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Biomedical subjects

K Wrenn

Publications and source records attributed to K Wrenn.

At least 19 recordsLinked to original sources
PubMed2001

Inappropriate fosphenytoin use in the ED.

The objective of the study was to evaluate how often intravenous (IV) fosphenytoin is used when oral phenytoin loading is possible. The methods included a retrospective chart review of all patients receiving IV fosphenytoin in the emergency department. We prospectively derived criteria that identify patients with seizures who could receive oral phosphenytoin loading (awake on arrival, alert, no emesis, and lack of endotracheal intubation, repeated seizures, or status epilepticus after arrival). The setting of the study was at an urban, university hospital emergency department with an annual census of 55,000 patients. The outcomes included the number of patients receiving IV fosphenytoin who could have received oral phenytoin loading. From February 1997 to June 1999, 55 patients received IV fosphenytoin. Thirty of these patients (55%, 95% confidence interval 41%-68%) were felt to have received fosphenytoin appropriately. The remaining 25 (45%, 95% confidence interval 32%-59%) patients could have been loaded orally with phenytoin. In a single institution, fosphenytoin administration is inappropriate almost half the time. Oral phenytoin loading is less expensive and safe.

Administration, Oral↗
PubMed1999

A midlife crisis.

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Abdominal Pain↗
PubMed1999

Physicians' perceptions about managed care restrictions on antibiotic prescribing.

The purpose of this study was to compare physicians' perceptions about managed care restrictions on drug prescribing with objective measures of the restrictions' effects. When asked a general question, 17 emergency medicine physicians in one urban, university hospital answered that they had to prescribe an antibiotic that was not their first choice because of managed care restrictions 32% of the time. The actual frequency of prescribing other than first-choice antibiotics, which was determined by asking the same physicians about the prescription of specific antibiotics for specific patients seen recently in the emergency department, was 6% ( p <.0001). We conclude that emergency medicine physicians treating patients in one managed care system significantly overestimated the restrictions imposed by managed care formularies on their antibiotic prescribing practices. Additional studies are warranted to measure the extent of this bias.

Anti-Bacterial Agents↗
PubMed1998

Moving on.

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Emergency Medicine↗
PubMed1997

Access to emergency care under TennCare: do patients understand the system?

STUDY OBJECTIVE: To determine patient understanding of how to properly gain access to urgent and emergency medical care under TennCare, a government-mandated managed health care initiative designed to replace Medicaid in Tennessee. METHODS: We prospectively surveyed a convenience sample of ED patients at university hospital ED with an annual census of 50,000 during two periods (summer 1994 and summer 1995). In 1994, 250 TennCare patients were enrolled (part 1). In 1995, 199 were enrolled (part 2). RESULTS: Patients from seven different TennCare managed care organizations (MCOs) were interviewed. Thirty-eight percent of part 1 patients and 37% of part 2 patients did not have or did not know the names of their primary care physicians (PCPs). Fifty-eight percent of the part 1 patients who knew their PCPs' names had never visited them. This figure had decreased to 25% by the time part 2 patients were surveyed. Seventy-three percent of part 1 patients interviewed did not call their PCPs before coming to the ED. This figure had decreased to 48% by the time part 2 patients were interviewed. Thirty-two percent of part 1 patients were aware that they were supposed to contact the PCP before visiting the ED, whereas 94% of part 2 patients were aware of this requirement. Thirty-one percent of part 1 patients and 40% of part 2 patients who tried to contact their PCPs were unsuccessful, most often because of a delay on the part of PCPs in returning calls. Fifty-six percent of part 1 patients and 69% of part 2 patients did not know that they might be held responsible for the bill if an ED visit was not considered a true emergency and was not approved by the MCO. CONCLUSION: Improvements in communication of pertinent information must be implemented in managed care systems such as TennCare to better inform participants of the proper use of the system. MCOs will not reduce inappropriate use of the ED if patients are not aware of their responsibilities and do not know their PCPs or how to gain access to them. PCP responsiveness to patients must also be improved.

Adult↗
PubMed1997

Attitudes toward the use of a metal detector in an urban emergency department.

STUDY OBJECTIVE: To determine the attitudes of patients, their family and friends, and ED staff toward a walk-through metal detector in the ED. METHODS: We conducted a survey of a convenience sample of ED patrons (patients and their friends and family) and staff at a university-affiliated Level I trauma center. RESULTS: We surveyed 176 patrons and 95 employees (35 nurses, 30 physicians, 16 security officers, and 14 staff members). Overall, 80% of the patrons and 85% of the employees said they liked the metal detector. Eighty-nine percent of the patrons and 73% of the employees said the metal detector made them feel safer. Only 12% of the patrons and 10% of the employees said the metal detector invaded their privacy or the privacy of others. Fewer than 1% of the patrons said they were less likely to return to our ED because of the metal detector, and 39% said it made them more likely to return. We detected no significant differences with regard to age, sex, or race. CONCLUSION: Most patrons and staff liked the metal detector and said it created a safer ED environment. Only a few disliked the presence of the metal detector or said it invaded their privacy. Institutions concerned about their employees' and patrons' perceptions of safety should consider installing metal detectors in their EDs.

Adolescent↗
PubMed1996

Adrenal carcinoma.

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Adrenal Gland Neoplasms↗
PubMed1996

Advance directives in the emergency department: too few, too late.

OBJECTIVE: To determine: 1) the number of patients arriving at the ED who had executed an advance directive (AD), 2) how many of the patients who had an AD brought the AD with them, and 3) whether those patients who did not have an AD had ever discussed ADs with their primary care providers (PCPs) or had ever heard of an AD. METHODS: A cross-sectional, observational survey of a convenience sample of high-risk patients presenting to the ED of a university hospital was performed. Patients presenting to the ED for acute complaints who were elderly or had an underlying disease that suggested a risk of death in the near future were considered high risk. RESULTS: Of the 238 patients surveyed, 90% had PCPs. However, only 22% had ADs. Of these, only 23% brought the AD to the ED. Of the patients who did not have ADs, 95% had never discussed ADs with their PCPs, and 42% did not know what an AD was. Blacks were less likely than whites to have ADs (p < 0.0002) or to know about them (p < 0.004). CONCLUSION: The majority of high-risk patients presenting to this ED do not have ADs. Among those high-risk patients who did have ADs, fewer than 25% brought the ADs with them. The development of ADs for high-risk patients and the availability of ADs in the ED are woefully inadequate. Emergency physicians need to collaborate with PCPs to remedy these deficiencies.

Adolescent↗
PubMed1995

Using the "GI cocktail": a descriptive study.

STUDY OBJECTIVE: To determine practice patterns regarding administration of the "GI cocktail" (a mixture of liquid antacid, viscous lidocaine, and an anticholinergic) in the emergency department in a single hospital and the responses and final dispositions of patients who received the cocktails. DESIGN: A retrospective review of ED charts. SETTING: Urban university hospital ED with an annual census of 50,000 visits. PARTICIPANTS: Ninety-seven consecutive patients who received a GI cocktail in the ED. RESULTS: Forty-nine patients (50%) received a GI cocktail for a chief complaint of abdominal pain and 40 (41%) for a chief complaint of chest pain. The reason for administration of a GI cocktail was documented on only one chart. Sixty-six patients (68%) received at least one other drug, at a median time of 9 minutes before administration of the GI cocktail. The most commonly coadministered drug was a narcotic (56 patients), followed by nitroglycerin (22 patients), antiemetics (13 patients), H2-blockers (13 patients), and aspirin (10 patients). Thirty-three patients (34%) had symptomatic relief with the cocktail alone, 35 (36%) had symptomatic relief with the cocktail plus other drugs, 7 (7%) had no response to the GI cocktail alone, and 5 (5%) had no response to the cocktail with other drugs. In 17 patients (18%) the response was not documented. Chest pain patients and abdominal pain patients had a similar frequency of response. There was also similarity of response between admitted and discharged patients. CONCLUSION: Although symptomatic relief after administration of a GI cocktail is often noted, it is difficult to differentiate the effects of the cocktail from those of other coadministered medications such as morphine or nitroglycerin. We urge ED physicians to use the GI cocktail in a rational manner.

Abdominal Pain↗
PubMed1995

Emergency intravenous pyelography in the setting of possible renal colic: is it indicated?

STUDY OBJECTIVE: To determine whether emergency IV pyelography (IVP) adds significant information to clinical judgment in the setting of possible renal colic. DESIGN: A prospective voluntary survey of a convenience sample of physicians at the time of patient encounter. SETTING: The emergency department of a university hospital, annual census 50,000 visits. PARTICIPANTS: Emergency medicine faculty physicians. INTERVENTION: Physicians were surveyed before and after IVP was performed on patients with possible renal colic. RESULTS: Over the course of 12 months, 62 patients with possible kidney stones were evaluated by 14 different faculty ED physicians, who filled out surveys. Before IVP results were obtained, 63% of patients were thought to have a high (more than 75%) probability of ureteral obstruction. In 59% of these patients, the IVP results showed ureteral obstruction. The IVP revealed unexpected findings in 42% of all patients, including normal results in 19%, ureteral stones in 5%, higher than expected grade of obstruction in 6%, and lower than expected grade of obstruction in 6%, and lower than expected grade of obstruction in 5%. Management was reported to have been changed in 60% of all patients for a wide variety of reasons, but consideration of alternative diagnosis was the most common reason, occurring in 23%. Management changes included unexpected hospital admission in five patients (9%) and emergency urologic consultation in five patients (9%). CONCLUSION: Emergency IVPs are useful in the evaluation of patients with suspected renal colic, primarily when they rule out ureteral obstruction and allow consideration of alternative diagnoses. Not uncommonly, emergency urologic consultation or hospitalization occurs on the basis of IVP findings.

Adolescent↗
PubMed1995

Ectopic attitude.

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Adolescent↗
PubMed1995

Breathlessness. Strategies aimed at identifying and treating the cause of dyspnea.

The cause of dyspnea should always be assumed to be physical in nature, although a psychological component may sometimes exist. The workup should include thorough history taking, physical examination, chest radiography, electrocardiography, and determination of arterial blood gas levels or pulse oximetry readings. Although pulse oximetry provides a rough approximation of tissue perfusion, it is less useful for the diagnosis of hypoxia or abnormalities of ventilation. It may be used to assess oxygenation when the cause of dyspnea is known. It is also useful to monitor the clinical course during treatment, which should be directed to the underlying process.

Dyspnea↗
PubMed1994

Screening for sickle-cell trait in the emergency department.

OBJECTIVE: To determine 1) whether young adult black patients in an emergency department (ED) are familiar with sickle-cell anemia and 2) how many of these patients know their own sickle-cell trait status. DESIGN: Black patients in an ED were interviewed. Women aged 18 to 40 years and men aged 18 to 50 were included. Sickle-cell screening was offered to the patients. SETTING: The ED of a large urban university hospital with an annual census of 50,000, approximately 25% of whom are black. PATIENTS: A convenience sample of 147 black patients presenting to the ED with minor medical conditions. INTERVENTIONS: The subjects were interviewed to determine their knowledge base regarding sickle-cell anemia and to determine how many knew their sickle-cell trait status. The subjects were tested for sickle-cell trait. MEASUREMENTS AND MAIN RESULTS: 98% of the patients had heard of sickle-cell anemia and 73% knew that it was a genetic disorder. Only 31% of the patients knew their sickle-cell status. Women were more likely than men to know their status. Approximately half of the patients who had family histories of the trait or the disease knew their own status. Two of the 47 patients (4%) tested had positive sickle-cell screen results. CONCLUSIONS: Most black patients of childbearing age presenting to the ED have heard of sickle-cell anemia and know that it runs in families, but few know their own trait status. Until access to primary care providers is improved, ED physicians who care for patients at risk for sickle-cell trait have an obligation to ask them about prior screening and either screen them or refer them for screening.

Adult↗
PubMed1994

Influenza and pneumococcal vaccination in the emergency department: is it feasible?

OBJECTIVE: To assess the numbers of high-risk adult patients presenting to the emergency department (ED) who have not been vaccinated against influenza or pneumococcal disease and whether emergency physicians are willing or able to routinely provide vaccination. DESIGN: A survey of patients in the ED considered to be at high risk for morbidity and mortality from influenza or pneumococcal disease; an anonymous, mail-back survey of emergency physicians. SETTING: The ED of a university-affiliated hospital with an annual census of 50,000 patient visits. PARTICIPANTS: A convenience sample of adult patients visiting the ED for any complaint who fulfilled the American Thoracic Society and Centers for Disease Control and Prevention requirements as a high-risk patient requiring vaccination with influenza or pneumococcal vaccine. The physicians surveyed were identified from the membership role of the state chapter of the American College of Emergency Physicians. MEASUREMENTS: 1) Influenza and pneumococcal vaccination rates for high-risk patients presenting to an ED during influenza season; 2) reasons for lack of immunization; 3) patient willingness to be vaccinated in the ED; 4) vaccination practice patterns for ED physicians; and 5) reasons why ED physicians are unwilling to give these vaccines. RESULTS: 212 high-risk patients were surveyed. 57% and 75% of these patients reported not having received the influenza vaccine and the pneumococcal vaccine, respectively. The main reasons for not being immunized included not being informed they needed it, a prior adverse reaction, and procrastination. Of the unvaccinated patients, 54% were willing to be vaccinated in the ED. Of the surveyed ED physicians, 89% and 93% never or rarely gave influenza and pneumococcal vaccines, respectively. 51% of the ED physicians were willing to give the vaccine. Unwillingness stemmed mainly from: 1) the perception that ED physicians are not primary care providers, 2) inadequate time or personnel; and 3) concerns about adverse reactions or medicolegal liability. Only 5% of the physicians reported organized case-finding mechanisms in their EDs. CONCLUSION: Significant numbers of high-risk patients who are unimmunized against influenza and pneumococcal pneumonia present to the ED. There is hesitancy among ED physicians about assuming the primary care task of providing such immunizations. Any attempt to institute a large-scale vaccination program in an ED setting needs to be carefully planned in a way to involve primary care providers and to decrease ED physician concerns and reluctance.

Attitude of Health Personnel↗
PubMed1994

Funding in the emergency medicine literature: 1985 to 1992.

STUDY OBJECTIVE: To examine the rate and source of funding of research articles published in the emergency medicine literature. DESIGN: Review of all nonmilitary US research articles published in Annals of Emergency Medicine, American Journal of Emergency Medicine, and Journal of Emergency Medicine during the years 1985 and 1992. METHODS: Data on research methodology, number of authors, number of institutions, and funding source were collected. MEASUREMENTS AND MAIN RESULTS: One hundred sixty-nine articles met the entry criteria published in 1985, and 207 met the criteria in 1992. Retrospective studies, case series, clinical trials, and laboratory studies were the most common research methodologies in both years. The number of multicenter studies increased between the two years (P < .006). The rate of funding increased from 21.3% in 1985 to 29.0% in 1992. The funding sources, however, did not change significantly between the two years. Funded studies published in the emergency medicine literature are less likely to be federally funded and more likely to be funded by industrial sources than studies published in the literature of other specialties. CONCLUSION: The majority of research articles published in the three journals during the two years did not list a source of funding. This is in contrast to other specialties, in which the majority of published research is funded. The emergency medicine literature relies more heavily on private industry funding than does the literature of other specialties.

Emergency Medicine↗