288 Emergency Department-Based Palliative Interventions

Abstract

Study Objectives: Our objective was to develop a set of physical exam and laboratory findings that in selected pediatric patients, combined with the FAST exam results, were sensitive and specific in detecting intra-abdominal injuries that correlated with CT scan results.Methods: This was a retrospective chart review of all trauma patients aged 0-17 years who were evaluated at an academic American College of Surgeons (ACS) verified Level 1 Adult and Pediatric Trauma center between January 1, 2015 and December 31, 2015. Inclusion criteria were: 1) complaint of blunt abdominal trauma; 2) a FAST exam and an abdominal CT scan performed; and 3) lab diagnostics completed. The included laboratory diagnostics were: blood count, liver function tests and lipase. After reviewing 302 patient records, 133 were included in the final analysis. We reviewed the literature and determined the history, physical exam and cutoff laboratory results to be used in the final analysis. The sensitivity, specificity, PPV and NPV of the FAST exam alone and in combination with the predetermined diagnostic criteria were calculated and the results were analyzed for correlation with CT scan results then reported using the phi-coefficient of correlation.Results: The FAST exam for detecting intra-abdominal injury in our selected patients had a sensitivity of 2.6% (95% CI: 0.7-8.5), a specificity of 97.2% (95% CI: 91.4-99.3), a PPV of 33.3% (95% CI: 1.76%-87.5%), and a NPV of 64.4% (95% CI: 54.4%-73.4%). The FAST exam, combined with our clinical criteria for detecting intra-abdominal injuries in our selected patients, had a sensitivity of 86.2% (95% CI: 67.4%-95.5%), a specificity of 96.4% (95% CI: 79.7%-99.8%), a PPV of 96.2% (95% CI: 78.4%-99.8%), and a NPV of 87.1% (95% CI: 65.2%-95.8%). When combined with the clinical criteria, the FAST exam correlated with the CT scan results (F¼ +0.83; p<0.0001), while the FAST exam alone did not (F¼ -0.01; p¼1).Conclusions: When combined with clinical findings, the FAST exam was sensitive and specific for detecting intra-abdominal injuries in select pediatric patients and correlated with abdominal CT scan findings. These results may be used to guide further imaging decisions in the assessment of pediatric blunt abdominal trauma.

Screening tools to identify patients with unmet palliative care needs in the emergency department: A systematic review

“…Patients with unmet PC needs who received a PC consultation postdischarge was reported to be 5%, 28 6%, 31 11%, 37,38 and 29% 12 in five studies. Five studies 23,25,26,36,46 applied an intervention with the objective of promoting PC consultations and reported that a range between 32% and 47% of patients with unmet PC needs received a PC consultation in the ED or hospital 23,25,26,46 . One of the intervention studies reported that 90% of patients with unmet PC needs received a referral to PC post‐discharge; however, only 43% of the patients attended the PC consultation 36 …”

“…Unlike many of the other screening tools, the original SPEED tool does not have prespecified criteria for a patient to be considered to have “unmet PC needs,” but, rather, aims to assist physicians identify specific needs of the patient. Two studies utilized a modified five‐item version of the SPEED instrument, which includes five questions regarding difficulties in pain management, home care, medication management, psychological support, and goals of care 23,46 . The items of the five‐item SPEED tool are scored on a Likert scale, however, the threshold score for each domain to identify a patient with unmet PC needs was not reported 23,46 .…”

“…with the objective of promoting PC consultations and reported that a range between 32% and 47% of patients with unmet PC needs received a PC consultation in the ED or hospital. 23,25,26,46 One of the intervention studies reported that 90% of patients with unmet PC needs received a referral to PC post-discharge; however, only 43% of the patients attended the PC consultation. 36…”

“…Alternatively, the median proportion of patients with unmet PC needs discharged from the ED was 23% (IQR 14%-28%). 12,16,19,20,23,25,29,38,39,45,46…”

“…Two studies utilized a modified five-item version of the SPEED instrument, which includes five questions regarding difficulties in pain management, home care, medication management, psychological support, and goals of care. 23,46 The items of the five-item SPEED tool are scored on a Likert scale, however, the threshold score for each domain to identify a patient with unmet PC needs was not reported. 23,46 Three studies applied the SPEED instrument on patients with active cancer 23,43,46 while one study only screened patients with end-stage heart failure.…”