Shoma Desai

Improving door-to-balloon time by decreasing door-to-ECG time for walk-in STEMI patients.

Introduction The American Heart Association/American College of Cardiology guidelines recommend rapid door-to-electrocardiography (ECG) times for patients with ST-segment elevation myocardial infarction (STEMI). Previous quality improvement research at our institution revealed that we were not meeting this benchmark for walk-in STEMI patients. The objective is to investigate whether simple, directed changes in the emergency department (ED) triage process for potential cardiac patients could decrease door-to-ECG times and secondarily door-to-balloon times. Methods We conducted an interventional study at a large, urban, public teaching hospital from April 2010 to June 2012. All patients who walked into the ED with a confirmed STEMI were enrolled in the study. The primary intervention involved creating a chief complaint-based “cardiac triage” designation that streamlined the evaluation of potential cardiac patients. A secondary intervention involved moving our ECG technician and ECG station to our initial triage area. The primary outcome measure was door-to-ECG time and the secondary outcome measure was door-to-balloon time. Results We enrolled 91 walk-in STEMI patients prior to the intervention period and 141 patients after the invention. We observed statistically significant reductions in door-to-ECG time (43±93 to 30±72 minutes, median 23 to 14 minutes p<0.01), ECG-to-activation time (87±134 to 52±82 minutes, median 43 to 31 minutes p<0.01), and door-to-balloon time (134±146 to 84±40 minutes, median 85 -75 minutes p=0.03). Conclusion By creating a chief complaint-based cardiac triage protocol and by streamlining ECG completion, walk-in STEMI patients are systematically processed through the ED. This is not only associated with a decrease in door-to-balloon time, but also a decrease in the variability of the time sensitive intervals of door-to-ECG and ECG-to-balloon time.

Labor and Delivery and Their Complications

Emergency department (ED) births are rare. In most cases, patients in labor are triaged directly to the obstetric suite for urgent management, maintaining a continuum of care with their primary providers. Because some births are precipitous and obstetric resources may not be immediately available, the emergency physician must possess the basic skills for intrapartum management of both normal and abnormal deliveries. In addition, a general knowledge of postpartum care is required in case of the occasional out-of-hospital delivery.

Case-controlled Analysis of Patient-based Risk Factors for Assault in the Healthcare Workplace

Introduction Violence against healthcare workers in the medical setting is common and associated with both physical and psychological adversity. The objective of this study was to identify features associated with assailants to allow early identification of patients at risk for committing an assault in the healthcare setting. Methods We used the hospital database for reporting assaults to identify cases from July 2011 through June 2013. Medical records were reviewed for the assailant’s (patient’s) past medical and social history, primary medical complaints, ED diagnoses, medications prescribed, presence of an involuntary psychiatric hold, prior assaultive behavior, history of reported illicit drug use, and frequency of visits to same hospital requesting prescription for pain medications. We selected matched controls at random for comparison. The primary outcome measure(s) reported are features of patients committing an assault while undergoing medical or psychiatric treatment within the medical center. Results We identified 92 novel visits associated with an assault. History of an involuntary psychiatric hold was noted in 52%, history of psychosis in 49%, a history of violence in the ED on a prior visit in 45%, aggression at index visit noted in the ED chart in 64%, an involuntary hold (or consideration of) for danger to others in 61%, repeat visits for pain medication in 9%, and history of illicit drug use in 33%. Compared with matched controls, all these factors were significantly different. Conclusion Patients with obvious risk factors for assault, such as history of assault, psychosis, and involuntary psychiatric holds, have a substantially greater chance of committing an assault in the healthcare setting. These risk factors can easily be identified and greater security attention given to the patient.

Estimating the impact of adopting the revised United Kingdom acetaminophen treatment nomogram in the U.S. population

Abstract Background: Acetaminophen toxicity is common in clinical practice. In recent years, several European countries have lowered the treatment threshold, which has resulted in increased number of patients being treated at a questionable clinical benefit. Objective: The primary objective of this study is to estimate the cost and associated burden to the United States (U.S.) healthcare system, if such a change were adopted in the U.S. Methods: This study is a retrospective review of all patients age 14 years or older who were admitted to one of eight different hospitals located throughout the U.S. with acetaminophen exposures during a five and a half year span, encompassing from 1 January 2008 to 30 June 2013. Those patients who would be treated with the revised nomogram, but not the current nomogram were included. The cost of such treatment was extrapolated to a national level. Results: 139 subjects were identified who would be treated with the revised nomogram, but not the current nomogram. Extrapolating these numbers nationally, an additional 4507 (95%CI 3641–8751) Americans would be treated annually for acetaminophen toxicity. The cost of lowering the treatment threshold is estimated to be

The Effect of Utilization Review on Emergency Department Operations

45 million (95%CI 36,400,000–87,500,000) annually. Conclusions: Adopting the revised treatment threshold in the U.S. would result in a significant cost, yet provide an unclear clinical benefit.

STEMI AND OUT OF HOSPITAL CARDIAC ARREST (START) REGISTRY: ANGIOGRAPHIC FINDINGS IN PATIENTS WITH AND WITHOUT SHOCKABLE INITIAL ARREST RHYTHMS

Study objective: Increasingly, hospitals are using utilization review software to reduce hospital admissions in an effort to contain costs. Such practices have the potential to increase the number of unsafe discharges, particularly in public safety‐net hospitals. Utilization review software tools are not well studied with regard to their effect on emergency department (ED) operations. We study the effect of prospectively used admission decision support on ED operations. Methods: In 2012, Los Angeles County + University of Southern California Medical Center implemented prospective use of computerized admission criteria. After implementation, only ED patients meeting primary review (diagnosis‐based criteria) or secondary review (medical necessity as determined by an on‐site emergency physician) were assigned inpatient beds. Data were extracted from electronic medical records from September 2011 through December 2013. Outcomes included operational metrics, 30‐day ED revisits, and 30‐day admission rates. Excluding a 6‐month implementation period, monthly summary metrics were compared pre‐ and postimplementation with nonparametric and negative binomial regression methods. All adult ED visits, excluding incarcerated and purely behavioral health visits, were analyzed. The primary outcomes were disposition rates. Secondary outcomes were 30‐day ED revisits, 30‐day admission rate among return visitors to the ED, and estimated cost. Results: Analysis of 245,662 ED encounters was performed. The inpatient admission rate decreased from 14.2% to 12.8%. Increases in discharge rate (82.4% to 83.4%) and ED observation unit utilization (2.5% to 3.4%) were found. Thirty‐day revisits increased (20.4% to 24.4%), although the 30‐day admission rate decreased (3.2% to 2.8%). Estimated cost savings totaled

1688Diagnosis of Pulmonary Tuberculosis among Admitted Patients at a Large, Urban Safety-net Facility — Los Angeles, 2010–2013

193.17 per ED visit. Conclusion: The prospective application of utilization review software in the ED led to a decrease in the admission rate. This was tempered by a concomitant increase in ED observation unit utilization and 30‐day ED revisits. Cost savings suggest that resources should be redirected to the more highly affected ED and ED observation unit, although more work is needed to confirm the generalizability of these findings.

Sepsis Bundle Adherence Is Associated with Improved Survival in Severe Sepsis or Septic Shock

Survival following out-of-hospital cardiac arrest plus ST-segment elevation myocardial infarction (OOHCA+STEMI) is worse in the absence of an initial shockable arrest rhythm (ventricular tachycardia or fibrillation). This study seeks to detail angiographic differences between those with and without

226: The Effect of Implementation of an Observation Unit on Emergency Department Wait Time to Initial Physician Evaluation, Emergency Department Length of Stay, Emergency Department Boarding Times, and Percentage of Patients Who Left Without Being Seen

Background. Health care facilities face substantial challenges in diagnosis and infection prevention for patients suspected to have infectious tuberculosis (TB). LAC + USC Medical Center is a large, urban safety-net facility with 105 confirmed TB cases reported in 2013, >1% of all reported cases in the United States. Methods. We reviewed all inpatient admissions from January 2010 to September 2013 with at least one sputum specimen collected for acid fast bacilli (AFB) smear and culture (nucleic acid amplification tests (NAATs) were not routinely performed). Using AFB culture for Mycobacterium tuberculosis as the gold standard, we evaluated the sensitivity and specificity of the first 3 AFB sputum smears and the incremental yield of consecutive sputa. We examined demographic differences among patients by AFB culture result; the chi-square test was used to detect differences in proportions. We calculated inpatient length of stay stratified by AFB smear results. Results. Among 2,775 inpatient admissions (2,572 unique patients), median age was 51 (IQR 42–59), 2,023 (72.9%) were male, and 1,568 (56.5%) were foreign-born. At least one sputum culture grewM. tuberculosis for 219 (7.9%); a positive culture was more frequent among foreign-born (10.4%) compared to U.S.-born patients (4.6%) (P < .001). The sensitivity and specificity of the first 3 sputum smears were 58.9% (CI 52.1–65.5) and 99.5% (CI 99.2–99.8), respectively. The incremental yields for each of the first 3 sputa were 86.8%, 6.2%, and 7.0% (for smear) and 91.8%, 4.1%, and 4.1% (for culture). Median length of stay was greater for admissions where at least one of the first 3 smears was positive (14.7 days (IQR 8.1–23.5)) compared to admissions where the first 3 smears were all negative (4.9 days (IQR 2.7–9.8)). Among 12 admissions with a positive sputum smear but no positive culture for M. tuberculosis, the median length of stay was 9.7 days (IQR 6.1–21.8). Conclusion. One culture-confirmed pulmonary TB case was diagnosed for every 13 inpatient evaluations. The sensitivity of the first 3 sputum smears was low; although specificity was high, false-positive smears represent a burden on hospital resources. The improved sensitivity and specificity of NAATs might have substantial impact at this institution. Disclosures. All authors: No reported disclosures.

199 Is Time to Antibiotics in Sepsis a Waste of Time

Introduction There have been conflicting data regarding the relationship between sepsis-bundle adherence and mortality. Moreover, little is known about how this relationship may be moderated by the anatomic source of infection or the location of sepsis declaration. Methods This was a multi-center, retrospective, observational study of adult patients with a hospital discharge diagnosis of severe sepsis or septic shock. The study included patients who presented to one of three Los Angeles County Department of Health Services (DHS) full-service hospitals January 2012 to December 2014. The primary outcome of interest was the association between sepsis-bundle adherence and in-hospital mortality. Secondary outcome measures included in-hospital mortality by source of infection, and the location of sepsis declaration. Results Among the 4,582 patients identified with sepsis, overall mortality was lower among those who received bundle-adherent care compared to those who did not (17.9% vs. 20.4%; p=0.035). Seventy-five percent (n=3,459) of patients first met sepsis criteria in the ED, 9.6% (n=444) in the intensive care unit (ICU) and 14.8% (n=678) on the ward. Bundle adherence was associated with lower mortality for those declaring in the ICU (23.0% adherent [95% confidence interval{CI} {16.8–30.5}] vs. 31.4% non-adherent [95% CI {26.4–37.0}]; p=0.063), but not for those declaring in the ED (17.2% adherent [95% CI {15.8–18.7}] vs. 15.1% non-adherent [95% CI {13.0–17.5}]; p=0.133) or on the ward (24.8% adherent [95% CI {18.6–32.4}] vs. 24.4% non-adherent [95% CI {20.9–28.3}]; p=0.908). Pneumonia was the most common source of sepsis (32.6%), and patients with pneumonia had the highest mortality of all other subsets receiving bundle non-adherent care (28.9%; 95% CI [25.3–32.9]). Although overall mortality was lower among those who received bundle-adherent care compared to those who did not, when divided into subgroups by suspected source of infection, a statistically significant mortality benefit to bundle-adherent sepsis care was only seen in patients with pneumonia. Conclusion In a large public healthcare system, adherence with severe sepsis/septic shock management bundles was found to be associated with improved survival. Bundle adherence seems to be most beneficial for patients with pneumonia. The overall improved survival in patients who received bundle-adherent care was driven by patients declaring in the ICU. Adherence was not associated with lower mortality in the large subset of patients who declared in the ED, nor in the smaller subset of patients who declared in the ward.