Pharmaceuticals as hospital hazards: managing the risks.

The recognition of pharmaceuticals as biologically active chemical hazards is a recent occurrence. Focusing primarily on the hazard potential of antineoplastic drugs, many hospitals have adopted the safe handling guidelines proposed by the Occupational Safety and Health Administration (OSHA) to mitigate worker health risk. More recently, occupational health professionals are acknowledging that other drugs also are potentially hazardous to hospital workers and therefore require review. The approach used by one university hospital to identify other potentially hazardous drugs and to develop handling procedures for them involved assembling a multidisciplinary committee to perform drug reviews, prioritize agents for evaluation, define criteria for a "hazardous drug" determination, specify handling procedures for "hazardous drugs," and require detailed toxicologic data from hospital studies on investigational drugs.

Emergency department detection and follow-up of high blood pressure: use and effectiveness of community health workers.

This study introduced trained paraprofessionals, community health workers (CHWs), into the emergency department (ED) to supplement providers' routine efforts in high blood pressure (HBP) detection, treatment, and follow-up among high-risk black men. In a demonstration project over a 2-year period, CHWs provided (1) BP and pulse measurements, and educational counseling regarding HBP and cardiovascular risk factors; (2) telephone preappointment reminders to improve ED follow-up visit rates; and (3) recontact of patients failing to show for their ED follow-up visits to improve return rates even after missed BP appointments. Results of preappointment reminders by CHWs showed a 19% improvement in appointment keeping (P less than .001). With a sample of patients who had failed to return for a follow-up visit, CHW contact was also effective, showing an overall improvement rate of 7% (P less than .001). The results reported support the idea that individuals from the community, trained as paraprofessionals, can improve appointment keeping as well as be useful in assisting in screening and counseling for chronic conditions within the ED. These CHWs are seen as having the additional advantage of enhancing the integration of the ED, the community, and continuing care sites. The approaches used in this study should be applicable and may serve as a model for the approach to other chronic conditions experienced in urban high-risk communities.

Using the emergency department as a screening site for high blood pressure. A method for improving hypertension detection and appropriate referral.

This study describes the development and testing of a high blood pressure protocol for use in emergency departments (ED) to enhance detection of those patients appropriate for subsequent referral. The protocol involves two serial blood pressure measurements and a patient interview to determine: 1) previous history of high blood pressure (HBP), 2) treatment in past year for HBP, and 3) usual source of medical care. The accuracy of patient reporting was validated by comparison with the patients' hospital record (reflecting outpatient and inpatient visits). Results indicate that these self-reports have high levels of sensitivity (range 90-100%) and specificity (range 79-96%). Use of the additional patient information increased the sensitivity of the screening protocol in identifying when and where a patient should be referred. Use of this methodology indicates that the protocol is a simple and effective method for HBP screening. The findings also suggest that the ED is an ideal site for screening the "hard-to-reach" hypertensive population.

Placement accuracy of percutaneous transthoracic pacemakers.

Experience has shown that the frequency of electrical capture of the heart with percutaneous transthoracic pacemakers is disappointingly low. The authors sought to determine whether the accuracy of ventricular placement could help to explain this observation. Six approaches were used in each of twenty adult patients who were examined at autopsy. Three parasternal approaches used the fifth intercostal space (5ICS). One pacing wire was inserted immediately to the left of the sternum along the parasternal line (5ICS-PS), one wire was inserted 4.0 cm to the left of the midsternal line (5ICS-4), and the third wire was inserted 6.0 cm to the left of the midsternal line (5ICS-6). All parasternal needle insertions were directed medially, dorsally, and cephalad toward the second right costrochondral junction at an angle of 30 degrees to the skin. Three subxiphoid approaches were performed through the left xyphocostal notch at an angle of 30 degrees to the skin. One pacing wire was directed toward the right shoulder (SXRS), one toward the sternal notch (SXSN) and one toward the left shoulder (SXLS). Accuracy of ventricular placement was assessed at autopsy. The success rates for the three parasternal approaches were as follows: 5ICS-PS = 0.85; 5ICS-4 = 0.80; 5ICS-6 = 0.90. For the three subxiphoid approaches success rates were as follows: SXRS = 0.25; SXSN = 0.50; SXLS = 0.65. All three parasternal approaches had higher success rates than the SXRS approach (P less than 0.05). In addition, the 5ICS-PS and 5ICS-6 approaches were more successful than the SXSN approach (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Injuries associated with percutaneous placement of transthoracic pacemakers.

Injuries associated with the percutaneous placement of transthoracic pacemakers are poorly documented. We prospectively sought to determine any injuries associated with various placement routes. Six different approaches were used in each of 20 adult patients examined at autopsy. Three parasternal approaches utilized the fifth intercostal space (5ICS). One pacing wire was inserted immediately to the left of the sternum along the parasternal line (5ICS-PS), one pacing wire was inserted 4 cm to the left of the midsternal line (5ICS-4), and the third wire was inserted 6 cm from the midsternal line (5ICS-6). All parasternal needle insertions were directed medially, dorsally, and cephalad toward the right second costochondral junction at an angle of 30 degrees to the skin. Three subxiphoid approaches were inserted through the left xyphocostal notch at an angle of 30 degrees to the skin. One pacing wire was directed toward the right shoulder, one toward the sternal notch, and one toward the left shoulder (SXLS). Injuries were assessed by autopsy, postmortem coronary angiography, and stereoscopic radiography. The 5ICS-PS approach resulted in fewer injuries when compared to all other approaches. Because previous work has demonstrated that the 5ICS-PS, 5ICS-6, and SXLS approaches are more accurate than the other approaches for transthoracic pacemaker insertion, the 5ICS-PS represents an approach that combines reasonable accuracy with the least likelihood for injury in the placement of percutaneous transthoracic pacing wires.

Delirium with phenytoin and disulfiram administration.

The case of a 54-year-old man with delirium secondary to phenytoin and disulfiram administration is presented. The pharmacology, interaction, and resulting toxicity of these two drugs are explored. The patient made an uneventful recovery when the medications were withheld.

Accuracy of screening for pulmonary embolism in the emergency room.

Pertinent historical, clinical, and laboratory findings were recorded for 37 consecutive patients who presented to the emergency room complaining of shortness of breath and chest pain but without evidence of coronary insufficiency, pneumonia, or musculoskeletal injury. 13 had pulmonary embolism suggested by lung scan with or without pulmonary angiogram, or, in 2 cases, by right heart catheterization. As a group, these patients in whom embolism was judged probable approached fairly closely the profiles of previous studies of patients with documented pulmonary emboli. Nonetheless, they differed very little, and in no clinically useful way short of lung scans and invasive studies, from the remaining 24 patients in whom embolism was judged unlikely. In the population served by this emergency room, which has a high morbidity from chest diseases and putative predisposing conditions to pulmonary embolism, screening patients for high and low probability groups for this diagnosis cannot be done on clinical grounds alone. Six-projection ventilation-perfusion lung scanning may be the only acceptable screening examination, and should be available directly from the emergency room in hospitals with an active emergency service.