrospective time series was carried out covering four time periods (May and October of 1997 and 1998). Five charts for each of 20 emergency physicians were randomly selected from each time period when possible. Each chart was reviewed using explicit criteria for documentation of time of initial assessment, oxygen saturation, Glasgow Coma Score, tetanus status, progress notes, time of progress notes, test results, and discharge instructions. The primary outcome was a by-item comparison of documentation proportion pooled for the time periods before versus after introduction of the new chart. Results were analysed using Stata (Version 5.0, Mac). RESULTS: 342 charts were reviewed. A significant improvement following introduction of the new chart was found in documentation of time of initial assessment (15.3%, 95% CI 9.8%­20.9% vs. 53.6%, 95% CI 46.3%­60.9%, p < 0.0001), tetanus status (2.5%, 95% CI 0.1%­4.8% vs. 6.7%, 95% CI 3.0%­10.4%, p < 0.03), and discharge instructions (42.9%, 95% CI 35.3%­50.5% vs. 64.8%, 95% CI 57.8%­71.8%, p < 0.0001). Documentation of other reviewed items was unchanged. CONCLUSION: Emergency physician documentation for some items can be improved by a change in chart format. Overall documentation proportions were low for many of the items studied, however no attempt was made to assess the necessity of specific documentation in each case. Further research is warranted on methods to improve physician documentation through changes in chart format.
Key words: documentation, emergency department

046 Data Recording and Resource Utilization by Low Back Pain Patients in the ED.
Bullard MJ, Kelly KD, Sher A, Dorji H, Voaklander D, Rowe BH. University of Alberta, Edmonton, Alta.

OBJECTIVES: To determine the diagnostic and treatment practices and chart documentation for low back pain (LBP) patients seen in the emergency department (ED).
METHODS: From 01/04/97 to 31/03/98 there were 4,233 patients with LBP seen in five regional EDs; 1,368 (32%) were seen at the University of Alberta Hospital (UAH). A structured form audit was completed on randomly selected patients at the UAH.
RESULTS: Of 500 ED visits selected, 50 (11%) patients were excluded because they were not seen by an ED physician or were misclassified. Of the remaining 450, 53% were male, mean age was 49 years and 143 (32%) were over the age of 50. Discharge diagnosis was mechanical LBP in 347 cases (77%) and discogenic pain in 68 (15%). Only 41 patients (9%) presented following an injury. Data abstraction revealed many charting omissions, including failure to document motor strength in 176 patients (39%), failure to document straight leg testing (n = 16, 23%), cross leg testing (n = 45, 66%), and bowel or bladder function (n = 43, 63%) in patients with suspected discogenic LBP, and failure to document cancer history (n = 86, 60%) and presence or absence of abdominal aortic aneurysm (n = 136, 95%) in patients over age 50 with non-traumatic LBP. Only 27 (6%) lumbar radiographs were ordered for patients with non-traumatic LBP. Most patients (n = 431, 96%) were discharged on non-steroidal or simple analgesics (n = 187, 42%), and only 36 received more potent narcotics. CONCLUSIONS: While the care of patients with LBP appeared to be consistent with recommended guidelines, documentation and writing legibility were poor. This study suggests a role for age and etiology-driven, structured LBP charting templates that would facilitate better record keeping, as well as decision prompts to assist physicians in managing patients with LBP.
Key words: documentation, back pain, emergency department

047 Validation of a Prediction Rule for Safe Early Discharge of Patients Given Naloxone for Presumed Opioid Overdose.
Christenson JM, Etherington J, Pennington S, Wanger K, Fernandes C, Grafstein E, Innes G, Spinelli JJ, Raboud J. St. Paul's Hospital, UBC, Vancouver, BC.

OBJECTIVES: To validate a previously developed clinical prediction rule which identified patients with presumed opioid overdose who were safe for early discharge. METHODS AND
RESULTS: 486 patients given prehospital or emergency department naloxone for presumed opioid overdose were prospectively evaluated one hour after naloxone administration for prediction rule parameters. The rule predicts safe discharge (at 1 hour) for patients with all of the following: respiratory rate >10 and <20 breaths/min, heart rate >50 and <100 beats/min, oxygen saturation >92% on room air, temperature >35.5 and <37.5, Glasgow coma score of 15, and ability to mobilize as usual. After discharge, patients were followed up by telephone and by searching regional hospital, coroner's and provincial vital statistics databases. In the study cohort, the following adverse outcomes occurred within 24 hours: death (2), assisted ventilations (22), supplemental oxygen for hypoxia (86), IV antibiotics for pneumonia, CNS infection or sepsis (15), fluid bolus for hypotension (19), inotrope (3), antiarrhythmic (2), or mannitol (0) administration, emergency surgical procedure (0), bicarbonate for acidosis (0), charcoal for other life-threatening overdose (9). The rule was 98.3% sensitive (95% CI, 93.9%­99.8%) and 36.8% specific (95% CI, 31.9%­41.9%) in predicting adverse events. CONCLUSION: The previously developed clinical rule to predict the safe discharge of patients with presumed opioid overdose will allow many patients to be discharged safely one hour after naloxone administration.
Key words: naloxone, opioid overdose, heroin, clinical prediction rule