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The Use of NHAMCS The Use of NHAMCS
Emergency Department Emergency Department ResearchResearch
Jim Edwards, BS.Jim Edwards, BS.Research AssociateResearch Associate
Department of Emergency MedicineDepartment of Emergency Medicine
University of Illinois
College of Medicine
Chicago, IL
ObjectivesObjectives
• Explain the NHAMCS database
• Implementation of database
• Recent publications
DescriptionDescription
• National Hospital Ambulatory Medical Care Survey
• Collect data on the utilization of services and provision of care in ED
DescriptionDescription•National sample•General and short stay hospitals
•No federal, military, or VA•50 states and D.C.•Began annually in 1992
DescriptionDescription
• Four stage sampling
–Geographically defined areas
–Hospitals within areas (~500)
–ED within hospitals (some > 1)
–Pt visits within ED (~24,000)
DescriptionDescription
• CDC personal train hospital staff on data collection
• Data on Patient Record Form during random 4 week recording period
Patient Record FormPatient Record Form
Data
DescriptionDescription
•Demographics
• Payment
•Complaints
•Diagnoses
• Imagining, labs, procedures
Data
DescriptionDescription•Meds
•Providers
•Reason for injury
•Wait time
Data
DescriptionDescription
•Pain
•Disposition
•Place of injury
•Hospital characteristics
• Initial V/S in 2002
CodingCoding
DescriptionDescription
• A Reason for Visit Classification (NCHS)
• ICD-9-CM
• Drug coding classification system (NCHS)
• National Drug Code Directory
SPSSSPSS
• Statistical program
• User friendly
• Handles more cases than Excel
SPSSSPSS
• Download data file
• Download documentation
• Merge files if needed
Joseph and Ward: New-Onset AF Joseph and Ward: New-Onset AF ResultsResults
• Conversion rate after 48 hrs– Sotalol 88%– Amiodarone 77%– Digoxin 58%– P < 0.05 when sotalol compared to digoxin
• Time to conversion SR– Sotalol 13.0 2.5– Amiodarone 18.1 2.9– Digoxin 26.9 3.4– P < 0.05 when sotalol and amiodarone compared to
digoxin
SPSSSPSS
• Imputed variables–Diagnosis
–Reason for visit
–Drugs
–Age ranges
SPSSSPSS
• Dummy variables–One or none
–Allows calculation of 2x2 tablesIV Narc
(1)No IV Narc
(0)
Admit
(1)
75
75%
5
5%
Discharged
(0)
5
5%
15
15%
Patient DemographicsPatient Demographics
CalculationsCalculations N ( %)
Sex
Male 264 (65)
Female 143 (35)
Age, y
Mean 41.5 ± 15.3
Median 40.0
<18 12 ( 3)
18-64 359 (88)
>65 36 ( 9)
Ethnicity
White 356 (88)
Black 38 ( 9)
Other 13 ( 3)
Patient DemographicsPatient Demographics
CalculationsCalculationsPain Level at Presentation
None 7 ( 2)
Mild 49 (12)
Moderate 102 (25)
Severe 102 (25)
Unknown 147 (36)
Mode of Arrival
Walk-in 348 (86)
Ambulance 36 ( 9)
Unknown 23 ( 6)
Patient DemographicsPatient Demographics
CalculationsCalculationsDiagnosis (n = 443)
Renal colic (788.0) 155 (35)
Calculus of the kidney (592.0) 188 (42)
Calculus of the ureter (592.1) 78 (18)
Unspecified urinary calculus (592.9) 6 ( 4)
Hydronephrosis (591.0) 6 ( 1)
Disposition
Admitted 59 (15)
ProceduresProcedures
CalculationsCalculations N ( %)
Diagnostic study 400 (98)
Other x-ray 132 (32)
CT 89 (22)
US 20 ( 5)
U/A 319 (78)
CBC 225 (55)
Procedure
Pain medication 346 (85)
IV fluids 251 (62)
Foley 12 ( 3)
MedicationsMedications
CalculationsCalculationsMedication Class N ( %)
Narcotic 277 (68)
Nonnarcotic 216 (53)
NSAID 191 (47)
Other nonnarcotic 25 ( 6)
Antiemetic 140 (34)
Narcotic and NSAID 139 (34)
Narcotic and other nonnarcotic 10 ( 2)
Narcotic and antiemetic 124 (31)
Nonnarcotic and antiemetic 80 ( 0)
MedicationsMedications
CalculationsCalculationsAgent N ( %)
Parenteral Agents
Narcotics
Meperidine 84 (21)
Morphine sulfate 59 (15)
Hydromorphone 37 ( 9)
Meperidine/Promethazine 11 ( 3)
Buprenorphine 6 ( 2)
Botorphanol tartrate 4 ( 1)
NSAIDs
Ketorolac 190 (47)
Anti-emetics
Promethazine 88 (22)
Prochlorperazine 32 ( 8)
Droperidol 11 ( 3)
Hydroxyzine 7 ( 2)
Metaclopramide 4 ( 1)
Odds Ratio/Pain MedicationOdds Ratio/Pain Medication
CalculationsCalculations N (%) OR 95% CI p-value
Ethnicity
White 306 (86) 1.7 0.76-3.68 0.23
Non-white 40 (79)
Age
<65 318 (86) 1.7 0.68-4.20 0.30
>65 53 (78)
Pain Severity
Severe 97 (95) 4.0 1.40-12.31 0.01
Moderate, mild, or none 131 (83)
Severe or moderate 185 (91) 2.9 1.26-6.85 0.01
Mild or none 43 (77)
Logistic Regression/Pain MedicationLogistic Regression/Pain Medication
CalculationsCalculations OR 95% CI p-value
Ethnicity
White 1.2 0.57-2.39 0.69
Age
<65 2.5 0.78-8.14 0.12
Pain Severity
Severe 2.6 0.88-7.81 0.08
Severe or moderate 2.2 0.91-5.29 0.08
AdvantagesAdvantages• No data collection needed
• IRB exemption
• Large number of cases
• Free
• Large sample
DisadvantagesDisadvantages
• Lack of information–Drug doses, route, meds before ED
–No pain relief measures
–No VS
–No lab or radiology results
Conclusions Conclusions • No data collection
• Can get lost in the database
• Having and knowing ALL the documentation is key
ConclusionsConclusions
• Lack of information
• Next year vital signs