1380 Correspondence / American Journal of Emergency Medicine 37 (2019) 1362-1393

come equipped or are retrofitted with the most current safety equipment since rollover deaths have been documented since the 1920s [7]. Finally, training and information for ED doctors, first re- sponders, and other care givers about the hazards and possible out- comes of tractor injuries, especially in Rural healthcare systems, could lead to faster Response times and more comprehensive care [7].

Daniel Vryhof¹ Todd Chassee¹ Matt Singh¹

Spectrum Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI, United States

Helen DeVos Children’s Hospital, Grand Rapids, MI, United States

Lindsey Ouellette²

Helen DeVos Children’s Hospital, Grand Rapids, MI, United States

Jeffrey Jones* Spectrum Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI, United States

Michigan State University College of Human Medicine, Department of Emergency Medicine, Grand Rapids, MI, United States

*Corresponding author at: 15 Michigan St NE Suite 701, Grand Rapids,

MI 49503, United States of America.

E-mail address: [email protected].

13 November 2018

https://doi.org/10.1016/j.ajem.2018.12.035

References

1. Jawa RS, Young DH, Stothert JC, et al. Farm machinery injuries: the 15-year experi- ence at an urban joint trauma center system in rural state. J Agromedicine 2013;18: 98-106.
2. Swanton AR, Young TL, Leinenkugel K, et al. Nonfatal tractor-related injuries present- ing to a state trauma system. J Safety Res 2015;53:97-102.
3. Jennissen C, Mathiasen R. An introduction to traumatic injuries and environmental

   hazards on the farm: part I tractors - what the heck is a PTO? J Rural Emerg Med 2015;2(1):12-25.

   Michigan State University College of Human Medicine, Occupational and Environmental Medicine. Work related fatalities. http://www.oem.msu.edu/index. php/work-related-injuries/work-related-fatalities. [accessed 17 October 2018].

4. National Farm Worker Ministry. Children in the fields. http://nfwm.org/resources/ children-in-the-fields/. [accessed 22 October 2018].
5. United States Department of Labor. Occupational Safety and Health Administration. https://www.osha.gov/about.html. [accessed 4 December 2018].
6. Myers JR, Hendricks KJ. Agricultural tractor overturn deaths: assessment of trends and risk factors. Am J Ind Med 2010;53:662-72.

   Refining reflex urine culture testing in the ED

   Screening for urinary tract infections is often performed by uri- nalysis (UA) which measures specific urine elements such as ni- trites, white blood cells , and Leukocyte esterase (LE). In our Emergency Department (ED), a positive UA, defined as positive nitrite, or N3 WBC, or positive LE, will automatically generate a urine culture to identify and quantify bacteriuria for specimens or- dered as a UA with reflex to culture. Our institution’s policy is that antibiotic treatment will be provided for patients with urine cul- ture results yielding 60,000 colony-forming units (cfu) per millili- ter (ml). Culture results of >=60,000 cfu per ml are reviewed by an ED physician to determine the course of action and treatment. Al- though treatment is based on chart review, there is inclination to treat positive UA and culture results >=60,000 cfu per ml. The Infec- tious Disease Society of America states there is no measureable benefit to screen for asymptomatic bacteriuria for most adults

   N18 years of age, unless atypical symptoms or patient characteris- tics are present [1-4].

   UA with reflex to culture is a common laboratory order that was initially designed to reduce the number of urine cultures and anti- biotic treatment for patients with negative UA results [5-7]. How- ever, reflexing specimens to urine culture based on positive UA does not include indications for UTI in the reflex algorithm [8,9]. Urine cultures ordered without clinical indication can lead to inap- propriate Antimicrobial treatment [10-14]. It is recommended that EDs examine automatic reflexes to culture based on UA results [15].

   In an urban tertiary care hospital in Illinois, USA from January 2016-December 2016, 23,722 UA specimens from the ED were or- dered as a UA with reflex to culture. Of the 23,722 specimens, 8721 were cultured, 2701/8721 (31%) were positive, defined as bacteri- uria >=60,000 cfu per mL or positive for yeast, and 6020/8721 (69%) were negative, defined as no growth or non-diagnostic growth (b60,000 cfu per ml).

   This project was approved by the local institutional review board as non-human subjects research. Through cause mapping, the project team discovered that 1) the high number of negative urine cultures was linked to UA with reflex to culture being ordered without an indica- tion, 2) UA with reflex to culture was pre-checked in several ED order sets, and 3) reflex to culture thresholds were less sensitive compared to other institutions. Additionally, not all physicians were clear on guidelines of when it was appropriate to order a UA with reflex to cul- ture in the ED.

   Based on completion of an impact to effort matrix and failure modes and effects analysis, the project team decided to update the ED abdominal pain and psychiatric pre-checked order sets, which had the highest negative urine culture rate, from pre- checked UA with reflex to culture to pre-checked UA, with urine culture available but unchecked. Education on when to screen for and treat a UTI, based on Infectious Disease Society of America guidelines, was provided at Emergency Medicine department meetings to ED attending physicians, administration and leader- ship, and midlevel providers [1-4]. A hardcopy of the information was given to attendees and an email was sent to all ED providers. The reflex to culture threshold was changed from N3 WBC to N4 WBC. UA specimens positive for nitrite or LE continued to reflex to urine culture. By incorporating the changes into the process of ordering urine cultures, the team believed the results would be sustainable long-term.

   Data was analyzed 5 months pre- and post-intervention. All statistics were performed in Minitab Statistical Software Version

   18.1. A p-value of b0.05 was considered significant. The number of UA with reflex to culture orders per day was reduced from 92 or- ders per day to 49 orders per day (mean) post-intervention (t-test, p b 0.001) (Fig. 1A). The number of UA orders per day without re- flex was significantly increased from 3 orders per day to 41 orders per day (median) post-intervention (Mann-Whitney U Test, p b 0.001) (Fig. 1B). The number of negative urine cultures per day was significantly reduced from 13 cultures per day to 6 cultures per day (median), a 54% reduction in negative urine cultures post-intervention with an estimated cost savings of $71,350 per year based on direct costs of urine cultures (Mann-Whitney U Test, p b 0.001) (Fig. 2).

   ED patient volumes remained stable throughout the pre- and post- intervention time periods. There were no significant changes in the num- ber of 72-hour returns to the ED and 30-day readmissions with diagnosis of UTI, sepsis, bacteremia, or pyelonephritis post-intervention (Fig. 3A-B). Providing education on when it is appropriate to screen for and treat a UTI, updating pre-checked order sets, and increasing reflex to culture thresholds led to a decreased number of negative urine cultures, reducing the high cost of quality waste from inappropriate urine culture testing in the ED. There is substantial opportunity for decreasing costs and

   Correspondence / American Journal of Emergency Medicine 37 (2019) 1362-1393 1381

   

   Fig. 1. Following education and updating the pre-checked order sets, the number of urinalysis with reflex to culture orders per day was significantly reduced (t-test, p b 0.001) (A) and the number of urinalysis orders per day was significantly increased (Mann-Whitney U test, p b 0.001) (B).

   

   Fig. 2. Following education, updating pre-checked order sets, and increasing the urinalysis with reflex to culture threshold, the number of negative urine cultures was significantly reduced (Mann-Whitney U Test, p b 0.001).

   improving Antimicrobial stewardship by addressing automatically reflexing UA results to culture.

   Declarations of interest

   None.

   Cassie Jaeger, PhD* Paul Sullivan, MS, MT(ASCP) Lindsey Petersen, RN

   Casey Coultas, RN

   Memorial Health System, Springfield, IL, USA

   *Corresponding author at: Memorial Medical Center, 701 North First

   Street, Springfield, IL 62781, USA. E-mail address: [email protected], [email protected], [email protected], [email protected]

   James Waymack, MD Shreya Lankala, MD David Griffen, MD, PhD

   Division of Emergency Medicine, Department of Surgery, Southern Illinois

   University School of Medicine, Springfield, IL, USA E-mail address: [email protected], [email protected],

   [email protected]

   14 December 2018

   https://doi.org/10.1016/j.ajem.2018.12.037

   References

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   1382 Correspondence / American Journal of Emergency Medicine 37 (2019) 1362-1393

   

   Fig. 3. The number of 72-hour Emergency Department returns per week (A) (Mann-Whitney U test, p = 0.915) and 30-day readmissions per week (B) (t-test, p = 0.694) with diagnosis of urinary tract infection , sepsis, bacteremia, or pyelonephritis was not significantly altered post-intervention.

   Hooton TM, Gupta K. Acute simple cystitis in women. In: Bloom A, editor. Waltham, Mass.: UpToDateUpToDate; 2018https://www.uptodate.com/contents/acute- simple-cystitis-in-women, Accessed date: 20 December 2018.

7. Hooton T. Acute simple cystitis in men. In: Bloom A, editor. Waltham, Mass.: UpToDate; 2018https://www.uptodate.com/contents/acute-simple-cystitis-in-men, Accessed date: 20 December 2018.
8. Hooton TM, Gupta K. Acute complicated urinary tract infection (including pyelone- phritis) in adults. In: Bloom A, editor. UpToDate. Waltham, Mass.: UpToDate; 2018https://www.uptodate.com/contents/acute-complicated-urinary-tract- infection-including-pyelonephritis-in-adults, Accessed date: 20 December 2018.
9. Humphries RM, Bard JD. Point-counterpoint: reflex cultures reduce laboratory work- load and improve antimicrobial stewardship in patients suspected of having urinary tract infections. J Clin Microbiol 2016;54:254-8 Available from: https://www.ncbi. nlm.nih.gov/pmc/articles/PMC4733168/. (26659213).
10. Jones CW, Culbreath KD, Mehrotra A, Gilligan PH. Reflect urine culture cancellation in the emergency department. J Emerg Med 2014;46:71-6 Available from: https:// www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0- S0736467913009992.pdf?locale=en_US. (24140018).
11. Fok C, Fitzgerald MP, Turk T, Mueller E, Dalaza L, Schreckenberger P. Reflex testing of male urine specimens misses few positive cultures may reduce unnecessary testing of normal specimens. Urology 2010;75:74-6 Available from: https://www. clinicalkey.com/service/content/pdf/watermarked/1-s2.0-S0090429509025278. pdf?locale=en_US. (19914703).
12. Yin P, Kiss A, Leis JA. Urinalysis orders among patients admitted to the general med- icine service. JAMA Intern Med 2015;175:1711-3 Available from: https:// jamanetwork.com/journals/jamainternalmedicine/fullarticle/2429104. (26280990).
13. Pallin DJ, Ronan C, Montazeri K, Wai K, Gold A, Parmar S, et al. Urinalysis in acute care of adults: pitfalls in testing and interpreting results. Open Forum Infect Dis 2014;23 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324184/. (25734092).
14. Leis JA, Gold WL, Daneman N, Shojania K, McGeer A. Downstream impact of urine cultures ordered without indication at two acute care teaching hospitals. Infect Con- trol Hosp Epidemiol 2013;34:1113-4 (24018932).
15. Lee MJ, Kim M, Kim NH, Kim CJ, Song KH, Choe PG, et al. Why is asymptomatic bac-

    teriuria overtreated?: a tertiary care institutional survey of resident physicians. BMC Infect Dis 2015;15:289 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4514993/. (26209977).

    Lin E, Bhusal Y, Horwitz D, Shelburne SA, Trautner BW. Overtreatment of enterococ- cal bacteriuria. Arch Intern Med 2012;172:33-8 Available from: https:// jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108639. (22232145).

16. Trautner B, Cope M, Cevallos M, Cadle R, Darouiche R, Musher D. Inappropriate treat- ment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital. Clin Infect Dis 2009;48:1182-8 Available from: https://academic.oup.com/cid/article/48/ 9/1182/407035. (19292664).
17. Silver SA, Baillie L, Simor AE. Positive urine cultures: a major cause of inappropriate antimicrobial use in hospitals? Can J Infect Dis Med Microbiol 2009;20:107-11 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807252/. (21119801).
18. Schulz L, Hoffman RJ, Pothof J, Fox B. Top ten myths regarding the diagnosis and treatment of urinary tract infections. J Emerg Med 2016;51:25-30 Available from: https://www.clinicalkey.com/#!/content/playContent/1-s2.0- S0736467916001220?returnurl=null&referrer=null. (27066953).

    Emergency department visits for chemical substance-related injuries

    The increasing use of chemicals worldwide has led to an increase in the incidence of chemical accidents [1]. acute exposure to chemicals can be fatal and usually necessitates emergency treatment [2,3]. Although large- and small-scale chemical accidents frequently occur [4], studies on human injuries from chemical exposure are limited, including the population who are usually exposed to harmful chemicals. Hence, this study aimed to analyze the types and characteristics of chemical injuries by analyzing patients who visited university hospitals due to acute ex- posure to chemical substances.

    This study enrolled patients unintentionally injured by acute expo- sure to chemical substances among those who visited the emergency departments of Soonchunhyang University Gumi Hospital and Ulsan University Hospital in South Korea between January 2007 and Decem- ber 2016. Both Gumi and Ulsan have high distribution of chemical use and high density of industrial complexes. Medical records were retro- spectively reviewed to collect data on sex, age, body areas exposed to the chemical, exposure mechanisms, diagnosis, disposition, and kinds and types of the chemical substances.

    A total of 828 patients were included in the cohort. Of these, 708 (85.5%) were men, and 120 (14.5%) were women. The mean patient