Journal Reviews

Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Eng J Med 2000; 342:1163-1170.

Discharge of ED patients who present with acute myocardial infarction or unstable angina is associated with increased mortality, says this study from the Center for Cardiovascular Health Services Research at New England Medical Center in Boston.

The percentage of patients who present to the emergency department with acute myocardial infarction or unstable angina who are not hospitalized is low. Of 10,689 patients with chest pain or other symptoms suggesting acute cardiac ischemia, 17% ultimately met the criteria for acute cardiac ischemia. A significant number of these patients were mistakenly discharged from the ED, according to the study’s findings.

Here are key findings of the study:

• Of 889 patients with acute myocardial infarction, 19 (2.1%) were mistakenly discharged from the ED.

• Of 966 patients with unstable angina, 22 (2.3%) were mistakenly discharged.

Patients who presented to the ED with acute cardiac ischemia were more likely not to be hospitalized if they were women less than 55 years old, were nonwhite, reported shortness of breath as their chief symptom, or had a normal or nondiagnostic electrocardiogram.

Patients with acute infarction were more likely not to be hospitalized if they were nonwhite or had a normal or nondiagnostic electrocardiogram. Failure to hospitalize is related to race, sex, and the absence of typical features of cardiac ischemia, the researchers conclude. "Continued efforts to reduce the number of missed diagnoses are warranted," they write. 

Tanabe P, Buschmann M. Emergency nurses’ knowledge of pain management principles. J Emerg Nurs 2000; 26:299-305.

ED nurses may not have a good understanding of how to manage pain or addiction, according to this study from Northwestern Memorial Hospital in Chicago. Data were collected anonymously from 305 ED nurses. Here are several key findings:

• Nurses scored poorly on understanding of the terms "addiction," "tolerance," and "dependence."

• Nurses scored poorly on knowledge of pharmacologic analgesic principles.

• Nurses with a master’s degree or nurses who attended a 1-day seminar on pain management achieved higher scores.

It is important for ED nurses to increase their knowledge of analgesic agents and perform objective pain assessments for all ED patients, the researchers say. "By doing so, emergency nurses will improve their ability to be valuable patient advocates," they write.

The researchers recommend the following:

• creating policies for pain management of difficult patients, such as known narcotic addicts;

• educating nurses about various analgesics given on a daily basis, including morphine, hydromorphone hydrochloride, fentanyl, and various oral and intravenous nonsteroidal anti-inflammatory drugs;

• working with the department of surgery to develop of protocols to treat patients with abdominal pain;

• educating nurses about non-pharmacologic interventions, such as use of ice, positioning, and various distraction methods. 

Dart RC, Goldfrank LR, Chyka, PA, et al. Combined evidence-based literature analysis and consensus guidelines for stocking of emergency antidotes in the United States. Ann Emerg Med 2000; 36:126-132.

Guidelines should be used for ED stockpiling of antidotes, according to this study that was supported by the United States Health Resource Services Administration and the American Association of Poison Control Centers, both based in Washington, DC. The guidelines were developed by presenting evidence-based medicine to a consensus panel. The panel recommended that 16 of the 20 antidotes under consideration be stocked in hospitals that accept emergency patients.

The researchers recommend the following:

• Consider your hospital’s unique needs. For example, if the hospital is in an agricultural region, you likely would want to maintain higher stocks of atropine and pralixomine for the treatment of organophosphate insecticide poisoning.

• When developing policies and procedures, obtain input from emergency physicians, critical care physicians, and regional poison control centers.

• Don’t depend on obtaining antidotes from neighboring facilities. It might be difficult to transfer antidotes quickly.

• Develop a chart listing antidotes and their location within your hospital.

• Designate a special area in the pharmacy specifically for the stocking of antidotes.

• Create a poisoning cart, similar to a code cart.

• Ensure that the location of antidotes, as well as the amount of each antidote stocked, is known and immediately accessible to all hospital personnel providing patient care.

The researchers caution that the guidelines should not be viewed as absolute rules. "Antidote use will change as new toxins are discovered, antidotes receive more study, and medical practice evolves," they write.