The Society for Academic Emergency Medicine (SAEM) held its 2008 annual meeting in Washington DC this spring. Dedicated to research, teaching, and patient care, SAEM is the premier scientific body dedicated to commercial-free advancement of emergency care. With 565 abstracts and another 20 Innovations in Medical Education abstracts, this year was no exception. Below are the 12 abstracts we thought had the most potential to change our practice.
Abstract #11 | Coronary CT for Rapid Discharge of Low Risk Patients with Potential Acute Coronary Syndromes
You probably hate making that dreaded phone call to the Cardiologist at 3 a.m. for the “soft” chest pain admission. So do I, but according to Dr. Judd Hollander and his investigators at the University of Pennsylvania that may be a thing of the past. They looked at 500 consecutive low-risk ACS patients (normal or nonspecific ECG and TIMI scores less than 3) who had either delayed or immediate coronary CTA in the ED. Overall, the 84% of patients with a negative CTA, defined by stenosis 100, were discharged home. A 30-day follow-up found no deaths and no myocardial infarctions. While this is a single-institution study and needs to be validated at other institutions, this project offers promise that in a selected group of patients it may be reasonable to discharge low-risk rule out ACS patients home with negative CTAs.
Abstract #169 | Effectiveness and Safety of Intranasal Naloxone for Treatment of Heroin Overdose by Ambulance Officers
Attempting to insert an IV into patients with heroin abuse can be challenging while giving naloxone IM can be dangerous to staff. Dr. Debra Kerr and her investigators appear to have found a new route (intranasal) that is equally effective to IM naloxone. In this prospective RCT, 135 patients received either IM or IN naloxone (2mg) via mucosal atomization. Success rates were similar: 68% for IN, 80% for IM naloxone. The intranasal route appears to be highly efficacious in delivering naloxone and should be considered for pre-hospital and ED providers in cases of heroin overdose.
Abstract # 272 | Setting Patient Expectations of Waiting Times Improves Patient Satisfaction in the Emergency Department
Amusement parks often exaggerate waiting times for roller coasters so that the customer expecting a 60-minute wait is satisfied when their wait is “only” 30-minutes. Would a similar strategy improve ED patient satisfaction? Using a pre-intervention, post-intervention design, these investigators tested this question in a suburban ED with 115,000 annual patient-visits with a random sampling of 45% of discharged patients with a 20% survey response rate. By informing patients that the length of time until they left the waiting room for clinical evaluation was 20% longer than historical averages, they demonstrated a significant improvement in patient satisfaction scores. While future trials will need to assess these exaggerations on other important outcomes (how many patients leave without being seen secondary to these exaggerations and how many of these have adverse outcomes, do patients or families feel deceived or mislead by these white lies?), such a policy may be one quick fix to offer increasingly overcrowded EDs striving to improve patient satisfaction scores without substantial monetary investments.
Abstract #442 | Isolated Recurrent Vomiting Rarely Predicts Brain Injury in Children with Blunt Minor Head Injury
It can be difficult to know what to do with the pediatric patient who bumps his head and presents with isolated vomiting. According to this study, head CTs in this subset are likely overkill. Dr. Martin Osmond and his colleagues looked at 3867 subjects at 10 pediatric teaching hospitals, age 0-16 y/o. Of the 226 patients with isolated recurrent vomiting (no other CNS signs or symptoms), 2 had evidence of traumatic brain injury on CT with neither of these cases requiring neurosurgical intervention. This can be a tough sell real-time to parents of children with head injury and vomiting, but according to this study, it seems reasonable to forgo the CT.
Abstract # 461 | Are Two Small IVs as Good as One Big IV?
Though resuscitation guidelines empirically recommend two large bore IVs, does the evidence support such advice? This prospective trial enrolled healthy volunteers to receive saline via one 18-gauge IV and two 20-gauge IVs while measuring fluid administration. While manufacturers suggested that a single 18-gauge could administer 105 cc/minute, the investigators found a rate of 36 cc/minute, with the two 20-gauge IVs delivering 41.3 cc/minute. The faster rate of the two 20-gauge protocol translated into a 500 cc bolus delivered 129 seconds faster. In patients with difficult IV access, two 20-gauge IVs may be equal or better than one 18-gauge IV.
Abstract # 493 | Acute Cerebral Ischemia Evaluation in the Emergency Department: Does Magnetic Resonance Imaging Change Disposition?
How many times have you ordered an MRI from the ED while contemplating admission for stroke? This four-month observational study sought to assess whether MRI altered disposition decisions from the EM physician viewpoint. The authors found that disposition was changed from admit to discharge in 30%, and discharge to admit in 7% while remaining the same in 63%. Disposition changed in 67% of those with a normal neurological exam and 28% of those with an abnormal neurological exam. While not yet widely available, time-consuming MRIs may soon be a useful adjunct to determining which stroke patients require admission for further testing.
Abstract # 540 | Parenteral Dexamethasone for Preventing Recurrent Migraine Headaches: A Systematic Review of the Literature
Recurrent migraine headaches are a common ED chief complaint. While many effective abortive migraine therapies exist, all produce a number of patients returning with recurrent migraines. These investigators conducted a systematic review of randomized controlled trials comparing corticosteroids with placebo or any other standard therapy for acute migraine attacks in adults. Based upon 7 studies, they found that single dose parenteral dexamethasone was similar to placebo for acute pain relief, but offered a significant improvement in 72-hour headache recurrence (NNT = 9) with no difference in side-effect profile.
We are all looking to improve our productivity and according to this study the answer is simple: have someone else document. Trained medical scribes worked with senior-level residents who evaluated 4,135 patients of which 22% were scribed. The average EM charge increased by $42 (15%) on scribed patients. While this study doesn’t prove that scribes are cost-effective, it is certainly interesting that the addition of a scribe improved chart documentation. If this holds true at other institutions, the addition of scribes to the ED may be the wave of the future.
Abstract # 135 | Cumulative Radiation Exposure and Cancer Risk from Diagnostic Imaging in Patients Presenting to the Emergency Department
Computerized tomography has revolutionized emergency imaging, but with a substantially higher radiation exposure what is the risk:benefit ratio for patients? Jay Falk’s group analyzed a cross-section of patients over five years including 13,387 studies on over 1200 patients. Over 70% of total radiation exposure occurred from three studies: CT abdomen/pelvis, CT chest, and nuclear cardiac testing. While the mean exposure was 45 milliseiverts (mSv), 150 patients were exposed to over 100 mSv. The authors estimated six additional cancers would occur as a result of these exposures. Physicians will need to be cognizant of the risks of imaging studies in emergency patient populations while discussing the benefits and risks of diagnostic tests.
Abstract # 188 | Emergency Department Patients Scheduled for Outpatient Stress Test Have a Very Good Compliance Rate
Do low-risk chest pain patients in whom outpatient stress tests are scheduled, actually comply with these medical recommendations? This University of Virginia retrospective 22-month study of 458 patients referred for such testing demonstrated a 10% noncompliance rate. While next-day stress testing compliance rates were superior to 2-days later protocols, indigent patients were less likely to have recommended, scheduled stress testing. These results may guide clinicians in assessing the risks of inpatient versus observation versus outpatient stress testing in their patient populations.
Abstract # 305 | Emergency Physician Attitudes, Knowledge and Barriers in Acute Stroke Treatment: The Instinct Study
Thrombolytic therapy for acute ischemic stroke represents a source of contention between emergency physicians. As part of the INSTINCT randomized controlled trial, these investigators conducted an anonymous 121-question survey of EM physicians, including 86% board-certified. With a 71% response rate, these investigators found that 83% would use tPA in an ideal setting, while 27% felt that in such a setting tPA was a standard of care. However, 65% felt that using tPA based upon current protocols was extremely uncomfortable for them without a consultant though 66% of those physicians felt that a telephone consult would be sufficient. The greatest barriers to using tPA were patient arrival time (96%), stroke team access (42%), and inability to maintain thrombolytic skills (33%). While further evidence to support the NINDS findings is awaited, the majority of physicians would currently use thrombolytics in stroke patients meeting NINDS criteria and an acceptable minority believe tPA is a legal standard of care.
Abstract # 325 | Methodological Quality of the American Board of Emergency Medicine Lifelong Self Assessment Reading Lists
Among medical specialties, EM leads the way in developing recommended reading lists through the LLSA, but some have questioned the quality of readings selected since 2004. Using internationally recognized quality assessment tools, these investigators rated all of the LLSA articles from 2004-2007. With excellent reliability, they found these articles were both relevant and newsworthy, but represented a low standard of evidence. Therefore, readers should be cautious in allowing the LLSA to guide clinical practice. Though the LLSA is an exemplary means of ensuring true continuing medical education, additional means of identifying relevant, newsworthy, high-quality evidence should be developed.
Disclaimer: Dr. Carpenter is a funded geriatric and patient safety researcher with a particular interest in Evidence-Based Medicine, Knowledge Translation, and the cognitive psychology of clinical decision-making. Dr. Breyer’s research interests include Resident Education and Ultrasonography.