Antoinette Colacone

Efficacy of Inhaled Steroids (Beclomethasone Dipropionate) for Treatment of Mild to Moderately Severe Asthma in the Emergency Department: A Randomized Clinical Trial

STUDY OBJECTIVE To examine the efficacy of an inhaled steroid, when added to a standard regimen of beta-agonist therapy, in the treatment of patients with mild to moderately severe asthma in the emergency department. METHODS A convenience sample of adult patients with asthma (FEV1 % predicted 40% to 69%) presenting to the ED was randomly assigned in a double-blind fashion into 2 treatment groups. The first group received 2.5 mg nebulized salbutamol plus 1 mg (4 puffs) of beclomethasone dipropionate (BDP) at baseline, 30 minutes, and at 1, 2, and 4 hours, delivered by a metered-dose inhaler (MDI) attached to a spacer device (Vent-AH-aler, Glaxo). The second group was given the same salbutamol regimen plus MDI placebo through the Vent-AH-aler. The primary endpoint was improvement in FEV1 %predicted at 6 hours. RESULTS Of 54 patients enrolled, 28 were assigned to the BDP group and 26 to the placebo group. Spirometry improved significantly in both groups over the 6 hours compared with baseline (ANOVA, P <.001). At 6 hours, the mean absolute improvement in FEV1 % predicted for BDP was 18% versus 17% for placebo (95% confidence interval for the absolute difference of 1% [-8% to 10%]). The proportion of patients in the BDP group who were hospitalized was 7% compared with 19% for patients in the placebo group (95% confidence interval for the difference of 12% [-6%, 30%]). CONCLUSION In this group of patients with mild to moderately severe asthma, 5 mg BDP delivered by MDI during the initial 4 hours of an emergency visit was of no added benefit over standard therapy, as measured by improvement in FEV1 % predicted at 6 hours. However, a trend toward a difference in admission favoring BDP was observed. [Afilalo M, Guttman A, Colacone A, Dankoff J, Tselios C, Stern E, Wolkove N, Kreisman H: Efficacy of inhaled steroids (beclomethasone dipropionate) for treatment of mild to moderately severe asthma in the emergency department: A randomized clinical trial.

The In-Hospital Interval: A Description of EMT Time Spent in the Emergency Department

Objective. We conducted a time-motion study of emergency medical technician (EMT) flow in an urban, academic emergency department (ED). Our objective was to describe the activity of the EMTs during their time in the ED. Secondary objectives included the association of time of day, age, andtriage code with the various time intervals. Methods. In this descriptive study, we combined information from two databases: prospectively collected time-motion data of EMTs presenting to one ED andan electronically collected prehospital call database of time data. The pretriage, triage, andposttriage time intervals were calculated, as well as total time spent in the ED as a proportion of total call time. Mean times with 95% confidence intervals (CIs) were reported. Analysis of variance was performed to examine the associations of time of day, age, andtriage code with time intervals. Results. Data were available for 152 calls. The mean pretriage interval was 8.79 (95% CI, 7.55–10.04) minutes, the mean triage interval was 5.14 (95% CI, 4.49–5.79) minutes, andthe mean posttriage interval was 31.33 (95% CI, 29.08–33.58) minutes. The proportion of the total call time that was spent in the ED was 45%. Subgroup analysis showed significant differences only between total time spent in the ED in the 7:30–10:00 AM period as compared with the other periods. Conclusions. More time was spent in the pretriage andposttriage intervals as compared with the triage interval. Further time-motion studies in the ED will be necessary to plan interventions aimed at decreasing the time spent in-hospital by EMTs.

The prognostic significance of moderate hyperamylasemia in the evaluation of the emergency department patient.

Hyperamylasemia of greater than five times the upper limit of the normal range (200 IU/L) is highly specific for the diagnosis of pancreatitis, but the meaning of lower values is unclear. The purpose of this study was to evaluate the prognostic significance of amylase values > 200 and < 1000 IU/L. A controlled historical cohort study was conducted to determine whether moderate hyperamylasemia is associated with an increased severity of outcome compared to patients with normal amylase values. Subjects met certain inclusion criteria and had a serum amylase of > 200 and < 1000 IU/L (normal < 200 IU/L). The case group consisted of 44 patients (medium serum amylase = 307.5 IU/L) and resembled the control group of 77 patients (median serum amylase = 117.5 IU/L) with regard to sex distribution and presenting complaint. However, the case group was older, was on more medications, and had a shorter duration of symptoms prior to the ED visit (< 72 h). Analysis of clinically important outcomes revealed that the groups were similar in terms of 6-month mortality, general admission rate, ICU admission rate, and rate of surgical intervention. The proportion of patients who had radiologically or endoscopically documented gastrointestinal pathology was also similar. The results demonstrate that patients with moderate hyperamylasemia (i.e. amylase < 1000 IU/L), notwithstanding the fact that they are older, are on more medications, and have more acute symptomatology, did not have a worse outcome than patients with the same complaints and normal amylases.

Meal-induced oxygen desaturation and dyspnea in chronic obstructive pulmonary disease

OBJECTIVE To study arterial oxygen saturation (SpO2) obtained by pulse oximetry and dyspnea during active eating (AE) and passive eating (PE) in patients with severe chronic obstructive pulmonary disease (COPD). DESIGN Patients were studied on two consecutive days with AE and PE, which occurred in random order. SpO2 was recorded for 20 mins before and during eating, and dyspnea was recorded by the patient using a 10 cm visual analogue scale before and upon completion of eating. SETTING Subjects were in-patients at an intermediate care facility who were hospitalized for pulmonary rehabilitation or for convalescence after an exacerbation of COPD. POPULATION STUDIED Thirty-five patients with severe COPD (forced expiratory volume in 1 s [FEV1] less than 50% predicted, FEV1 to forced vital capacity ratio less than 65%) were studied. Mean age was 70.5 7.1 years. MAIN RESULTS Mean SpO2 decreased significantly (P<0.05) from 91.7 3.4% to 90.1 4.0% during AE, and 91.7 3.2% to 90. 8 3.6% during PE. Mean lowest SpO2 was lower and percentage of time with SpO2 less than 90% was greater during eating compared with corresponding control periods during both AE and PE. Dyspnea increased significantly (P<0.05) from 1.4 1.2 to 3.3 2.3 cm during AE, and from 1.5 1.5 to 2.4 2.2 cm during PE. The increase in dyspnea was significantly greater during AE than PE. CONCLUSIONS Eating is an activity that can adversely affect SpO2 and increase dyspnea in patients with severe COPD. Oxygen desaturation and particularly increased dyspnea may at least in part relate to the recruitment of upper extremity muscles during eating.

Patient Needs, Required Level of Care, and Reasons Delaying Hospital Discharge for Nonacute Patients Occupying Acute Hospital Beds

Abstract: This study aims to determine the proportion of nonacute patients occupying acute care beds and to describe their needs, the appropriate level of alternative care, and reasons preventing discharge. Data from 952 patients hospitalized in an acute care unit for 30 days were obtained from their medical charts and by consulting with the medical team at two tertiary teaching hospitals. Among them, 333 (35%) were determined nonacute on day 30 of hospitalization. According to the Appropriateness Evaluation Protocol (AEP), 55% had no medical, nursing, or patient needs. Among nonacute patients with AEP needs, 88% were related to nursing/life‐support services and 12% related to patient condition factors. Regarding alternative level of care, 186 (56%) were waiting for out‐of‐hospital resources, of which 36% were waiting for palliative care, 33% for long‐term care, 18% for rehabilitation, and 12% for home care. For the remaining 147 (44%) nonacute patients, the alternative resources remained undetermined although acute care was no longer required. Main reasons preventing discharge included unavailability of alternative resources, ongoing assessment to determine appropriate resources, ongoing process with community care, and family/patient education/counseling. Available subacute facilities and community‐based care would liberate acute care beds and facilitate their appropriate use.

What is the Impact of the Implementation of an Evidence Based ProceduralSedation Protocol in the Emergency Department

Background: Procedural sedation and analgesia (PSA) enables emergency physicians to provide pain and anxiety relief for many procedures. However, PSA introduces an independent risk factor and requires continuous monitoring. Recently, we applied the principles of knowledge translation (KT) to develop and implement a PSA protocol in our ED. Objectives: To evaluate the impact of a PSA protocol developed and implemented using KT principles on changes in ED physician practices with respect to length of monitoring time in resuscitation area, complication rate, medication types and doses. Methods: Design: Pre- Post retrospective chart review. Setting: Adult tertiary-care academic centre. Participants: Patients who underwent PSA in the ED as per physician billing code from September 2008 to August 2010. The Pre protocol implementation was from Sept 2008 to Aug 2009 and the Post was from Sept 2009 to Aug 2010. One of the authors (NM) reviewed all charts and recorded patient information such as sociodemographics, past medical history, allergies, monitoring time, complications, medication and doses. Pre and post periods information was compared using two-sample T-test and Chi-square test as appropriate. Results: There were 318 billing codes for PSA from September 2008 to August 2010 of which the 150 occurred during the Pre protocol period and 134 during the Post protocol implementation period. Excluded were 34 patients due to lack of documentation. There were no statistical differences in Pre vs. Post for baseline characteristics (mean age+standard deviation (52+20 vs. 53+22 years), male gender (54% vs. 53%), with a past medical history (36% vs. 47%) and allergies (16% vs. 15.7%)). As well no differences in outcomes with respect to complication rate (7.4% vs. 9.9%) and medication types (70% vs. 65% Ketafol, 23% vs. 23% propofol) and doses used. However, monitoring time in minutes recorded from time of first medication given until patient was moved out of resuscitation area was significantly reduced during the Post period (Pre period: mean 49 (95% CI: 42-56) versus Post period: mean 19 (95% CI: 17-21). Conclusion: The implementation of the PSA protocol using KT principles resulted in a significant and important decrease in monitoring time required for PSA thus liberating important resources in busy EDs.