Analysis of Patients With Ventricular Assist Devices Presenting to an Urban Emergency Department

Ryan P. McKillip, MD; Anand Gopalsami, MD; Magdeline Montoya, MD; Gene Kim, MD; James J. Walter, MD; Colleen Juricek, MS; Eric Shappell, MD MHPE

Disclosures

Western J Emerg Med. 2018;19(6):907-911. 

In This Article

Methods

Study Design

This was a retrospective chart review of ED visits made by patients with LVADs during a five-year period (July 1, 2009 – June 30, 2014). The institutional review board approved the study protocol and waived informed consent requirements.

Study Setting and Population

The study site was an urban, academic medical center with approximately 60,000 annual adult ED visits. The institution's heart failure service maintains a database of all patients who have received LVADs at the institution. We queried a health record database for ED encounters by all 349 patients who had LVADs during the study period. Encounters that occurred prior to a patient's LVAD placement or after heart transplant were excluded.

Study Protocol and Measurements

Abstraction of the chart data used a combined deductive and inductive process. Data extracted for each encounter included patient demographics, chief complaint, evaluation, diagnostic testing, interventions, final ED ICD-9 diagnoses, and disposition. Two physician authors (ES, AG) reviewed 45 randomly selected encounters to develop presentation categories: device-specific; bleeding (e.g. gastrointestinal [GI], epistaxis); infection (e.g. bacteremia, driveline infection); heart failure exacerbation; arrhythmia; anemia; pain (chest, abdominal, or other); neurologic; dehydration; musculoskeletal; pulmonary; GI (non-bleeding); venous-access related; or other (including endocrine, renal, rheumatologic, oncologic, dermatologic, or psychiatric presentations).

We subcategorized device-specific presentations as abnormal device readings/alarms, grossly damaged equipment, or non-specific complaints. Bleeding and driveline infections, while related to having an LVAD due to requisite anticoagulation and percutaneous wiring, respectively, were not categorized as device-specific. Presentation categories were determined after review of the entire chart and were not mutually exclusive (e.g., a patient presenting with dyspnea who is diagnosed with a heart failure exacerbation from pump thrombosis would be categorized as both "heart failure exacerbation" and "device-specific: non-specific complaint").

The abstractors used the 14 a priori presentation categories and three subcategories to sort the remaining encounters. Conflicting or ambiguous chart elements were discussed between abstractors until consensus interpretation was reached. Interrater percent agreement on 10 random charts was calculated (satisfactory agreement ≥90%). As a secondary analysis, we studied outcomes in bounce-back encounters (defined as a second ED visit within seven days of discharge).

Data Analysis

We analyzed data to calculate the frequency of, and reason for, presentation to the ED by patients with LVADs. A detailed review of device-specific encounters was performed to better understand the disposition and interventions in these patients. We compared categorical and continuous data using chi-squared and single-tailed unpaired t-testing, respectively.

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