JOURNAL OF E M E R O E W C T NURSING/Research Abstracts

var ia t ion in t empera tu re across the rates. Little var ia t ion in Tsoln occurred dur ing da ta collection (mean + SD = 21.14 + 0.796 ~ C).

Conclusion: The Level i fluid warmer wi th the D-60HL tub ing and the Hot Line warmer w i th L-70 tub ing provided fluid at grea ter t h a n 37 ~ C at flow ra tes t e s t ed in th is study.

7. Reliability of Clinical Assessments by Emergency Nurses and Physi- ciaus in the Evaluation of Dehydration in Children. Kathleen A. Murphy, Marc Gorelick. Chi ldren ' s Hospital of Philadelphia, 34th & Civic Cente r Blvd., Philadelphia, PA 19104.

Purpose: Dehydra t ion resul t ing from gas t roenter i t i s or other acu te i l lnesses is a c o m m o n problem in pedia t r ic e m e r g e n c y care. Accura t e diagnosis , b a s e d on clinical s igns and symptoms, is essent ia l to make proper t r iage and t r e a t m e n t decis ions. Al though these f indings are s o m e w h a t subjec- tive, the re are no exis t ing da ta examin ing the cons i s tency of a s s e s s m e n t s by different observers. The purpose of this s tudy was to de t e rmine the in te robserver reliability b e t w e e n exper i enced e m e r g e n c y personne l in thei r clinical evalua- t ion of the s igns of dehydra t ion in children.

Design/setting: A cross-sect ional concordance s tudy was con- d u c t e d at an urban, ter t iary care pedia t r ic e m e r g e n c y depar tmen t .

Sample: A conven i ence sample inc luded 71 chi ldren age 2 weeks to 6 years s e e n in the e m e r g e n c y d e p a r t m e n t wi th a chief compla in t of vomit ing, diarrhea, or poor oral fluid in- take. Excluded were chi ldren w i th coexis t ing ser ious illness, or those t rea ted at ano ther hea l th care facility.

Methodology: Study personne l inc luded pedia t r ic e m e r g e n c y nurses and phys ic i ans wi th a m i n i m u m of 4 years of pedi- atr ic exper ience. Prior to therapy, e ach sub jec t was inde- penden t ly eva lua ted by two s tudy observers (nurse/nurse , or nurse /phys ic ian) who comple ted a checkl is t of n ine s igns and symptoms b a s e d on the World Health Organizat ion cri- teria: general appearance ; respiratory pat terns; radial pulse; s u n k e n fontanelle; skin turgor; sunken eyes; a b s e n c e of tears; humid i ty of m u c o u s m e m b r a n e s ; ur ine output; and capillary refill m e a s u r e m e n t accord ing to a s tandard ized protocol. Measu res of reliability were de te rmined , including the kappa s ta t i s t ic and the proport ion of posi t ive and neg- at ive agreement .

Result: Kappa, r ep resen t ing overall a g r e e m e n t corrected for chance , varied from 0.27 to 0.76 for the 10 clinical findings. Two of the findings, abnormal respiratory pa t t e rns and skin turgor, had unaccep t ab l y low kappas of less t h a n 0.35. Kappa was very similar w h e n nu r se /nu r se pairs and nurse / phys ic ian pairs were analyzed separately. For all f indings, specific a g r e e m e n t was greater t han overall agreement : proport ion of posi t ive a g r e e m e n t r anged from 0.33 to 0.89, while proport ion of nega t ive a g r e e m e n t r anged from 0.85 to 0.95.

Conr There is some variabil i ty in the a s s e s s m e n t s igns of dehydra t ion even by expe r i enced observers; however, the level of a g r e e m e n t is accep tab le for the mos t commonly elici ted findings. Both nurses and phys ic ians show a simi- lar degree of consis tency. Nurs ing a s s e s s m e n t s of chi ldren at risk for dehydra t ion should emphas ize those clinical find- ings wi th accep tab le in te robserver reliability.

8. Parentally Abducted Children: Cues to Suspected Diagnosis. Heidi A. Hodges, Margare t Auld Bruya. PO Box 1295, Spokane, WA 99210.

Purpose: In 1988, more t han 350,000 chi ldren were abduc ted . Number s of a b d u c t e d chi ldren repor ted to miss ing chil- d ren ' s organizat ions are inc reas ing each year. A b d u c t e d chi ldren are difficult to locate. A b d u c t e d chi ldren are likely to be t r ea ted in e m e r g e n c y set t ings . This s tudy explored the knowledge, ability to diagnose, and wil l ingness to report parental ly a b d u c t e d children by e m e r g e n c y hea l th services (EHS) professionals.

Design and setting: A randomized strat i f ied geographic sam- piing m e t h o d se lec ted n ine s ta tes w i th in three regions of the Uni ted Sta tes for th is exploratory, descr ip t ive study. South- eas t s t a tes were Alabama, Kentucky, and Tennessee . North- w e s t s t a tes were Minnesota , North Dakota, and Wyoming. Sou thwes t s t a t e s were Colorado, New Mexico, and Okla- homa.

Sample: Subjects from se lec ted s t a t e s were randomly se- lec ted from s ta t e lists p u r c h a s e d from the Emergency Nurses Associat ion, the Amer i can College of Emergency Physicians, nu r se pract i t ioner associat ions, and the Amer- i can A c a d e m y of Phys ic ian Ass is tan ts . Subjects had less t h a n 1 to more t h a n 20 years of exper ience in hea l th care. Regis tered nurses compr ised 67%, phys ic ians 23%, nurse pract i t ioners 7%, phys ic ian as s i s t an t s 1%, and LPNs 0.01%. Most of the sub jec t s were paren t s a n d 7% reported prior ex- pe r ience w i th child abduct ion.

Methodology: Surveys were mai led to 298 EHS professionals. Each subjec t rece ived the Knowledge of Parental Abduc t ion scale, Hodges A b d u c t e d Child Cue scale, Clinical Scenarios, and demograph i c quest ionnaire . A follow-up pos tcard was mai led to all subjects .

Result: One h u n d r e d th i r teen i n s t r u m e n t s were re tu rned (38%). EHS professionals ' knowledge correlated highly (r= 0.76, p < 0.01) wi th child abduc t i on experts and corre- la ted signif icant ly wi th d iagnosis (r = 0.31, p = 0.001). Sce- narios dep ic t ing a b d u c t e d chi ldren were correctly identif ied 66% of the t ime. E igh teen of 25 cues were valued to diag- nose child abduct ion. Subjects repor t ing exper ience wi th a b d u c t e d chi ldren provided d iagnos t ic cues. In tent ion to report was less t han diagnosis. Uncer ta in ty and belief the child was not e n d a n g e r e d were the mos t frequently reported reasons for in t en t ion not to report.

Conclusion: EHS professionals can correctly identify paren- tally a b d u c t e d chi ldren g iven s imula ted scenarios. Cues valued by subjec t s wi thou t exper ience wi th child abduc t ion are closely a l igned wi th d iagnost ic cues provided by sub- jects wi th experience. These cues may be useful in recog- n i t ion of parental ly abduc t ed chi ldren wi th in the emergency set t ing. In clinical scenarios, i n t en t ion to report was less t h a n recognit ion. Research is n e e d e d to validate d iagnost ic cues valued by EHS professionals a n d to p3aborate upon reasons for in ten t ion not to report.

9. Phlebitis in Field.Started IVs, Margare t Belcher. Universi ty of Louisville Hospital, 530 S. Jackson, Louisville, KY 40292.

Purpose: The purpose of this s tudy was to de te rmine the in- c idence of phlebi t is assoc ia ted wi th in t ravenous lines (IVs)

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started in the field by paramedics and registered nurses. In the field was defined as any IV started outside the physical confines of a health care set t ing or in the emergency department, that was not dressed with a clear occlusive dressing and labeled with the date, time, gauge, and initialed. Due to an increased inc idence of phlebitis reported at one urban medical center, a policy was writ ten to support the pract ice of pulling and restart ing every field-started IV when the pat ient was admit ted to an inpatient unit. This s tudy was done in response to that policy.

Methods: Between July 1991 and April 1992 all patients admit ted to the hospital on randomly selected days via the emergency depar tment with field-started IVs had their IV sites observed daily for 3 consecut ive days for s igns and symptoms of phlebitis. Phlebitis for the purpose of this study was defined as a 5 mm diameter of erythema at the venipuncture site, red streaks extending I cm upward from the IV site, or purulent drainage from the venipuncture area,

Results: One hundred forty-one (N = 141) IV sites were observed; 101 were started by RNs in the emergency depar tment and 40 by paramedics prior to the pat ients ' ar- rival at the emergency department. Nine IV sites became phlebitic; two were identified on day 1, five on day 2, and two on day 3. Seven of the phlebitic sites were started with #18 angiocatheters and two with #16 angiocatheters. The phlebitic sites included three in the hand, three in the fore- arm, two in the antecubital area, and one in the wrist. Five of the nine phlebitic sites were started by RNs, the remain- ing four were initiated by paramedics. Overall, the phlebitic rate was 0.06% (9 of 141). Insertion site, angiocatheter size, dressing and labeling of the site, and whether the site was started by an RN or paramedic did not influence phlebitis.

Conclusion: The results of this s tudy did not support the cur- rent policy of discont inuing field-started IVs. Maintaining IVs initiated in the emergency depar tment or prehospital care set t ing decreases health care costs by eliminating un- necessary nursing t ime and IV setup costs. This s tudy is significant to emergency nursing; it demonstrates that although IVs are started on unstable critically ill patients, the technique is safe and complications minimal.

10. The Almshouse Revisited: Heavy Users of Emergency Services. Ruth E. Malone. University of California, San Francisco School of Nursing N319X, San Francisco, CA 94143-0602.

Purpose: A small subgroup of ED patients is responsible for a disproportionate amount of ED visits and costs. This sub- group, heavy users of ED services, is identified as a medi- cally and socially vulnerable population. Interventions aimed at reducing this group's use of ED services have not proven effective, for reasons which remain unclear. The broad ob- ject ive of this study was to improve understanding of the phenomenon of heavy ED use. The primary aims were to: describe the context in which heavy ED use occurs and ex- plore the meanings of such use to patients who are heavy ED users; uncover the dimensions of the "problem" by ex- amining it from several perspectives, and explicate the findings within a policy perspective. The study was grounded in Heidegger ian interpretive phenomenology.

Desigr~ Interpretive ethnography utilizing multiple data points.

Research Abstracts/JOURNAL OF EMERGENCY NURSING

Setting: Two inner-city t rauma center, teaching hospital emergency depar tments in separate cities.

Sample: Patients identified by nurses as frequent visitors were interviewed by the researcher. Forty-six patients par- t icipated in taped unstructured interviews. Approximately 50 to 60 nurses and other hospital staff participated in taped, informal, break-room discussions of their experiences with frequent ED visitors. Other staff and patients were observed during fieldwork. Medical records of a subsample of the pa- t ient sample were also reviewed.

Methodology: Transcribed interviews, observational notes, and medical records data were t reated as text analogues for interpretive analysis. Data analysis used the interrelated processes of themat ic analysis, analysis of exemplars, and search for paradigm cases. Second-level analysis examined findings from the data and compared them for "fit" with policy assumptions.

Results: Patients identified as heavy ED users shared two commonalities: They all had social or medical problems not readily "fixable" by standard medical treatment, and their problems raised issues of legi t imacy and helplessness for both providers and patients. Many of these patients are viewed as "hopeless cases," yet some "former" heavy ED users were found to be making significant contributions. Is- sues of legitimacy, recognition, vulnerability, possibility for change, and communi ty were common themes in the dis- course of both pat ients and providers.

Conclusions: Deficit-focused views of these patients leave out their commonali ty with ourselves, the meaningful context within which their behaviors make sense, their values, fears, and concerns, and their contributions. Breakdowns of fam- ily and communi ty and the changes within health care mean that caregivers in "safety ne t" set t ings such as the emer- gency depar tment are asked to assume greater burdens. In- stitutional and social policies based on narrowly focused medical-economic models of care render more basic needs invisible and contribute to the medicalization of social problems and the objectification of patients.

11. ST Monitoring and the Early Diagnosis of Myocardial lschemia/In- farction in the Low-Risk Chest Pain Patient. Anthony J. Joseph, Jill Hertzendorf, Susan C. Finefrock,* Mary Ann Zanetos. Riv- erside Methodist Hospitals, 3535 Olentan~] River Road,

Columbus, OH 43214.

Objectives: To show that use of continuous 12-1ead ST mon- itoring (STM) in low-risk chest pain patients decreases time to diagnosis of ischemia/infarction and has predictive value

for stress testing.

Methods: Randomized, prospective trial in which 281 consec- utive patients with a chief complaint of chest pain and meet- ing elic~bility requirements were assigned to either the chest pain protocol (CPK/CK-MB and EKG at 0, 6, and 12 hours after arrival) or that, plus continuous ST monitoring.

Subjects: 30 years or older, no heart disease, had at least one major or two minor risk factors (AHA). Subjects had stress thallium test ing after 12 hours if not contraindicated and were followed up in 30 days.

Setting: Community hospital emergency depar tment with 65,000 visits/year.

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