Impact and feasibility of an emergency department-based ventilator-associated pneumonia bundle for patients intubated in an academic emergency department.

BACKGROUND: Ventilator-associated pneumonia (VAP) has been linked to emergency department (ED) intubation and length of stay (LOS). We assessed VAP prevalence in ED intubated patients, feasibility of ED VAP prevention, and effect on VAP rates. METHODS: This was a quality improvement initiative using a pre/post design. Phase 1 (PRE1) comprised patients before intensive care unit (ICU) bundle deployment. Phase 2 (PRE2) occurred after ICU but before ED deployment. Phase 3 (POST) included patients received VAP prevention starting at ED intubation. Log-rank test for equality and Cox regression using a Breslow method for ties were performed. Bundle compliance was reported as percentages. Number needed to treat (NNT) was calculated by ventilator day. RESULTS: PRE1, PRE2, and POST groups were composed of 195, 192, and 153 patients, respectively, with VAP rates of 22 (11.3%), 11 (5.7%), and 6 (3.9%). Log-rank test showed significant reduction in VAP (χ2 = 9.16, P = .0103). The Cox regression hazard ratio was 1.38 for the Clinical Pulmonary Infection Score (P = .001), and the hazard ratio was 0.26 for the VAP bundle (P = .005). Bundle compliance >50% for head-of-bed elevation, oral care, subglottic suctioning, and titrated sedation improved significantly with introduction of a registered nurse champion. NNT varied from 7 to 11. CONCLUSIONS: VAP was common for ED intubated patients. ED-based VAP prevention is feasible. We demonstrate significant reduction in VAP rates, which should be replicated in a multicenter study.

Physician documentation of sepsis syndrome is associated with more aggressive treatment.

INTRODUCTION: Timely recognition and treatment of sepsis improves survival. The objective is to examine the association between recognition of sepsis and timeliness of treatments. METHODS: We identified a retrospective cohort of emergency department (ED) patients with positive blood cultures from May 2007 to January 2009, and reviewed vital signs, imaging, laboratory data, and physician/nursing charts. Patients who met systemic inflammatory response syndrome (SIRS) criteria and had evidence of infection available to the treating clinician at the time of the encounter were classified as having sepsis. Patients were dichotomized as RECOGNIZED if sepsis was explicitly articulated in the patient record or if a sepsis order set was launched, or as UNRECOGNIZED if neither of these two criteria were met. We used median regression to compare time to antibiotic administration and total volume of fluid resuscitation between groups, controlling for age, sex, and sepsis severity. RESULTS: SIRS criteria were present in 228/315 (72.4%) cases. Our record review identified sepsis syndromes in 214 (67.9%) cases of which 118 (55.1%) had sepsis, 64 (29.9%) had severe sepsis, and 32 (15.0%) had septic shock. The treating team contemplated sepsis (RECOGNIZED) in 123 (57.6%) patients. Compared to the UNRECOGNIZED group, the RECOGNIZED group had a higher use of antibiotics in the ED (91.9 vs.75.8%, p=0.002), more patients aged 60 years or older (56.9 vs. 33.0%, p=0.001), and more severe cases (septic shock: 18.7 vs. 9.9%, severe sepsis: 39.0 vs.17.6%, sepsis: 42.3 vs.72.5%; p<0.001). The median time to antibiotic (minutes) was lower in the RECOGNIZED (142) versus UNRECOGNIZED (229) group, with an adjusted median difference of -74 minutes (95% CI [-128 to -19]). The median total volume of fluid resuscitation (mL) was higher in the RECOGNIZED (1,600 mL) compared to the UNRECOGNIZED (1,000 mL) group. However, the adjusted median difference was not statistically significant: 262 mL (95% CI [ -171 to 694 mL]). CONCLUSION: Patients whose emergency physicians articulated sepsis syndrome in their documentation or who launched the sepsis order set received antibiotics sooner and received more total volume of fluid. Age <60 and absence of fever are factors associated with lack of recognition of sepsis cases.

An innovative longitudinal curriculum to increase emergency medicine residents' exposure to rarely encountered and technically challenging procedures.

BACKGROUND: Procedural skills have historically been taught at the bedside. In this study, we aimed to increase resident knowledge of uncommon emergency medical procedures to increase residents' procedural skills in common and uncommon emergency medical procedures and to integrate cognitive training with hands-on procedural instruction using high- and low-fidelity simulation. METHODS: We developed 13 anatomically/physiologically-based procedure modules focusing on uncommon clinical procedures and/or those requiring higher levels of technical skills. A departmental expert directed each session with collaboration from colleagues in related subspecialties. Sessions were developed based on Manthey and Fitch's stages of procedural competency including 1) knowledge acquisition, 2) experience/technical skill development, and 3) competency evaluation. We then distributed a brief, 10-question, online survey to our residents in order to solicit feedback regarding their perceptions of increased knowledge and ability in uncommon and common emergency medical procedures, and their perception of the effectiveness of integrated cognitive training with hands-on instruction through high- and low-fidelity simulation. RESULTS: Fifty percent of our residents (11/22) responded to our survey. Responses indicated the procedure series helped with understanding of both uncommon (65% strongly agreed [SA], 35% agreed [A]) and common (55% SA, 45% A) emergency medicine procedures and increased residents' ability to perform uncommon (55% SA, 45% A) and common (45% SA, 55% A) emergency medical procedures. In addition, survey results indicated that the residents were able to reach their goal numbers. CONCLUSION: Based on survey results, the procedure series improved our residents' perceived understanding of and perceived ability to perform uncommon and more technically challenging procedures. Further, results suggest that the use of a cognitive curriculum model as developed by Manthey and Fitch is adaptable and could be modified to fit the needs of other medical specialties.

Alternative methods to central venous pressure for assessing volume status in critically ill patients.

INTRODUCTION: Early goal-directed therapy increases survival in persons with sepsis but requires placement of a central line. We evaluate alternative methods to measuring central venous pressure (CVP) to assess volume status, including peripheral venous pressure (PVP) and stroke volume variation (SVV), which may facilitate nurse-driven resuscitation protocols. METHODS: Patients were enrolled in the emergency department or ICU of an academic medical center. Measurements of CVP, PVP, SVV, shoulder and elbow position, and dichotomous variables Awake, Movement, and Vented were measured and recorded 7 times during a 1-hour period. Regression analysis was used to predict CVP from PVP and/or SVV, shoulder/elbow position, and dichotomous variables. RESULTS: Twenty patients were enrolled, of which 20 had PVP measurements and 11 also had SVV measurements. Multiple regression analysis demonstrated significant predictive relationships for CVP using PVP (CVP = 6.7701 + 0.2312 × PVP - 0.1288 × Shoulder + 12.127 × Movement - 4.4805 × Neck line), SVV (CVP = 14.578 - 0.3951 × SVV + 18.113 × Movement), and SVV and PVP (CVP = 4.2997 - 1.1675 × SVV + 0.3866 × PVP + 18.246 × Awake + 0.1467 × Shoulder = 0.4525 × Elbow + 15.472 × Foot line + 10.202 × Arm line). DISCUSSION: PVP and SVV are moderately good predictors of CVP. Combining PVP and SVV and adding variables related to body position, movement, ventilation, and sleep/wake state further improves the predictive value of the model. The models illustrate the importance of standardizing patient position, minimizing movement, and placing intravenous lines proximally in the upper extremity or neck.

The distribution of the h-index among academic emergency physicians in the United States.

BACKGROUND: Hirsch's h-index (h) attempts to measure the combined academic impact and productivity of a scientist by counting the number of publications by an author, ranked in descending order by number of citations, until the paper number equals the number of citations. This approach provides a natural number or index of the number of publications and the number of citations per publication. H was first described in physics and was demonstrated to be highly predictive of continued academic activity, including recognized measures of scientific excellence such as membership in the National Academy of Sciences and being a Nobel laureate. Citation rates, research environments, and years of experience all affect h, making any comparisons appropriate only for scientists working in the same field for a similar time period. The authors are unaware of any report describing the distribution of h among academic emergency physicians (AEPs). OBJECTIVES: The objective was to describe the distribution of h for AEPs and to determine whether Hirsch's demonstration of the h-index as a predictor of continued scholarly activity among physicists would also apply to AEPs. METHODS: Academic EPs were identified from lists provided on allopathic U.S. emergency medicine (EM) residency program websites. "Harzing's Publish or Perish," a free program available on the Web that queries Google Scholar, was used to calculate h for each AEP. Agreement between raters was analyzed on a subset of 100 EPs. An analysis of the 20 EPs with the top h-indices was performed to characterize the entire body of their scholarly work, and their h-indices were calculated at 12 and 24 years into their careers. RESULTS: A total of 4,744 AEPs from 136 programs were evaluated. Nine programs did not publicly list the faculty at their institutions and were excluded. A linear weighted kappa was used to measure rater concordance, with agreement of 98.3% and κ = 0.92 (95% confidence interval [CI] = 0.861 to 0.957). The majority of AEPs had h-indices of zero or one (59%), 85% had h-indices less than six, 95% less than 13, and 99% less than 24. Ten percent of AEPs had h/(years in publication) of 0.5 or greater. For the top 20 EPs, the mean (± standard deviation [±SD]) h-index increased from 7.6 (±4.6) to 23.5 (±9.4) between years 12 and 24. The mean (±SD) increase in h-index was 15.8 (±7.6). CONCLUSIONS: The h-index can be used to characterize the academic productivity of AEPs. An h/year of 0.5 or greater is characteristic of the most productive EPs and represents only 10% of all AEPs. The 12-year h-index of top-performing EPs was strongly related to their future academic productivity. The distribution of h among EPs may provide a means for individual investigators and academic leaders to evaluate performance and identify EPs with future success in EM research.

Agreement between emergency medical services and expert blood pressure measurements.

BACKGROUND: Emergency Medical Services (EMS)-measured blood pressures (BPs) are utilized for administering medications in the field and for triage decisions. Retrospective work has demonstrated poor agreement between EMS and Emergency Department (ED) BP but has lacked a valid, reliable reference standard. STUDY OBJECTIVES: To compare EMS BP measurements with those of trained research assistants (RA) and observe measurement technique for sources of error. METHODS: A prospective study was performed with a large urban EMS. BP measurements were made by RA within 5 min of patients presenting to the ED. EMS personnel were asked about technique. EMS personnel were then observed while RA simultaneously measured BP. Analysis was performed using methods outlined by Bland and Altman. RESULTS: There were 100 patients enrolled for each phase. In the first phase, the mean difference in systolic BP was -3.8 ± 18.6 mm Hg (95% confidence interval [CI] -8.3 to 0.59), and the mean difference in diastolic BP was 0.42 ± 13.8 mm Hg (95% CI -3.3 to 4.1). In the second phase, the mean difference in systolic BP was -4.6 ± 10.1 mm Hg (95% CI -6.6 to -2.6) and the mean difference in diastolic BP was -3.6 ± 10.6 mm Hg (95% CI -3.6 to -0.2). EMS personnel failed to properly place the cuff or deflate it 2-3 mm Hg/s in over 90% of the readings. They failed to properly inflate the cuff in 74% of the patients, and failed to properly place the stethoscope in 40%. EMS personnel demonstrated a significant preference for the terminal digit of "0" (p < 0.0001). CONCLUSIONS: EMS and expert BP measurements showed smaller discrepancies than those previously noted, especially with simultaneous measurements. However, EMS demonstrated poor adherence to American Heart Association recommendations for measuring BP. EMS also showed terminal digit preference.

Analysis of automated external defibrillator device failures reported to the Food and Drug Administration.

STUDY OBJECTIVE: Automated external defibrillators are essential for treatment of cardiac arrest by lay rescuers and must determine when to shock and if they are functioning correctly. We seek to characterize automated external defibrillator failures reported to the Food and Drug Administration (FDA) and whether battery failures are properly detected by automated external defibrillators. METHODS: FDA adverse event reports are catalogued in the Manufacturer and User Device Experience (MAUDE) database. We developed and internally validated an instrument for analyzing MAUDE data, reviewing all reports in which a fatality occurred. Two trained reviewers independently analyzed each report, and a third resolved discrepancies or passed them to a committee for resolution. RESULTS: One thousand two hundred eighty-four adverse events were reported between June 1993 and October 2008, of which 1,150 were failed defibrillation attempts. Thirty-seven automated external defibrillators never powered on, 252 failed to complete rhythm analysis, and 524 failed to deliver a recommended shock. In 149 cases, the operator disagreed with the device's rhythm analysis. In 54 cases, the defibrillator stated the batteries were low and in 110 other instances powered off unexpectedly. Interrater agreement between reviewers 1 and 2 ranged by question from 69.0% to 98.6% and for most likely cause was 55.9%. Agreement was obtained for 93.7% to 99.6% of questions by the third reviewer. Remaining discrepancies were resolved by the arbitration committee. CONCLUSION: MAUDE information is often incomplete and frequently no corroborating data are available. Some conditions not detected by automated external defibrillators during self-test cause units to power off unexpectedly, causing defibrillation delays. Backup units frequently provide shocks to patients.

Course of untreated high blood pressure in the emergency department.

INTRODUCTION: No clear understanding exists about the course of a patient's blood pressure (BP) during an emergency department (ED) visit. Prior investigations have demonstrated that BP can be reduced by removing patients from treatment areas or by placing patients supine and observing them for several hours. However, modern EDs are chaotic and noisy places where patients and their families wait for long periods in an unfamiliar environment. We sought to determine the stability of repeated BP measurements in the ED environment. METHODS: A prospective study was performed at an urban ED. Research assistants trained and certified in BP measurement obtained sequential manual BPs and heart rates on a convenience sample of 76 patients, beginning with the patient arrival in the ED. Patients were observed through their stay for up to 2 hours, and BP was measured at 10-minute intervals. Data analysis with SAS PROC MIXED (SAS Institute, Cary, North Carolina) for regression models with correlated data determined the shape of the curve as BP changed over time. Patients were grouped on the basis of their presenting BP as normal (less than 140/90), elevated (140-160/90-100), or severely elevated (greater than 160/100) for the regression analysis. RESULTS: A statistically significant downward trend in systolic and diastolic BP was observed only for those patients presenting with severely elevated BPs (ie, greater than 160/100). CONCLUSION: We demonstrate a statistically significant decline in systolic and diastolic BP over time spent in the ED only for patients with severely elevated presenting BPs.

United States-Mexico border crossing: experiences and risk perceptions of undocumented male immigrants.

Undocumented immigrants crossing the US-Mexico border face many hazards as they attempt to enter the United States, including heat and cold injury, dehydration, and wild animal encounters. In the Tucson sector of the US-Mexico border, there are over 100 deaths a year from heat-related injuries alone. Public awareness campaigns have been undertaken to disseminate information on the dangers inherent in crossing. Little is known, however, about the ways in which undocumented immigrants actually receive information regarding the risks of crossing the border, how such information impacts their preparation for crossing or how the journey itself effects their motivation to cross again in the future. A qualitative descriptive method was used to describe and analyze information from adult males who had attempted to illegally cross the US-Mexico Border and had recently been returned to Mexico. Semi-structured interviews were conducted, and responses were classified into several broad themes. Interviews were conducted and analyzed iteratively until thematic saturation was achieved. The responses validated the established risks as being commonplace. A total of eight (8) male undocumented immigrants participated in the interviews. Individuals sought information prior to crossing from the media, their families and friends, and acquaintances in border towns. They did not appear to value any particular information source over any other. New areas of risk were identified, such as traveling with others who might have new or existing medical problems. There was also substantial concern for the family unit as both a source of inspiration and motivation. The family emerged as an additional at-risk unit due to the destabilization and financial strain of having one of its members leave to attempt to immigrate to the US for work. While many planned to cross again, the majority of the men in our sample had no intention of seeking permanent residence in the US, instead planning to work and then return to their families in Mexico. This preliminary study found that individuals crossing the US-Mexico border appear willing to put themselves and their families at substantial perceived risk in order to seek economic opportunity. Future public awareness campaigns may choose to shift focus solely from the individual risk of the crossing to the additional risks to family and community.

Description and evaluation of a canine volunteer blood donor program.

Human volunteer blood donor programs are commonplace, but the concept of nonhuman animal blood banking is relatively new. Few studies exist regarding efficacy, donor screening, and safety for volunteer companion animals. This retrospective study evaluated a nonprofit, community-based canine volunteer donor program using community blood drives. Of 98 potential donors, 14 were ineligible to donate, including 4 who tested seropositive for blood-borne pathogens. Of 84 donors, 45 were Dog Erythrocyte Antigen (DEA) 1.1 positive and 39 were DEA1.1 negative. Donations totaling 143 included 29 repeat donors (35%). No serious adverse events occurred. Minor adverse events included acute donor reaction (2.8%), hematoma (4.2%), rebleeding (2.1%), and skin irritation (0.7%). Adverse event rates were comparable to data for human blood donations. A substantial fraction of donors donated multiple times, suggesting that volunteer donors and their guardians perceived the donation process to be safe and effective. This article discusses the issue of donor consent and use of the term volunteer. This study indicates that nonprofit, community-based canine volunteer donor programs for animal blood banks can be successful while maintaining high safety standards and ethical treatment of volunteers.

The validity of emergency department triage blood pressure measurements.

OBJECTIVE: Automated blood pressure (ABP) devices are ubiquitous at emergency department (ED) triage. Previous studies failed to evaluate ABP devices against accepted reference standards or demonstrate triage readings as accurate reflections of blood pressure (BP). This study evaluated ED triage measurements made using an ABP device and assessed agreement between triage BP and BP taken under recommended conditions. METHODS: A prospective study was conducted at an urban teaching hospital. Patients were enrolled by convenience sampling. Simultaneous automated and manual triage BPs were obtained using one BP cuff with a Y-tube connector. Research assistants were certified in obtaining manual BP as described by the British Hypertension Society (BHS). Patients were placed in a quiet setting, and manual BP was repeated by American Heart Association (AHA) standards. Data analysis was performed using methods described by Bland and Altman. The ABP device was assessed using Association for the Advancement of Medical Instrumentation (AAMI) and BHS criteria. RESULTS: One hundred seventy-one patients were enrolled. Systolic BP (sBP) range was 81 to 218 mm Hg; diastolic BP (dBP) range was 43 to 130 mm Hg. Automated vs. manual sBP difference was 3.8 +/- 11.2 mm Hg (95% confidence interval [CI] = 2.1 to 5.4); dBP difference was 6.6 +/- 9.0 mm Hg (95% CI = -7.9 to -5.2). Manual triage BP vs. AHA standard SBP difference was 11.6 +/- 12.8 mm Hg (95% CI = 9.1 to 14.1); dBP difference was 9.9 +/- 10.4 mm Hg (95% CI = 7.9 to 12.0). The ABP device failed to meet AAMI criteria and received a BHS rating of "D." Poor operator technique and extraneous patient and operator movement appeared to hamper accuracy. CONCLUSIONS: ABP triage measurements show significant discrepancies from a reference standard. Repeat measurements following AHA standards demonstrate significant decreases in the measured blood pressures.