Class of 2011 Abstract / OBJECTIVES: To compare fixed equianalgesic doses of morphine and fentanyl with regard to analgesic response for patients who presented to the ED with moderate to severe pain. METHODS: A retrospective cohort study of clinical data obtained through patient medical record review. Median pain reduction on the numeric pain scale was compared between the morphine and fentanyl groups. Independent variables of interest included: Age, sex, weight, initial pain score, injury severity, triage severity and injury type. RESULTS: : Pain scores were reported to be worse in the fentanyl group, p= 0.0002. However pain reduction was similar between the groups; median (IQR) of 2 (1-3) and 2 (1-4) in the morphine and fentanyl groups respectively, p= 0.6707. Injuries were more severe in the fentanyl group; injury severity score (ISS) median (IQR) of 5 (1-9) and 9 (3-12), p=0.0312 and more patients in the fentanyl group required additional opioids within 30 min of their first ED opioid dose, 15 (18%) and 31 (37%), p=0.006. CONCLUSION: Patients in both the morphine and fentanyl groups received similar analgesic response. Patients in the fentanyl group had a higher severity of injury, received higher doses of opioids from the EMS, and required the second dose of opioid sooner than patients in the morphine group.

Class of 2012 Abstract / Specific Aims: Cellulitis accounts for the majority of skin and skin structure infections in patients who present to the emergency departments in the United States. The primary objective of this study was to evaluate the appropriateness of empiric cellulitis therapy prescribed in an emergency department of an academic medical center. The secondary objective of the study was to compare the cost-effectiveness of the empirical cellulitis therapy prescribed at the institution. Methods: This retrospective chart review study has been approved by the Institutional Review Board. Adult patients evaluated at an emergency department of a tertiary care, academic medical center, diagnosed with cellulitis and prescribed empiric antibiotic therapy between October and November 2010 were evaluated. Subjects were excluded if they required hospitalization or surgical intervention in an operating room or if they were diagnosed with necrotizing fasciitis, orbital cellulitis, or a diabetic foot infection. Data collected for each subject included type of cellulitis, therapy prescribed, and outcomes. Appropriateness of empiric cellulitis therapy was determined by expert opinion and guideline statements. A chi- square test was used to evaluate the statistical significance of treatment failure between the prescribed antibiotic groups. An independent t-test was used to analyze the cost between the prescribed antibiotic groups. An incremental cost-effectiveness ratio was used to determine the cost- effectiveness of the prescribed antibiotic groups. Main Results: The majority of patients were given a prescription for either clindamycin montherapy (37%) or trimethoprim-sulfamethoxazole plus cephalexin (40%) as empiric therapy when discharged from the emergency department. While follow-up (either repeat emergency department visit or clinic visit within the academic medical healthcare network) was only available in 78% of subjects, there was no statistical difference (p=0.51) in therapy outcomes between these two empiric therapy groups. Conclusions: Types of antimicrobials, doses, and duration of therapy prescribed for outpatient empiric cellulitis therapy at a single medical center were not consistent.

Lower gastrointestinal bleeding (LGIB) can result in serious adverse events. Appropriate risk stratification of LGIB patients can improve their care. Previous risk scores to identify severe LGIB patients have limitations, therefore we developed clinical decision tool to accurately identify LGIB patients presenting to the emergency department (ED) who are at risk for 30-day adverse outcomes that would overcome these limitations. We conducted a health records review and compared two methods of regression analysis on our data in order to develop a clinical decision tool. We identified five risk factors that have a high sensitivity and good predictive value for identifying low risk LGIB patients: age ≥ 75 years, INR ≥2.0, hemoglobin ≤ 100 g/l, ongoing bleeding in the ED and a medical history of colorectal polyps. Future, large, prospective studies should be done to validate the results, after which implementation studies should be conducted.

Introduction: In 2010, of the 129 million visits to the emergency department (ED), 240,000 resulted in the patient dying or being pronounced dead on arrival. This number is likely to continue to increase as a significant portion of the American population ages and seeks care in the ED. Though care in the ED is focused on saving lives, death cannot always be prevented. Consequently, nurses face many barriers to providing quality end-of-life (EOL) care in the ED when death occurs. The purpose of this study was to identify suggestions emergency nurses have to improve EOL care specifically in rural ED's. Methods: A 57-item questionnaire was sent to 52 rural hospitals in the Intermountain West and Alaska. One of the 57 questions asked nurses to identify the one aspect of EOL care they would change for dying patients in the ED. Each qualitative response was individually reviewed by a research team and then coded into a theme. Results: Four major themes and three minor themes were identified. The major themes were providing greater privacy during EOL care for patients and family members, increasing availability of support services, additional staffing, and improved staff and community education. Discussion: Providing adequate privacy for patients and family members is a major barrier to providing EOL care in the ED. This is largely due to poor department design, especially in rural ED's where space is limited. Lack of support services such as religious leaders, social workers, and additional staffing are also barriers to providing quality EOL care in rural ED's. Consequently, rural nurses are commonly pulled away from EOL care to perform ancillary duties because additional support personnel are lacking. Conclusion: Providing EOL care in the ED is an extremely challenging and demanding task. It is especially difficult in rural ED's where staffing and resources are limited. Consequently, it is imperative that supportive behaviors are acknowledged and barriers are identified to improve EOL care provided to patients and family members in rural ED's. Due to the current lack of research in rural EOL care, further research is justified regarding this topic.

Emergency department (ED) use for behavioral-health-associated diagnoses has steadily increased in adult and pediatric populations, accounting for 1 out of every 8 ED visits. The increase in pediatric behavioral health ED visits, combined with limited resources for treatment, has created a challenge for EDs faced with extended boarding and constant observation of this population. The generalized behavioral health guidelines used at the practice site have not been adapted for the pediatric population. This project focused on providing age- and developmentally appropriate best practice guidelines for children under constant observation in the children's emergency department (CED) using Havelock's theory of planned change as the framework. Practice in the CED was compared to best practice recommendations identified in the literature and community standards including workflow, defined roles and responsibilities, addressing the needs of the parent/guardians, and defined outcomes. These best practices were incorporated in a guideline developed to provide age- and developmentally appropriate recommendations. An expert panel comprising the behavioral health nurse manager and children's emergency department nurse manager reviewed the guideline using the AGREE II tool, and the guideline was revised based on the composite results from the 6 domains in the AGREE II tool. Based on these composite results and panel feedback, domain 5 was revised to include an auditing and monitoring plan. In addition to improving the safety and care for the CED patient population, this project also serves to increase awareness of the topic while emphasizing on the need for additional research and evidence-based practice focused on pediatric behavioral health patients.

Excerpt: The study by Doyle et al1 concluded that “Implementing rapid triage and fast track guidelines can affect nurse-sensitive patient outcomes related to safety and care delivery in a pediatric emergency department,” but the support for the conclusions was weak because of 2 shortcomings: (1) the authors did not use a side-by-side control group, and (2) the findings can be explained by the Hawthorne effect.

Pain is the leading cause of Emergency Department (ED) visits making it one of the primary concerns of the emergency medical field. The experience of pain is subjective and unique to every individual making it difficult to effectively manage. As a result, the subjective nature of pain is also commonly associated with drug-seekers often claiming to have pain simply to receive narcotics to support their addiction. There have been numerous studies completed to determine how to effectively recognize drug-seeking. This integrative literature review will identify the common behaviors that have been seen as indicators of drug-seeking in the ED. The evidence collected from articles published between 2001 and 2011 examined the use of assessment tools, drug screening, and prescription monitoring programs for distinguishing drug-seekers. The evidence did not identify a specific evaluation tool used to recognize drug-seekers; however, the research did suggested that using these techniques can help to identify drug-seeking behavior allowing emergency medical staff to effectively manage pain in the ED.

PhD Thesis / Background: Overcrowding in emergency departments (EDs) due to avoidable visits places a significant strain on health systems. There is no known valid classification to identify avoidable ED visits in Canadian administrative data. Research Questions: Which physician interventions and patient characteristics are important to classify avoidable ED visits, and does a novel classification (the Emergency Department Avoidability Classification; EDAC), which incorporated these features, demonstrate validity? Methods: Two independent modified Delphi consensus studies determined ED physician interventions and patient characteristics that classified avoidable ED visits. These studies involved emergency and family medicine physicians across Ontario, Canada. Binary logistic regression was used to examine ED physician interventions in the National Ambulatory Care Reporting System (NACRS) database for associations with patient characteristics. These results constructed the EDAC criteria. ED physicians from an academic hospital evaluated randomly selected retrospective ED visits (n=320) which were also evaluated using the EDAC to assess their avoidability. The primary outcome of this thesis was correlation between the classification and ED physician judgements, measured using a Spearman rank correlation and ordinal logistic regression. The secondary outcome was to compare the correlations of previously published classifications with ED physician judgements. The tertiary outcome was to compare prevalence estimates of avoidable ED visits for all classifications. Results: Consensus showed strong evidence on 146 of 150 (97.3%) ED physician interventions, with 103 (68.7%) deemed suitable for non-ED care. Consensus was established on eight of nine patient characteristics, with four characteristics identified as useful in specifying avoidable ED visits: age (18-70 years), triage acuity (non-emergent), specialist consult in the ED (none) and ED visit outcome (discharged). An adjusted retrospective cohort study found the ED interventions had a strong association with patient characteristics determined in the consensus study: not aged over 65 years, having a non-emergent triage acuity and not being admitted to hospital. The classification was highly correlated with ED physician judgements (r=0.64, p<0.01), with a significant association to classify avoidable ED visits (OR=80.0, 95% CI=17.1-374.9) and strong accuracy (82.8%). The EDAC was the most accurate classifier of avoidable ED visits compared to previously published classifications. The EDAC identified a prevalence of 25.1% ED visits as avoidable and common patient conditions associated with such visits as traumatic injuries, symptoms/signs/abnormal findings, diseases of the musculoskeletal system, mental and behavioural disorders, and diseases of the respiratory system. Conclusion: My thesis developed and established the EDAC as an accurate classifier of avoidable ED visits with supporting evidence of validity and superior performance to previously published classifications. The EDAC can be easily integrated with administrative ED data and has strong potential for use in defining avoidable ED visits by health policy stakeholders. / Thesis / Doctor of Philosophy (PhD)

No / Immediate reporting, commonly referred to as a ‘hot reporting’, has been advocated as a method of effectively supporting clinical decision making. However, its implementation nationally has been limited with poor understanding of its value in practice. A cross sectional attitudinal survey was distributed to emergency department clinicians (medical and nursing staff) and radiographers to explore perceptions of an immediate reporting service in terms of its influence on professional role and autonomy, patient care and service quality. A total of 87 (n = 87/155; 56.1%) completed questionnaires were returned. The findings suggest that significant support for immediate reporting exists. Immediate reporting is believed to improve service quality, reduce clinical errors and provide opportunity for image interpretation skills development. However, responses were not consistent across clinical professions and staff grades. The immediate reporting of emergency department images is perceived to benefit patient, emergency department clinicians and hospital organisation.

Sepsis is one of the leading causes of death in U.S. hospitals, resulting from organ dysfunction caused by an inappropriate inflammatory reaction to an infection. Timely treatment with empiric antibiotics in the emergency department is crucial to facilitate positive patient outcomes. The Surviving Sepsis Campaign (SSC) recommends initiating empiric antibiotic therapy within one hour of presentation to the emergency department. Some emergency departments have implemented sepsis management protocols to guide care and ensure timely treatment. The purpose of this study is to determine the effect of a formal sepsis protocol in the emergency department on the time to antibiotic administration. A literature review was conducted using CINAHL, Cochrane Database, Health Source: Nursing/Academic Edition, and MEDLINE. Results from one systematic review, eight quasi-experimental studies, and four quality improvement projects suggested that implementation of a sepsis management protocol in an emergency department may decrease the time to antibiotic administration. (< 10 = spell out) Eleven of the 13 articles reported decreased time to antibiotic administration by as much as 8-193 minutes compared to pre-protocol. One study met the SSC goal of 1 hour and reported a median administration time of 17 minutes. Time to antibiotics was influenced by protocols based on published sepsis guidelines, inclusion of antibiotic guidelines, nurse-initiated treatment, and education for emergency clinicians regarding sepsis management. Emergency departments should implement sepsis protocols adapted to their local institution to decrease time to antibiotic administration and reduce mortality of sepsis patients. Further research on how sepsis protocols affect antibiotic administration time is needed.