Intravenous administration of prochlorperazine by 15-minute infusion versus 2-minute bolus does not affect the incidence of akathisia: a prospective, randomized, controlled trial.

STUDY OBJECTIVE: We sought to compare the rate of akathisia after administration of intravenous prochlorperazine as a 2-minute bolus or 15-minute infusion. METHODS: We conducted a prospective, randomized, double-blind study in the emergency department of a central-city teaching hospital. Patients aged 18 years or older treated with prochlorperazine for headache, nausea, or vomiting were eligible for inclusion. Study participants were randomized to receive 10 mg of prochlorperazine administered intravenously by means of 2-minute push (bolus group) or 10 mg diluted in 50 mL of normal saline solution administered by means of intravenous infusion during a 15-minute period (infusion group). The main outcome was the number of study participants experiencing akathisia within 60 minutes of administration. Akathisia was defined as either a spontaneous report of restlessness or agitation or a change of 2 or more in the patient-reported akathisia rating scale and a change of at least 1 in the investigator-observed akathisia rating scale. The intensity of headache and nausea was measured with a 100-mm visual analog scale. RESULTS: One hundred patients were enrolled. One study participant was excluded after protocol violation. Seventy-three percent (73/99) of the study participants were treated for headache and 70% (70/99) for nausea. In the bolus group, 26.0% (13/50) had akathisia compared with 32.7% (16/49) in the infusion group (Delta=-6.7%; 95% confidence interval [CI] -24.6% to 11.2%). The difference between the bolus and infusion groups in the percentage of participants who saw a 50% reduction in their headache intensity within 30 minutes was 11.8% (95% CI -9.6% to 33.3%). The difference in the percentage of patients with a 50% reduction in their nausea was 12.6% (95% CI -4.6% to 29.8%). CONCLUSION: A 50% reduction in the incidence of akathisia when prochlorperazine was administered by means of 15-minute intravenous infusion versus a 2-minute intravenous push was not detected. The efficacy of prochlorperazine in the treatment of headache and nausea likewise did not appear to be affected by the rate of administration, although no formal statistical comparisons were made.

Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices.

STUDY OBJECTIVE: We sought to determine the number of interruptions and to characterize tasks performed in emergency departments compared with those performed in primary care offices. METHODS: We conducted an observational time-motion, task-analysis study in 5 nonteaching community hospitals and 22 primary care offices in 5 central Indiana cities. Twenty-two emergency physicians and 22 office-based primary care physicians (PCPs) were observed at work. The number of interruptions, tasks, simultaneous tasks, and patients concurrently managed were recorded in 1-minute increments during 150- to 210-minute observation periods. RESULTS: Emergency physicians were interrupted an average of 9.7 times per hour compared with 3.9 times per hour for PCPs, for an average difference of 5.8 times per hour (95% confidence interval [CI] 4.2 to 7.4). PCPs spent an average of 11.4 minutes per hour performing simultaneous tasks compared with 6.4 minutes per hour for emergency physicians (average difference, 5.0 minutes; 95% CI 1.2 to 8.8). Emergency physicians spent an average of 37.5 minutes per hour managing 3 or more patients concurrently compared with 0.9 minutes per hour for PCPs. PCPs spent significantly more time performing direct patient care, and emergency physicians spent significantly more time in analyzing data, charting, and taking reports on patients. CONCLUSION: Emergency physicians experienced more interruptions and managed more patients concurrently than PCPs. PCPs spent more time performing simultaneous tasks than emergency physicians. Our study suggests there are important ergonomic differences between emergency medicine and office-based primary care work environments that may require different training approaches, design considerations, and coping strategies.

Inadvertent administration of sufentanil instead of fentanyl during sedation/analgesia in a community hospital emergency department: a report of two cases.

The authors report two cases of inadvertent administration of sufentanil instead of fentanyl during patient sedation/analgesia in a community hospital emergency department (ED). Both cases resulted in reversible adverse drug events (ADEs) to the respective patients. In tracing the steps involved in the cause of these errors, the authors discovered several components common to identified pathways that result in ADEs. These include similarities in product packaging appearance and names of these two medications, along with nursing unfamiliarity with the medications. Medication "sound-alikes" and "look-alikes" continue to be a source of potential error in the ED.

Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"?

OBJECTIVE: Although interruptions have been shown in aviation and other work settings to result in error with serious and sometimes fatal consequences, little is known about interruptions in the emergency department (ED). The authors conducted an observational, time-motion task-analysis study to determine the number and types of interruptions in the ED. METHODS: Emergency physicians were observed in three EDs located in an urban teaching hospital, a suburban private teaching hospital, and a rural community hospital. A single investigator followed emergency staff physicians for 180-minute periods and recorded tasks, interruptions, and breaks-intask. An "interruption" was defined as any event that briefly required the attention of the subject but did not result in switching to a new task. A "break-intask" was defined as an event that required the attention of the physician for more than 10 seconds and subsequently resulted in changing tasks. RESULTS: The mean (+/-SD) total number of patients seen at all three sites during the 180-minute study period was 12.1 +/- 3.7 patients (range 5-20). Physicians performed a mean of 67.6 +/- 15.7 tasks per study period. The mean number of interruptions per 180-minute study period was 30.9 +/- 9.7 and the mean number of breaks-in-task was 20.7 +/- 6.3. Both the number of interruptions (r = 0.63; p < 0.001) and the number of breaks-in-task (r = 0.56; p < 0.001) per observation period were positively correlated with the average number of patients simultaneously managed. CONCLUSIONS: Emergency physicians are "interruptdriven." Emergency physicians are frequently interrupted and many interruptions result in breaks-in-task.

How do physicians and nurses spend their time in the emergency department?

STUDY OBJECTIVES: To determine how emergency physicians and nurses spend their time on emergency department activities. METHODS: An observational time-and-motion study was performed at a 36-bed ED with annual census of 84,000 in a central city teaching hospital sponsoring an emergency medicine residency program. Participants were emergency medicine faculty physicians, second- and third-year emergency medicine resident physicians, and emergency nurses. A single investigator followed individual health care providers for 180-minute periods and recorded time spent on various activities, type and number of activities, and distance walked. Activities were categorized as direct patient care (eg. history and physical examination), indirect patient care (eg. charting), or non-patient care (eg. break time). RESULTS: On average, subjects spent 32% of their time on direct patient care, 47% on indirect patient care, and 21% on non-patient care Faculty physicians, residents, and emergency nurses differed in the time spent on these three categories of activities. Although the overall time spent on direct patient care activities was not significantly different, emergency nurses spent more of their time (2.2%) providing comfort measures (a subcategory of direct patient care) than did faculty physicians (.05%) or resident physicians (.03%). Emergency nurses spent 38.9% of their time performing indirect care, whereas faculty physicians spent 51.3% and resident physicians 53.7%. Resident physicians spent more time charting than did faculty physicians or emergency nurses (21.4%, 11.9%, and 6.9%, respectively). Emergency nurses spent more time on personal activities than did physicians, and faculty physicians walked less than either emergency nurses or resident physicians. CONCLUSION: Emergency physicians and nurses spent almost half of their time on indirect patient care. Physicians spent significantly more time on indirect patient care activities and significantly less time on personal activities than did nurses.

Radiographic detection of gravel in soft tissue.

STUDY OBJECTIVE: We sought to quantify the detectable size of varying compositions of gravel using a cadaveric chicken leg wound model and standard plain-film two-view radiographs. METHODS: We conducted a randomized, blinded, descriptive study with the assistance of faculty from the emergency medicine and radiology residency programs of a private urban teaching hospital. A standardized wound was created in each of 160 cadaver chicken legs. Zero, one, or two pieces of gravel of four differing compositions, ranging in size from .25 to 2.0 mm, were inserted into the wounds as determined with computer-generated randomization. The legs were then radiographically imaged (anteroposterior and lateral views). Three faculty physicians independently interpreted the radiographs to determine the number of foreign bodies and rated the ease of visibility. We calculated sensitivity, specificity, and interobserver reliability. RESULTS: The accuracy with which gravel was detected ranged from an average of 97.7% for 2-mm and 1-mm particles to less than 75% for .5-mm and .25-mm particles. Visibility ratings were also lower for particles in the smaller ranges. Sensitivity was greater for the emergency physicians than for the radiologists, but their specificity was lower. Salt-and-pepper gravel was the most easily identified foreign body. CONCLUSION: In this wound model, gravel particles of less than 1 mm were not accurately identified.

Wound care.

Soft-tissue injuries remain one of the most common problems encountered in the emergency department. This article discusses techniques to minimize pain during the evaluation and repair process, methods to decrease healing complications, and repair considerations.

Level I trauma certification and emergency medicine resident major trauma experience.

OBJECTIVE: American College of Surgeons (ACS) and Residency Review Committee for Emergency Medicine (RRC-EM) guidelines conflict regarding the role of emergency physicians in directing major trauma resuscitations. This article describes the impact of ACS level I trauma certification on emergency medicine (EM) resident trauma experience. METHODS: A written survey and a follow-up letter were sent to all 101 EM program directors as of August 16, 1994. The survey addressed demographics and trauma experience at hospitals designated by the RRC-EM as primary training sites. RESULTS: There were 95 (94%) survey respondents. Estimates of the percentage of trauma resuscitations directed by EM residents were significantly lower at level I centers (52% +/- 27%, 95% CI 45-59%) than they were at non-level I centers (70% +/- 30%, 95% CI 58-82%) (p < 0.01). There was no significant difference in trauma census between level I and non-level I centers. Of 14 respondents who said they were cited by the RRC-EM for inadequate trauma experience, ten (71%) were in ACS level I trauma centers (p = 1.0). Twelve of the 14 respondents cited for inadequate trauma experience were in either the Northeast or the Midwest. CONCLUSIONS: EM residents direct a smaller percentage of major trauma resuscitations at ACS level I hospitals than they do at non-level I facilities. This finding is not offset by an increased trauma census at level I facilities and may be more pronounced in the Northeast and the Midwest.

Hand washing frequency in an emergency department.

Objectives Previous studies, conducted mainly in ICUs, have shown low compliance with hand-washing recommendations, with failure rates approaching 60%. Hand washing in the emergency department has not been studied. We examined the frequency and duration of hand washing in one emergency department and the effects of three variables: level of training, type of patient contact (clean, dirty, or gloved), and years of staff clinical experience. Design Observational. Setting ED of a 1100-bed tertiary referral, central city, private teaching hospital. Participants Emergency nurses, faculty, and resident physicians. Participants were informed that their activities were being monitored but were unaware of the exact nature of the study. Interventions An observer recorded the number of patient contacts and activities for each participant during 3-hour observation periods. Activities were categorized as either clean or dirty according to a scale devised by Fulkerson. The use of gloves was noted and hand-washing technique and duration were recorded. A hand-washing break in technique was defined as failure to wash hands after a patient contact and before proceeding to another patient or activity. Results Eleven faculty, 11 resident physicians, and 13 emergency nurses were observed. Of 409 total contacts, 272 were clean, 46 were dirty, and 91 were gloved. Hand washing occurred after 32.3% of total contacts (SD, 2.31%). Nurses washed after 58.2% of 146 contacts (SD, 4.1%), residents after 18.6% of 129 contacts (SD, 3.4%), and faculty after 17.2% of 134 contacts (SD, 3.3%). Nurses had a significantly higher hand washing frequency than either faculty (p < 0.0001) or resident physicians (p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Hand washing frequency in an emergency department.

STUDY OBJECTIVE: Previous studies, conducted mainly in ICUs, have shown low compliance with hand-washing recommendations, with failure rates approaching 60%. Hand washing in the emergency department has not been studied. We examined the frequency and duration of hand washing in one ED and the effects of three variables: level of training, type of patient contact (clean, dirty, or gloved), and years of staff clinical experience. DESIGN: Observational. SETTING: ED of an 1,100-bed tertiary referral, central city, private teaching hospital. PARTICIPANTS: Emergency nurses, faculty, and resident physicians. Participants were informed that their activities were being monitored but were unaware of the exact nature of the study. INTERVENTIONS: An observer recorded the number of patient contacts and activities for each participant during three-hour observation periods. Activities were categorized as either clean or dirty according to a scale devised by Fulkerson. The use of gloves was noted and hand-washing technique and duration were recorded. A hand-washing break in technique was defined as failure to wash hands after a patient contact and before proceeding to another patient or activity. RESULTS: Eleven faculty, 11 resident physicians, and 13 emergency nurses were observed. Of 409 total contacts, 272 were clean, 46 were dirty, and 91 were gloved. Hand washing occurred after 32.3% of total contacts (SD, 2.31%). Nurses washed after 58.2% of 146 contacts (SD, 4.1%), residents after 18.6% of 129 contacts (SD, 3.4%), and faculty after 17.2% of 134 contacts (SD, 3.3%). Nurses had a significantly higher hand washing frequency than either faculty (P < .0001) or resident physicians (P < .0001). Hand washes occurred after 28.4% of 272 clean contacts (SD, 2.34%), which was significantly less (P < .0001) than 50.0% of 46 dirty contacts (SD, 7.4%) and 64.8% of 91 gloved contacts (SD, 5.0%). The number of years of clinical experience was not significantly related to hand-washing frequency (P = .82). Soap and water were used in 126 of the hand washes, and an alcohol preparation was used in the remaining six. The average duration of soap-and-water hand washes was 9.5 seconds. CONCLUSION: Compliance with hand washing recommendations was low in this ED. Nurses washed their hands significantly more often than either staff physicians or resident physicians, but the average hand-washing duration was less than recommended for all groups. Poor compliance in the ED may be due to the large number of patient contacts, simultaneous management of multiple patients, high illness acuity, and severe time constraints. Strategies for improving compliance with this fundamental method of infection control need to be explored because simple educational interventions have been unsuccessful in other health care settings.

Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department.

STUDY OBJECTIVE: Studies have documented the efficacy of normal saline irrigation in decreasing wound infection rates. Wounds traditionally are irrigated using a syringe and needle with manual injection of fluid, a time- and labor-intensive method. We compared irrigation times and infection rates for wounds cleansed with syringe irrigation versus a new, single-use canister of pressurized (8 psi) sterile normal saline. DESIGN: Prospective, randomized, controlled. SETTING: Two Level I emergency departments in tertiary care hospitals, both with emergency medicine residency programs. PARTICIPANTS: Patients with lacerations requiring closure were eligible. Exclusion criteria were wounds above the clavicle more than ten hours old, wounds below the clavicle more than six hours old, insulin-dependent diabetes mellitus, or antibiotic or steroid therapy. Patients (550) were entered between August 1, 1990, and January 31, 1991. Characteristics of the two treatment groups were similar for patient age, age of the wound, size and depth of the laceration, and number of sutures. INTERVENTIONS: Lacerations were irrigated with 250 mL saline in a syringe or 220 mL saline in a pressurized canister for each 5 cm of laceration. At follow-up or suture removal, patients were evaluated for signs of wound complications (cellulitis, ascending lymphangitis, purulent discharge, or dehiscence). MAIN RESULTS: The mean irrigation time for the pressurized canister group (281) was 3.9 minutes versus 7.3 minutes in the syringe irrigation group (254) (P < .0001). The complication rate for the pressurized canister group was 5.0% compared with 3.6% for the syringe irrigation group (not significant, P = .50). Only three of the 20 total complications required antibiotics (two in the pressurized canister group, one in the syringe irrigation group). CONCLUSION: Syringe irrigation times were nearly twice as long as the pressurized canister irrigation times. Use of the pressurized canister facilitates ease of irrigation and markedly decreases the time involved in this traditionally labor-intensive activity. In addition, delivery of the saline is no longer operator dependent, ensuring generation of pressures appropriate for wound cleansing. The pressurized canisters may be useful in standardizing irrigation in wound management research.

Wound evaluation and cleansing.

The approach to wound management in the Emergency Department does not differ from that used in evaluating other complaints. This consists of a problem-directed history and physical examination. The history should probe for host and wound factors that increase the risk of a poor outcome. The examination should emphasize a search for the involvement of underlying structures. Appropriate cleansing remains the foundation for good wound management. Until a rapid inexpensive test is available to identify wounds with low bacterial counts, the clinician should assume that all wounds have bacterial loads capable of causing infection. Therefore, most wounds should be cleansed by irrigation with at least 200 mL of normal saline. Larger quantities or 1% povidone-iodine solution may be used in wounds that have high wound or host risk factors. Wound exploration should occur in a well-lit environment and combine good hemostasis with appropriate analgesia and anesthesia.

Outpatient wound preparation and care: a national survey.

STUDY OBJECTIVE: To sample the practice styles of emergency physicians caring for acute traumatic wounds. DESIGN: Written survey. SETTING: US emergency departments obtained from the American College of Emergency Physicians mailing list. SUBJECTS: Randomly selected ACEP members. MAIN RESULTS: One hundred fifty-one of 285 (53%) survey mailings were returned. Eighty-six percent of respondents were primarily clinicians, and the majority (61.6%) worked in EDs with annual patient visits between 21,000 and 50,000. The majority of respondents (64.2%) were certified by the American Board of Emergency Medicine. Nineteen percent managed wounds based on provider preference despite the existence of written wound management protocols. We identified a variety of practices that are contrary to current literature and textbook recommendations. Fifty-eight (38%) soaked wounds, whereas 21% used either 10% povidone iodine or hydrogen peroxide to cleanse wounds. One hundred one (67%) scrubbed the entire wound surface using, among other methods, cotton gauze (59%) or a coarse, bristle-laden sponge (38%). Forty (27%) irrigated wounds using techniques that have not been proven to deliver the 5 to 8 psi necessary for adequate tissue cleansing. Delayed primary closure, a treatment option for lacerations at increased risk for infection, was infrequently or never practiced by 76% of respondents. All respondents administered IV antimicrobials at least occasionally for simple outpatient lacerations. CONCLUSION: Methods of preparing, treating, and following outpatient wounds vary among emergency physicians, and these results support the idea that no de facto standard of care exists for this clinical problem. Outpatient wound care techniques routinely practiced (ie, soaking, scrubbing, use of full-strength hydrogen peroxide or full-strength povidone iodine) may be harmful based on limited animal and human research, whereas other proven techniques (ie, delayed primary closure) are infrequently practiced by many emergency physicians.

A rare etiology for pulmonary embolism: basilic vein thrombosis.

A 61-year-old white male with recurrent thrombophlebitis developed a painful left arm. He was initially diagnosed with superficial thrombophlebitis and treated conservatively for several days without improvement. He subsequently developed right-sided pulmonary embolism. Hypercoagulability was not present, and venography confirmed the left basilic vein as the sole thrombogenic source. Twelve to twenty percent of documented pulmonary emboli arise from deep veins of the upper extremity. To our knowledge, only one case of basilic vein thrombosis causing pulmonary embolism exists in the literature. Clinical vigilance to this uncommon entity may reduce attendant morbidity and mortality.

Plantar puncture wounds: controversies and treatment recommendations.

Future studies are needed to define the natural history of plantar puncture wounds; delineate optimal initial evaluation techniques; examine the role of broad-spectrum antimicrobials for prophylaxis; treatment, or both; and investigate optimal therapy for immunocompromised patients.

Preliminary observations on the effects of hyperbaric oxygen therapy on western diamondback rattlesnake (Crotalus atrox) venom poisoning in the rabbit model.

Intermittent hyperbaric oxygen therapy has been shown to reduce skeletal muscle necrosis in a compartment syndrome animal model. To study whether intermittent exposure to hyperbaric oxygen augments antivenin therapy in reducing muscle necrosis, we injected sublethal doses of Western Diamondback rattlesnake (Crotalus atrox) venom intramuscularly into the hind legs of New Zealand White rabbits. In this pilot study, the animals were divided into three treatment groups. The first group received one vial of antivenin intravenously, the second group received one vial of antivenin intravenously plus three hyperbaric oxygen treatments, and the third group received no treatments. There were no statistically significant differences among the groups. These preliminary observations suggest that muscle necrosis secondary to Crotalus atrox venom poisoning is not significantly altered either by Antivenin [Crotalidae] Polyvalent at the dose level we used or in combination with intermittent hyperbaric oxygen treatments in this rabbit model.