Preeti Dalawari

Racial Differences in Opiate Administration for Pain Relief at an Academic Emergency Department

Introduction The decision to treat pain in the emergency department (ED) is a complex, idiosyncratic process. Prior studies have shown that EDs undertreat pain. Several studies demonstrate an association between analgesia administration and race. This is the first Midwest single institution study to address the question of race and analgesia, in addition to examining the effects of both patient and physician characteristics on race-based disparities in analgesia administration. Methods This was a retrospective chart review of patients presenting to an urban academic ED with an isolated diagnosis of back pain, migraine, or long bone fracture (LBF) from January 1, 2007 to December 31, 2011. Demographic and medication administration information was collected from patient charts by trained data collectors blinded to the hypothesis of the study. The primary outcome was the proportion of African-Americans who received analgesia and opiates, as compared to Caucasians, using Pearson’s chi-squared test. We developed a multiple logistic regression model to identify which physician and patient characteristics correlated with increased opiate administration. Results Of the 2,461 patients meeting inclusion criteria, 57% were African-American and 30% Caucasian (n=2136). There was no statistically significant racial difference in the administration of any analgesia (back pain: 86% vs. 86%, p=0.81; migraine: 83% vs. 73%, p=0.09; LBF: 94% vs. 90%, p=0.17), or in opiate administration for migraine or LBF. African-Americans who presented with back pain were less likely to receive an opiate than Caucasians (50% vs. 72%, p<0.001). Secondary outcomes showed that higher acuity, older age, physician training in emergency medicine, and male physicians were positively associated with opiate administration. Neither race nor gender patient-physician congruency correlated with opiate administration. Conclusion No race-based disparity in overall analgesia administration was noted for all three conditions: LBF, migraine, and back pain at this institution. A race-based disparity in the likelihood of receiving opiate analgesia for back pain was observed in this ED. The etiology of this is likely multifactorial, but understanding physician and patient characteristics of institutions may help to decrease the disparity by raising awareness of practice patterns and can provide the basis for quality improvement projects.

Oligoanalgesia in Blunt Geriatric Trauma

BACKGROUND Research suggests that older age can influence perception, assessment, and treatment of acute pain, resulting in inadequate pain control for geriatric patients. OBJECTIVE The purpose of this study was to determine if geriatric trauma patients are less likely to receive analgesia in our emergency department (ED). METHODS This retrospective chart review includes blunt trauma adult patients who presented to a Level I trauma center ED between June 1 and December 31, 2012. Age was categorized as ≥65 years old and 18-64 years old. χ(2) was used to analyze differences in patients receiving pain medication by age groups. Analysis excluded those with no or low pain. A logistic regression model estimated the odds ratio of analgesic use controlling for age, pain level, sex, race, alcohol, drugs, Glasgow Coma Scale, ED length of stay, and Injury Severity Score. T-test compared differences in analgesia administration time. RESULTS Four hundred and sixty-three blunt trauma patients were included in the analysis. Seventy percent of those ≥65 years received analgesia, compared with 84% of those 18-64 years old (p < 0.01). The mean time to analgesia administration was 92 min (≥65 years) compared to 61 min (18-64 years) (p = 0.03). Those ≥65 years were 69% less likely (odds ratio = 0.31; 95% confidence interval 0.16-0.59) to receive analgesia compared to patients aged 18-64 years, after controlling for confounders. CONCLUSIONS Trauma patients ≥ 65 years of age are less likely to receive analgesia than the younger cohort in our ED and waited longer to get it.

Promoting tobacco cessation utilizing pre-health professional students as research associates in the emergency department

OBJECTIVE The objective of this study was to investigate the extent to which volunteer research associates (RAs) can be utilized to screen emergency department patients and their visitors for tobacco use and effectively refer tobacco users requesting help to state Tobacco Quitlines. METHODS A sample of 19,149 individuals in 10 emergency departments around the country was enrolled into a prospective, interventional study on tobacco cessation by pre-health professional RAs. Participants who screened positive for tobacco use were provided a brief description of Tobacco Quitline programs and then offered a faxed referral to their respective state Quitline. RESULTS A total of 10,303 (54%) participants reported tobacco use for more than one month during their lives, with 3861 (20%) currently using every day and an additional 1340 using on some days (7%). Most importantly, 2151 participants requested a faxed Tobacco Quitline referral (36% of individuals who used tobacco in the past month). DISCUSSION Pre-health professional RAs were shown to be an effective and cost-efficient resource for providing a strongly recommended service in the emergency department. Patient care (and the care of their visitors) was supplemented, emergency department personnel were not provided with additional burden, and RAs were provided with valuable experience for their futures in the health professions.

PUBLIC PERCEPTIONS OF HOSPITAL RESPONSIBILITIES TO THOSE PRESENTING WITHOUT MEDICAL INJURY OR ILLNESS DURING A DISASTER

Abstract Background During natural and manmade disasters, the hospital is perceived as a central rallying and care site for the public, for both those with and without emergency medical needs. The expectations of the public may outstrip hospital plans and abilities to provide nonmedical assistance. Objective Our objective was to determine the public expectations of the hospital during disasters regarding resource provision. Methods A survey was distributed to adult patients or family members at three emergency departments (EDs). Respondents were asked to evaluate hospital responsibility to provide nine resources to those without emergency medical needs, including vaccination, medication refill or replacement, food and water, grief/stress counseling, Federal Emergency Management Agency (FEMA) access assistance, short/long-term shelter, family reunification, and hospital. Additionally, respondents answered questions regarding prior disaster experience and demographics. Results There were 961 respondents (66.9% were female, 47.5% were white, and 44.6% were black). Respondents agreed or strongly agreed that the hospital should provide the following services: event-specific vaccination (84%), medication refill/replacement (76.5%), food and water (61%), grief or stress counseling (53%), FEMA access assistance (52%), short-term shelter (51%), family reunification (50%), long-term shelter (38%), and hospital transportation (29%). Those 36–45 years of age were less likely to expect services (p < 0.05) and non-whites and those with a family member with a medical condition requiring electricity were more likely to expect services (p < 0.001 and p < 0.05, respectively). There were no differences based on frequency of ED use, sex, income, or prior disaster experience. Conclusion There is a high public expectation that hospitals will provide significant nonmedical disaster relief. Understanding these expectations is essential to appropriate community disaster planning.

Public expectations for nonemergency hospital resources and services during disasters

OBJECTIVE The publics expectations of hospital services during disasters may not reflect current hospital disaster plans. The objective of this study was to determine the publics expected hospital service utilization during a pandemic, earthquake, and terrorist bombing. METHODS A survey was distributed to adult patients or family members at 3 emergency departments (EDs). Participants identified resources and services they expect to need during 3 disaster scenarios. Linear regression was used to describe factors associated with higher expected utilization scores for each scenario. RESULTS Of the 961 people who participated in the study, 66.9% were women, 47.5% were white, and 44.6% were black. Determinants of higher pandemic resource utilization included persons who were younger (P < .01); non-white (P < .001); had higher ED visits (P < .01), hospitalization (P = .001), or fewer primary care provider visits (P = .001) in the past year; and did not have a reunification plan (P < .001). Determinants of higher earthquake resource utilization included persons who were non-white (P < .001); who were a patient or spouse (vs parent) participating in the study (P < .05 and P = .001); and had higher ED visits in the past year (P = .001). Determinants of higher bombing resource utilization included persons who were female (P = .001); non-white (P < .001); had higher ED (P = .001) or primary care provider (P < .01) visits in past year; and experienced the loss of home or property during a past disaster (P < .05). CONCLUSIONS Public expectations of hospitals during disasters are high, and some expectations are inappropriate. Better community disaster planning and public risk communication are needed.

Knowledge of Alcohol Impairment in Boaters in Southern Illinois

BACKGROUND Alcohol is the leading contributor to boating deaths. Earlier literature estimates that 30-40% of people drink alcohol while boating. OBJECTIVE The objective of this study was to directly approach boaters at the dock to assess the prevalence of alcohol consumption while boating, as well as their knowledge of alcohol impairment. METHODS This was a cross-sectional survey of a convenience sample of boaters aged 21 years and older at Illinois lakes and rivers during July 2011. Participants completed a survey of alcohol use and impaired boating knowledge consisting of six multiple-choice questions. A χ(2) analysis was used to assess knowledge differences by demographic variables. RESULTS Two hundred and ten people participated. Less than one fourth of participants correctly answered 4 of the 5 knowledge questions. Eighty-four percent correctly reported the watercraft blood alcohol legal limit. Eighty-one percent erroneously believed that it was more dangerous for the driver to be intoxicated than the passenger. There were no differences in knowledge by sex, education, boat ownership, or driver status. Seventy-six percent admitted to drinking alcohol while boating. Younger participants (aged 21 to 40 years) were significantly more likely to report drinking while boating compared with older participants (p < 0.05). CONCLUSIONS A majority of participants imbibe while boating and with only a rudimentary understanding of the dangers. Designated drivers (for boating) campaigns might falsely imply imbibing-passenger safety. Public health officials should readdress the dangers of passenger drinking, especially with the younger age group, to help decrease alcohol-related morbidity and mortality.

Racial Differences in Beliefs of Physician Prescribing Practices for Low-Cost Pharmacy Options

BACKGROUND Previous studies have reported that certain populations are sensitive to high out-of-pocket drug costs, and drug noncompliance leads to poorer health outcomes. OBJECTIVE Our aim was to measure patient awareness of discount pharmacy options, cost barriers to medication access, and beliefs about health care providers use of low-cost medications. METHODS This cross-sectional 17-item survey was administered to patients in the emergency department of an urban trauma center in February 2011. Differences in responses by sex and race groups were assessed. A logistic regression model was created to estimate the association of sociodemographic factors and medication use with awareness of discount pharmacy options. RESULTS Five hundred and fifty-two surveys were analyzed. Among respondents who were prescribed medications within the past year, three fourths of patients felt comfortable asking physicians for cheaper medicines. Slightly more than half were aware of low-cost pharmacy options, and 78% of these respondents correctly listed at least one of these pharmacies. Caucasian patients were more comfortable than African American patients asking for cheaper medicines (82.5% vs. 72.2%; p < 0.05) and were more aware of low-cost prescription programs (63.9% vs. 43.5%; p < 0.001). When adjusted for insurance status and current medication use, Caucasian patients were 2.7 times more likely to name a valid discount pharmacy option compared to African Americans (95% confidence interval 1.85-4.07). CONCLUSIONS This study suggests populations may be more uncomfortable initiating a discussion about medication costs and selection of lower-cost alternatives. Health care providers may need to develop communication strategies in which medication cost is addressed with sensitivity and consistency.

Just another sore throat

A 22-year-old male with a medical history of asthma presented to the emergency department (ED) with sore throat, limited head rotation to the left side, and odynophagia for 5 days. The patient had been seen the day before at the student health clinic and prescribed antibiotics for pharyngitis, but came to the ED for worsening symptoms. The patient described no similar symptoms occurring in the past. The patient reported a subjective fever as well as left-sided otalgia, but denied shortness of breath or difficulty swallowing secretions. Mild hoarseness was noted. Vital signs including temperature were within normal limits and the patient appeared nontoxic. Physical examination revealed a tender and firm left-sided cervical mass on the sternocleidomastoid muscle from the angle of the mandible to the clavicle with palpable lymphadenopathy. The larynx was displaced to the right. Intraoral examination revealed a midline uvula with no peritonsillar bulge or tonsillar exudate. Laboratory work showed a white blood count of 11.9 with a 75% neutrophil differential and mono slide test was negative. Axial computed tomography with contrast revealed a 4.0 4.7 8.7 cm left parapharngyeal rimenhancing abscess from the hyoid down to the thyroid

Short answer question case series: a case of total body pain

A middle-aged male with sickle β thalassaemia presents to the emergency department with increasing joint, abdominal and back pain with fatigue and intermittent fevers, nausea and vomiting for 1 week. Vital signs included a pulse of 99 beats/min, BP of 144/82 mm Hg, RR of 16 times/min, a pulse oximetry of 100% on room air, and temperature of 37.0. On physical exam, he had mild, diffuse abdominal pain with a normal motor-sensory exam of the lower extremities but increased left hip pain on extension of left leg. He kept his knees and hips in a flexed position. Labs revealed a normal leukocyte count, haemoglobin and reticulocyte count. 1. What are the concerning historical and physical exam findings? 2. What imaging should be considered? 3. What does the CT (figure 1) demonstrate? 4. What other work-up should be obtained? 5. How should these patients be treated? 1. This patient does not appear to be having a vaso-occlusive crisis. Although he is afebrile and does not have a leukocytosis, he is relatively immunocompromised and may not mount …

Neck pain and swelling in a young man

A middle aged man presents to the emergency department (ED) with right-sided neck pain and swelling. He had a right internal jugular vein (IJ) catheter during a hospitalisation for intestinal haemorrhage 2 weeks ago. Shortly thereafter, the patient noted progressively worsening neck pain and swelling, with dysphagia, odynophagia and pain with neck movement over the last 2 days. The patient denies fevers, chills, vocal changes, respiratory distress, dyspnoea, chest pain or recent drug use. On exam, the patient appears uncomfortable, with a blood pressure 133/74, heart rate 108 BPM, respiratory rate of 16, pulse oximetry of 100% and temperature of 36.6°C. He has swelling and tenderness to palpation of the right neck and right lower jaw. 1. What is your differential diagnosis? 2. What are the appropriate tests to obtain in this patient? 3. What does the CT imaging show; does this change or narrow your differential diagnosis? 4. What is …