2005 CAEP / ACMU Scientific Abstracts - Poster Presentations: 72-84
2005 Scientific Abstracts
CJEM 2005;7(3):176-211
May 29 - June 1, 2005
Edmonton, Alta.
Disclaimer: The large number of abstracts submitted and the short time interval between submission and publication does not permit communication with authors, abstract revision, or CJEM editorial review. The following abstracts are presented, unedited, as they were submitted to the CAEP Research Committee. Abstract authors are from the department or division of emergency medicine of their respective universities unless otherwise specified.
Avertissement : Le grand nombre de résumé soumis et le court délai entre leur réception et la date de publication on empêché la communication avec les auteurs, la révision des résumés, ou l'évaluation par le comité de réduction du JCMU. Les résumés qui suivent sont présentés non édités, tel qu'ils ont été soumis au Comité de Recherche de l'ACMU. Les auteurs des résumés sont rattachés au département de médecine d'urgence de leur université respective, sauf indication contraire.
all abstracts: 1-14, 15-29, 30-44, 45-58, 59-71, 72-84, 85-99, 100-116
indices: author index | keyword index
indices: author index | keyword index
Poster Presentations (Abstracts #59 to #115)
Clinical Practice
72
A prospective evaluation of clinical pharmacy services in the emergency department.
INTRODUCTION: Elderly ED patients receive multiple prescription medications and are at risk for significant drug related problems (DRP). Clinical pharmacists provide valuable services in many patients care disciplines, however incorporation into the ED team is uncommon. The objective of this study was to prospectively assess the effect of a clinical pharmacist in the ED on identification and management of DRP's in elderly patients receiving > 4 outpatient medications compared to a historical control group. METHODS: A prospective evaluation of elderly (> 65 years) patients was performed comparing patients receiving pharmacist intervention to historical case controls. In the intervention group, the pharmacist conducted patient interviews over 1 one month period and documented drug related problems, medication history clarifications, and recommendations made to resolve identified DRP's. A retrospective chart review of elderly ED patients who were seen over the same time period 1 year prior served as controls. RESULTS: In total, 41 patients were assessed by the clinical pharmacist in the ED, and 75 patient charts were reviewed. The groups were similar when age, mean number of prescription medications per patient and medication class were compared. Pharmacists identified one additional DRP per patient in both the control and intervention groups. In total, 2.24 DRP's were identified in the prospective group compared to 2.13 in the control. DRP's identified by the pharmacist in the prospective group were more likely to be of minor severity (26.42% vs. 8.43%, p = 0.005), and resulted in more action take to resolve the DRP (35.85% vs. 0.00%, p < 0.0001) compared to the control group. CONCLUSION: Pharmacists have a beneficial impact in the identification and resolution of DRP's in an elderly ED patients. Key words: elderly; adverse drug effects; therapy
73
Efficacy, safety and patient/physician satisfaction of propofol for procedural sedation in the emergency department: a prospective observational study.
INTRODUCTION: To evaluate the efficacy, safety and patient/physician satisfaction with the use of propofol for procedural sedation in the Emergency Department (ED). METHODS: All patients receiving propofol for procedural sedation in the ED between 1/12/03 and 31/12/04 were prospectively evaluated. Propofol was administered using a standardized protocol which included an initial dose of 0.25-0.5 mg/kg followed by 10-20 mg/min until sedated. Efficacy was evaluated using procedural success rate and recovery time. Adverse respiratory effects were defined as apnea > 30s or any oxygen saturation < 90%. Hypotension was defined as > 20% reduction in systolic blood pressure from baseline. Patient and physician satisfaction were determined using a 5-point Likert scale. Descriptive statistics using mean ± SD were utilized. RESULTS: 74 patients were included with a mean age of 50.7 ± 19.4 years and 43% were female. Procedures included orthopedic manipulations (51%), direct current cardioversion (35%) and abscess incision and drainage (14%). The mean total propofol dose required was 1.6 ± 0.9 mg/kg. Procedural success was achieved in 87% of cases and the mean patient recovery time was 8.3 ± 4.6 minutes. Ten patients (14%) experienced adverse effects which included apnea > 30s (1), oxygen saturation < 90% (2), emesis with oxygen saturation < 90% (1) and hypotension (6). All patients were very satisfied or satisfied with the procedure and 92% reported no recall. 87% of physicians were very satisfied or satisfied with the sedation/conditions achieved during the procedure. CONCLUSIONS: Propofol appears to be a safe and effective agent for performing procedural sedation in the ED and was associated with high patient and physician satisfaction. Key words: propofol; procedural sedation; patient satisfaction; physician satisfaction
74
Utilization of clinical pharmacy services in the emergency department.
INTRODUCTION: Decentralization of clinical pharmacy services is a developing area of practice promoting patient safety and effective medication utilization. Emergency departments have been identified as high risk areas for medical errors. The purpose of this study was to document the utilization of clinical pharmacy services in a tertiary care Emergency Department (ED). METHODS: As part of a prospective trial of clinical pharmacy services in the ED, a pharmacist documented all activities performed while in the Queen Elizabeth II Health Sciences Centre ED in Halifax, Nova Scotia over a four week period. The activities were classified into five categories. The incidence, ED team member requesting advice, and time to complete the activities were recorded. RESULTS: The pharmacist provided a total of 137 clinical services over nineteen - 8 hour ED shifts (50% evenings). Forty percent of clinical services included retrieval of medication histories, 20% each on drug information questions and patient counseling, 10% on physician medication order clarifications. Recommendations to physician and nursing staff accounted for the remainder of the services provided. Half of the services provided were for the purposes of a concurrent prospective study. However, of the remaining 50 % of services, requests for pharmacist intervention were initiated by physicians, nurses, and remote pharmacists 20%, 18%, and 11% respectively. Fifty percent of the interventions required 11-30 minutes to complete, followed by 34% requiring 5-10 minutes, 15% requiring 31-60 min and 1.5% requiring more than 60 minutes. CONCLUSION: The introduction of clinical pharmacy services in a tertiary care, teaching ED is widely accessed by various members of the health care team. Key words: therapy; medical administration; pharmacy services; emergency medicine
75
Analgesia administration for acute abdominal pain in the pediatric emergency department.
INTRODUCTION: To document the use of analgesia for children with acute abdominal pain in the Pediatric-Emergency-Department (PED) and to compare between children with suspected appendicitis in a high versus low probability. METHODS: Patients 0-16 years recruited prospectively as part of another PED study in Toronto. History of present illness and physical exam was available, and information on analgesia administered in the PED was retrospectively collected from charts. Physicians' probability of appendicitis before any imaging was recorded. A follow-up call was made to verify final diagnosis. RESULTS: We included 438 patients, 16% with appendicitis. Analgesics were given 154 times to 112 patients. Thirty one percent of the cohort received analgesia before seeing the physician, mostly febrile, 37% after seeing physician and 17% after seeing pediatric-surgery consultant. 15% received multiple dosages. Underdosing was recorded in 14% of medications, mostly morphine (24%). Analgesia was given significantly more often to children with high probability of appendicitis. Age was not a factor in analgesia administration. CONCLUSIONS: Children with abdominal pain receive more analgesia when the physician suspect appendicitis, yet only in half of the cases, and only 15% receive opioids. Opioid underdosing happens in a quarter of times it is given. Key words: analgesia; abdominal pain; children
76
The provincial airway database (PAWD) of the British Columbia ambulance service.
INTRODUCTION: PAWD was developed to test the feasibility of collecting data on prehospital endotracheal intubations (ETI) by ALS paramedics. METHODS: Zoomerang® software was used to create a web-based, password protected database with multiple-choice menus supplemented by free text. From 05/05/04 till 20/08/04, paramedics voluntarily, anonymously, and prospectively entered data on ETIs. RESULTS: PAWD captured 172 ETI attempts. All entries were complete. 163 (94.8%: 95% CI 90.3-97.6%) ETIs were successful. 114 pts (66.3%: 95% CI 58.7-73.3%) were male: average age 60.8 yrs (newborn-91 yrs) and weight 78.9 kg (0.3-220 kg). GCS = 3 in 142 (82.6%: 95% CI 76.1-87.9%) pts. Glottic views were Cormack-Lehane (CL) grade III or IV in 44 (26%: 95% CI 19.2-32.8%) pts. Grade III or IV views were common outdoors at night (8/15; 53%: 95% CI 26.6-78.7%) and in pts with head injury (5/15; 33.3%: 95% CI 11.8-61.6%) or major trauma (4/12 33.3%: 95% CI 9.9%-65.1%). Airways were soiled (blood, vomitus, other) in 73 (42.4%: 95% CI 35.0-50.2%) cases. Lidocaine, morphine, and midazolam were the most commonly used intubation drugs. There was 1 laryngoscopy attempt in 87 cases (50.6%: 95% CI 42.9-58.2%), 2 attempts in 52 (30.2%: 95% CI 23.5-37.7%), 3 attempts in 21 (12.2%: 95% CI 7.7-18.1%), and > 4 attempts in 12 (7.0%: 95% CI 3.7-11.9%). Nine patients (5.2%: 95% CI 2.4-9.7%) could not be intubated. Of these, 8 (88.9%: 95% CI 51.8-99.7%) had CL grade III or IV views, 5 (55.5%: 95% CI 21.2-86.3%) had soiled airways, 3 (33.3%: 95% CI 7.5-70.1%) had head and neck trauma and 1 (11.1% 95%: CI 0.2-48.3%) drowning victim had laryngospasm. Reported complications included airway bleeding in 11 (6.4%: 95% CI 3.2-11.2%) cases, airway swelling in 3 (1.7%: 95% CI 0.3-5.0%) cases, and 1 case (0.6%: 95% CI 0.0-3.2%) each of injury to the hypopharynx and extubation during transport. CONCLUSIONS: We have described 172 prehospital ETI reported to PAWD. Technical objectives of accessibility, confidentiality, and ease of data extraction were met. PAWD would be improved with mandatory reporting. Key words: EMS; airway; endotracheal intubation; database
77
Categories of drug related problems identified in elderly emergency department patients.
INTRODUCTION: Elderly ED patients receive multiple prescription medications and are risk for significant drug related problems (DRPs). The provision of clinical type pharmacy services to patients in hospital can identify these DRPs to enhance patient safety and promote effective medication use. The objective of this study was to document the types of DRPs identified in elderly patients receiving > 4 outpatient medications receiving pharmacist intervention compared to a historical control group. METHODS: A prospective evaluation of elderly (>65 years) patients was performed comparing patients receiving pharmacist intervention to historical case controls. In the intervention group, the pharmacist conducted patient interviews over a one month period. A retrospective chart review of elderly ED patients who were seen over the same time period 1 year prior served as controls. DRPs in each group were identified and categorized according to the Hepler-Strand definition. RESULTS: In total, 41 patients were assessed by the clinical pharmacist in the ED, and 75 charts were reviewed. The total number of DRPs identified in the prospective patients was 160, while 92 DRPs were found from the chart review. A significantly greater amount of DRPs were identified as patients having an untreated indication (47.5% vs. 34.5%, p = 0.05) in control patients. Conversely, in the group receiving pharmacist intervention, more DRPs were classified as patients failing to receive drug (18.5% vs. 30.4%, p = 0.03). CONCLUSION: Pharmacist intervention alters the number and type of DRPs identified in an elderly population at risk of polypharmacy visiting the ED. Key words: elderly; emergency medicine; adverse drug events
78
Effect of a clinical predictive tool for Streptococcal pharyngitis on emergency physicians practice.
INTRODUCTION: To evaluate the impact of implementation of a predictive tool for Strep throat infection on emergency physicians (EP) medical management of sore throat. METHODS: A non-randomised multicenter pre and post evaluation in university-affiliated emergency departments. Attitudes of EP regarding investigation and treatment of sore throat were collected from a chart review in 2002. A previous Canadian validated clinical predictive score of sore throat was then explained and implemented in three different emergency departments by used of remainders and «clinical data sheets». A post phase analysis was done four months after implementation in each ED. Outcome measures were obtained by comparing pre and post phases. RESULTS: 191 charts and 195 charts were respectively reviewed in pre and post implementation phase. Pre phase:, 63,9% (122/191) of EP followed the clinical predictive score for throat culture when all criteria of the score was noted in the chart. 71.2% (136/191) followed the appropriate recommendations for treatment. Post phase: 73.4% (143/195) of throats cultures were done according to standards and 74.9% (146/195) of treatment plans were considered adequate. Outcome measures comparison showed statistically significant increase in adherence to throat cultures recommendations: 9.5%, p = 0,045 and but not for treatment recommendation: 3.7% (from 71.2% to 74.9%, p = 0.41). Interestingly, we observed an important increase in antibiotic prescriptions in the post phase analysis from 42.6% (81/190) to 52.1% (100/192, p = 0.06). CONCLUSIONS: Our study confirmed that EPs are using clinical score to guide their management of sore throat. We also showed that implementation of a specific clinical predictive score for throat cultures may improve adherence to throat culture indications and improve efficiency in medical management of sore throat. Further evaluation of EP attitudes at one and two year post implementation is recommended to determine long term adherence. Key words: clinical scoring; pharyngitis; diagnosis
79
Impact of clinical practice guideline on management of critically elevated international normalized ratio (INR) in three emergency departments.
OBJECTIVE: To determine the impact of clinical practice guideline (CPG) on management of critical INR (> 5.0) and to examine practice variation in three emergency departments (EDs). METHODS: We conducted a retrospective chart review of 239 consecutive patients aged > 18 presenting to a university (U), university-affiliated (UA) and community (C) hospital with critically elevated INR. Patients presenting between 04/02-03/03 were eligible. An electronic Clinical Practice Guideline (eCPG) has been available at the university site since 01/02 and the management of critical INRs was compared to the other EDs. RESULTS: Patients characteristics among sites were similar: mean age was 70, 54% were male, and 82% presented with a GCS of 15. These patients often required admission (63%) and 5 died in the ED. Mean INR was 8.1 and most patients at each site presented with varying combinations of signs and symptoms (hematuria, melena, pain etc.). Many (41%) patients were at high risk for bleed and rates were similar between sites; however, 33% of patients were at high risk for clot with differences observed between sites (U = 41%, UA = 28%, C = 26%; p = 0.09). Only 4% of charts demonstrated use of eCPG at the U. The use of vitamin K (Vit K) was high (52%), while fresh frozen plasma (FFP; 18%) and packed RBC (PRBC; 13%) was lower; rates of use were similar across sites. CONCLUSIONS: The frequency and complexity of patients presenting with elevated INR varies across sites; however, treatment approaches appear similar. An eCPG designed to improve the ED management of elevated INRs has not changed practice appreciably. Interventions to reduce FFP and Vit K use still appear warranted. Key words: practice guidelines; quality improvement; critical incidents; INR
80
Variation in diagnosis and management of uncomplicated pediatric clavicle fractures in tertiary care centres in Canada.
INTRODUCTION: Recently literature reported that a majority of physicians are able to accurately diagnose uncomplicated clavicle fractures (CF) with clinical exam alone. This would limit the use of X-rays (XR) and decrease patient stays in the Emergency Department, reduced exposure to radiation and overall costs. Recent reports suggest that there is no need for follow-up of uncomplicated CF. The primary purpose of this study was to assess the current practice patterns of Canadian pediatric emergency physicians (PEP) with respect to diagnosis and management of CF. METHODS: A survey was sent to 170 PEPs working either full or part-time in a pediatric emergency department at 10 tertiary care centres in Canada. The 8 questions survey invited them to provide opinions regarding use of XR to diagnose uncomplicated CF, treatment and follow-up. RESULTS: 115 (67.6%) surveys were returned. 92 (80%) of respondents acquired XR in all cases (AXR) of suspected CF, 18 (15.7%) acquired XR in only select cases (SXR), and 5 (4.3%) nurses fast-track all suspected CF to X-ray. The most common reasons to SXR were location (medial or lateral), medico legal, and age of the patient. MD's using SXR felt that acquisition of an XR does not alter management (p = 0.05), and that patients with uncomplicated clavicle fractures require no follow-up at all (P = 0.019). No difference SXR and AXR was found with respect to XR altering prognosis, choice of treatment. Type of fracture (comminuted vs. displaced) did not alter treatment or analgesia choice. 68% of chose simple sling as the management of choice. Follow up was family physician (74%). Most commonly chosen analgesic was ibuprofen. CONCLUSIONS: There is a great deal of variation among PEP with respect to need for XR to diagnose uncomplicated CF, treatment and follow-up recommendations, despite reports in the literature suggesting no need for XR or follow-up. Further research is required to define need for XR in pediatric patients with suspected CF, as well as optimum treatment and follow-up. Key words: clinical guidelines; clavicle fractures; children; diagnosis
81
Written consent for interventions in the paediatric emergency department: physicians' practices and attitudes.
INTRODUCTION: There is a need to improve physician practices regarding informed consent. Studies have confirmed patient's desire to be fully informed regarding the treatment process, but have been equivocal in determining their desire for active participation in clinical decision-making. Little literature exists regarding physician's attitudes toward written consent for interventions. METHODS: 167 physician PEPs at the 10 academic Paediatric Emergency Departments (PED) received an anonymous survey containing questions regarding written consent for interventions. Interventions included IV starts, simple (SWR) and complicated wound repair (CWR), lumbar punctures (LP), endotracheal intubation (ETI), administering blood products (ABP), fracture reduction (FR) and procedural sedation (PS). Data was analyzed using SPSS, student T, Chi-square and Kappa tests. RESULTS: 96 (57.5%) PEPs responded to the survey. 43% worked in PEDs with their own specific policies on written consent, 43% followed a hospital-wide policy, while 13% worked in centres with no policy. Of the 8 interventions surveyed, PEPs believed that consent should be obtained in: PS 74%, ABP 60%, FR 55%, LP 31%, CWR 13%, ETI 7%, SWI 1% and 0% for IV starts. Surprisingly, 26% of PEPs felt that consent was unnecessary for PS, whilst 40% felt it unnecessary for FR. 18% felt that written consent should not be required for any interventions. Comparison of agreement between physicians current consent practice and optimal consent practice for PED interventions demonstrated poor agreement for ETI and CWR (κ < 0.2), fair agreement for ABP (κ 0.20.4) and moderate agreement for LP, FR and PS (κ 0.4-0.6). CONCLUSIONS: These results suggest that PEPs feel that written consent for interventions is warranted for many complex interventions (e.g. FR, PS). These results also demonstrate a disparity between current and optimal written consent practices in Canadian PEPs. There appears to be a need to develop a national consensus on interventional consent. Key words: consent; survey; pediatrics
82
The management of critically ill patients in the emergency department: a retrospective analysis.
INTRODUCTION: Previous studies have demonstrated that critically ill patients remain in the Emergency Department (ED) for prolonged periods of time. The rapid implementation of invasive procedures and intensive therapy is thought to have a positive affect on patient outcomes. In particular, early goal directed therapy of critically ill septic patients while in the Emergency Department has been demonstrated to reduce mortality. The objective of our study was to examine the epidemiology of critically ill patients receiving care in a Canadian tertiary care adult emergency department. METHODS: This study was a retrospective chart review of all ED patients admitted directly to the ICU over a one-year period. Prehospital, ED and ICU data was collected for the first 24 hours of admission and included patient demographics, triage acuity, physiologic parameters, procedures performed and length of stay in the ED and ICU. RESULTS: One hundred and sixty five critically ill patients were included in this study with an overall hospital mortality of 23.2%. Patient mean age was 55.4 years (SD 19.4 years), and 56.4% were male. Of the 165 patients, 115 (69.7%) required intubation, with the majority being performed in the ED (75/115, 65.2%) and in the prehospital setting (33/115, 28.7%). Central venous access was obtained in 49 patients (29.7%) with only 10 (20.4%) performed while patients were in the ED. Similarly, arterial lines were inserted in 92 patients (55.8%), with 12 (13.0%) completed in the ED. The mean length of stay in the ED of critically ill patients requiring ICU admission was 6.7 hours (SD 4.6 hours). CONCLUSIONS: Critically ill patients are managed in the Emergency Department for a significant length of time. The majority of early airway control occurs in the prehospital setting and the ED, however few patients undergo invasive procedures while in the Emergency Department. Key words: critical care; emergency medicine; epidemiology
83
Pharmacists identify more drug related problems than physicians in elderly emergency department patients.
INTRODUCTION: Elderly patients who present to the ED are often receiving multiple medications for chronic medical problems. Emergency physicians need to accurately evaluate their patients medications to ensure that significant drug related problems (DRP's) are minimized. Due to multiple factors inherent in busy emergency departments, the identification of DRP's by emergency physicians may be incomplete. The purpose of this study is to determine whether the introduction of a clinical pharmacist in the ED increases the identification of DRP's in elderly emergency department patients. METHODS: A prospective evaluation was performed in patients > 65 years of age who presented to the Queen Elizabeth Health Sciences Center Emergency Department, Halifax, Nova Scotia. A clinical pharmacist conducted patient interviews and reviewed outpatient medications after ED physician assessment over a one-month period. DRP incidence and severity were identified utilizing a published classification, and recommendations made to resolve identified DRP's were provided to the attending emergency physician. DRPs identified by the emergency physicians were prospectively recorded. RESULTS: The clinical pharmacist evaluated 41 patients in the ED, in which a total of 92 DRPs were identified (2.24 DRPs per patient). Assessment by a clinical pharmacist identified an additional 53 DRP's compared to the 39 DRPs initially identified by the emergency physicians. Physicians identified more DRPs classified as "marked severity" while the pharmacist identified an increased number of "modest and minor severity" DRPs. Emergency physicians were more likely to immediately modify prescribed medication when they identified a DRP. CONCLUSION: Pharmacists identify an increased number of DRPs than emergency physicians. Key words: elderly; adverse drug events; emergency medicine; pharmacists
Decision Analysis
84
The role of the history in predicting the need for CT scan in minor head injury.
INTRODUCTION: The history is often underutilized in the evaluation of patients with minor head injury (MHI). This study measured the accuracy and reliability of specific history findings in MHI. METHODS: As part of the Canadian CT Head Rule Study, this prospective cohort study enrolled patients who presented with GCS 13-15 after loss of consciousness, amnesia, or confusion at 9 tertiary care EDs. MDs recorded standardized history findings; in some cases, 2nd physicians performed interobserver assessments. Patients underwent CT to determine the outcome, clinically important brain injury. Analyses included univariate association, kappa, sensitivity, specificity, adjusted odds ratios by stepwise logistic regression. RESULTS: 5858 patients were enrolled with mean age 39 years, important brain injury 8%, neurological intervention 1.5%. Table 1 (of Abstract 84) shows % of injury and non-injury patients with the history findings and statistical outcomes. Hosmer-Lemeshow value was 0.84, suggesting a good fit for the data. CONCLUSIONS: The CCHR Study represents the largest collection of data involving patients with minor head injury. Historical variables comprise 4 of the 7 criteria of the CCHR. A history of 'age > 65', 'dangerous mechanism', 'amnesia > 30 mins prior to injury', or 'repeated vomiting' each puts patients at higher risk of clinically important brain injury. These findings should be carefully reviewed when managing patients with minor head injury. Key words: clinical guidelines; minor head injury; inter-observer agreement
| History finding | Inj / No inj, % |
Kappa | Sens / Spec, % | OR |
| Vomiting ≥ 2 | 25 / 9 | 0.86 | 25 / 91 | 3.6 |
| Age ≥ 65 yr | 24 / 9 | N/A | 24 / 90 | 3.2 |
| Dangerous mechanism | 47 / 24 | N/A | 47 / 76 | 2.8 |
| Amnesia > 30 min before | 27 / 21 | N/A | 27 / 79 | 2.1 |
| Loss of consc. > 5 min | 8 / 5 | N/A | 8 / 95 | NS |
| Headache | 61 / 62 | 0.61 | 61 / 38 | NS |
| Suspected chronic alcohol | 16 / 12 | 0.71 | 16 / 88 | NS |
| All p values were 0.0001 except Headache, which had a p value of 0.011 | ||||
all abstracts: 1-14, 15-29, 30-44, 45-58, 59-71, 72-84, 85-99, 100-116
indices: author index | keyword index
indices: author index | keyword index
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