Homework: Medical Record Review.
Homework: Medical Record Review.
Using the medical record review, this population was enriched (62%) with septic patients making the positive predictor value (PPV) a more relevant indicator of the performance of this test.
Conclusion: Plasma from each study subject was assayed for the presence of iNOS – an intracellular enzyme that is only expressed after induction by lipopolysaccharide (LPS) and/or inflammatory cytokines – that is released into the circulatory system when the normal apoptotic scavenging process becomes dysregulated and the induced cells become secondarily necrotic, swell and burst. Subsequently, iNOS is released in microvesicles into the circulation and, thus, can serve as a sepsis biomarker. The plasma iNOS assay correlated well with the medical record’s diagnoses of sepsis and is a promising assay for the triage of ED patients. In contrast, the plasma iNOS assay did not correlate as well to the ED physician’s clinical assessment suggesting that the initial diagnosis of sepsis while patients are in the ED is often difficult. We are hopeful the iNOS biomarker will allow ED physicians to better evaluate potential septic patients in the future, but further studies are needed to validate our assumptions.
ORDER CUSTOM, PLAGIARISM-FREE PAPER
Paramedics Receiving Training in Low Acuity
121 Complaints Demonstrate Safety in Alternate Destination Disposition Recommendations
Masroor M, Schlesinger SA, Nguyen TH, Koenig KL, Schultz CH, Miler K/University of California, Irvine, Irvine, CA
Study Objectives: In 2015, the Orange County Fire Chiefs Association (OCFCA) launched the Alternate Destinations Pilot Project as part of the California Community Paramedicine Pilot. The regional project was designed to permit paramedic transport of low acuity patients to Urgent Care Centers (UCC) instead of emergency departments (ED). Outside groups expressed concern that paramedics would be unable to differentiate low-acuity patients from those with significant illness. The objective of this study is to evaluate whether paramedics with additional training in Alternate Destination evaluation can safely identify patients appropriate for transport to a non- emergency care center.
Methods: The University of California, Irvine Center for Disaster Medical Sciences provided research support to the regional project. Alternate Destination Paramedic Trainees (ADPT) received 4 hours of continuing education on evaluating low acuity patients for appropriateness of transport to UCC. Eligible patients were defined as those with extremity injuries, soft tissue infection or injury, lacerations with controlled bleeding, cough, and/or fever. ADPTs evaluated this cohort of patients, and were prompted by their electronic Patient Care Records to enter disposition recommendations. Patients deemed “appropriate for UCC” and contacted during UCC operating hours were offered enrollment in the OCFCA pilot and transport to UCC. Transporting fire department personnel collected outcome data from all patients transported to “pilot partner hospitals” or UCCs as part of their Quality Assurance process, regardless of enrollment in the pilot project or final transport destination. Fire departments provided data to University of California, Irvine, Center for Disaster Medical Sciences researchers, who performed research oversight and data analysis of the overall project. ADPT disposition recommendations were deemed appropriate if the patients were transported to and discharged from the UCC, or if the patient was transported to an ED and discharged from there within 6 hours of arrival.
Results: ADPTs are projected to evaluate 800 patients over the first year of the pilot project. Based on current data (from the first six months of the project) they will
designate approximately 200 of these patients as appropriate for UCC. This patient cohort will be transported to partner hospitals or UCCs from which outcome data will be retrievable. If the true percentage of patients with inappropriate disposition is 5%, power calculations and a priori outcomes thresholds suggest that a sample size of at least 200 patients designated as “appropriate for Urgent Care” will provide 80% power to conclude that the percentage of inappropriate disposition recommendations was less than 10%.
Conclusion: Given our preliminary (first 6 months) data, we anticipate that overall data will demonstrate ADPT-trained paramedics make safe and appropriate disposition recommendations for patients with selected low-acuity complaints. This would directly contradict previous studies that demonstrated significant paramedic undertriage of prehospital patients.
An Evaluation of Screening Tools to Predict
122 Opioid Misuse in the Emergency Department
Chalmers CE, Wilson MP, Mullinax SZ, Brennan JJ/UC San Diego Department of Emergency Medicine Behavioral Emergencies Research (DEMBER) Lab, San Diego, CA
Study Objectives: Several screening tools currently exist to identify opiate misuse in patients with chronic pain complaints. However, these screens are typically used in outpatient settings, and there is little work on their usefulness in the emergency department (ED). The goal of this study was to assess the effectiveness of three screening tools for opioid misuse within the emergency department to predict which patients are at risk for misuse of their prescribed narcotics for chronic, non-cancer pain.
Methods: This was a prospective observational study enrolling a convenience sample of patients who presented to an academic ED for a chief complaint of pain � 6 months or for a refill request of an opiate. Patients completed the Opioid Risk Tool (ORT), Screener and Opioid Assessment for Patients with Pain – Revised (SOAPP-R), and Current Opioid Misuse Measure (COMM). High risk for opiate misuse on the ORT was defined as scoring in the high-risk category, while low risk for opiate misuse was defined as scoring in the low or moderate-risk category. These measures were compared against a composite gold standard of nine aberrant behaviors, including soliciting opiate prescriptions from 3 or more physicians, forging or selling prescriptions, or an abnormal urine drug screen, all of which have been previously shown in existing literature to indicate drug abuse. The presence of aberrant behaviors was monitored in the patient’s electronic medical record and in California’s Prescription Drug Monitoring Program, the Controlled Substance Utilization Review and Evaluation System (CURES). 100% of patients had CURES data in the 90 days after their ED visit and 68.8% had CURES data for the full 90 days before their ED visit. We calculated the sensitivity, specificity, and diagnostic odds ratios for each of the screening tools and used receiver operator characteristic (ROC) curves to assess their effectiveness to predict risk of opioid misuse.
Results: A total of 154 enrolled patients were enrolled in the study (mean age¼48; 49.6% female). Abdominal and back pain accounted for 47.4% of the chief complaint. 86 patients (55.8%) were determined to be at risk for opiate misuse, as defined by displaying one or more aberrant behaviors within 3 months before or after their ED visit. Using the published cutoff scores defining high risk for opioid misuse in each of the assessment tools, the sensitivity of these tools to correctly classify patients at risk for opiate misuse were 38.4%, 60.5%, and 50.6% in the ORT, SOAPP-R, and COMM respectively. The specificity of the assessment tools were 58.8% for the ORT, 50.0% for the SOAPP-R, and 52.1% for the COMM. The positive predictive values of the ORT, SOAPP-R, and COMM were 0.54, 0.60, and 0.57, respectively. The area under the ROC curve for the ORT, SOAPP-R, and COMM was 0.510 (95% confidence interval [CI], 0.416-0.604), 0.579 (95% CI, 0.487-0.670), and 0.574 (95% CI, 0.483-0.665), indicating poor accuracy for each of the measures.
Conclusion: In a preliminary study among emergency department patients with nonmalignant chronic pain, the currently established opioid misuse screening tools poorly determine which individuals are at a high risk for opioid-related aberrant behaviors. Further studies are needed to investigate the applicability of these tools in the emergency department. Homework: Medical Record Review.
Volume 68, no. 4s : October 2016
Homework: Medical Record Review.