David M. Richardson

Is early analgesia associated with delayed treatment of appendicitis

PURPOSE We sought to investigate the relationship between delay in treatment of appendicitis and early use of analgesia. BASIC PROCEDURES We designed a matched case-control study, with patients having delayed treatment of appendicitis as the cases and patients with no delay in treatment of appendicitis as controls matched for age, sex, Alvarado score, and date of diagnosis. Of 957 patients with appendicitis, there were 103 delayed cases. Matching patients were identified yielding 103 controls. MAIN FINDINGS In comparing cases and controls for early opiate use (26/103 cases, 24/103 controls), there was no association with delayed treatment (odds ratio, 1.11; P = .745; 95% confidence interval, 0.59-3.89). When comparing cases and controls for early NSAID use (29/103 cases, 17/103 controls), an association was found with delayed treatment (odds ratio, 1.98; P = .045; 95% confidence interval, 1.01-3.89). CONCLUSION For early analgesia in appendicitis, we did not find an association with delayed treatment for opiate analgesia, but there did appear to be an association with nonsteroidal anti-inflammatory analgesia.

Analysis of sex differences in preadmission management of ST-segment elevation (STEMI) myocardial infarction.

BACKGROUND Many reports suggest gender disparity in cardiac care as a contributor to the increased mortality among women with heart disease. OBJECTIVE We sought to identify gender differences in the management of Myocardial Infarction (MI) Alert-activated ST-segment elevation myocardial infarction (STEMI) patients that may have resulted from prehospital initiation. METHODS A retrospective database was created for MI Alert STEMI patients who presented to the emergency department (ED) of an academic community hospital with 74,000 annual visits from April 2000 through December 2008. Included were patients meeting criteria for an MI Alert (an institutional clinical practice guideline designed to expedite cardiac catheterization for STEMI patients). Data points (before and after initiation of a prehospital alert protocol) were compared and used as markers of therapy: time to ECG, receiving β-blockers, and time to the catheterization laboratory (cath lab). Differences in categorical variables by patient sex were assessed using the χ(2) test. Medians were estimated as the measure of central tendency. Quantile regression models were used to assess differences in median times between subgroups. RESULTS A total of 1231 MI Alert charts were identified and analyzed. The majority of the study population were male (70%), arrived at the ED via ambulance (60.1%), and were taking a β-blocker (67.8%) or aspirin (91.6%) at the time of the ED admission. Female patients were more likely than male patients to arrive at the ED via ambulance (65.9% vs 57.6%, respectively; P = 0.014). The median age of female patients was 68 years, whereas male patients were significantly younger (median age, 59 years; P < 0.001). The proportion of patients currently taking a β-blocker or low-dose aspirin did not vary by gender. Overall, 78.2% of the MI Alert patients arriving at the ED were MI2 (alert initiated by ED physician), and this did not vary by gender (P = 0.33). A total of 1064 MI Alert patients went to the cath lab: 766 male patients (88.9%) and 298 female patients (80.8%). Overall, the median time to cath lab arrival was 79 minutes for men and 81 minutes for women (P = 0.38). Overall, the median time to cath lab arrival significantly decreased from MI1 to MI3, (P(trend) < 0.001). For prehospital-initiated alerts (MI3), the median time to cath lab arrival was the same for men and women (64 minutes; P = 1.0). For hospital-initiated alerts, time to cath lab arrival was 82 minutes for male patients and 84 minutes for female patients (P = 0.38). Prehospital activation of the process decreased the time to the cath lab by 19 minutes (P < 0.001; 95% CI, 13.2-24.8). CONCLUSION No significant gender differences were apparent in the STEMI patients analyzed, whether the MI Alert was initiated in the ED or prehospital initiated. Initiating prehospital-based alerts significantly decreased the time to the cath lab.

Computer-Based Reminder System Effectively Impacts Physician Documentation

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Using Lean Methodology to Decrease Wasted RN Time in Seeking Supplies in Emergency Departments

BACKGROUND: Timely stocking of essential supplies in an emergency department (ED) is crucial to efficient and effective patient care. OBJECTIVE: The objective of this study was to decrease wasted nursing time in obtaining needed supplies in an ED through the use of Lean process controls. METHODS: As part of a Lean project, the team conducted a “before and after” prospective observation study of ED nurses seeking supplies. Nurses were observed for an entire shift for the time spent outside the patient room obtaining supplies at baseline and after implementation of a point-of-use storage system. RESULTS: Before implementation, nurses were leaving patient rooms a median of 11 times per 8-hour shift (interquartile range [IQR], 8 times per 8-hour shift) and 10 times per 12-hour shift (IQR, 23 times per 12-hour shift). After implementation of the new system, the numbers decreased to 2.5 per 8-hour shift (IQR, 2 per 8-hour shift) and 1 per 12-hour shift (IQR, 1 per 12-hour shift). CONCLUSION: A redesigned process including a standardized stocking system significantly decreases the number of searches by nurses for supplies.

Using Medical Student Quality Improvement Projects to Promote Evidence-Based Care in the Emergency Department

Introduction The Association of American Medical Colleges’ (AAMC) initiative for Core Entrustable Professional Activities for Entering Residency includes as an element of Entrustable Professional Activity 13 to “identify system failures and contribute to a culture of safety and improvement.” We set out to determine the feasibility of using medical students’ action learning projects (ALPs) to expedite implementation of evidence-based pathways for three common patient diagnoses in the emergency department (ED) setting (Atrial fibrillation, congestive heart failure, and pulmonary embolism). Methods These prospective quality improvement (QI) initiatives were performed over six months in three Northeastern PA hospitals. Emergency physician mentors were recruited to facilitate a QI experience for third-year medical students for each project. Six students were assigned to each mentor and given class time and network infrastructure support (information technology, consultant experts in lean management) to work on their projects. Students had access to background network data that revealed potential for improvement in disposition (home) for patients. Results Under the leadership of their mentors, students accomplished standard QI processes such as performing the background literature search and assessing key stakeholders’ positions that were involved in the respective patient’s care. Students effectively developed flow diagrams, computer aids for clinicians and educational programs, and participated in recruiting champions for the new practice standard. They met with other departmental clinicians to determine barriers to implementation and used this feedback to help set specific parameters to make clinicians more comfortable with the changes in practice that were recommended. All three clinical practice guidelines were initiated at consummation of the students’ projects. After implementation, 86% (38/44) of queried ED providers felt comfortable with medical students being a part of future ED QI initiatives, and 84% (26/31) of the providers who recalled communicating with students on these projects felt they were effective. Conclusion Using this novel technique of aligning small groups of medical students with seasoned mentors, it is feasible for medical students to learn important aspects of QI implementation and allows for their engagement to more efficiently move evidence-based medicine from the literature to the bedside.