Stephan Russ

Prevalence of incidental findings in trauma patients detected by computed tomography imaging

STUDY OBJECTIVE The primary intention of spiral computed tomography (SCT) in trauma patients is to identify significant injuries. However, unanticipated information is often discovered. We hypothesize that SCT often identifies clinically significant incidental findings in trauma patients. METHODS This was a retrospective protocol chart review of consecutive adult trauma patients seen at a level I trauma center. A complete SCT was defined as computed tomography imaging of the head, cervical spine, chest, abdomen, and pelvis, thoracic, and lumbar spine. Incidental findings were classified into 2 categories: type 1, which requires urgent evaluation, and type 2, which requires informing the patient but does not mandate urgent follow-up. RESULTS We reviewed 3246 patient charts and 3092 met inclusion criteria. Type 1 findings were reported in 990 (32.0%; 95% confidence interval [CI], 30.4%-33.7%) patients. Type 2 findings were found in 1274 (41.2%; 95% CI, 39.5%-42.9%) patients. Female sex (odds ratio, 1.38; 95% CI, 1.16-1.65) and older age (odds ratio, 2.61; 95% CI, 2.33-2.93) were independently associated with a higher prevalence of type 1 findings. There were 631 incidental findings concerning for neoplasm, which included 196 pulmonary nodules, 99 liver, 36 renal, 23 brain, and 11 breast masses. CONCLUSIONS A significant number of trauma patients evaluated with SCT are diagnosed with potentially serious incidental findings. For long-term care and medicolegal concerns, physicians need to inform patients of these incidental findings and the need for further evaluation.

Placing Physician Orders at Triage: The Effect on Length of Stay

STUDY OBJECTIVE Emergency department (ED) crowding is a significant problem nationwide, and numerous strategies have been explored to decrease length of stay. Placing a physician in the triage area to rapidly disposition low-acuity patients and begin evaluations on more complex patients is one strategy that can be used to lessen the effect of ED crowding. The goal of this study is to assess the effect of order placement by a triage physician on length of stay for patients ultimately treated in a bed within the ED. METHODS We conducted a pre-experimental study with retrospective data to evaluate patients with and without triage physician orders at a single academic institution. A matched comparison was performed by pairing patients with the same orders and similar propensity scores. Propensity scores were calculated with demographic and triage data, chief complaint, and ED capacity on the patients arrival. RESULTS During the 23-month study period, a total of 66,909 patients were sent to the waiting room after triage but still eventually spent time in an ED bed. A quarter of these patients (23%) had physician orders placed at triage. After a matched comparison, patients with triage orders had a 37-minute (95% confidence interval 34 to 40 minutes) median decrease in time spent in an ED bed, with an 11-minute (95% confidence interval 7 to 15 minutes) overall median increase in time until disposition. CONCLUSION Our study suggests that early orders placed by a triage physician have an effect on ED operations by reducing the amount of time patients spend occupying an ED bed.

Reducing Blood Culture Contamination in the Emergency Department: An Interrupted Time Series Quality Improvement Study

OBJECTIVES Blood culture contamination is a common problem in the emergency department (ED) that leads to unnecessary patient morbidity and health care costs. The study objective was to develop and evaluate the effectiveness of a quality improvement (QI) intervention for reducing blood culture contamination in an ED. METHODS The authors developed a QI intervention to reduce blood culture contamination in the ED and then evaluated its effectiveness in a prospective interrupted times series study. The QI intervention involved changing the technique of blood culture specimen collection from the traditional clean procedure to a new sterile procedure, with standardized use of sterile gloves and a new materials kit containing a 2% chlorhexidine skin antisepsis device, a sterile fenestrated drape, a sterile needle, and a procedural checklist. The intervention was implemented in a university-affiliated ED and its effect on blood culture contamination evaluated by comparing the biweekly percentages of blood cultures contaminated during a 48-week baseline period (clean technique) and 48-week intervention period (sterile technique), using segmented regression analysis with adjustment for secular trends and first-order autocorrelation. The goal was to achieve and maintain a contamination rate below 3%. RESULTS During the baseline period, 321 of 7,389 (4.3%) cultures were contaminated, compared to 111 of 6,590 (1.7%) during the intervention period (p < 0.001). In the segmented regression model, the intervention was associated with an immediate 2.9% (95% confidence interval [CI] = 2.2% to 3.2%) absolute reduction in contamination. The contamination rate was maintained below 3% during each biweekly interval throughout the intervention period. CONCLUSIONS A QI assessment of ED blood culture contamination led to development of a targeted intervention to convert the process of blood culture collection from a clean to a fully sterile procedure. Implementation of this intervention led to an immediate and sustained reduction of contamination in an ED with a high baseline contamination rate.

A clinical prediction model to estimate risk for 30-day adverse events in emergency department patients with symptomatic atrial fibrillation.

STUDY OBJECTIVE Atrial fibrillation affects more than 2 million people in the United States and accounts for nearly 1% of emergency department (ED) visits. Physicians have little information to guide risk stratification of patients with symptomatic atrial fibrillation and admit more than 65%. Our aim is to assess whether data available in the ED management of symptomatic atrial fibrillation can estimate a patients risk of experiencing a 30-day adverse event. METHODS We systematically reviewed the electronic medical records of all ED patients presenting with symptomatic atrial fibrillation between August 2005 and July 2008. Predefined adverse outcomes included 30-day ED return visit, unscheduled hospitalization, cardiovascular complication, or death. We performed multivariable logistic regression to identify predictors of 30-day adverse events. The model was validated with 300 bootstrap replications. RESULTS During the 3-year study period, 914 patients accounted for 1,228 ED visits. Eighty patients were excluded for non-atrial-fibrillation-related complaints and 2 patients had no follow-up recorded. Of 832 eligible patients, 216 (25.9%) experienced at least 1 of the 30-day adverse events. Increasing age (odds ratio [OR] 1.20 per decade; 95% confidence interval [CI] 1.06 to 1.36 per decade), complaint of dyspnea (OR 1.57; 95% CI 1.12 to 2.20), smokers (OR 2.35; 95% CI 1.47 to 3.76), inadequate ventricular rate control (OR 1.58; 95% CI 1.13 to 2.21), and patients receiving β-blockers (OR 1.44; 95% CI 1.02 to 2.04) were independently associated with higher risk for adverse events. C-index was 0.67. CONCLUSION In ED patients with symptomatic atrial fibrillation, increased age, inadequate ED ventricular rate control, dyspnea, smoking, and β-blocker treatment were associated with an increased risk of a 30-day adverse event.

ED crowding and the use of nontraditional beds

BACKGROUND AND OBJECTIVES In an effort to compensate for crowding, many emergency departments (EDs) evaluate and treat patients in nontraditional settings such as gurneys in hallways and conference rooms. The impact of this practice on ED evaluation time is unknown. RESEARCH DESIGN AND SUBJECTS A historical cohort of adult ED visits to an academic hospital between August 1, 2009 and August 1, 2010, was used to evaluate the relationship between ED bed assignment (traditional, hallway, or conference room bed) and mean ED evaluation time, defined as the time spent in an ED bed before admission or discharge. Chief complaints were categorized into the 5 most frequent categories: abdominal/genitourinary, joint/muscle, general (fever, malaise), head/neck, and other. Multiple linear regression and marginal prediction were used to calculate the mean ED evaluation times for each bed type, overall, and by chief complaint category. RESULTS During the study period, 15 073 patient visits met the inclusion criteria. After adjustment for patient and ED factors, assignments to hallway and conference room beds were associated with increases in a mean ED evaluation time of 13.3 minutes (95% confidence interval, 13.2-13.3) and 10.9 minutes (95% confidence interval, 10.8-10.9), respectively, compared with the traditional bed ED evaluation time. This varied by chief complaint category. CONCLUSIONS Use of nontraditional beds is associated with increases in mean ED evaluation time; however, these increases are small and may be further minimized by restricting the use of nontraditional beds to patients with specific chief complaints. Nontraditional beds may have a role in improving ED throughput during times of crowding.

Risk factors for bradycardia requiring pacemaker implantation in patients with atrial fibrillation.

Symptomatic bradycardia may complicate atrial fibrillation (AF) and necessitate a permanent pacemaker. Identifying patients at increased risk for symptomatic bradycardia may reduce associated morbidities and health care costs. The aim of this study was to investigate predictors for developing bradycardia requiring a permanent pacemaker in patients with AF. The records of all patients treated for AF or atrial flutter in an academic hospitals emergency department from August 1, 2005, to July 31, 2008, were reviewed. Survival and the presence of a pacemaker as of November 1, 2011, were determined. Cases were defined as patients with pacemakers placed for bradycardia after their AF diagnoses. Patients without pacemakers who were followed constituted the control group. Variables for the logistic regression analysis were identified a priori. A post hoc model was fit adjusting for AF type and atrioventricular nodal blocker use. Of the 362 patients in the cohort, 119 cases had permanent pacemakers implanted for bradycardia after AF diagnosis, and 243 controls were alive without pacemakers. The median follow-up time was 4.5 years (interquartile range 3.8 to 5.4). Odds ratios were determined for age at the time of AF diagnosis (1.02, 95% confidence interval [CI] 1 to 1.04), female gender (1.58, 95% CI 0.95 to 2.63), previous heart failure (2.72, 95% CI 1.47 to 5.01), and African American race (0.33, 95% CI 0.12 to 0.94). The post hoc model identified permanent AF (odds ratio 2.99, 95% CI 1.61 to 5.57) and atrioventricular nodal blocker use (odds ratio 1.43, 95% CI 0.85 to 2.4). In conclusion, in patients with AF, heart failure and permanent AF each nearly triple the odds of developing bradycardia requiring a permanent pacemaker; although not statistically significant, our results suggest that women are more likely and African Americans less likely to develop bradycardia requiring pacemaker implantation.

The AFFORD Clinical Decision Aid to Identify Emergency Department Patients With Atrial Fibrillation at Low Risk for 30-Day Adverse Events

There is wide variation in the management of patients with atrial fibrillation (AF) in the emergency department (ED). We aimed to derive and internally validate the first prospective, ED-based clinical decision aid to identify patients with AF at low risk for 30-day adverse events. We performed a prospective cohort study at a university-affiliated tertiary-care ED. Patients were enrolled from June 9, 2010, to February 28, 2013, and followed for 30 days. We enrolled a convenience sample of patients in ED presenting with symptomatic AF. Candidate predictors were based on ED data available in the first 2 hours. The decision aid was derived using model approximation (preconditioning) followed by strong bootstrap internal validation. We used an ordinal outcome hierarchy defined as the incidence of the most severe adverse event within 30 days of the ED evaluation. Of 497 patients enrolled, stroke and AF-related death occurred in 13 (3%) and 4 (<1%) patients, respectively. The decision aid included the following: age, triage vitals (systolic blood pressure, temperature, respiratory rate, oxygen saturation, supplemental oxygen requirement), medical history (heart failure, home sotalol use, previous percutaneous coronary intervention, electrical cardioversion, cardiac ablation, frequency of AF symptoms), and ED data (2 hours heart rate, chest radiograph results, hemoglobin, creatinine, and brain natriuretic peptide). The decision aids c-statistic in predicting any 30-day adverse event was 0.7 (95% confidence interval 0.65, 0.76). In conclusion, in patients with AF in the ED, Atrial Fibrillation and Flutter Outcome Risk Determination provides the first evidence-based decision aid for identifying patients who are at low risk for 30-day adverse events and candidates for safe discharge.

Atrial fibrillation and flutter outcomes and risk determination (AFFORD): design and rationale.

BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia affecting over 700,000 individuals in Japan and 2.2 million in the USA. The proper management of patients with AF is critical due to the well-documented association with heart failure and stroke. A strategy to better define the emergency department (ED) management, admission decisions, and spectrum of risk from low to high is needed. METHODS AND SUBJECTS The atrial fibrillation and flutter outcomes and risk determination investigation is a prospective, observational cohort study to develop a multivariable clinical prediction rule that accurately estimates risk for adverse outcomes in patients presenting to the ED with symptomatic AF. We will enroll 430 patients at 2 sites who present to the ED with symptomatic AF defined as a new or established diagnosis of AF or atrial flutter that require ED evaluation for a complaint thought related to their rhythm disturbance. The studys endpoint is to develop an accurate, objective, internally validated, reliable clinical prediction rule to risk-stratify ED patients presenting with AF exacerbations. The rule will incorporate patient history and examination findings and laboratory studies obtained upon ED presentation, as well as trends over the first 2 h of care. This investigations primary outcome is the incidence of any AF-related adverse event at 5 days and 30 days. We expect to complete the study by the end of 2014. The study was registered at Clinicaltrials.gov NCT01138644.

Personal experiences and attitudes towards intimate partner violence in healthcare providers in Guyana

BACKGROUND Intimate partner violence (IPV) is prevalent throughout the world and is a devastating public health problem. Healthcare workers (HCWs) are tasked with treating victims of IPV but may be victims themselves. Guyana is a lower-middle income country in South America. This study sought to determine the knowledge and attitudes of Guyanese HCWs and their perceived barriers to providing care in addition to determining the prevalence of IPV victimization and perpetration among HCWs. METHODS HCWs at the only tertiary care hospital in the Guyana completed an anonymous survey that comprised 30 questions relating to IPV. RESULTS The survey was completed by 87.5% of eligible HCWs. Of the respondents, 81.8% were female, 49.9% had ever experienced abuse and 21% admitted to perpetrating violence. Multivariate analysis found that the age groups 31-40 years (OR 2.3, 95% CI 1.1-4.6) and 41-50 years (OR 2.3, 95% CI 1.2-4.7) had higher odds of accepting justification for physical violence, and so did nursing staff (OR 4.3, 95% CI 1.4-13.1). Overall, 29.9% of HCWs accepted justification for physical violence in at least one of the named scenarios. CONCLUSION This study demonstrates a high prevalence of IPV among HCWs and identifies prevailing attitudes regarding IPV. This knowledge is essential in developing effective, appropriate training programs and identifies a need to address IPV among the healthcare workforce.

Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients

Study objective: Induction doses of etomidate during rapid sequence intubation cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged as an alternative for rapid sequence intubation induction. Among adult trauma patients intubated in the emergency department, we compare clinical outcomes among those induced with etomidate and ketamine. Methods: The study entailed a retrospective evaluation of a 4‐year (January 2011 to December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing rapid sequence intubation in the emergency department of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression, adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included ICU‐free days and ventilator‐free days evaluated with multivariable ordered logistic regression using the same covariates. Results: The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared with 17.3% among those induced with etomidate (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 0.92 to 2.16). Patients induced with ketamine had ICU‐free days (adjusted OR 0.80; 95% CI 0.63 to 1.00) and ventilator‐free days (adjusted OR 0.96; 95% CI 0.76 to 1.20) similar to those of patients induced with etomidate. Conclusion: In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard rapid sequence intubation induction agent for adult trauma patients, patient‐centered outcomes were similar for patients who received etomidate and ketamine.