Keith Wrenn

Usefulness of blood cultures in pyelonephritis

To evaluate the usefulness of blood cultures in patients admitted with pyelonephritis, a retrospective chart review was-conducted of inpatients at a 594-bed urban, academic medical center from 1990 through 1992 with a primary discharge diagnosis of pyelonephritis. A total of 338 patients had this primary discharge diagnosis. One or more sets of blood cultures were obtained in 307 patients (91%). Fifty-six (18%) patients had a positive blood culture; 24 (32%) positive blood cultures grew coagulase-negative Staphylococcus species, in all but two instances considered a skin contaminant. Of the blood cultures drawn, only 1 (0.2%) grew a pathogenic organism not found in the urine culture, with no impact on clinical management. These results support the conclusion that blood cultures are rarely clinically useful and seldom vary from urine culture results. Potential annual cost savings of between

The Use of Structured, Complaint-Specific Patient Encounter Forms in the Emergency Department

10 million and

Factors affecting stress in emergency medicine residents while working in the ED.

20 million in the United States could result from eliminating routine blood cultures in the setting of uncomplicated acute pyelonephritis.

Anxiety levels in EMS providers: Effects of violence and shift schedules

STUDY OBJECTIVE To assess the effect of preprinted, structured, complaint-specific patient encounter forms on documentation, use of testing, and treatment compared with free-text record keeping. DESIGN Nonrandomized case-control trial. SETTING University-affiliated, tertiary referral hospital emergency department. METHODS The records of all patients with lacerations, pharyngitis, asthma, or isolated closed-head injury during an eight-month period were reviewed. INTERVENTION Use of structured complaint-specific patient encounter forms versus traditional free-text record keeping. MAIN OUTCOME MEASURE The null hypothesis was that there would be no differences in documentation, test use, or practice when the structured forms were used compared with free-text record keeping. RESULTS Differences in documentation that favored the use of the structured forms for all four problems studied were seen consistently. Not only was documentation improved, but test use also was affected in a way that decreased use. In addition, in certain areas (eg, treatment of pharyngitis), clinical practice also was changed. CONCLUSION Structured, problem-specific ED records improve documentation and affect both resource use and clinical practice. These forms may be useful for improving communication and reimbursement as well as for medicolegal documentation. They provide a method for standardized quality assurance review and clinical data abstraction. Finally, they provide a method for active dissemination of clinical standards.

ADENOSINE DOSE SHOULD BE LESS WHEN ADMINISTERED THROUGH A CENTRAL LINE

OBJECTIVES The aim of this study was to identify factors other than work hours in the emergency department (ED) work environment contributing to resident stress. METHODS This study involved a prospective cohort evaluation of emergency medicine residents in the ED. Twelve surveys were collected from 18 subjects, 4 each from the day, evening, and night shifts. The Perceived Stress Questionnaire and a visual analog stress scale were administered. Data collected included the shift number of a given consecutive sequence of shifts, number of procedures performed, number of adverse events, average age of the patients seen by the resident, triage nurse-assigned acuities of the patients seen by the resident during the shift, the number of patients seen during a shift, the number of patients admitted by the resident during the shift, anticipated overtime after a shift, and shift-specific metrics related to overcrowding, including average waiting room time both for the individual residents and for all patients, average waiting room count for all patients, and average occupancy of the ED for all patients. RESULTS Among the 216 studied shifts, there was considerable variability in stress both within and between residents. In the multivariate mixed-effect regression analysis, only anticipated overtime and process failures were correlated with stress. Factors related to ED overcrowding had no significant effect on resident stress. CONCLUSIONS Resident stress was most impacted by anticipation of overtime and adverse events. Overcrowding in the ED and traditional measures of workload did not seem to affect stress as much.

Interaction between the trauma team and families: lack of timely communication.

We tried to measure anxiety levels in emergency medical service (EMS) providers to determine the effects of (1) having had a violent encounter during a shift and (2) different shift schedules, conducting a prospective observational study over 3 months in an urban EMS system setting. A convenience sample of 23 EMTs and 40 EMT-Ps was observed. Anxiety levels were measured using the Spielberger State-Trait Anxiety Inventory. A total of 99 inventories were completed by 63 EMS providers. The mean state (32.6+/-8) and trait (31.7+/-7.1) scores were less than normative scores (35.7+/-10.4 and 34.9+/-9.2 respectively) for working adult males (P = .004 and .007, respectively). Paramedics had lower anxiety scores than basic EMTs (P = .015 and .039) and years of experience also decreased anxiety scores (P < .0001). There was no significant difference in state scores between those EMS providers who had encountered violence during the preceding 12 hours and those providers who had not. Comparisons of state scores of providers assessed at hour 12 of a 12 hour shift, hour 12 of a 24 hour shift, and hour 24 of a 24 hour shift failed to show any significant differences. Although the working environment of the EMS provider contains numerous stressors and uncertainties, this population of providers were no more anxious than the general working public. Advanced training and years of experience decreased anxiety. Violent encounters during a shift did not appear to affect anxiety levels. There was no difference in anxiety levels in providers who worked 12 and 24 hour shifts.

Percutaneous feeding tube replacement in the ED--are confirmatory x-rays necessary?

A patient with a port-a-cath was given 12 mg of adenosine for paroxysmal supraventricular tachycardia (PSVT), resulting in prolonged (13 s) bradycardia and severe side effects. When the same patient presented 2 weeks later for recurrent PSVT, only 3 mg of adenosine was needed to terminate the episode, without the patient experiencing prolonged bradycardia or severe side effects. The literature suggests that for patients with central venous catheters, a lower dose of adenosine should be used to terminate PSVT.

A midlife crisis

Families of critically ill patients desire early information regarding the condition of their relative. The purpose of this study was to determine how long family members waited before someone from the trauma team met with them to discuss the condition of their relative. This was a prospective, single-blinded study of a convenience sample of 63 trauma patients conducted at a trauma center. Observers recorded the time of arrival of the patient, time of family arrival, and the time the family was first contacted by the trauma team. Families arrived 38 +/- 35 minutes after the patient. The mean time families waited before contact with the trauma team was 37 +/- 34 minutes. This study shows that the trauma team is often slow in communicating with the family of the victim. One member of the caregiving team should be designated to advise the family on the condition of the patient as soon as possible.

The Epidemiology and Diagnosis of Penetrating Eye Injuries

OBJECTIVE No study to date has addressed whether confirmatory x-ray after ED percutaneous feeding tube (PFT) replacement is always necessary. We hypothesized that x-ray confirmation of PFT replacement is not necessary in patients lacking both tract immaturity and trauma to the tract during dislodgement or replacement. Therefore confirmatory x-rays could safely be avoided for these patients. METHODS Medical records of 113 adult PFT encounters that met inclusion criteria between December 2000 and March 2004 at an urban university hospital ED seeing approximately 50,000 adult patients per year were reviewed. RESULTS Ninety-four patients (83%) presented secondary to dislodgement, and 19 patients (17%) presented secondary to malfunction. Forty-seven patients (42%) did not have confirmatory x-rays, and 66 (58%) had confirmatory x-rays. None of the patients discharged without a confirmatory x-ray returned with evidence of improper PFT placement. Of the 66 patients who had a confirmatory x-ray, 62 (94%) x-rays showed the feeding tube was in the correct location. In 4 patients, the x-ray showed either the PFT was not in the stomach or evidence of tract compromise. All of these patients had trauma to the tract and 3 of 4 were in immature tracts. There were only 19 patients of the total group of 113, however, who had neither trauma nor an immature tract. CONCLUSION Although uncommon, significant problems with PFT placement occur with the potential for catastrophic consequences. It appears that immaturity of the tract and trauma to the tract, either potential or actual, are the major risk factors for such complications.

Laryngoscope blade with fiberoptic scope for remote viewing and method for teaching the proper insertion of a laryngoscope blade into the airway of a patient

heritage and had been assured by his African-American father that he could not have inherited a sickle-cell gene despite the fact that there was a vague history of an aunt and cousin who might have died with sickle-cell disease. When he returned to the USA, haemoglobin electrophoresis was done and showed sickle-cell trait with 43% haemoglobin S and 57% haemoglobin A. A followup CT scan of his abdomen in November, 1998, showed resolution of splenomegaly and the subcapsular splenic infarct.