Influence of emergency department patient volumes on CT utilization rate of the physician in triage.

BACKGROUND: Physician in triage (PIT) has been used as a potential solution to emergency department (ED) overcrowding and to decrease ED length of stay (LOS). This study examined the relationship between computerized tomography (CT) utilization of PIT and ED patient volumes. We hypothesized that despite the pressure on PIT to improve throughput on the busiest days, they will continue to utilize CT at the same rate. METHODS: This retrospective chart review evaluated CT ordering patterns of PIT on patients with abdominal pain who presented to the ED over a 6-year period. CT utilization rate was calculated on days with the lowest 5% (LD5) and highest 5% (HD5) volumes based on average yearly volume. CT positive and negative rates were correlated with volume using Chi square analysis. Odds ratio and confidence intervals were calculated for the magnitude of effect difference. RESULTS: We found no statistically significant difference in CT utilization rate on HD5 vs LD5 (p = 0.833). There was a statistically significant increase in the rate of negative CT scans on HD5 (p = 0.046) which represented a 17% relative difference. LOS was longer on HD5 (p = 0.013) and when a CT scan was ordered (p < 0.001). CONCLUSION: No difference was found in the rate at which the PIT ordered CT scans on high volume vs low volume days. The rate of CT scans without clinically relevant findings did increase slightly on high volume days. LOS was longer on high volume days and when a CT was ordered.

CT ordering patterns for abdominal pain by physician in triage.

BACKGROUND: Overcrowding in the Emergency Department is a problem with many strategies for intervention such as the physician in triage (PIT). This brief evaluation is designed to minimize diagnostic uncertainty and expedite the work up when the patient is seen in the Emergency Department. We hypothesized that this would increase CT imaging which would be increasingly negative as the pressure to maintain throughput rises on busy days in the Emergency Department. METHODS: We designed a retrospective study in which ordering patterns of Emergency physicians was explored using a group of patients with abdominal pain, presenting to triage in a 2year period. We compared CT ordering rates on the 5% highest and lowest volume days (HD5 and LD5) and examined the bivariate relationship between volume and imaging utilization. RESULTS: There was no statistical significance in the rate of CT's ordered collectively by PIT physicians on HD5 compared with LD5 with a p-value of 0.25. There is a trend toward increased utilization when each physician is compared to themselves on HD5 vs. LD5 but these were not statistically significant differences. The percentage of "clinically relevant" CTs was not determined to be different, but there was an increase in the LOS when a CT was ordered on both LD5 and HD5 (HD5 p-value 0.009; LD5 p-value 0.0004). CONCLUSION: There is no difference in CT ordering patterns for abdominal pain by PIT between HD5 and LD5. Likewise CT ordering patterns do not demonstrate a difference in percentage of clinically relevant CTs.

Comparative evaluation of continuous intercostal nerve block or epidural analgesia on the rate of respiratory complications, intensive care unit, and hospital stay following traumatic rib fractures: a retrospective review.

BACKGROUND: Thoracic trauma accounts for 10%-15% of all trauma admissions. Rib fractures are the most common injury following blunt thoracic trauma. Epidural analgesia improves patient outcomes but is not without problems. The use of continuous intercostal nerve blockade (CINB) may offer superior pain control with fewer side effects. This study's objective was to compare the rate of pulmonary complications when traumatic rib fractures were treated with CINB vs epidurals. METHODS: A hospital trauma registry provided retrospective data from 2008 to 2013 for patients with 2 or more traumatic rib fractures. All subjects were admitted and were treated with either an epidural or a subcutaneously placed catheter for continuous intercostal nerve blockade. Our primary outcome was a composite of either pneumonia or respiratory failure. Secondary outcomes included total hospital days, total ICU days, and days on the ventilator. RESULTS: 12.5% (N=8) of the CINB group developed pneumonia or had respiratory failure compared to 16.3% (N=7) in the epidural group. No statistical difference (P=0.58) in the incidence of pneumonia or vent dependent respiratory failure was observed. There was a significant reduction (P=0.05) in hospital days from 9.72 (SD 9.98) in the epidural compared to 6.98 (SD 4.67) in the CINB group. The rest of our secondary outcomes showed no significant difference. CONCLUSION: This study did not show a difference in the rate of pneumonia or ventilator-dependent respiratory failure in the CINB vs epidural groups. It was not sufficiently powered. Our data supports a reduction in hospital days when CINB is used vs epidural. CINB may have advantages over epidurals such as fewer complications, fewer contraindications, and a shorter time to placement. Further studies are needed to confirm these statements.

Tetanus seropositive prevalence and perceived protection from emergency admissions.

BACKGROUND: Emergency physicians see many people who present to the emergency department stating that they are immunized against tetanus, when in fact, they are not. The patient history is not dependable for determining true tetanus status and simple patient surveys do not provide actual prevalence. The objective of this study was to determine the prevalence of tetanus status by antibody titer seropositivity and quantify such status among patients reporting tetanus protection. METHODS: This study is a single center prospective convenience sample of patients presenting to the emergency department 12 years of age or older. Patients deemed study candidates and willing to be in the study filled out an eight-question questionnaire that included the question 'is your tetanus shot up to date'. A blood sample was then drawn for tetanus antibody titer and quantified according to a pre-determined cutoff for protection. RESULTS: A total of 163 patients were enrolled. Of patients responding yes to the query 'is your tetanus shot up to date' 12.8% (N=5) of them were not seropositive. Of the 26 people who were seronegative in the study all had been to a doctor in the past year and 88.5% (N=23) had been to their family physician. CONCLUSION: The study suggests that it may be difficult to trust the tetanus immunization history given by patients presenting to the emergency room. The study also observed that a large percentage of patients who were serenegative were seen by a primary care physician and not had a necessary tetanus immunization.