Correspondence / American Journal of Emergency Medicine 32 (2014) 178–189
In our study, inappropriateness was more common when the indication was prophylactic. Most antibiotics were not justified and were abusively prescribed. Hospitalization in VED stood out as the second independent predictive factor for inappropriate antimicrobial use. Critical conditions in which patients are admitted to this room may explain these frequent unjustified prescriptions. These 2 risk factors for antibiotic misuse are not found in other surveys. 5. Conclusion This study conducted in a developing country shows a high rate of antibiotic misuse particularly in the setting of prophylactic antibiotherapy and in patients requiring hospitalization in vital ED. B. Armel MD Surgical Emergency Unit, Ibn Sina Hospital, Rabat, Morocco K. Berechid MD S. Himmich MD Medical Emergency Unit, Ibn Sina Hospital, Rabat, Morocco E-mail address: [email protected] J. Tadili MD A. Kettani MD M. Faroudy MD Surgical Emergency Intensive Care Unit, Ibn Sina Hospital Rabat, Morocco A. Azzouzi MD Surgical Intensive Care Unit, Ibn Sina Hospital, Rabat, Morocco A. Benchekroun MD Surgical Emergency Unit, Ibn Sina Hospital, Rabat, Morocco R. Abouqal MD N. Madani MD Medical Emergency Unit, Ibn Sina Hospital, Rabat, Morocco
181
nant for cardiac arrest outcome. Their study reports that the use of a CPRmeter is associated with a better quality of chest compression (CC), including rhythm and depth. However, we think there are some shortcomings for its application. The CPRmeter is (according to the authors) the only real-time feedback device for CC. We agree with the authors that this has been previously proven to improve the quality of CC in out-of-hospital cardiac arrest [2]. However, no benefit in terms of outcome has ever been reported to our knowledge. This device is held by the operator and placed on the chest of the patient, thereby having the potential to alter the effect of compressions on circulation. The CPRmeter used in the trial helped laypersons to achieve a sufficient rate and depth of CC, although the direct effect on compression might not be helpful. As suggested in the 2010 European Resuscitation Council Guidelines, CPR feedback devices may help in CPR training, although not in real-life situations [3]. The study also took place before the 2010 recommendation that increased the minimum depth of CC to 50 mm [4]. In their study, Buléon et al [1] considered CC satisfactory when a depth of greater than 38 mm was achieved. We think this is a significant shortcoming in their study, as the depth of CC is one of the most difficult elements to achieve for the inexperienced bystander [5]. The placement of a device between the operator and the chest could increase the rate of inadequate CC. The authors conclude that the CPRmeter improved the CC quality performed by students: depth of CC remained insufficient in regard to the recent recommendations; hence, only the rate of CC can be interpreted as improved. We believe that other methods to improve the rate of CC exist (namely, metronome), without the potential of altering the quality of the CC. We advise caution regarding the interpretation and application of this trial and believe that further studies with a deeper threshold to assess both CC compression and clinical outcome are indicated. Of note, the authors did not find any “learning effect” when they reassessed students 4 months after having used the CPRmeter in their first session. Use of the CPRmeter for training may not be beneficial, when compared with traditional Basic Life Support courses [5].
http://dx.doi.org/10.1016/j.ajem.2013.10.037 References [1] Raz R, Hassin D, Kitzes-Cohen R, et al. Antibiotic prescribing for adults and children in Israeli emergency rooms. Int J Antimcrob Agents 2003;22:100–5. [2] Mettler J, Simcock M, Sendi P, et al. Empirical use of antibiotics and adjustment of empirical antibiotic therapies in a university hospital: a prospective observational study. BMC Infect Dis 2007;7:21. [3] Goulet H, Daneluzzi V, Dupont C, et al. Evaluation de la qualité des prescriptions d’antibiotiques dans le service d’accueil des urgences d’un CHU en région parisienne. Med Mal Infect 2009;39:48–54. [4] Natsh S, Kullberg BJ, Van der Meer JW, et al. Delay in administering the first dose of antibiotics in patients admitted to hospital with serious infections. Eur J Clin Microbiol Infect Dis 1998;17:681–4. [5] Galayduyk N, Colodner R, Chazan B, et al. Adherence to guidelines on empiric use of antibiotics in the emergency room. Infection 2008;36:408–14. [6] Schouten JA, Hulscher ME, Natsh S, et al. Barriers to optimal antibiotic use for community acquired pneumonia at hospitals: a qualitative study. Qual Saf Health Care 2007;16:143–9.
Y. Freund MD A.L. Philippon MD Emergency department Hopital Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris Université Pierre et Marie Curie, Paris, France E-mail address: [email protected] S. Carreira MD A. Duguet MD, PhD Pneumology department and intensive care unit Hopital Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris Université Pierre et Marie Curie, Paris, France http://dx.doi.org/10.1016/j.ajem.2013.10.038
References
CPRmeter for inexperienced layperson, bystander's friend or patient's foe? To the Editor, We read with great interest the report on the randomized crossover trial by Buléon et al [1]. As the authors highlighted, the quality of cardiopulmonary resuscitation (CPR) is a great determi-
[1] Buléon C, Parienti JJ, Halbout L, et al. Improvement in chest compression quality using a feedback device (CPRmeter): a simulation randomized crossover study. American Journal of Emergency Medicine. in press. [2] Hostler D, Everson-Stewart S, Rea TD, et al. Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: prospective, cluster-randomised trial. BMJ 2011;342:d512. [3] Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010;81:1219–76. [4] Koster RW, Sayre MR, Botha M, et al. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81: e48–70.7.
182
Correspondence / American Journal of Emergency Medicine 32 (2014) 178–189
[5] Nicol P, Carr S, Cleary G, Celenza A. Retention into internship of resuscitation skillslearned in a medical student resuscitation program incorporating an Immediate Life Support course. Resuscitation 2011;82:45–50.8
Table 2 Communications with 70 patients in spinal immobilization No. of encounters (%)
Communication with patients with trauma who were in spinal immobilization
To the Editor, Motor vehicle accidents comprise approximately 1.3% of emergency department (ED) visits annually in the United States [1]. A previous study demonstrated that successful communication with patients regarding reasons for hospital admission was correlated with increased patient satisfaction [2]. Emergency department patients have reported a perceived need for improved communication with health care providers [3]. Another recent study demonstrated that the satisfaction of patients with trauma is improved when health care providers provide both instrumental and attentive care [4]. A simulated study confirmed the importance of narrative communication with emergency patients throughout the patient encounter [5]. This study was undertaken to identify factors associated with patient satisfaction among ED patients who have been involved in acute trauma and are in spinal immobilization and to assess the effectiveness of communication between health care providers and patients with trauma. This prospective observational cohort study was conducted at University of Toledo Medical Center, an urban trauma level 1 ED with an annual patient volume of 34 000. The study was approved by the University of Toledo institutional review board. Eligible participants included consenting ED patients 18 years and older with acute trauma who were in spinal immobilization (cervical collar and backboard). Prisoners, non–English-speaking patients, mentally incapacitated patients, and patients in severe distress were excluded from the study. Research assistants observed encounters with eligible ED patients for the first 30 minutes of ED care. Standardized locations where the patient could see a partial or full facial view of providers communicating with them were defined. Seventy subjects were observed in the acute trauma resuscitation phase, and 64 subjects completed the patient satisfaction survey. Participants were predominantly white (81%) and male (60%). Mechanisms of injury included motor vehicle accident (57%), fall (31%), and assault (7%; Table 1). Among 667 observed communications with patients, only 20% of speakers introduced themselves and 205 of speakers used the patient's name. A
Table 1 Demographic information of 70 patients in spinal immobilization Total no. of patients Male, n (%) White, n (%) African American, n (%) Hispanic, n (%) Mechanism of injury, n (%) A—assault F—fall M—motor vehicle accident O—other Trauma team level, n (%) 1 2 Consult ED evaluation only Age (y), mean ± SD
70 42 (60) 57 (81) 12 (17) 1 (1) 5 (7) 22 (31) 40 (57) 3 (4) 4 (6) 22 (31) 7 (10) 37 (53) 42 ± 19
Role P—physician N—nurse S—staff E—EMT ST—student Introduced self? Y—yes N—no Used patient name Y—yes N—no Oriented patient to trauma care Y—yes N—no Location of speaker A—head of bed B—side of bed above the waist C—side of bed below the waist D—foot of bed Distance of speaker 0—leaning over stretcher 1—foot or less from the edge 2—2 ft or less from the edge 3—3 ft or more from the edge Total no. of communications encounters (up to 10 encounters per patient were observed and recorded)
261 (39) 275 (41) 96 (14) 32 (5) 3 (b1) 134 (20) 532 (80) 136 (20) 531 (80) 109 (16) 558 (84) 126 436 86 19
(19) (65) (13) (3)
240 (36) 345 (52) 56 (8) 26 (4) 667
EMT, emergency medical technician.
minority of speakers oriented patients to trauma care (16%). Most speakers addressed the patient from locations in which patients had full facial views of providers, either at the head of the stretcher or the side of the stretcher above the waist (19% and 65%, respectively; Table 2). The most common ED procedures included radiographs, urinary catheter, and intravenous access. Of the 166 observed procedures, 72% were explained to the patient before the procedure. Most patients were highly satisfied with the medical care provided (88% score ≥ 4; range, 1-5), and most patients were highly satisfied with the quality of communication (85% score ≥ 4; range, 1-5).
Table 3 Patient satisfaction and association with demographic factors
n Female Male African American White Mechanism of injury A—assault F—fall M—motor vehicle accident O—other Trauma team level 1 2 Consult ED evaluation only Age (y) a b c
2
χ Test. Fisher exact test. Wilcoxon test.
Satisfaction with care, score 5
Satisfaction with care, score 3 or 4
35 12 (34%) 23 (66%) 5 (14%) 30 (86%)
28 14 (50%) 14 (50%) 7 (26%) 20 (74%)
1 (3%) 7 (20%) 26 (74%)
3 (11%) 12 (43%) 11 (39%)
1 (3%)
2 (7%)
2 (6%) 7 (20%) 5 (14%) 21 (60%) 39 ± 18
0 (0%) 12 (43%) 2 (7%) 14 (50%) 43 ± 19
P
.21a .25a
.03b
.16a
.34c
In our study, inappropriateness was more common when the indication was prophylactic. Most antibiotics were not justified and were abusively prescribed. Hospitalization in VED stood out as the second independent predictive factor for inappropriate antimicrobial use. Critical conditions in which patients are admitted to this room may explain these frequent unjustified prescriptions. These 2 risk factors for antibiotic misuse are not found in other surveys. 5. Conclusion This study conducted in a developing country shows a high rate of antibiotic misuse particularly in the setting of prophylactic antibiotherapy and in patients requiring hospitalization in vital ED. B. Armel MD Surgical Emergency Unit, Ibn Sina Hospital, Rabat, Morocco K. Berechid MD S. Himmich MD Medical Emergency Unit, Ibn Sina Hospital, Rabat, Morocco E-mail address: [email protected] J. Tadili MD A. Kettani MD M. Faroudy MD Surgical Emergency Intensive Care Unit, Ibn Sina Hospital Rabat, Morocco A. Azzouzi MD Surgical Intensive Care Unit, Ibn Sina Hospital, Rabat, Morocco A. Benchekroun MD Surgical Emergency Unit, Ibn Sina Hospital, Rabat, Morocco R. Abouqal MD N. Madani MD Medical Emergency Unit, Ibn Sina Hospital, Rabat, Morocco
181
nant for cardiac arrest outcome. Their study reports that the use of a CPRmeter is associated with a better quality of chest compression (CC), including rhythm and depth. However, we think there are some shortcomings for its application. The CPRmeter is (according to the authors) the only real-time feedback device for CC. We agree with the authors that this has been previously proven to improve the quality of CC in out-of-hospital cardiac arrest [2]. However, no benefit in terms of outcome has ever been reported to our knowledge. This device is held by the operator and placed on the chest of the patient, thereby having the potential to alter the effect of compressions on circulation. The CPRmeter used in the trial helped laypersons to achieve a sufficient rate and depth of CC, although the direct effect on compression might not be helpful. As suggested in the 2010 European Resuscitation Council Guidelines, CPR feedback devices may help in CPR training, although not in real-life situations [3]. The study also took place before the 2010 recommendation that increased the minimum depth of CC to 50 mm [4]. In their study, Buléon et al [1] considered CC satisfactory when a depth of greater than 38 mm was achieved. We think this is a significant shortcoming in their study, as the depth of CC is one of the most difficult elements to achieve for the inexperienced bystander [5]. The placement of a device between the operator and the chest could increase the rate of inadequate CC. The authors conclude that the CPRmeter improved the CC quality performed by students: depth of CC remained insufficient in regard to the recent recommendations; hence, only the rate of CC can be interpreted as improved. We believe that other methods to improve the rate of CC exist (namely, metronome), without the potential of altering the quality of the CC. We advise caution regarding the interpretation and application of this trial and believe that further studies with a deeper threshold to assess both CC compression and clinical outcome are indicated. Of note, the authors did not find any “learning effect” when they reassessed students 4 months after having used the CPRmeter in their first session. Use of the CPRmeter for training may not be beneficial, when compared with traditional Basic Life Support courses [5].
http://dx.doi.org/10.1016/j.ajem.2013.10.037 References [1] Raz R, Hassin D, Kitzes-Cohen R, et al. Antibiotic prescribing for adults and children in Israeli emergency rooms. Int J Antimcrob Agents 2003;22:100–5. [2] Mettler J, Simcock M, Sendi P, et al. Empirical use of antibiotics and adjustment of empirical antibiotic therapies in a university hospital: a prospective observational study. BMC Infect Dis 2007;7:21. [3] Goulet H, Daneluzzi V, Dupont C, et al. Evaluation de la qualité des prescriptions d’antibiotiques dans le service d’accueil des urgences d’un CHU en région parisienne. Med Mal Infect 2009;39:48–54. [4] Natsh S, Kullberg BJ, Van der Meer JW, et al. Delay in administering the first dose of antibiotics in patients admitted to hospital with serious infections. Eur J Clin Microbiol Infect Dis 1998;17:681–4. [5] Galayduyk N, Colodner R, Chazan B, et al. Adherence to guidelines on empiric use of antibiotics in the emergency room. Infection 2008;36:408–14. [6] Schouten JA, Hulscher ME, Natsh S, et al. Barriers to optimal antibiotic use for community acquired pneumonia at hospitals: a qualitative study. Qual Saf Health Care 2007;16:143–9.
Y. Freund MD A.L. Philippon MD Emergency department Hopital Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris Université Pierre et Marie Curie, Paris, France E-mail address: [email protected] S. Carreira MD A. Duguet MD, PhD Pneumology department and intensive care unit Hopital Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris Université Pierre et Marie Curie, Paris, France http://dx.doi.org/10.1016/j.ajem.2013.10.038
References
CPRmeter for inexperienced layperson, bystander's friend or patient's foe? To the Editor, We read with great interest the report on the randomized crossover trial by Buléon et al [1]. As the authors highlighted, the quality of cardiopulmonary resuscitation (CPR) is a great determi-
[1] Buléon C, Parienti JJ, Halbout L, et al. Improvement in chest compression quality using a feedback device (CPRmeter): a simulation randomized crossover study. American Journal of Emergency Medicine. in press. [2] Hostler D, Everson-Stewart S, Rea TD, et al. Effect of real-time feedback during cardiopulmonary resuscitation outside hospital: prospective, cluster-randomised trial. BMJ 2011;342:d512. [3] Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010;81:1219–76. [4] Koster RW, Sayre MR, Botha M, et al. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation 2010;81: e48–70.7.
182
Correspondence / American Journal of Emergency Medicine 32 (2014) 178–189
[5] Nicol P, Carr S, Cleary G, Celenza A. Retention into internship of resuscitation skillslearned in a medical student resuscitation program incorporating an Immediate Life Support course. Resuscitation 2011;82:45–50.8
Table 2 Communications with 70 patients in spinal immobilization No. of encounters (%)
Communication with patients with trauma who were in spinal immobilization
To the Editor, Motor vehicle accidents comprise approximately 1.3% of emergency department (ED) visits annually in the United States [1]. A previous study demonstrated that successful communication with patients regarding reasons for hospital admission was correlated with increased patient satisfaction [2]. Emergency department patients have reported a perceived need for improved communication with health care providers [3]. Another recent study demonstrated that the satisfaction of patients with trauma is improved when health care providers provide both instrumental and attentive care [4]. A simulated study confirmed the importance of narrative communication with emergency patients throughout the patient encounter [5]. This study was undertaken to identify factors associated with patient satisfaction among ED patients who have been involved in acute trauma and are in spinal immobilization and to assess the effectiveness of communication between health care providers and patients with trauma. This prospective observational cohort study was conducted at University of Toledo Medical Center, an urban trauma level 1 ED with an annual patient volume of 34 000. The study was approved by the University of Toledo institutional review board. Eligible participants included consenting ED patients 18 years and older with acute trauma who were in spinal immobilization (cervical collar and backboard). Prisoners, non–English-speaking patients, mentally incapacitated patients, and patients in severe distress were excluded from the study. Research assistants observed encounters with eligible ED patients for the first 30 minutes of ED care. Standardized locations where the patient could see a partial or full facial view of providers communicating with them were defined. Seventy subjects were observed in the acute trauma resuscitation phase, and 64 subjects completed the patient satisfaction survey. Participants were predominantly white (81%) and male (60%). Mechanisms of injury included motor vehicle accident (57%), fall (31%), and assault (7%; Table 1). Among 667 observed communications with patients, only 20% of speakers introduced themselves and 205 of speakers used the patient's name. A
Table 1 Demographic information of 70 patients in spinal immobilization Total no. of patients Male, n (%) White, n (%) African American, n (%) Hispanic, n (%) Mechanism of injury, n (%) A—assault F—fall M—motor vehicle accident O—other Trauma team level, n (%) 1 2 Consult ED evaluation only Age (y), mean ± SD
70 42 (60) 57 (81) 12 (17) 1 (1) 5 (7) 22 (31) 40 (57) 3 (4) 4 (6) 22 (31) 7 (10) 37 (53) 42 ± 19
Role P—physician N—nurse S—staff E—EMT ST—student Introduced self? Y—yes N—no Used patient name Y—yes N—no Oriented patient to trauma care Y—yes N—no Location of speaker A—head of bed B—side of bed above the waist C—side of bed below the waist D—foot of bed Distance of speaker 0—leaning over stretcher 1—foot or less from the edge 2—2 ft or less from the edge 3—3 ft or more from the edge Total no. of communications encounters (up to 10 encounters per patient were observed and recorded)
261 (39) 275 (41) 96 (14) 32 (5) 3 (b1) 134 (20) 532 (80) 136 (20) 531 (80) 109 (16) 558 (84) 126 436 86 19
(19) (65) (13) (3)
240 (36) 345 (52) 56 (8) 26 (4) 667
EMT, emergency medical technician.
minority of speakers oriented patients to trauma care (16%). Most speakers addressed the patient from locations in which patients had full facial views of providers, either at the head of the stretcher or the side of the stretcher above the waist (19% and 65%, respectively; Table 2). The most common ED procedures included radiographs, urinary catheter, and intravenous access. Of the 166 observed procedures, 72% were explained to the patient before the procedure. Most patients were highly satisfied with the medical care provided (88% score ≥ 4; range, 1-5), and most patients were highly satisfied with the quality of communication (85% score ≥ 4; range, 1-5).
Table 3 Patient satisfaction and association with demographic factors
n Female Male African American White Mechanism of injury A—assault F—fall M—motor vehicle accident O—other Trauma team level 1 2 Consult ED evaluation only Age (y) a b c
2
χ Test. Fisher exact test. Wilcoxon test.
Satisfaction with care, score 5
Satisfaction with care, score 3 or 4
35 12 (34%) 23 (66%) 5 (14%) 30 (86%)
28 14 (50%) 14 (50%) 7 (26%) 20 (74%)
1 (3%) 7 (20%) 26 (74%)
3 (11%) 12 (43%) 11 (39%)
1 (3%)
2 (7%)
2 (6%) 7 (20%) 5 (14%) 21 (60%) 39 ± 18
0 (0%) 12 (43%) 2 (7%) 14 (50%) 43 ± 19
P
.21a .25a
.03b
.16a
.34c
