Page 95 - JSOM Spring 2018

BJACH has approximately 23,000 visits per year. It is con- Eleven patients (10.7%) were admitted to the hospital. Of
sidered a Level 3 Army Emergency Medical Services ED that these, nine were discharged in less than 24 hours. Five of the
provides care mostly for active-duty personnel and dependents 11 patients were admitted because of rhabdomyolysis, with
with a small volume of retirees. It is a small community hospi- a CK level higher than 5,000U/L in all of them. One patient
tal in a very rural area. was admitted for acute kidney injury with a creatinine level of
2.0mg/dL. The remaining four patients had documented signs
This was a retrospective review of heat injuries brought to the of altered mental status (AMS) or dehydration. The two pa-
ED from 1 May 2014 through 30 September 2014. tients who stayed longer than 24 hours were both discharged
in less than 48 hours. Both of the patients who were admitted
Selection of Patients and kept in the hospital for longer than 24 hours were noted
Daily reports log all training-related injuries and are reported in the chart to have AMS during the ED visit.
to hospital command. Daily reports were reviewed for heat
injuries. All patients brought in from the field were included. Discussion
Patients were excluded if they were seen at another clinic be-
fore being brought to the ED or had laboratory studies done In this retrospective review of patients transferred from the
before arriving in the ED. This usually occurs when labora- field directly to the ED for heat injuries, we found low clini-
tory studies are ordered by providers at the Combined Troop cal yield to routine screening laboratory studies. Most labora-
Medical Clinic. tory studies did not result in a change in clinical management.
Very few studies appeared to have an actual effect on clinical
Outcome Measures management. Of the patients who were admitted, most were
Data were recorded by SGS on a standardized data collection discharged in less than 24 hours, which calls into question
spreadsheet using Microsoft Excel. The primary measure- whether the admission was required during the initial contact
ment was the occurrence of clinically significant abnormalities or perhaps outpatient management could have been used. The
found on screening laboratory studies. Clinically significant only patients who required admission longer than 24 hours
was defined as admission to the hospital as a result of the had AMS documented as a symptom during the ED encounter,
laboratory finding. Secondary measurements include admis- which indicates that symptom-based treatment plans may be a
sion and discharge rates. Laboratory study findings were con- better method to determine resource use.
sidered abnormal if outside of laboratory parameters. The
following laboratory studies were included: comprehensive There are several issues that must be considered when evalu-
metabolic panel or basic metabolic panel, complete blood cell ating the utility of laboratory studies with or without a clear
count, coagulation panel, urinalysis, and creatine kinase (CK). indication. First, there is significant cost to the healthcare sys-
tem that comes along with ordering laboratory studies. Al-
though it is common practice in many settings, there is cost to
Results
the Defense Healthcare Agency as a result of performing these
During the project, 147 daily command reports (96%) were studies. Second, there are significant measurable and immea-
available for the 5-month period. There were 104 Soldiers surable costs incurred during transportation of these patients.
brought to the ED directly from the field for evaluation. The At the Joint-Readiness Training Center, the austere training
average age was 24.6 years (range, 18–56 years) and 102 locations often used are remote and at a significant distance
(98%) were male. from the BJACH ED. Often, there is very limited road access,
making ground transportation difficult and sometimes unreli-
Laboratory studies were ordered for 101 of 104 patients. able. As such, AIREVAC frequently is used. This incurs the
Table 1 outlines the types and numbers of laboratory studies costs of flight crew time, the aircraft, and fuel. There is also
ordered and the rate of abnormalities. Select laboratory study inherent danger that comes with flying, with at least one he-
abnormalities will be outlined here. Creatinine measurements licopter wreck resulting during the project period (personal
were abnormal in 40 patients (mean, 1.61mg/dL; maximum, communication). This poses danger to the flight crew and
2.8mg/dL). Leukocytosis was present in 57% of CBC counts military equipment.
performed (mean percentage of leukocytes, 13.6%; maximum,
22.9%). An elevated CK level was present in 75% of those Given that the laboratory findings of most of the patients in
performed (mean, 1,163U/L; maximum, 15,627U/L). this study did not change clinical management, it may be rea-
sonable to infer that a visit to the ED is not necessary for all
Soldiers based on an arbitrarily chosen temperature cutoff.
TABLE 1 Outline of Abnormal Findings of Laboratory Tests Based
on Reference Ranges Rather, it may be reasonable for a symptom-based manage-
Tests With Patients ment method to be considered.
Total Abnormal Admitted to
Performed, No. Findings, No. Hospital, No. Limitations
Test (%) (%) (%) The retrospective design of this study limits the ability to un-
Comprehensive derstand the provider thought process and medical decision-
metabolic panel 101 (97) 73 (72) 1 (0.99) making that led to the decision to admit or discharge a patient.
Complete blood 93 (89) 53 (57) 0 (0) The limits in documentation restrict the ability to extract in-
cell count formation that may have been pertinent to the decision to ad-
Coagulation 19 (18) 7 (37) 0 (0) mit or discharge.
panel
Urinalysis 85 (82) 35 (41) 0 (0) Additionally, the charts were reviewed by SGS only, which
Creatine kinase 97 (93) 73 (75) 5 (5.2) may have led to errors in data collection. Although charts

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