MA; Massachusetts General Hospital, Boston, MA; Mount Sinai Hospital, New York, ... Jeanmonod R, Agresti D, Pester J, Hamden K, Jeanmonod D/St. Luke's.
Research Forum Abstracts
76
Implementation of a Tranexamic Acid Protocol in the Emergency Department
Geyer BC, Gates J, Lee J, Shah K, Raja AS/Brigham and Women’s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Mount Sinai Hospital, New York, NY
Study Objectives: Tranexamic Acid (TXA) has a demonstrated mortality benefit in patients presenting with acute traumatic hemorrhage, but is not widely adopted in U.S. emergency departments (EDs). Subsequent to making TXA available in our ED, we implemented a TXA protocol supported by simultaneous provider education, a resident journal club, and a computerized provider order entry template linked to the massive transfusion protocol (MTP) template. We then evaluated the use and appropriateness of TXA administration before and after protocol implementation, with the hypothesis that use would increase such that more than 50% of eligible patients would receive TXA. Methods: We performed a retrospective review of the first 50 patients receiving packed red blood cells (PRBCs) in the ED following TXA protocol implementation and compared them to a consecutive sample of the 50 patients who received PRBCs immediately prior to protocol implementation. Patients were considered eligible for TXA administration if they sustained a traumatic injury, presented within three hours of the injury, and required at least 4 units of PRBCs within the first hour of their treatment (a trigger for our MTP). Patients were also considered eligible if they received TXA independent of the MTP, as attending physician discretion was an indication for TXA in our protocol. Data were analyzed utilizing t-tests or Chi-squared tests for continuous and dichotomous variables, respectively. Results: Overall, 51% of the total population receiving PRBCs had traumatic injury, 35% of which was penetrating trauma. Following the implementation of the protocol, there was a significant increase in TXA administration for patients receiving PRBCs in the ED (0% vs. 28%, p 17 years, fluency in English, and hemodynamic stability. Patients’ perceptions of pain, embarrassment and anxiety were rated on a 100-point visual analog scale (VAS) where 0 ¼ no pain/embarrassment/ anxiety and 100 ¼ the worst pain/embarrassment/anxiety imaginable. Patients were surveyed before and after ultrasound(s). Based on a previous study, patients were informed using scripted text that the average additional time to receive a radiology ultrasound is 3 hours. Results are reported as means, medians, ranges, and standard deviation (SD) where appropriate. Paired t-tests were used. The study was approved by the Institutional Review Board. Results: Ninety-two women were enrolled with one lost form, resulting in 91 cases for analysis. Some patients left prior to completing post-TVU surveys resulting in less surveys than TVUs. Average patient age was 25.5 (SD 5.7), gravidity 3.1, parity 1.2. 60 patients (66%) presented with pain, and 31 (34%) with bleeding. Sixty-three patients (69%) had heard of TVU, and 49 (55%) had had a prior TVU. Prior to any ultrasound, the average anxiety regarding TVU was 32 (SD 30) on VAS. Women reported their source of anxiety as pain (35%), fetal well-being (22%), and embarrassment (11%). Thirty-five percent had no anxiety. Women stated they were willing to wait a median of 60 minutes in order to avoid an ED TVU that was repeated by radiology. Sixty-six women (73%) had no sex preference for their examiner; the rest preferred a female sonographer. Fifteen patients (16%) had an ED TVU only, 17 (19%) had a Rad TVU only, and 14 (15%) had both. Forty-five patients had TAU only performed. Of the 27 women who completed surveys after ED TVU, 23 (85%) would agree to another ED TVU under similar circumstances. 25 (93%) reported no change or more positive perception of TVU after the exam. One hundred percent of the women who had both an ED and Rad TVU felt that the ED TVU was worthwhile in order to potentially save a 3-hour wait. The average VAS pain score for women who had an ED TVU was 36 (SD 29) and embarrassment score was 20 (SD 25). Of those who had both ED and Rad TVU, the pain and embarrassment scores (ED TVU VAS score - Rad TVU VAS score) were not significantly different (D ¼ 11, p¼0.12; D ¼ 4, p¼0.5 respectively). Of those women who had an
Annals of Emergency Medicine S31
