as compressible or realistic. Although life-span was not specifically examined in this study, our models were stored in a refrigerator and were unchanged 3 months later.

5/8-in. Penrose drains were used in this experiment to replicate the ap- proximate size of the popliteal vein. One inch is also a standard size of Penrose drains, which could be used to replicate the common femoral vein, another important area of venous confluence and potential thrombus formation.

Because DVT is a common and potentially life-threatening disease

entity, EM physicians may benefit from a reliable and affordable Training model to ensure quality ultrasound education. Ballistic gelatin phantoms represent one such way of simulating sonographic DVT pathology.

Michael Doctor, MD Patrick Olivieri, MD Sebastian D Siadecki, MD

Gabriel Rose, DO Aaran Drake, MD Turandot Saul, MD?

Department of Emergency Medicine, Mount Sinai St. Luke’s Mount Sinai

West, New York, NY

*Corresponding author at: Emergency Department, Mount Sinai St. Luke’s Mount Sinai West, 1000 10th Avenue, Room GE-01, New York,

NY 10019. Tel.: +1 212 523 3981

fax: +1 212 523 8000

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.10.016

References

1. Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a Public health concern. Am J Prev Med 2010;38(4 Suppl.):S495-501.
2. Jolly BT, Massarin E, Pigman EC. Color Doppler ultrasonography by emergency physicians for the diagnosis of acute deep venous thrombosis. Acad Emerg Med Off J Soc Acad Emerg Med 1997;4(2):129-32.
3. Blaivas M, Lambert MJ, Harwood RA, Wood JP, Konicki J. Lower-extremity Doppler for deep venous thrombosis-can emergency physicians be accurate and fast? Acad Emerg Med Off J Soc Acad Emerg Med 2000;7(2):120-6.
4. Magazzini S, Vanni S, Toccafondi S, Paladini B, Zanobetti M, Giannazzo G, et al. Duplex ultrasound in the emergency department for the diagnostic management of clinically suspected deep vein thrombosis. Acad Emerg Med Off J Soc Acad Emerg Med 2007;14(3):216-20.
5. Burnside PR, Brown MD, Kline JA. Systematic review of emergency physician- performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med Off J Soc Acad Emerg Med 2008;15(6):493-8.
6. Theodoro D, Blaivas M, Duggal S, Snyder G, Lucas M. Real-time B-mode ultrasound in the ED saves time in the diagnosis of Deep vein thrombosis . Am J Emerg Med 2004;22(3):197-200.
7. Soucy ZP, Mills L, Rose JS, Kelley K, Ramirez F, Kuppermann N. Creation of a high-fidelity, low-cost pediatric Skull fracture ultrasound phantom. J Ultrasound Med 2015;34(8):1473-8.
8. Richardson C, Bernard S, Dinh VA. A cost-effective, gelatin-based phantom model for learning ultrasound-guided fine-Needle aspiration procedures of the head and neck. J Ultrasound Med 2015;34(8):1479-84.
9. Jafri F, Runde D, Saul T, Lewiss RE. An inexpensive and easy Simulation model of ocular ultrasound that mimics normal anatomy as well as abnormal ophthalmologic conditions. J Ultrasound Med 2011;30(4):569-73.
10. Heiner JD. A new simulation model for skin abscess identification and management. Simul Healthc 2010;5(4):238-41.
11. Amini R, Kartchner JZ, Stolz LA, Biffar D, Hamilton AJ, Adhikari S. A novel and inexpensive ballistic gel phantom for ultrasound training. World J Emerg Med 2015;6(3):225-8.
12. Kendall JL, Faragher JP. Ultrasound-guided central venous access: a homemade phantom for simulation. CJEM 2007;9:371-3.

    Impact of the educational program on outcomes among patients with sepsis hospitalized from the ED

    

    To the Editor,

    Sepsis is a common disease contributing to significant mortality. Strategies including blood cultures before antibiotic therapy, early

    appropriate antibiotic therapy, early goal-directed therapy, acute respi- ratory distress syndrome and lung protective protocols, targeted blood glucose control, and use of corticosteroid have been recommended for mortality reduction in patients with sepsis [1,2]. However, compliance with these sepsis care bundles was generally poor in much of Asian countries [3]. Educational programs have been demonstrated to im- prove compliance with these care bundles and survival among patients with severe sepsis and septic shock [4,5]. Nonetheless, the benefits of such educational programs in patients with nonsevere sepsis have not been previously evaluated.

    A quasi-experimental study was conducted among patients hospi- talized with nonsevere sepsis from the emergency department of a tertiary care center in central Thailand. The preintervention period was from July 1, 2012 to June 30, 2013, followed by the period of imple- mentation of an educational program and hospital-wide sepsis guide- lines (July 1, 2013 to December 31, 2013) and the postintervention

    period (January 1, 2014 to December 31, 2014). This study was ap- proved by Faculty of Medicine, Thammasat University Ethics Commit- tee. Inclusion criteria included all adult patients (age >=18 years) who were diagnosed as having sepsis but not severe sepsis or septic shock [1] and admitted to non-intensive care unit (ICU) internal medicine wards from the emergency department. Exclusion criteria were patients who had already received antibiotic therapy before the onset of sepsis, those whom the onset of sepsis could not be deter- mined, and those who could not be followed up for the primary outcome assessment. Antibiotic therapy was judged as appropriate ac- cording to an Infectious diseases specialist. The hospital-wide sepsis guidelines based on the international sepsis guidelines [1] were imple- mented on July 1, 2013. During the 6-month intervention period, an ed- ucation program consisting of training of health care workers (HCWs) on the sepsis guidelines, diagnosis and management of sepsis, and em- pirical antibiotic therapy via monthly didactic sessions by an infectious diseases specialist was implemented. Evaluation of care process was performed monthly, and feedback was provided to HCWs via monthly notification letter.

    The final cohorts consisted of 156 and 157 patients in the

    preintervention and postintervention periods (Fig. 1). Characteristics of both cohorts are shown in Table 1. The 30-day mortality rate was lower in the postintervention cohort but did not reach the significant level (20% vs 24%) (Table 2). In the survival analysis, there was no signif- icant difference in survival between the 2 cohorts (Fig. 2). Characteris- tics of patients who died and survived at 30 days were compared in Table 3. Independent factors associated with 30-day mortality were ad- mission to high-workload wards (adjusted odds ratio, 2.96; 95% confidence interval, 1.59-5.51; P = .001) and length of hospital stay (adjusted odds ratio, 1.02; 95% confidence interval, 1.01-1.04; P =

    .004 for each day longer). Compliance with sepsis care process in both cohorts is shown in Table 2. After the study interventions, the rate of performing culture before antibiotic administration significantly in- creased (96% vs 90%), and the duration from the diagnosis of sepsis to performing culture was significantly shorter (45 vs 115 minutes). There was a trend toward significance that the rate of glucose control was better (66% vs 56%).

    Our study findings suggest that implementing the educational pro- gram along with hospital-wide sepsis guidelines did not significantly re- duce the mortality among patients with nonsevere sepsis. This finding was different from previous reports showing Mortality benefits of edu- cational programs among patients with severe sepsis and septic shock [4-6]. The nonsignificant mortality reduction in our study may be ex- plained by the lower baseline mortality rate of nonsevere sepsis com- pared with those of severe sepsis and septic shock. With the same magnitude of benefit, the reduction may not reach statistical signifi- cance. In addition, the effect size of the educational program and guide- lines implementation may not be as large as we estimated. Lastly, compliance with some of the sepsis care processes did not significantly change after the interventions.

    

    Fig. 1. Study flow of the study patients.

    Table 1

    Demographic and clinical characteristics of the study patients

    Characteristics	Preintervention cohort (N = 156)	Postintervention cohort (N = 157)	P
    Age, y (mean [SD])	70 (17)	67 (18)	.10
    Male sex	88 (56)	74 (47)	.11
    comorbid diseases
    Hypertension	79 (51)	67 (43)	.18
    Dyslipidemia	43 (28)	27 (17)	.03
    Diabetes mellitus	30 (19)	42 (27)	.47
    Neoplasm	25 (16)	30 (19)	.56
    COPD	16 (10)	17 (11)	1.00
    CKD stage III-V	10 (6)	22 (14)	.04
    Chronic liver disease	5 (3)	10 (6)	.30
    Coronary artery disease	1 (1)	0 (0)	.50
    Source of infection			.60
    Respiratory tract	67 (43)	70 (45)
    Urinary tract	45 (29)	36 (23)
    Gastrointestinal tract and abdomen	10 (6)	14 (9)
    Skin and soft tissue	4 (3)	8 (5)
    Bone and joint	2 (1)	1 (1)
    Central nervous system	1 (1)	2 (1)
    Catheter-associated bacteremia	0 (0)	2 (1)
    Multiple source	1 (1)	2 (1)
    Unknown	26 (17)	22 (14)
    Time of sepsis diagnosis			.91
    Weekday (8.00 AM-4.00 PM)	49 (31)	52 (33)
    Weekday (4.00 PM-8.00 AM)	54 (35)	55 (35)
    Weekends	53 (34)	50 (32)
    Physician who diagnosed and treated sepsis			.80
    Intern	22 (14)	24 (15)
    Resident (first year)	45 (29)	38 (24)
    Resident (second year)	61 (39)	65 (41)
    Resident (third year)	21 (14)	24 (15)
    Fellow	0 (0)	1 (1)
    Attending Admission warda	7 (5)	5 (3)	.61
    High-workload wards	75 (48)	80 (51)
    Low-workload wards	81 (52)	77 (49)

    Note: Data are in number (%), unless otherwise indicated.

    Abbreviations: CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease.

    ^a High-workload wards were defined as wards that had patient-to-nurse ratio of greater than or equal to 4:1, whereas low-workload wards were wards with less than 4:1 patient-to- nurse ratio.

    Table 2

    Outcomes and sepsis care processes of the study patients

    Characteristics	Preintervention cohort (N = 156)	Postintervention cohort (N = 157)	P
    Outcomes
    30-d mortality	38 (24)	31 (20)	.34
    Length of hospital stay, d (mean [SD])	18 (14)	19 (19)	.68
    ICU admission	22 (14)	17 (11)	.38
    Sepsis care process
    Performing culture before antibiotic administration	140 (90)	150 (96)	.05
    Time from sepsis diagnosis to performing culture, min (mean [SD])	115 (493)	45 (196)	.01
    Appropriate antibiotic therapy	152 (97)	153 (98)	1.00
    Antibiotic administration within 1 h of sepsis diagnosis	73 (47)	77 (49)	.69
    Antibiotic administration within 3 h of sepsis diagnosis	116 (74)	110 (70)	.45
    Antibiotic administration within 6 h of sepsis diagnosis	139 (89)	135 (86)	.49
    Time from sepsis diagnosis to antibiotic administration, min (mean [SD])	182 (309)	208 (327)	.44
    Glucose controla	88 (56)	104 (66)	.07

    Note: Data are in number (%), unless otherwise indicated.

    ^a Defined as the ability to control patients‘ blood glucose less than or equal to 180 mg/dL during periodic monitoring until sepsis had resolved.

    Table 3

    Characteristics and sepsis care processes of all study patients stratified by mortality outcome

    Characteristics	Died at 30 d	Survived at	P
    	(N = 69)	30 d (N = 244)
    Age, y (mean [SD])	72 (16)	67 (18)	.06
    Male sex	30 (44)	121 (50)	.41
    Comorbid diseases
    Hypertension	34 (49)	112 (46)	.62
    Dyslipidemia	15 (22)	55 (23)	.89
    Diabetes mellitus	15 (22)	57 (23)	.78
    Neoplasm	15 (22)	40 (16)	.30
    COPD	4 (6)	29 (12)	.14
    CKD stage III-V	2 (3)	30 (12)	.02
    Chronic liver disease	3 (4)	12 (5)	.85
    Coronary artery disease	0 (0)	1 (0.4)	.60
    Source of infection			.57
    Respiratory tract	36 (52)	101 (41)
    Urinary tract	17 (25)	64 (26)
    Gastrointestinal tract and abdomen	6 (9)	18 (7)
    Skin and soft tissue	3 (4)	9 (4)
    Bone and joint	0 (0)	3 (1)
    Central nervous system	1 (2)	2 (1)
    Catheter-associated bacteremia	0 (0)	2 (1)
    Multiple source	0 (0)	3 (1)
    Unknown	6 (9)	42 (17)
    Time of sepsis diagnosis			.27
    Weekday (8.00 AM-4.00 PM)	27 (39)	74 (30)
    Weekday (4.00 PM -8.00 AM)	19 (28)	90 (37)
    Weekends	23 (33)	80 (33)
    Physician who diagnosed and treated sepsis .37
    Intern	7 (10)	39 (16)
    Resident (first year)	22 (28)	61 (25)
    Resident (second year)	26 (38)	100 (41)
    Resident (third year)	9 (13)	36 (15)
    Fellow	0 (0)	1 (0.4)

    Fig. 2. Probability of survival of patients with nonsevere sepsis in the preintervention and postintervention cohorts.

    We observed significant improvement in performing culture before antibiotic administration, time from diagnosis to culture, and glucose control after the interventions. These results suggest that our interven- tions can improve compliance with sepsis care processes by overcoming the knowledge barriers among HCWs and having impact on translating evidence and guidelines into practice [7]. The association between ad- mission to high-workload wards and mortality may be due to the less intensity of care provided to patients in high-workload wards [8] or the propensity that patients with more severe diseases are hospital- ized in high-workload wards. The increase in length of hospital stay may represent patients’ more severe diseases and contribute to risks for Nosocomial infections and adverse events associated with mortality. Feedback and assessment of actual change in compliance

    Attending 5 (7) 7 (3)

    dmission warda .003
    High-workload wards	45 (65)	110 (45)
    Low-workload wards	24 (35)	134 (55)

    A

    with all sepsis care processes in an individual HCW are needed along	Sepsis care process
    with Close monitoring of patients at risk for mortality to improve the	Performing culture before antibiotic administration	62 (90)	228 (93)	.31
    sepsis outcomes.	Time from sepsis diagnosis to performing	100 (330)	75 (320)	.62

    culture, min (mean [SD])

    Appropriate antibiotic therapy	66 (96)	239 (98)	.29
    Time from sepsis diagnosis to antibiotic	201 (78)	193 (169)	.85
    administration, min (mean [SD])
    Glucose control	38 (55)	154 (63)	.23
    Outcomes
    Length of hospital stay, d (mean [SD])	24 (24)	17 (13)	.02
    ICU admission	12 (17)	27 (11)	.18

    Thana Khawcharoenporn, MD, MSc Division of Infectious Diseases, Faculty of Medicine Thammasat University, Pathumthani 12120, Thailand Corresponding author at: Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand Tel.: +66 81 836 5576; fax: +66 2 926 9793

    E-mail address: [email protected]

    Note: Data are in number (%), unless otherwise indicated.

    ^a High-workload wards were defined as wards that had patient-to-nurse ratio of greater than or equal to 4:1, whereas low-workload wards were wards with less than 4:1 patient-to-nurse ratio.

    Ariya Konsantad, MD

    Department of Internal Medicine, Faculty of Medicine, Thammasat

    University, Pathumthani 12120, Thailand

    http://dx.doi.org/10.1016/j.ajem.2016.10.017

    References

    Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296-327.

13. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sep- sis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637.
14. Phua J, Koh Y, Du B, Tang YQ, Divatia JV, Tan CC, et al. Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study. BMJ 2011;342:d 3245.
15. Ferrer R, Artigas A, Levy MM, Blanco J, Gonzalez-Diaz G, Garnacho-Montero J, et al. Improvement in process of care and outcome after a multicenter severe sepsis educa- tional program in Spain. JAMA 2008;299:2294-303.
16. Girardis M, Rinaldi L, Donno L, Marietta M, Codeluppi M, Marchegiano P, et al. Effects on man- agement and outcome of severe sepsis and septic shock patients admitted to the intensive care unit after implementation of a sepsis program: a pilot study. Crit Care 2009;13:R143.
17. Chen Y, Chang S, Pu C, Tang G. The impact of nationwide education program on clin- ical practice in sepsis care and mortality of severe sepsis: a population-based study in Taiwan. PLoS One 2013;8:e77414.
18. Rubenfeld GD. Translating clinical research into clinical practice in the intensive care unit: the central role of respiratory care. Respir Care 2004;49:837-43.
19. Tucker J. Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK Neonatal intensive care units: a prospective eval- uation. Lancet 2002;359:99-107.

    Impact of language on prescription fill rates after discharge from a pediatric ED?,??, ?,??,???

    

    To the Editor,

    Successful discharge from a pediatric emergency department (PED) hinges on quality discharge communication. Yet, patients and care- givers frequently have deficient comprehension of diagnosis, treatment, and management at the time of discharge. Moreover, there is limited knowledge of specific interventions that result in clear improvement in this comprehension [1]. A caregiver’s comprehension of the medical treatment plan at the time of discharge enhances further medication ad- herence [2,3]. medication adherence is key to overall treatment of dis- ease, and improved adherence decreases return visits, need for hospital admission, and overall health care costs [4,5]. The first step to medication adherence is getting the prescription filled. Previous studies have identified prescription fill rates from PEDs of 44% to 98% [6-8]; yet, few studies included non-English speaking caregivers. It is known that Spanish-speaking families have increased barriers to quality discharge in- structions from the PED [1], and therefore be at higher risk for medication nonadherence. The goal of this study was to examine language-based dis- parities in prescription fill rates. A secondary goal was to explore the im- pact that written discharge instructions have on medication adherence.

    We performed a cross-sectional study of children 0 to 18 years old who presented to our tertiary PED and who were discharged with a di- agnosis likely to yield a prescription. Eligible patients were identified using International Classification of Disease, Ninth Revision codes that

    ? Authorship: All listed authors are responsible for the reported research, concept, and design; analysis and interpretation of data; drafting or revising the manuscript; and they have all approved the manuscript as submitted.

    ?? Financial disclosure: All authors have indicated that they have no financial relation-

    ships relevant to this article to disclose.

    ? Conflict of interest: All authors have indicated that they have no conflicts of interest

    to disclose.

    ?? Clinical Trial Registration: N/A.

    ??? Funding source: No external funding for this manuscript.

    are frequently associated with a prescription at the time of PED dis- charge, including diagnoses of Otitis media, urinary tract infection, pneumonia, cellulitis, abscess, streptococcal pharyngitis, lymphadenitis, and asthma. The PED visits during a 4-month time frame (January to July 2015) were reviewed. We then reviewed the electronic medical re- cord for each encounter to ascertain that a prescription had been pro- vided at the conclusion of the PED visit and to collect demographic data. All data were entered a dedicated RedCap database [9]. Records from this database were then used to conduct a phone survey in the caregiver’s self-identified Preferred language (English or Spanish). The survey included questions regarding whether the caregiver recalled being prescribed a medication. Additional questions pertained to timing of prescription filling, barriers to obtaining medications, and the degree to which discharge methods influenced their likelihood of filling the prescription. This study protocol was reviewed by our institutional re- view board and a waiver of written informed consent was provided. Caregivers provided verbal consent to complete the phone survey.

    We identified 854 potential patient encounters and 296 patient en- counters fulfilled inclusion criteria for complete electronic medical re- cord review. Among 296 eligible participants, 97 (32.8%) completed the phone survey. Demographics of the completed survey participants are detailed in Table. Among completed surveys, 57 (58.9%) were com- pleted by English-speaking caregivers and 40 (41.1%) by Spanish- speaking caregivers. In total, 91 (93.8%) participants report filling their prescription. Of the 6 participants who did not fill their prescription, 2 (3.5%) were English-speaking caregivers and 4 (10%) were Spanish- speaking (P = .19, Pearson ?²). They cited reasons for nonadherence in- cluding improved symptoms (n = 2), insurance concerns (n = 1), and prescription for a refill (n = 2, both SABA prescriptions). Logistical re- gression modeling was done to examine adjusted associations between demographic descriptors including patient’s age, preferred language, and insurance status with the outcome of prescription filling. There were no associations between these covariates and prescription filling. Participants were also surveyed on how long after the PED visit they filled their prescription. Thirty-nine percent of caregivers filled the pre- scription within 24 hours of PED visit, with 89% of prescriptions filled within 48 hours. Spanish-speaking caregivers were more likely to fill their prescription quickly when compared with the English-speaking

    caregivers (P = .023, Pearson ?²).

    Finally, comparison was made between caregiver’s preferred lan- guage and in what language discharge instructions from the PED visit were distributed. All English-speaking caregivers received instructions only in English. Of the 40 Spanish-speaking caregivers, 13 (33%) re- ceived discharge instructions only in English; the remaining 27 (66%)

    Table

    Demographic data

    Age, y (IQR)	6.0 (2.0-9.0)
    Race
    White	48 (50)
    African-American	19 (20)
    Asian	1 (1)
    American Indian	1 (1)
    Unknown	13 (13)
    Declined	15 (16)
    Ethnicity Non-Hispanic	45 (46)
    Hispanic	44 (45)
    Unknown	6 (6)
    Declined	2 (2)
    Sex

    Male 49 (51)

    Female 48 (49)

    Insurance status

    Commercial 14 (14)

    Government-funded 83 (86)

    Values are number (percentage).