Research Forum Abstracts

Conclusions: The overall compliance rate of outpatient stress testing was poor.When compared to the insured group, the lack of insurance did not adversely affect thecompliance rate.

Is Triage Time a Valid Measure of “Time Zero” for Severe

98 Sepsis and Septic Shock Patients in the EmergencyDepartment?

Haddad S, Goltser Y, Baner N, Kintzer E, Sama A, Rudoplh G, Ward MF, D‘Amore J,Slesinger T/North Shore University Hospital, Manhasset, NY

Background: The 2012 Surviving Sepsis Campaign (SSC) Guidelines recommendearly, protocolized, resuscitation of all patients with sepsis-induced tissuehypoperfusion (SITH): a systolic blood pressure (SBP)<90mmHg after initial fluidchallenge or a blood lactate concentration � 4mmol/L. The SSC sepsis bundle involvesobtaining lactate levels, blood cultures, and administering antibiotics and 30mL/kgcrystalloid within three hours of development of SITH. These recommendations arethe current standard of care and are consistent with the measures endorsed by theNational Quality Forum.

Study Objectives: The SSC has confirmed the use of triage time as “time zero” inthe emergency department (ED) for data collection and compliance reporting with thesepsis bundle. The purpose of this study was to assess the validity of triage time as asurrogate for time of presentation of SITH in the ED.

Methods: This was a retrospective consecutive chart review study conductedat a tertiary care ED where both direct bedding and standard triage areemployed. All ED charts between September and December 2012 werereviewed. Patients included in the analysis were >18 years old, had a lactateordered, a documented new infection, and met both SIRS criteria (2 of thefollowing: P>90, RR>20, T>101 or <96.8, WBC>12,000 or <4,000) andSITH criteria (defined in this study as a SBP<90 regardless of fluidadministration and/or a lactate�4mmol/L) in the ED. Statewide Planning andResearch Cooperative System (SPARCS) reports from September to December2012 were cross-referenced to ensure that all patients meeting inclusion criteriawere included in analysis. Discharged patients were excluded. Relevant data wasextracted, including triage time, vital signs, laboratory values and time meetingSIRS criteria and SITH criteria. Descriptive statistics were calculated (medianand 95% confidence intervals).

Results: 29,305 charts were reviewed. Of the 7,760 charts that screened inwith lactate order, 194 met inclusion criteria and were included in data analysis.44.1% of patients met SITH criteria with a SBP<90 (and normal lactate),40.0% with a lactate�4 (and normal SBP), and 14.4% with both a SBP<90and a lactate �4. Only 14.4% of patients met 2 of the 3 available SIRS criteriaat triage. 82.1% of patients met SIRS criteria with a P>90, 53.8% of patientswith a RR>20, 27.2% of patients with a T>101 or <96.8, and 49.7% ofpatients with a WBC>12,000/<4,000. Patients met SIRS criteria a median of38 minutes (95% CI: 47.42-70.58) after triage. Only 12.3% of patients had aSBP<90 at triage. Patients met SITH criteria (a SBP<90 and/or a lactate�4) amedian of 54 minutes (95% CI: 77.93-116.10) after triage.

Conclusions: The American College of Emergency Physicians (ACEP) hasraised significant concerns regarding the scientific validity and reliability oftriage time as “time zero.” In this study only 14.4% of patients met 2 of the 3SIRS criteria available at triage, and even fewer- 12.3% of patients- had aSBP<90mmHg at triage. Patients met SIRS criteria 38 minutes after triage, andSITH criteria 54 minutes after triage. As many lab values are not yet availableat triage, this time is not an accurate surrogate for time of identification ofSITH. Future efforts should focus on identifying a marker that may allow formore appropriate reporting of compliance with the sepsis resuscitation bundle.

Electrocardiogram Patterns as Predictors of Pulmonary

99 EmbolismCo I/University of Illinois-Chicago, Chicago, IL

Study Objective: Electronic medical records are a relatively new technologythat allows emergency physicians to quickly review patients’ previous medicalrecords including previous electrocardiograms (EKGs). Multiple previous studieshave looked at EKG patterns predictive of pulmonary embolism (PE) at time ofPE diagnosis, though none have examined EKG changes in these patients whencompared with their previous EKGs. The objective of this study is to identify

Volume 62, no. 4s : October 2013

the most common EKG changes in patients with known PE when their EKGsare compared with their previous.

Methods: The study was conducted at an urban community teaching hospital withan annual emergency department (ED) census of approximately 60,000. Aretrospective chart review of all patients diagnosed with PE in the ED from 2008-2013was performed. Only those patients with PE diagnosed by high probability ventilation-perfusion scan or by identification of a PE in the pulmonary artery bifurcation (saddleembolism), main or lobar arteries on computer tomography (CT) were included in thestudy. Each patient’s presenting EKG was compared with their most recent EKGobtained prior to the diagnosis of PE. Patients with EKGs showing a paced rhythmwere excluded from the study.

Results: There were 116 cases reviewed. The mean age was 62.9 years (Range: 23-96years) with 66% being female. The average duration of time from previous EKG toEKG at presentation was 14 months (Range: 1day - 48months). The most commonchange noted was sinus tachycardia (41%). 34% of patients had new T-wave inversionswith the majority occurring in the inferior and lateral leads. 24% had new T-waveflattening, also most commonly in the inferior and lateral leads. New ST-depressionwas present in 9% of patients, with majority in the inferior and lateral leads. Twopatients (1.7%) had new ST-depressions in the anterior leads consistent with a rightheart strain pattern, six patients (5.2%) had a new S1Q3T3 pattern, four patients(3.4%) had a new right bundle branch block and seven (6%) had a new right axisdeviation. 19% of patients had no change in their EKG.

Conclusions: The most common EKG change when compared to previous inthe setting of PE is sinus tachycardia, present in approximately 40% of cases.New T-wave changes and ST-depressions are present in a minority of patients,with these changes most commonly occurring in the inferior and lateral leads.Only a small minority of patients with PE will have a new S1Q3T3 or rightheart strain pattern. Approximately one-fifth of patients with PE will have nochange in their EKG.

Acute Cholecystitis: A Dischargeable Diagnosis?

100 Lakoff D, Cherkas D, Parekh A/Icahn School of Medicine at MountSinai/Elmhurst Hospital Center, Queens, NY; New York Methodist, Brooklyn, NY

Background: The standard management for patients diagnosed with acutecholecystitis (AC) is antibiotics, admission and cholecystectomy. If improperlytreated, significant complications can occur leading to high morbidity andmortality. Our institution implemented a pathway to discharge clinically stablepatients with mild disease. This pathway included patients who were afebrile,pain-controlled, tolerating fluids, with normal white blood cell (WBC) counts,liver function tests (LFT) and lipase, with no significant comorbidities andpresumed to be reliable. At discharge, they are given prescriptions and a surgicalfollow-up appointment.

Study Objectives: Our hypothesis is that there is a subset of reliable patientspresenting to the adult ED, without significant comorbidities with mild disease, forwhom emergent admission and surgery is not needed and a conservative approach isfeasible.

Methods: Elmhurst Hospital is a city hospital located in Queens, NY and has>100 000 visits per year. We reviewed charts of patients discharged with AC from theadult ED from March 2007 to March 2010. We excluded only incarcerated patientsfrom analysis.

Charts of all patients were examined for abnormal vitals, past medical history,WBC count, LFTs, lipase, imaging modality, administration of antibiotics andnarcotics in the ED, surgical consultation, PO trial, return visits to the ED for the samecomplaint, surgical clinic notes and operative reports.

Results: A query of our electronic medical record revealed 574 patient chartsdiagnosed with AC between 3/1/07-3/10/10. Of those, 71 patients (12%)were discharged from the ED. Ages ranged from 17-78 years and 62% were female.Of those discharged, 53/71 (75%) attended surgery clinic for follow up with 34 (64%)having cholecystectomy. There were only two return visits; neither of whomexperienced any significant complications or were admitted for definitive care. 16/71(23%) did not follow up or revisit the ED.

Conclusions: In a busy city hospital, utilization of our mild AC algorithmreduced admission rates by 12% with 75% attending their recommendedfollow-up appointments. Despite the 23% lost to follow-up, this review suggeststhat a subset of these patients can be safely discharged from the ED. Thistranslates to significant overall cost savings and warrants further prospectivestudy.

Annals of Emergency Medicine S39