Mark C. Henry

Wound Registry: Development and Validation

STUDY OBJECTIVE More than 11 million patients with traumatic wounds are seen annually in emergency departments. We developed and validated a data registry for traumatic wounds treated in the ED. DESIGN Prospective, consecutive patient enrollment with a validation cohort of a convenience sample of 100 patients. SETTING University-affiliated hospital ED. PARTICIPANTS For all patients with traumatic wounds requiring sutures, wound registry data sheets were completed at the time of initial visit using a closed-question format. Data recorded included demographic characteristics, time from injury to evaluation, pertinent medical history, wound characteristics, type of anesthesia, details of wound-cleansing methods, details of wound closure, and postoperative care. We devised a follow-up tool to evaluate for the presence of infection and short-term cosmetic appearance. Interphysician reliability was assessed for wound description, presence of infection, and cosmetic appearance by use of the kappa statistic. RESULTS A wound registry data collection instrument that takes less than 1 minute to complete and enables the collection of most wound management techniques used by emergency physicians was found to have substantial interobserver concordance for wound description (kappa range, .55 to .97), wound infection (kappa = 1.0) and overall cosmetic appearance (kappa = .61). CONCLUSION The wound registry is a reliable data collection instrument that is easy to use. It may be useful as a continuous quality-improvement tool or for standardization of wound surveillance and treatment data to facilitate future prospective studies in wound management.

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.

STUDY OBJECTIVE We developed and implemented an institutional protocol aimed at reducing crowding by admitting boarded patients to hospital inpatient hallways. We hypothesized that transfer of admitted patients from the emergency department (ED) to inpatient hallways would be feasible and not create patient harm. METHODS This was a retrospective cohort study in a suburban, academic ED with an annual census of 70,000. We studied consecutive patients admitted from our ED between January 2004 and January 2008. In 2001, a multidisciplinary team developed and implemented an institutional protocol in which admitted adult patients boarded in the ED were transferred to hospital inpatient hallways under select conditions. We extracted data from the electronic medical record system, measuring patient demographics, ED disposition (discharge, admit to floor, admit to hallway), ED length of stay, and inhospital mortality. We report ED length of stay, subsequent transfer to an ICU, and hospital mortality of patients admitted to standard and hallway inpatient beds. RESULTS Of 55,062 ED patients admitted, there were 1,798 deaths. Of all admissions, 2,042 (4%) went to a hallway; 53,020 went to a standard bed. Patients admitted to standard and hallway beds were similar in age (median [interquartile range] 55 years [37 to 72 years] and 54 years [41 to 70 years], respectively) and sex (48.2% and 50% female patients, respectively). The median (interquartile range) times from ED triage to actual admission in patients admitted to standard and hallway beds were 426 minutes (306 to 600 minutes) and 624 (439 to 895 minutes) minutes, respectively (P<.001). Median ED census at triage was lower for standard bed admissions than for hallway patients (44 [33 to 53] versus 50 [38 to 61], respectively, P<.001). Inhospital mortality rates were higher among patients admitted to standard beds (2.6%; 95% confidence interval [CI] 2.5% to 2.7%) than among patients admitted to hallway beds (1.1%; 95% CI 0.7% to 1.7%). ICU transfers were also higher in the standard bed admissions (6.7% [95% CI 6.5% to 6.9%] versus 2.5% [95% CI 1.9% to 3.3%]). CONCLUSION Transfer of ED-boarded admitted patients to an inpatient hallway occurs during high ED census and waiting times for admission but does not appears to result in patient harm.

The Public Access Defibrillation (PAD) trial: study design and rationale.

The PAD Trial is a prospective, multicenter, randomized clinical study testing whether volunteer, non-medical responders can improve survival from out-of-hospital cardiac arrest (OOH-CA) by using automated external defibrillators (AEDs). These lay volunteers, who have no traditional responsibility to respond to a medical emergency as part of their primary job description, will form part of a comprehensive, integrated community approach to the treatment of OOH-CA. The study is being conducted at 24 field centers in the United States and Canada. Approximately 1000 community units (e.g. apartment or office buildings, gated communities, sports facilities, senior centers, shopping malls, etc.) were randomized to treatment by trained laypersons who will provide either cardiopulmonary resuscitation (CPR) alone or CPR plus use of an AED, while awaiting arrival of the communitys emergency medical services responders. The primary endpoint is the number of OOH-CA victims who survive to hospital discharge. Secondary endpoints include neurological status, health-related quality of life (HRQL), cost, and cost-effectiveness. Data collection will last approximately 15 months and is expected to be completed in September 2003.

Correlation Among Clinical, Laboratory, and Hepatobiliary Scanning Findings in Patients With Suspected Acute Cholecystitis

STUDY OBJECTIVE To assess the ability of various clinical and laboratory parameters to predict the results of hepatobiliary scintigraphy (HBS) in patients with suspected acute cholecystitis. METHODS This was a retrospective chart review of all patients referred from the emergency department for an HBS in 1993 to exclude acute cholecystitis. The setting was a university-affiliated tertiary care hospital with an annual census of approximately 42,000. The participants were 100 consecutive patients who were seen in the ED and had an HBS and obtainable medical records. Medical records of all patients referred from the ED for an urgent HBS in 1993 were retrospectively reviewed for the following information: demographics, historical information, physical findings, laboratory findings, biliary scintigraphic findings, and surgical pathologic findings. Comparisons were made between patients with a positive or negative HBS. Sensitivities, specificities, and positive and negative predictive values were calculated for dichotomous variables with a positive HBS as a control standard. A separate analysis was performed for patients with pathologically confirmed acute cholecystitis. RESULTS Fifty-three patients had a positive HBS, and 47 had a negative HBS. A history of fever had a positive predictive value of 100% and a sensitivity of 14.6%. The presence of Murphys sign was both sensitive (97.2%) and highly predictive (93.3%) of a positive HBS yet was not documented in 35 cases. All other variables were not found to be helpful in predicting the results of HBS. Pathologic diagnoses were available in 44 patients. Of 40 patients with pathologically confirmed acute cholecystitis, fever and leukocytosis were absent at the time of presentation in 36 (90%) and 16 (40%) of the cases, respectively. Murphys sign was absent in 3 (10%) of 29 of these patients. A stepwise analysis failed to identify any combination of clinical variables that was associated with a higher probability of a positive HBS. CONCLUSION No single or combination of clinical or laboratory findings at the time of ED presentation identified all patients with a positive HBS. Murphys sign had the highest sensitivity and positive predictive value yet was poorly documented. Liberal use of biliary scintigraphy or ultrasound is encouraged to avoid underdiagnosis of acute cholecystitis.

Evaluation of American college of surgeons trauma triage criteria in a suburban and rural setting

In suburban and rural counties, patient transport to specialized facilities such as trauma centers may result in prolonged transport times with the resultant loss of ambulance coverage in the primary service area. We evaluated the American College of Surgeons trauma triage criteria as modified by New York State to determine the ability of these criteria to predict the need for trauma center care in victims of blunt traumatic injury. Blunt trauma patients were retrospectively identified through review of patient care reports for the presence either of mechanism or of physiological criteria for transport to a trauma center. Controls were randomly selected from patients with blunt trauma not meeting any of the criteria. Main outcome parameters were the emergency department (ED) disposition, length of hospital stay, need for intensive care unit (ICU) care, and major nonorthopedic operative interventions. There were 857 patients enrolled. The presence either of mechanism or of physiological criteria increased the likelihood of hospital admission (control, 11%; mechanism, 35%; and physiological, 33%). Relative to patients without any criteria, the presence of mechanism criteria alone did not identify patients who required a prolonged length of stay (67% vs 71%), intensive care unit services (13% vs 19%) or major nonorthopedic operative interventions (0.2% vs 1.6%). The presence of physiological criteria increased the likelihood of requiring all of these services. These comparisons held true for victims of motor vehicle accidents, pedestrians struck by motor vehicles, and people who fell from heights above ground level. Patients with physiologic criteria may benefit from transport directly to a trauma center. Because of the low need for operative intervention and ICU services, patients with no criteria or mechanism criteria at long distances from a trauma center may be initially evaluated at the closest hospital and transferred to a trauma center if hospitalization or ICU care is necessary. Further study to determine the predictive value of certain individual mechanism criteria is warranted.

Outcome of patients who refused out-of-hospital medical assistance

Activation of the emergency medical services (EMS) system does not always result in transport of a patient to the hospital. This study assessed the outcomes of patients who refused medical assistance in the field, to determine if refusal of medical assistance (RMA) is associated with poor outcomes. Four high-volume suburban volunteer ambulance corps participated in the study. Consecutive patients who refused medical assistance were prospectively enrolled. Medical and identifying data were collected for each patient. Telephone follow-up was conducted to determine the patients condition and if the patient sought further care after RMA. Primary endpoints were whether the patient sought further care, was admitted to a hospital, or died subsequent to RMA. Follow-up was successfully obtained for 199 of 321 patients enrolled (62%). Of these 199 patients, 95 (48%) sought further medical care within 1 week for the same complaint, with 13 being admitted to the hospital. Six of the 13 admitted patients had chief complaints of a cardiac or respiratory nature. One patient died during hospital admission. Even if none of the patients lost to follow-up had sought further care, a substantial number of patients who refuse out-of-hospital medical assistance seek further care. Some of these patients require hospital admission, especially those with cardiac or respiratory complaints. Efforts to minimize RMA should be especially focused on patients with such complaints.

Introduction of a Stat Laboratory Reduces Emergency Department Length of Stay

OBJECTIVES Emergency department (ED) length of stay (LOS) impacts patient satisfaction and overcrowding. Laboratory turnaround time (TAT) is a major determinant of ED LOS. The authors determined the impact of a Stat laboratory (Stat lab) on ED LOS. The authors hypothesized that a Stat lab would reduce ED LOS for admitted patients by 1 hour. METHODS This was a before-and-after study conducted at an academic suburban ED with 75,000 annual patient visits. All patients presenting to the ED during the months of August and October 2006 were considered. A Stat lab located within the central laboratory was introduced in September 2006 to reduce laboratory TAT. The test TATs and ED LOS before (August 2006) and after (October 2006) implementing the Stat lab for all ED patients were the data of interest. ED LOS before and after the Stat lab was introduced was compared with the Mann-Whitney U-test. A sample size of 5,000 patients in each group had 99% power to detect a 1-hour difference in ED LOS. RESULTS There were 5,631 ED visits before and 5,635 visits after implementing the Stat lab. Groups were similar in age (34 years vs. 36 years) and gender (51% males in both). The percentages of patients with laboratory tests before and after Stat lab implementation were 68.7 and 71.3%, respectively. Test TATs for admitted patients were significantly improved after the Stat lab introduction. Implementation of the Stat lab was associated with a significant reduction in the median ED LOS from 466 (interquartile range [IQR] = minutes before to 402 (IQR = 296-553) minutes after implementing the Stat lab. The effects of the Stat lab on ED LOS were less marked for discharged patients. CONCLUSIONS Introduction of a Stat lab dedicated to the ED within the central laboratory was associated with shorter laboratory TATs and shorter ED LOS for admitted patients, by approximately 1 hour.

Prospective Countywide Evaluation of the Effects of Motor Vehicle Safety Device Use on Hospital Resource Use and Injury Severity

STUDY OBJECTIVE We evaluated the efficacy of safety devices (seat belts and air bags) on hospital resource use and injury severity while controlling for variables known to affect outcome of motor vehicle crashes. METHODS We conducted a prospective observational study of motor vehicle crash victims who were transported to the hospital in a suburban-rural county with a population of 1.4 million. Out-of-hospital providers recorded patient demographic characteristics, mechanism of injury (based on American College of Surgeons criteria), and use of seat belts or air bags. Hospital charts were reviewed for hospital admission, length of hospital stay, ICU stay, surgery, major nonorthopedic surgery or death, and severe injury (Injury Severity Score > 15). RESULTS The study group comprised 1,446 motor vehicle crash victims. Median age was 30 years, 47% were male, and 69% used safety devices. The use of safety devices reduced the likelihood of hospital admission (adjusted odds ratio [OR], .67; 95% confidence interval [CI], .46 to .98) surgery (adjusted OR, .52; 95% CI, .27 to 1.01), major surgery or death (adjusted OR, .14; 95% CI, .04 to .52), and severe injuries (adjusted OR of injury Severity Score > 15, .39; 95% CI, .19 to .83). CONCLUSION The use of safety devices is associated with decreased hospital resource use and less severe injuries for victims of motor vehicle crashes who are transported to the hospital by emergency medical services providers, even after adjustment for many other variables known to affect the outcome of motor vehicle crashes. Continued efforts to promote safety device use are warranted.

Level of training, wound care practices, and infection rates

This prospective, nonrandomized descriptive study compares the traumatic wound infection rates in patients based on level of training of emergency department (ED) practitioners. Wounds were evaluated in 1,163 patients. A wound registry data sheet was prospectively completed on all patients sutured in the ED. All practitioners were assigned a unique identification number. Follow-up data was obtained at the time of the return visit. Patients failing to return were contacted by telephone. Data were analyzed for patient wound infection rates by practitioner level of training. Patient wound infection rates by practitioner level of training were: medical students, 0/60 (0%); all resident physicians, 17/547 (3.1%); physician assistants, 11/305 (3.6%); and attending physicians 14/251 (5.6%), P was not significant. Comparison of junior (medical students and interns) to senior practitioners (all other practitioners) found no difference in infection rates (8/262 [3.1%] v 34/901 [3.8%], P = .58). In conclusion, carefully selected patients sutured by closely supervised medical students and junior residents have infection rates as low as those sutured by more experienced practitioners.

Cerebral oximetry levels during CPR are associated with return of spontaneous circulation following cardiac arrest: an observational study

Objectives Cerebral oximetry using near-infrared spectroscopy measures regional cerebral oxygen saturation (rSO2) non-invasively and may provide information regarding the quality of cerebral oxygen perfusion. We determined whether the level of rSO2 obtained during cardiopulmonary resuscitation is associated with return of spontaneous circulation (ROSC) and survival in Emergency Department (ED) patients presenting with cardiac arrest. Methods We conducted a retrospective, observational study of adult ED patients presenting at an academic medical centre with cardiac arrest in whom continuous cerebral oximetry was performed. Demographic and clinical data including age, gender, presenting rhythm and mean rSO2 readings were abstracted. Cerebral oxygenation was measured with a commercially available oximeter. Results A convenience study sample included 59 patients ages 18–102 years (mean age 68.7 ± 14.9 years); 50 (84.7%) were men. Presenting rhythms included pulseless electrical activity (21), asystole (20) and ventricular fibrillation/tachycardia (17). 24 patients (40.6%) had ROSC and only 1 (1.7%) survived to hospital discharge. Patients with and without ROSC were similar in age and presenting cardiac rhythms. The mean of mean rSO2 levels was higher in patients with ROSC, 43.8 (95% CI 40.1 to 47.6) compared with those without ROSC, 34.2 (95% CI 30.6 to 37.8); p=0.001. 91.7% of patients with ROSC had a rSO2 of 30% or greater compared with 62.9% in those without ROSC (p=0.01). The area under the curve for mean rSO2 as a predictor of ROSC was 0.76 (95% CI 0.64 to 0.89). Conclusions In ED patients with cardiac arrest higher cerebral oxygen saturations are associated with higher rates of ROSC.