V. Rupp

Noninvasive measurement of carbon monoxide levels in ED patients with headache.

ObjectivesCarbon Monoxide (CO), the third most common cause of acute poisoning death, is easily overlooked in the emergency department (ED). Nonspecific complaints such as headache, weakness, or malaise may easily result in misdiagnosis. The objectives of this study are to determine the frequency of CO poisoning in patients presenting to the ED complaining of headaches and to determine the feasibility of using noninvasive CO analyzers as a screening tool.MethodsThis prospective controlled study examined, during the winter months, adult patients presenting with a complaint of atraumatic, afebrile headaches. All subjects submitted a sample for a CO breath analyzer. Participants with elevated carboxyhemoglobin (COHb) levels (nonsmoker > 2%, smokers > 5%) underwent venous COHb testing. Control patients, without headaches, presenting to the ED were similarly studied.ResultsWe enrolled 170 subjects and 98 controls. Of the 170 subjects, 12 (7.1%) had elevated COHb levels confirmed by venous COHb levels. Of the 98 controls, 1 (1.0%) had an elevated COHb level (p<0.05). There were no differences in demographic factors between the two groups (p > 0.16).ConclusionsNoninvasive measurement of CO levels in ED patients with headaches is rapid and specific. During winter months, elevated CO levels are present in over 7% of ED patients with headaches.

Impact of Education on Physician Attitudes toward Computed Tomography Utilization and Consent

BACKGROUND There are risks to ordering computed tomography (CT) scans. OBJECTIVE We set out to determine whether emergency physician attitudes and their predictions of CT ordering behaviors could be influenced by education. METHODS We surveyed emergency physicians at a Level I trauma center with a yearly census of 74,000. Physicians were given a baseline survey that encompassed demographics, attitudes toward CT informed consent, and ordering behaviors. After receiving an education session regarding CT risks, each participant received a follow-up survey. Data analysis was performed using frequencies and chi-squared. RESULTS Seventy-five physicians participated; 69% residents and 31% attendings; 34% were female and 66% male. Thirteen percent reported they did not know if informed consent was required for CT scans obtained in the Emergency Department. Pre-education, 89% reported sometimes ordering a CT scan due to a consultant request that they felt was not indicated, and 92% reported that they sometimes ordered a CT scan to appease a patient or family. Eighty-five percent reported that they sometimes ordered a CT scan defensively due to malpractice risk. After education, physicians were more likely to believe a patient should give informed consent before CT (p<0.01) and predicted that they would be more likely to discuss the risks/benefits of CT with their patients all of the time (p=0.001). CONCLUSION After education about the risks of CT utilization, emergency physicians were more likely to believe that patients should give informed consent before CT scan and predicted that they would be more likely to discuss the risks and benefits of CT with their patients.

Management of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial

BACKGROUND Benign paroxysmal positional vertigo (BPPV) is a common presenting problem. OBJECTIVE Our aim was to compare the efficacy of vestibular rehabilitation (maneuver) vs. conventional therapy (medications) in patients presenting to the emergency department (ED) with BPPV. METHODS This was a prospective, single-blinded physician, randomized pilot study comparing two groups of patients who presented to the ED with a diagnosis of BPPV at a Level 1 trauma center with an annual census of approximately 75,000. The first group received standard medications and the second group received a canalith repositioning maneuver. The Dizziness Handicap Inventory was used to measure symptom resolution. RESULTS Twenty-six patients were randomized; 11 to the standard treatment arm and 15 to the interventional arm. Mean age ± standard deviation of subjects randomized to receive maneuver and medication were 59 ± 12.6 years and 64 ± 11.2 years, respectively. There was no significant difference in mean ages between the two treatment arms (p = 0.310). Two hours after treatment, the symptoms between the groups showed no difference in measures of nausea (p = 0.548) or dizziness (p = 0.659). Both groups reported a high level of satisfaction, measured on a 0-10 scale. Satisfaction in subjects randomized to receive maneuver and medication was 9 ± 1.5 and 9 ± 1.0, respectively; there was no significant difference in satisfaction between the two arms (p = 0.889). Length of stay during the ED visit did not differ between the treatment groups (p = 0.873). None of the patients returned to an ED for similar symptoms. CONCLUSIONS This pilot study shows promise, and would suggest that there is no difference in symptomatic resolution, ED length of stay, or patient satisfaction between standard medical care and canalith repositioning maneuver. Physicians should consider the canalith repositioning maneuver as a treatment option.

Training Mothers in Infant Cardiopulmonary Resuscitation With an Instructional DVD and Manikin.

CONTEXT Classes in infant cardiopulmonary resuscitation (CPR) can be time consuming and costly. OBJECTIVE To determine whether mothers in an obstetric unit could learn infant CPR by using a 22-minute instructional kit and to assess the value and confidence they gained by learning CPR. DESIGN Quasi-experimental study with enrollment between January and December 2008. SETTING Obstetric unit in Lehigh Valley Hospital, a suburban teaching hospital in Allentown, Pennsylvania. PARTICIPANTS Mothers at least 18 years old who had given birth within the previous 24 hours. INTERVENTION The experimental group included mothers without prior CPR training who watched a 22-minute instructional DVD and practiced on a manikin. The control group included mothers with prior conventional CPR training. MAIN OUTCOME MEASURES In both groups, knowledge and proficiency were assessed with written and practical examinations developed by certified CPR instructors. Participant surveys were conducted at 3 times: immediately before dissemination of course materials, within 24 hours after the mother agreed to participate in the study, and 6 months after initial evaluation. RESULTS A total of 126 mothers were enrolled in the study: 79 in the experimental group, 25 in the control group, and 22 who withdrew from the study. Written and practical examinations were used to determine proficiency, and composite scores were generated, with a maximum composite score of 12. The composite scores were statistically significantly higher in the experimental group than in the control group, with median scores of 10 and 7, respectively (P<.001). Twenty-two mothers (21%) had been previously offered CPR training. In the experimental group, 76 mothers (96%) felt more confident as caregivers after learning CPR. Before training in both groups, 84 mothers (81%) stated that learning CPR was extremely important, compared with 100 mothers (96%) after training (P=.001). CONCLUSION Use of an instructional kit is an effective method of teaching CPR to new mothers. Mothers reported that learning CPR is extremely important and that it increases their confidence as caregivers.

A randomized, controlled trial to evaluate topical anesthetic for 15 minutes before venipuncture in pediatrics.

OBJECTIVES The aim of the study was to assess the differences in reported pain from venipuncture comparing liposomal 4% lidocaine with placebo cream in a pediatric population. Other factors assessed were patient anxiety, difficulty of venipuncture, and history of venipuncture. METHODS A prospective, randomized, double-blind, placebo control study design was used in which subjects were assigned to receive either liposomal 4% lidocaine or placebo cream. The study population consisted of pediatric patients aged 5 to 18 years old who presented to 1 site of a multisite, academic, community emergency department. Once subjects had consented and randomized, the liposomal 4% lidocaine or placebo cream was applied for 15 minutes under occlusion. A 6-point validated FACES pain scale was used to evaluate each patients level of pain during venipuncture. Patient anxiety was evaluated using a 100-mm visual analogue scale before, during, and after the venipuncture. Heart rate was captured as an indirect measurement of pain. RESULTS There were no significant differences between the study and placebo groups (P > .05) in mean levels of patient ratings of anxiety, patient heart rate, or the patients mean rating of pain before, during, or after the venipuncture procedure. There was an association between increased anxiety with an increase in venipuncture pain and an inverse association between age and pain. CONCLUSION Topical liposomal 4% lidocaine cream in this case did not prove to be effective with a 15-minute dwell time under occlusion because there were no differences in pain between study groups.

Analysis of sex differences in preadmission management of ST-segment elevation (STEMI) myocardial infarction.

BACKGROUND Many reports suggest gender disparity in cardiac care as a contributor to the increased mortality among women with heart disease. OBJECTIVE We sought to identify gender differences in the management of Myocardial Infarction (MI) Alert-activated ST-segment elevation myocardial infarction (STEMI) patients that may have resulted from prehospital initiation. METHODS A retrospective database was created for MI Alert STEMI patients who presented to the emergency department (ED) of an academic community hospital with 74,000 annual visits from April 2000 through December 2008. Included were patients meeting criteria for an MI Alert (an institutional clinical practice guideline designed to expedite cardiac catheterization for STEMI patients). Data points (before and after initiation of a prehospital alert protocol) were compared and used as markers of therapy: time to ECG, receiving β-blockers, and time to the catheterization laboratory (cath lab). Differences in categorical variables by patient sex were assessed using the χ(2) test. Medians were estimated as the measure of central tendency. Quantile regression models were used to assess differences in median times between subgroups. RESULTS A total of 1231 MI Alert charts were identified and analyzed. The majority of the study population were male (70%), arrived at the ED via ambulance (60.1%), and were taking a β-blocker (67.8%) or aspirin (91.6%) at the time of the ED admission. Female patients were more likely than male patients to arrive at the ED via ambulance (65.9% vs 57.6%, respectively; P = 0.014). The median age of female patients was 68 years, whereas male patients were significantly younger (median age, 59 years; P < 0.001). The proportion of patients currently taking a β-blocker or low-dose aspirin did not vary by gender. Overall, 78.2% of the MI Alert patients arriving at the ED were MI2 (alert initiated by ED physician), and this did not vary by gender (P = 0.33). A total of 1064 MI Alert patients went to the cath lab: 766 male patients (88.9%) and 298 female patients (80.8%). Overall, the median time to cath lab arrival was 79 minutes for men and 81 minutes for women (P = 0.38). Overall, the median time to cath lab arrival significantly decreased from MI1 to MI3, (P(trend) < 0.001). For prehospital-initiated alerts (MI3), the median time to cath lab arrival was the same for men and women (64 minutes; P = 1.0). For hospital-initiated alerts, time to cath lab arrival was 82 minutes for male patients and 84 minutes for female patients (P = 0.38). Prehospital activation of the process decreased the time to the cath lab by 19 minutes (P < 0.001; 95% CI, 13.2-24.8). CONCLUSION No significant gender differences were apparent in the STEMI patients analyzed, whether the MI Alert was initiated in the ED or prehospital initiated. Initiating prehospital-based alerts significantly decreased the time to the cath lab.

Gender Disparity in Emergency Department Non-ST Elevation Myocardial Infarction Management

BACKGROUND Many studies have looked at differences between men and women with acute coronary syndrome. These studies demonstrate that women have worse outcomes, receive fewer invasive interventions, and experience delay in the initiation of established medical therapies. OBJECTIVE Using innovative technology, we set out to unveil and resolve any gender disparities in the evaluation and treatment of patients presenting with a positive troponin while in the emergency department. Our goal was to assess the feasibility of using a business management query system to create an automated data report that could identify deficiencies in standards of care and be used to improve the quality of treatment we provide our patients. METHODS Over a 12-month period, key markers for patients with non-ST elevation myocardial infarction (NSTEMI) were tracked (e.g., time to electrocardiogram, door to medications). During this time, educational endeavors were initiated utilizing McKessons Horizon Business Insight™ (McKesson Information Solutions, Alpharetta, GA) to illustrate gender differences in standard therapy. Subsequently, indicators were evaluated for improvement. RESULTS Substantial improvements in key indicators for management of NSTEMI were obtained and gender differences minimized where education was provided. CONCLUSION The integration of these information systems allowed us to create a successful performance improvement tool and, as an added benefit, nearly eliminated the need for manual retrospective chart reviews.

Emergency Department Visits from a Local Amusement Park

BACKGROUND There are limited published data examining Emergency Department (ED) presentations associated with amusement parks, and even fewer data on presentations not associated with roller coaster rides. STUDY OBJECTIVES To determine the spectrum of medical and traumatic presentations to two EDs from nearby amusement parks. METHODS A retrospective chart review of prospectively identified, enrolled, and surveyed patients was conducted at two EDs in Pennsylvania during the summer of 2006. Any patient presenting with a medical or traumatic complaint that occurred within 12 h of ED presentation and was associated with a visit to the local amusement park was prospectively identified and details of the visit were retrospectively reviewed. RESULTS There were a total of 325 discharge diagnoses for the 296 ED visits identified; 74% of discharge diagnoses were trauma related. The most common traumatic diagnoses were laceration (27%) and head injury or concussion (14%). The most common non-traumatic diagnosis was heat-related illness (24%). Twenty-nine percent of discharge diagnoses were directly associated with amusement park rides. Eighty-nine percent of patients were discharged home. There were no mortalities reported. CONCLUSION The majority of ED visits from nearby amusement parks were benign and did not require hospitalization.

Patient Attitudes Regarding Consent for Emergency Department Computed Tomographies

Introduction Little is known about patient attitudes towards informed consent for computed tomography (CT) in the emergency department (ED). We set out to determine ED patient attitudes about providing informed consent for CTs. Methods In this cross-sectional questionnaire-based survey study, we evaluated a convenience sample of patients’ attitudes about providing informed consent for having a CT at 2 institutional sites. Historically, at our institutional network, patients received a CT at approximately 25% of their ED visits. The survey consisted of 17 “yes/no” or multiple-choice questions. The primary outcome question was “which type of informed consent do you feel is appropriate for a CT in the Emergency Department?” Results We analyzed 300 survey responses, which represented a 90% return rate of surveys distributed. Seventy-seven percent thought they should give their consent prior to receiving a CT, and 95% were either comfortable or very comfortable with their physician making the decision regarding whether they needed a CT. Forty percent of the patients felt that a general consent was appropriate before receiving a CT in the ED, while 34% thought a verbal consent was appropriate and 15% percent thought a written consent was appropriate. Seventy-two percent of the ED patients didn’t expect to receive a CT during their ED visit and 30% of the ED patients had previously provided consent prior to receiving a CT. Conclusion Most patients feel comfortable letting the doctor make the decision regarding the need for a CT. Most ED patients feel informed consent should occur before receiving a CT but only a minority feel the consent should be written and specific to the test.