RCH EMERGENCY PHYSICIAN CQI CLINICAL

SURVEY

35 of 36 CEPA members responded GOAL: Get to know what others are doing with

respect to referrals, practice patterns, etc. May be a useful tool in the development of

future educational sessions Not all questions were answered Most questions were generic Some questions were not entirely fair

◦ Forced into limited answers◦ Many different patient variables exist

Clinical Survey

GOAL: Move towards either having 2nd EP present

or at least making them aware of procedural sedation.

Pre-test probability is a major factor. Depends on mechanism of injury, age,

body habitus. CT scan in older patients (> 50 yrs), obese

patients (anticipate poor / difficult to interpret plain films) or high risk mechanism.

Younger patients with low risk mechanism – use clinical decision rule; usually start with plain films.

COMMENTS RE PLAIN FILM VS. CT CERVICAL SPINE

SHOULD ALL PATIENTS WITH A SIGNIFICANT TRAUMATIC BRAIN INJURY BE SEEN BY A NEUROSURGEON PRIOR TO DISCHARGE IRREGARDLESS OF WHICH HOSPITAL THEY PRESENT TO??

SIGNIFICANT TBI = ANY BLOOD PRESENT ON CT SCAN (SAH, SMALL SDH) +/- SKULL #

Standard of Care for TBI Patients

Need to consider other factors – age, medical co-morbidities, abnormal urologic anatomy, immunocompromised

Consider IVT for pts with past hx of antibiotic resistance or recurrence

IVT for pts with pyelo and known kidney stone

IVT FOR PYELONEPHRITIS - comments

Use clinical gestalt Size of the involved area – IVT for larger

areas Location of involvement IVT if suspicious of poor compliance or loss

to follow up

IVT FOR CELLULITIS - comments

Usually put them on antibiotics for a few days only

Use of Septra may decrease the rate of re-infection if MRSA

Gradually switching to not using antibiotics in these patients

ANTIBIOTICS FOR UNCOMPLICATED ABCESS - comments

DOES THE ROUTINE CULTURE OF AN UNCOMPLICATED ABCESS CHANGE THE TREATMENT IN ANY WAY?

COST VS. BENEFIT MAY INFLUENCE TREATMENT OF FUTURE INFECTIONS

XRAYS FOR BONY INJURIES PAIN CONTROL ABDOMINAL PAIN PEDIATRIC FEVER PEDIATRIC LACERATIONS DYSPNEA with FEVER VAGINAL BLEEDING

IS IT TIME TO LOOK (AGAIN) AT NURSE INITIATED ORDERS FOR OTHER PROBLEMS?

WHY SIGN UP FOR PATIENTS? Nursing staff (and other EP’s) knows who is

responsible for individual patients Keeps track of where your patients are in

the Dept If you are going to check their EMR / PCI

anyways; why not sign up for them? Easier transfer of care to another physician Wireless ER in the future “Paperless” ER???

GOAL: Our group needs to make a better effort in

signing up for patients on Meditech.

With the move to a Wireless ED and a “paperless” ED; the expectation is that the signup rate for our group would be 100%

WHY SIGN UP FOR PATIENTS?

Troponin Use in Low Risk Patients

Timing of biomarker testing is critical; sensitivity of a single troponin for MI within the first hour of symptoms is 10% to 45% and increases to more than 90% at 8 or more hours.

Retrospective study of 588 low-risk patients with nondiagnostic ECGs and negative troponins drawn 6 to 9 hours after symptom onset reported a 0.3% rate of adverse events and no deaths at 30 days.

Atrial Fibrillation and Flutter in the EDStiell et al; Can. Journal of Cardiology; 2011 We recommend that synchronized electrical

cardioversion or pharmacologic cardioversion may be used when a decision is made to cardiovert patients in the emergency department. (Strong Recommendation, Moderate-Quality Evidence).

We suggest that antiarrhythmic drugs may be used to pretreat patients before electrical cardioversion in ED in order to decrease early recurrence of AF and to enhancecardioversion efficacy (Conditional Recommendation, Low-Quality Evidence).

Atrial Fibrillation and Flutter in the EDStiell et al; Can. Journal of Cardiology; 2011RECOMMENDATION

We recommend that electrical cardioversion may be conducted in the ED with 150-200 joules biphasic waveform as the initial energy setting (Strong Recommendation, Low-Quality Evidence).

Values and preferences. This recommendation places a high value on the avoidance of repeated shocks and the avoidance of ventricular fibrillation that can occur with synchronizedcardioversion of AF at lower energy levels. It isrecognized that the induction of VF is a rare but easily avoidable event.

CLINICAL SURVEY - SUMMARY Gained some perspective on what other

EP’s are doing Critical assessment of your own practice Develop some group expectations Possible future educational sessions1. Initiation and cessation of IV therapy2. Atrial fib in the ER3. Use of troponins in low risk chest pain pts.4. Nurse initiated orders in the ER

QUESTIONS??