Jasmine Chohan

Triage Pain Scores and the Desire for and Use of Analgesics

STUDY OBJECTIVE Inadequate analgesia (oligoanalgesia) is a common phenomenon. In an effort to improve pain recognition and management, pain scores are mandated by The Joint Commission. When patients with pain do not receive analgesics, treatment is considered deficient. However, the mere presence of pain does not imply that all patients desire analgesics. We determine how often patients in pain desire and receive analgesics in the emergency department (ED). We hypothesize that many ED patients in pain do not desire analgesics and that most who want them receive them. METHODS We conducted a prospective observational study of pain-related visits to an academic ED during the spring of 2007. Standardized collection of demographic and clinical data was performed, and patients rated their pain severity on a 0 to 10 numeric rating scale. The main outcome measures were the desire for and administration of analgesics during the ED visit. Univariate and multivariate logistic regression was used to identify factors associated with patient desire for and administration of analgesics. RESULTS We enrolled 392 patients. Mean (SD) age was 39 years (19), 50% were female patients, 76% were white. Mean (SD) initial pain score was 7.1 (2). Of the 392 patients, 199 (51% [95% confidence interval (CI) 46% to 56%]) desired analgesics and 227 (58% [95% CI 53% to 63%]) received analgesics within 92 (SD 106) minutes. Of patients desiring analgesics, 162 (81% [95% CI 75% to 86%]) received them. Reasons for not wanting analgesics included pain tolerable (47%), analgesic taken at home (11%), and wanting to remain alert (7%). Pain scores were higher in those patients who wanted analgesics than in those patients who did not want analgesics (7.8 [95% CI 7.5 to 8.1] versus 6.4 [95% CI 6.1 to 6.7]; difference 1.4 [95% CI 0.9 to 1.8]). In multivariate analysis, pain scores (odds ratio [OR] 1.3 for every 1-point increase in pain score) and constant pain (OR 2.0) were significant factors that predicted wanting analgesics, whereas pain scores (OR 1.2) and desiring analgesics (OR 7.4) were significant predictors of receiving analgesics. CONCLUSION Nearly half of all ED patients in pain do not desire analgesics and most who desire analgesics receive them. Although the average pain score for patients not wanting analgesics was lower, it was often in the moderate to severe range. Patients should be asked whether they have pain and whether they want analgesics regardless of their pain scores.

Patients overwhelmingly prefer inpatient boarding to emergency department boarding.

BACKGROUND Boarding of admitted patients in the emergency department (ED) is a major cause of crowding. One alternative to boarding in the ED, a full-capacity protocol where boarded patients are redeployed to inpatient units, can reduce crowding and improve overall flow. OBJECTIVE Our aim was to compare patient satisfaction with boarding in the ED vs. inpatient hallways. METHODS We performed a structured telephone survey regarding patient experiences and preferences for boarding among admitted ED patients who experienced boarding in the ED hallway and then were subsequently transferred to inpatient hallways. Demographic and clinical characteristics, as well as patient preferences, including items related to patient comfort and safety using a 5-point scale, were recorded and descriptive statistics were used to summarize the data. RESULTS Of 110 patients contacted, 105 consented to participate. Mean age was 57 ± 16 years and 52% were female. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. The overall preferred location after admission was the inpatient hallway in 85% (95% confidence interval 75-90) of respondents. In comparing ED vs. inpatient hallway boarding, the following percentages of respondents preferred inpatient boarding with regard to the following 8 items: rest, 85%; safety, 83%; confidentiality, 82%; treatment, 78%; comfort, 79%; quiet, 84%; staff availability, 84%; and privacy, 84%. For no item was there a preference for boarding in the ED. CONCLUSIONS Patients overwhelmingly preferred the inpatient hallway rather than the ED hallway when admitted to the hospital.

Interrater reliability of hemodynamic profiling of patients with heart failure in the ED.

OBJECTIVE Hemodynamic profiling (HP) of patients with heart failure (HF) based on clinical assessment of central congestion and peripheral perfusion has been widely used by cardiologists to help guide therapy and determine prognosis but has never been tested or validated in the emergency department (ED). We hypothesized that the interrater reliability of HP in the ED would be good or greater than 0.6. METHODS Study design. This was a prospective, observational study. Setting. It was conducted in an academic suburban ED with emergency medicine residency. Subjects. A convenience sample of patients presenting to the ED with suspected acute decompensated HF was enrolled. Measures. Demographic and clinical information was collected using standardized data collection forms. Two emergency medicine physicians (masked to each other) evaluated all patients and classified them into 1 of 4 hemodynamic categories based on the presence or absence of central congestion (wet or dry) and peripheral hypoperfusion (cold or warm): warm and dry, warm and wet, cold and dry, and cold and wet. B-type natriuretic peptide levels, objective test of cardiac function, and final cardiologist diagnoses were obtained. Data analysis. Interrater reliabilities for overall hemodynamic profile and individual elements of congestion and perfusion were calculated using kappa coefficients. RESULTS Sixty-eight patients were enrolled. Their mean age was 72 +/- 14 years, 53% were female, and 78% were white. Of the patients, 79% had a final diagnosis of HF. Most patients (>60%) were considered wet and warm. Interrater agreement for HP was 64%, kappa = 0.28 (95% confidence interval, 0.01-0.51). Interrater agreement was poor to fair for all elements of congestion and perfusion except peripheral edema (kappa = 0.67) and a narrow pulse pressure (kappa = 0.66). CONCLUSIONS Hemodynamic profiling of patients with HF by emergency physicians in the ED is not highly reliable. One in 5 patients thought to have HF in the ED did not have a final diagnosis of HF.

Risk of venous thromboembolism in patients with borderline quantitative D-dimer levels

OBJECTIVE The lower threshold for D-dimer in evaluating patients with low clinical risk of venous thromboembolism (VTE) ranges from 200 to 500 ng/mL. We compared the rates of VTE in patients based on D-dimer values. We hypothesized that the rate of VTE in low-risk patients with D-dimer levels less than 500 would be less than 1%. METHODS STUDY DESIGN This was a retrospective chart review: SETTING The study was performed in a academic, suburban emergency department (ED). SUBJECTS Emergency department patients with suspected VTE and D-dimer obtained were included in the study. D-dimer assay: The D-dimer assay is a quantitative instrumentation latex suspension of plasma specimens. OUTCOMES Presence of VTE within 30 days of ED visit. DATA ANALYSIS Assuming a 0% event rate in patients with D-dimer levels between 200 and 500 ng/mL, a sample of 450 patients would result in a 95% confidence interval upper limit of 0.6%. RESULTS There were 1270 ED patients with suspected VTE in which D-dimer levels were performed between October 2005 and October 2006. Patient mean age was 47.8 +/- 19.3 years; 63.2% were female, 78.2% were white. Of all D-dimer levels, 497 (39.1%) were less than 200 ng/mL, 479 (37.7%) were between 200 and 500 microg/mL, and 294 (23.1%) were greater than 500 ng/mL. There were no VTE events diagnosed in any of the patients with D-dimer levels less than 200 ng/mL. Four patients with D-dimer levels between 200 and 500 microg/mL had a pulmonary embolism on computed tomography angiography. Of these 4 patients, 3 had moderate clinical risk based on Wells criteria and one had a false-positive computed tomography. There were no cases of VTE in the remaining 475 patients (0%; 95% confidence interval 0%-0.6%). CONCLUSION The rate of confirmed VTE in low-risk patients with D-dimer levels between 200 and 500 ng/mL is very low. Low-risk patients with suspected VTE with D-dimer levels less than 500 ng/mL might not require additional testing.

Pretreatment of Patients Requiring Oral Contrast Abdominal Computed Tomography With Antiemetics: A Randomized Controlled Trial of Efficacy

STUDY OBJECTIVE Ingestion of diatrizoate meglumine before abdominal computed tomography (CT) is time consuming. We hypothesized that pretreatment with metoclopramide or ondansetron would result in faster ingestion of diatrizoate meglumine than placebo. METHODS The study was a double-blind, randomized controlled trial on adults requiring oral contrast abdominal CT. Patients were randomized to placebo, metoclopramide 10 mg, or ondansetron 4 mg intravenously 15 minutes before ingesting 2 L of diatrizoate meglumine. The primary outcome was time to complete diatrizoate meglumine ingestion. Secondary outcome measures included volume of diatrizoate meglumine ingested, 100-mm visual analog scale for nausea at 15-minute intervals, time to CT, vomiting, and use of rescue antiemetics. The study was powered to detect a 60-minute difference in diatrizoate meglumine ingestion time between saline and medication groups. RESULTS One hundred six patients were randomized; placebo (36), metoclopramide (35), and ondansetron (35). Groups were similar in baseline characteristics. Median (interquartile range) times for diatrizoate meglumine ingestion were placebo 109 minutes (82 to 135 minutes); metoclopramide 105 minutes (75 to 135 minutes); and ondansetron 110 minutes (79 to 140 minutes) (P=.67). Vomiting was less frequent with metoclopramide (3%) than placebo (18%) or ondansetron (9%) (P=.11). The visual analog scale for nausea at each point was not significantly different between groups (P=.11). The need for rescue antiemetics was lowest for metoclopramide (3%) compared with placebo (27%) and ondansetron (12%) (P=.02). CONCLUSION Pretreatment with ondansetron or metoclopramide does not reduce oral contrast solution ingestion time.

Predictors of sustaining burn injury: does the use of common prevention strategies matter?

The incidence of burn injury has decreased over the past several decades. Although this has been largely attributed to increased prevention awareness, few studies evaluate the effectiveness of implementing standard burn prevention strategies in preventing burn injury. The authors hypothesized that patients who sustain burns use burn prevention strategies less frequently than those who do not. This was a case-control study composed of a prospective survey questionnaire and retrospective burn registry query, which was performed in a suburban academic medical center with a burn unit. All burn patients seen by the burn service in the year 2008 and a nonrandom sample of nonburned emergency department patients and visitors during the same time period were enrolled. Demographics included age, gender, income, education, house type, insurance status, and prevention strategy usage including smoke alarms, carbon monoxide detectors, fire extinguishers, and escape plans. The primary outcome of interest in this study was burn injury. Chi-square tests were used to compare rates, Students t-tests were used to compare mean values of continuous variables between burn patients and others, and multivariate logistic regression was used to determine the strongest predictors of sustaining burn injury. One hundred ninety-four burn patients and 348 nonburned emergency department patients and visitors were surveyed. Burn patients reported the same rates of smoke alarm usage (96.9 vs 96.3%, P = .692), carbon monoxide detectors (75.3 vs 67.2%, P = .05), and higher rates of fire extinguisher ownership (80.4 vs 72.7%, P = .045) when compared with others. In multivariable analysis, the strongest predictor of sustaining burn injury was less than high school education (odds ratio [OR] 3.61, 95% confidence interval [CI] 1.27–10.27), whereas English as a primary language (OR 0.48, 95% CI 0.26–0.89), a graduate degree (OR 0.10, 95% CI 0.02–0.42), income >

Physical fitness cannot be used to predict the likelihood of acute coronary syndromes in ED patients with chest pain

50,000 (OR 0.46, 95% CI 0.29–0.72), and keeping flammable liquids in a locked place (OR 0.59, 95% CI 0.44–0.80) were protective against burn injury. Smoke alarms (OR 0.75, 95% CI 0.22–2.61), fire extinguishers (OR 1.34, 95% CI 0.80–2.32), and having an escape plan (OR 0.85, 95% CI 0.56–1.29) were not protective. Patients who sustain burn injury use burn prevention strategies at similar rates when compared with those who do not. When holding demographic characteristics constant, utilization of most burn prevention strategies is not protective of sustaining burn injury. Those with lower levels of education and income remain more susceptible to burn injury.

Patient history and physician suspicion accurately exclude pregnancy

OBJECTIVE The objective of the study was to explore the association between physical fitness and the likelihood of acute coronary syndrome (ACS) in patients presenting to the emergency department (ED) with chest pain (CP). We hypothesized that the likelihood of ACS would be lower in physically fit patients and higher in patients with exercise-induced CP. METHODS The study involved a prospective, descriptive cohort in an academic suburban ED. Subjects were ED patients with CP admitted for suspected ACS. Demographic and clinical data were collected by trained research assistants using standardized forms. Patients were surveyed on level of fitness and whether they had ever experienced anginal type symptoms during exercise. Acute coronary syndrome was considered present if the patient had electrocardiographic evidence of infarction or ischemia; elevated troponin I levels; greater than 70% stenosis of culprit coronary artery; or a positive nuclear, echocardiographic, or treadmill stress test result. Patients readmitted within 30 days for reinfarction, cardiogenic shock, or arrhythmias were also considered to have ACS. The association between physical fitness and ACS was determined using χ(2) tests and odds ratios (ORs). RESULTS One hundred patients were enrolled. Mean age was 55.8 (±15.3) years; 36% were female; 85% were white. Thirteen (13%) patients had positive troponins, 22 of 36 catheterized patients had greater than 70% coronary artery stenosis, and 6 (6%) had abnormal stress test results. There were no deaths or reinfarctions within 30 days. The rate of ACS was similar in patients who were physically fit and those who were not (24% vs 37%; OR, 0.5 [95% confidence interval, 0.2-1.3]) and in patients who had experienced exercise-induced CP and those who had not (32% vs 29%; OR, 1.2 [95% confidence interval, 0.4-3.2]). Neither the frequency nor the intensity of exercise was associated with ACS. CONCLUSIONS Physically fit patients with CP were as likely to have ACS as those not physically fit. A history of exercise-induced CP was not associated with an increased likelihood of ACS.