the use of nhamcs emergency department research. jim edwards, bs. research associate department of...
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The Use of NHAMCS The Use of NHAMCS
Emergency Department Emergency Department ResearchResearch
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Jim Edwards, BS.Jim Edwards, BS.Research AssociateResearch Associate
Department of Emergency MedicineDepartment of Emergency Medicine
University of Illinois
College of Medicine
Chicago, IL
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ObjectivesObjectives
• Explain the NHAMCS database
• Implementation of database
• Recent publications
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DescriptionDescription
• National Hospital Ambulatory Medical Care Survey
• Collect data on the utilization of services and provision of care in ED
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DescriptionDescription•National sample•General and short stay hospitals
•No federal, military, or VA•50 states and D.C.•Began annually in 1992
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DescriptionDescription
• Four stage sampling
–Geographically defined areas
–Hospitals within areas (~500)
–ED within hospitals (some > 1)
–Pt visits within ED (~24,000)
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DescriptionDescription
• CDC personal train hospital staff on data collection
• Data on Patient Record Form during random 4 week recording period
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Patient Record FormPatient Record Form
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Data
DescriptionDescription
•Demographics
• Payment
•Complaints
•Diagnoses
• Imagining, labs, procedures
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Data
DescriptionDescription•Meds
•Providers
•Reason for injury
•Wait time
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Data
DescriptionDescription
•Pain
•Disposition
•Place of injury
•Hospital characteristics
• Initial V/S in 2002
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CodingCoding
DescriptionDescription
• A Reason for Visit Classification (NCHS)
• ICD-9-CM
• Drug coding classification system (NCHS)
• National Drug Code Directory
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SPSSSPSS
• Statistical program
• User friendly
• Handles more cases than Excel
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SPSSSPSS
• Download data file
• Download documentation
• Merge files if needed
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Joseph and Ward: New-Onset AF Joseph and Ward: New-Onset AF ResultsResults
• Conversion rate after 48 hrs– Sotalol 88%– Amiodarone 77%– Digoxin 58%– P < 0.05 when sotalol compared to digoxin
• Time to conversion SR– Sotalol 13.0 2.5– Amiodarone 18.1 2.9– Digoxin 26.9 3.4– P < 0.05 when sotalol and amiodarone compared to
digoxin
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SPSSSPSS
• Imputed variables–Diagnosis
–Reason for visit
–Drugs
–Age ranges
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SPSSSPSS
• Dummy variables–One or none
–Allows calculation of 2x2 tablesIV Narc
(1)No IV Narc
(0)
Admit
(1)
75
75%
5
5%
Discharged
(0)
5
5%
15
15%
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Patient DemographicsPatient Demographics
CalculationsCalculations N ( %)
Sex
Male 264 (65)
Female 143 (35)
Age, y
Mean 41.5 ± 15.3
Median 40.0
<18 12 ( 3)
18-64 359 (88)
>65 36 ( 9)
Ethnicity
White 356 (88)
Black 38 ( 9)
Other 13 ( 3)
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Patient DemographicsPatient Demographics
CalculationsCalculationsPain Level at Presentation
None 7 ( 2)
Mild 49 (12)
Moderate 102 (25)
Severe 102 (25)
Unknown 147 (36)
Mode of Arrival
Walk-in 348 (86)
Ambulance 36 ( 9)
Unknown 23 ( 6)
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Patient DemographicsPatient Demographics
CalculationsCalculationsDiagnosis (n = 443)
Renal colic (788.0) 155 (35)
Calculus of the kidney (592.0) 188 (42)
Calculus of the ureter (592.1) 78 (18)
Unspecified urinary calculus (592.9) 6 ( 4)
Hydronephrosis (591.0) 6 ( 1)
Disposition
Admitted 59 (15)
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ProceduresProcedures
CalculationsCalculations N ( %)
Diagnostic study 400 (98)
Other x-ray 132 (32)
CT 89 (22)
US 20 ( 5)
U/A 319 (78)
CBC 225 (55)
Procedure
Pain medication 346 (85)
IV fluids 251 (62)
Foley 12 ( 3)
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MedicationsMedications
CalculationsCalculationsMedication Class N ( %)
Narcotic 277 (68)
Nonnarcotic 216 (53)
NSAID 191 (47)
Other nonnarcotic 25 ( 6)
Antiemetic 140 (34)
Narcotic and NSAID 139 (34)
Narcotic and other nonnarcotic 10 ( 2)
Narcotic and antiemetic 124 (31)
Nonnarcotic and antiemetic 80 ( 0)
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MedicationsMedications
CalculationsCalculationsAgent N ( %)
Parenteral Agents
Narcotics
Meperidine 84 (21)
Morphine sulfate 59 (15)
Hydromorphone 37 ( 9)
Meperidine/Promethazine 11 ( 3)
Buprenorphine 6 ( 2)
Botorphanol tartrate 4 ( 1)
NSAIDs
Ketorolac 190 (47)
Anti-emetics
Promethazine 88 (22)
Prochlorperazine 32 ( 8)
Droperidol 11 ( 3)
Hydroxyzine 7 ( 2)
Metaclopramide 4 ( 1)
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Odds Ratio/Pain MedicationOdds Ratio/Pain Medication
CalculationsCalculations N (%) OR 95% CI p-value
Ethnicity
White 306 (86) 1.7 0.76-3.68 0.23
Non-white 40 (79)
Age
<65 318 (86) 1.7 0.68-4.20 0.30
>65 53 (78)
Pain Severity
Severe 97 (95) 4.0 1.40-12.31 0.01
Moderate, mild, or none 131 (83)
Severe or moderate 185 (91) 2.9 1.26-6.85 0.01
Mild or none 43 (77)
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Logistic Regression/Pain MedicationLogistic Regression/Pain Medication
CalculationsCalculations OR 95% CI p-value
Ethnicity
White 1.2 0.57-2.39 0.69
Age
<65 2.5 0.78-8.14 0.12
Pain Severity
Severe 2.6 0.88-7.81 0.08
Severe or moderate 2.2 0.91-5.29 0.08
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AdvantagesAdvantages• No data collection needed
• IRB exemption
• Large number of cases
• Free
• Large sample
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DisadvantagesDisadvantages
• Lack of information–Drug doses, route, meds before ED
–No pain relief measures
–No VS
–No lab or radiology results
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Conclusions Conclusions • No data collection
• Can get lost in the database
• Having and knowing ALL the documentation is key
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ConclusionsConclusions
• Lack of information
• Next year vital signs