Prescription Pattern Analysis for Patients with abdominal pain in Emergency Department Using Clinical Pathway Assistant Program A Mi Shin 1, Myong Hwa Park 2, Hyo Chan Jeon 1, Hee Joon Park 3 Won Hyun Cho, M.D. 4, Yoon Nyun Kim, M.D. 3 Health Care Information and Technology Center 1, College of Nursing 2, Keimyung University, Daegu, Korea Department of Medical Informatics 3, Department of Surgery 4, Keimyung University School of Medicine, Daegu, Korea Abstract : Key Words :
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4 Fig. 1. Result of processing of patients with abdominal pain in Emergency Department. Fig. 2. Analysis of admission diagnosis patients with abdominal pain in Emergency Department. Fig. 3. Analysis of the causes of abdominal pain in the digestive system.
5 Table 1. Frequency of initial clinical processing for diagnosis of patient with abdominal pain in Emergency Department (n=1,648) Category Assessment Test Treatment Activity Intervention Vital sign CBC & diff. count * Routine urinalysis(random urine) PT aptt Serum electrolytes (Na +, K +, Cl ) Routine test for admission Amylase Lipase ECG Chest (PA) Abdomen (erect, supine) IV # start Ambulation 1,551 (94.1) 1,557 (94.4) 1,544 (94.2) 1,549 (93.9) 1,548 (93.9) 1,564 (94.9) 1,540 (93.4) 1,464 (88.8) 1,443 (87.5) 1,518 (92.1) 1,564 (94.9) 1,319 (80.0) 1,589 (96.4) 1,539 (93.3) * Common blood cell count & differential count; Prothrombin time; Activated partial thromboplastin time; Electrocardiography; Simple chest radiography; Simple abdominal radiography; # Intravenous.
6 Table 2. Analysis of doctor s orders according to diagnosis Category Intervention Cholangitis Cholecystitis Pancreatitis Stomach Ca *. Assessment Vital sign 43 (100) 103 (100) 35 (97.2) 32 (94.1) Test Blood typing & screen (ABO, Rh, Ab screen) Cross matching Blood gas analysis CRP GT Ammonia CKMB (serum) Troponin I CK LDH Ca 2+ ionized (ph 7.4) ESR # PB smear ** Fibrinogen CA 199 (EIA ) CEA (EIA) Fetoprotein AntiHBs (EIA) HBs Ag (EIA) AntiHBc ##, total (EIA) AntiHCV *** (EIA) AntiHAV (IgM ) (EIA) AntiHBc (IgM) (EIA) Antimycoplasma Iron TIBC BUN (serum) Creatinine (serum) Na + (urine) Creatinine (urine) AFB stain (urine) Gram stain (urine) Legionella Ag test (urine, random) S.pneumoniae Ag test (urine, random) Legionella Ag test (urine, catheter) S. pneumoniae Ag test (urine, catheter) AFB stain (sputum) Gram stain (sputum) Antibiotics sensitivity (urine) Antibiotics sensitivity (sputum) Antibiotics sensitivity (blood) 12 (27.9) 12 (27.9) 17 (39.5) 33 (76.7) 12 (27.9) 10 (23.2) 9 (20.9) 9 (20.9) 8 (18.6) 8 (18.6) 15 (34.8) 32 (74.4) 32 (74.4) 31 (72.0) 24 (55.8) 15 (34.8) 23 (53.4) 19 (44.1) 19 (44.1) 18 (41.8) 18 (41.8) 16 (37.2) 8 (18.6) 5 (11.6) 5 (11.6) 8 (18.6) 71 (68.9) 71 (68.9) 44 (42.7) 39 (37.8) 22 (21.3) 17 (16.5) 31 (30.0) 31 (30.0) 27 (26.2) 27 (26.2) 18 (17.4) 36 (34.9) 30 (29.1) 30 (29.1) 24 (23.3) 20 (19.4) 19 (18.4) 19 (18.4) 19 (18.4) 15 (14.5) 16 (15.5) 14 (13.5) 13 (12.6) 41 (39.8) 15 (41.6) 15 (41.6) 13 (36.1) 19 (52.7) 8 (22.2) 4 (11.1) 4 (11.1) 4 (11.1) 5 (13.8) 9 (25.0) 19 (52.7) 18 (50.0) 18 (50.0) 16 (44.4) 13 (36.1) 15 (41.6) 13 (36.1) 13 (36.1) 12 (33.3) 13 (36.1) 11 (30.5) 5 (13.8) 8 (22.2) 4 (11.1) 19 (52.7) 12 (35.2) 12 (35.2) 12 (35.2) 9 (26.4) 5 (14.7) 6 (17.6) 6 (17.6) 6 (17.6) 5 (14.7) 6 (17.6) 10 (29.4) 8 (23.5) 12 (35.2) 9 (26.4) 6 (17.6) 7 (20.5) 6 (17.6) 6 (17.6) 5 (14.7) 5 (14.7) 9 (26.4)
7 Table 2. Analysis of doctor's orders according to diagnosis I (continued) Category Intervention Cholangitis Cholecystitis Pancreatitis Stomach Ca *. Test Treatment Medication Activity Simple abdomen (supine) CT ###, dynamic (abdomen & pelvic) CT, dynamic (abdomen) Fluid 0.9% N/S 1 5% D/S 1 NG tube **** ECG monitoring (electrode) ERCP ERCP & EST & stone remove Isepacin Ceftriaxon Triaxone Ceradoran Pacetin Amikin Epocelin Ranitidin Pantoloc Pethidine Dicknol Liveract Algiron Trizele Ursa Ulcermin Ciprofloxacin Foy Futhan NovolinR Macperan Mvh Thiamine Absolute bed rest 24 (55.8) 8 (18.6) 20 (46.5) 12 (27.9) 8 (18.6) 21 (48.8) 14 (32.5) 10 (23.2) 8 (18.6) 21 (48.8) 19 (44.1) 16 (37.2) 13 (30.2) 7 (16.2) 9 (20.9) 7 (16.2) 5 (11.6) 6 (13.9) 5 (11.6) 43 (100) 67 (65.0) 11 (10.6) 57 (55.3) 30 (29.1) 19 (18.4) 12 (11.6) 41 (39.8) 32 (31.0) 65 (63.1) 29 (28.1) 13 (12.6) 18 (17.4) 15 (14.5) 29 (28.1) 12 (11.6) 103 (100) 17 (47.2) 7 (19.4) 19 (52.7) 8 (22.2) 8 (22.2) 18 (50.0) 17 (47.2) 12 (33.3) 8 (22.2) 22 (61.1) 5 (13.8) 35 (97.2) 5 (14.7) 12 (35.2) 13 (38.2) 7 (20.5) 5 (14.7) 5 (14.7) 11 (32.3) 8 (23.5) 32 (94.1) Initial treatment was removed from data. Cholangitis n=43, Cholecystitis n=103, Pancreatitis n=36, Stomach Ca. n=34. * Cancer; Creactive protein; Gamma glutamyl transferase; Creatine kinase MB fraction; Creatine kinase; Lactate dehydrogenase; # Erythrocyte sedimentation rate; ** Peripheral blood smear; Carbohydrate antigen 199; Enzyme immunoassay; Carcinoembryonic antigen; Antibody to hepatitis B surface antigen; Hepatitis Bsantigen; ## Antibody to hepatitis B core antigen; *** Antibodies against hepatitis C virus; Antibodies to hepatitis A virus; Immunoglobulin M; Total ironbinding capacity; Blood urea nitrogen; Acid fast bacilli stain; ### Computed tomography; **** Nasogastric tube; Electrocardiography; Eendoscopic retrograde cholangiopancreatography; Endoscopic sphincterectomy.
8 Table 3. Analysis of doctor's orders according to diagnosis II Category Intervention Appendicitis Intestinal obstruction CAPD * peritonitis Discharge Assessment Vital Sign 186 (98.4) 53 (100) 40 (95.2) 450 (85.3) Test Blood typing & screen 164 (86.7) 46 (86.7) 26 (61.9) 179 (33.9) (ABO, Rh, Ab screen) Cross matching 164 (86.7) 46 (86.7) 26 (61.9) 179 (33.9) CKMB (serum) 20 (10.5) 7 (13.2) 17 (40.4) Troponin I 20 (10.5) 7 (13.2) 17 (40.4) CK 6 (11.3) 16 (38.0) LDH 6 (11.3) 16 (38.0) CRP 31 (16.4) 19 (45.2) ESR 19 (10.0) 19 (45.2) Fibrinogen 19 (45.2) PB smear # 19 (45.2) HCG ** (quantitative) 43 (22.7) Blood gas analysis 7 (13.2) 38 (90.4) 110 (20.8) BUN (serum) 16 (38.0) Creatinine (serum) 16 (38.0) ALT 12 (28.5) AST 12 (28.5) Bilirubin, total (serum) 12 (28.5) Glucose (serum) 12 (28.5) Creatinine (urine) 37 (88.0) Na + (urine) 37 (88.0) Antibiotics sensitivity (blood) 22 (11.6) Gram stain (other, body fluid) 28 (66.6) KOH mount (other, body fluid) 25 (59.5) Cell & diff. count (dialysis fluid) 35 (83.3) AFB stain ## (other, body fluid) 28 (66.6) Antibiotics sensitivity (blood, site: dalysis) 21 (50.0) Antibiotics sensitivity 15 (35.7) (acitic, site; dialysis; CAPD) Antibiotics sensitivity (scitic, site: dialys) 9 (21.4)
9 Table 3. Analysis of doctor's orders according to diagnosis II (continued) Category Intervention Appendicitis Intestinal obstruction CAPD peritonitis Discharge Test Treatment Medication Activity Anaerobic culture (ascitic, site: dialysis) Fungal culture (ascitic, site: dialysis) Abdomen (KUB *** ) Abdomen (Lat Right) CT, dynamic (abdomen & pelvic) US (abdomen, others) Fluid 5% D/S 1 L 0.9% N/S 50 ml Peritoneal dialysis Kgambrosol trio Perisis 1.5% Fleet enema Isepacin Refosporen Gentamicin Ceftriaxon Ampibactam Amikin Epocelin Ranitidin TRIZELE Tabinul Ceradoran Heparin Pethidine Absolute Bed Rest Ambulation 129 (68.2) 39 (20.6) 131 (69.3) 88 (46.5) 22 (11.6) 20 (10.5) 20 (10.5) 102 (53.9) 34 (17.9) 111 (58.7) 53 (28.0) 56 (29.6) 185 (97.8) 42 (79.2) 7 (13.2) 7 (13.2) 6 (11.3) 31 (58.4) 52 (98.1) 20 (47.6) 20 (47.6) 36 (85.7) 14 (33.3) 6 (14.2) 8 (19.0) 20 (47.6) 16 (38.0) 12 (28.5) 30 (71.4) 31 (73.8) 31 (73.8) 7 (16.6) 40 (95.2) 150 (28.4) 58 (11.0) 101 (19.1) 446 (84.6) Initial treatment was removed from data. Appendicitis n=189, Intestinal obstruction n=53, CAPD peritonitis n=42, Discharge n=527. * Continuous ambulatory peritoneal dialysis; Creatine kinase MB fraction; Creatine kinase; Lactate dehydrogenase; Creactive protein; Erythrocyte sedimentation rate; # Peripheral blood smear; ** Human chorionic gonadotropin; Blood urea nitrogen; Alanine transaminase; Aspartate transaminase; Potassium hydroxide mount; Differential count; ## Acid fast bacilli stain; *** Kidney, ureter & bladder; Computed tomography; Ultrasonography.
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11 Table 4. Initial clinical pathway for patients with abdominal pain in Emergency Department Category Intervention Assessment Test Treatment Activity Explanation Vital sign History taking Site of pain onset / site of pain at present / radiation of pain Pain (Constant /Intermittent), severity (Moderate /Severe), previous similar pain (Yes /No), duration of pain, progression of pain (Better /Same /Worse) Aggravating factors (Movement /Coughing /Respiration /Food /Other /None) Reliving factors (Lying still /Vomiting /Antacids /Food /Others /None) Nausea /vomiting /anorexia /indigestion /jaundice (Yes /No) Bowels (Normal /Constipation /Diarrhea /Blood /Mucus) Micturition (Normal /Frequency /Dysuria /Dark /Hematuria) Drugs for abdominal pain (Yes /No), on medications (Antibiotics /Steroids /Others), CAD * (Yes /No), previous abdominal surgery (Yes/ No) PMH of: cancer /diverticulosis /pancreatitis /kidney failure /gallstones, other significant PMH (Yes/ No) Female: pregnant (Yes /No), vaginal. discharge (Yes /No), dizzy/faint (Yes /No) Physical Examination Degree of pain (Low 12345678910 High) Mood (Normal /Upset /Anxious) Color (Normal /Pale /Flushed /Jaundice /Cyanosis), Scars (Yes /No) Rebound (Yes /No), guarding (Yes /No), rigidity (Yes /No), mass (Yes /No) Murphy's sign present (Yes /No) Bowel sounds (Normal /Absent /Increased) Intestinal movement (Normal /Poor/ Nil /Peristalsis) Rectalvaginal tenderness (Left /Right /General /Mass /None) Location of tenderness CBC & diff. count, Routine urinalysis (random urine), Serum electrolytes (Na +, K +, Cl ), Routine test for admission, Amylase, ECG, Chest (PA), Abdomen (erect, supine) IV # start Bed rest Orientation about general treatment in emergency department Clinical pathway of patient with abdominal pain * Coronary artery disease; Past medical history; Common blood cell count & differential count; Electrocardiography; Simple chest radiography; Simple abdominal radiography; # Intravenous.
12 Table 5. Clinical pathway according to diagnosis for patients with abdominal pain in Emergency Department Appendicitis Cholangitis Cholecystitis Intestinal obstruction Pancreatitis Stomach cancer CAPD * peritonitis Discharge Assessment Vital sign Vital sign Vital sign Vital sign Vital sign Vital sign Vital sign Vital sign Test Treatment Review about initial test results hcg (quantitative) CT, dynamic: abdomen & pelvic US : abdomen & others Review about initial test results Anti HBs (EIA ) HBs Ag # (EIA) CT, dynamic: abdomen & pelvic ERCP ERCP & EST ## & stone remove Review about initial test results CT, dynamic: abdomen & pelvic Review about initial test results Blood typing & screen (ABO, Rh, Ab screen) Review about initial test results CT, dynamic: abdomen & pelvic NG tube *** insertion Review about initial test results CT, dynamic: abdomen & pelvic Review about initial Review about test results initial test BUN ** /creatinine results (serum) ALT /AST Bilirubin, total (serum) Cell & diff. count (dialysis fluid) Abdomen: KUB CT, dynamic: abdomen & pelvic Peritoneal dialysis Medication Ceftriaxon Ceftriaxon Foy Ranitidin Pethidine NovolinR Ranitidin Ceradoran Amikin Heparin Activity Bed Rest Bed Rest ABR Bed Rest ABR Bed Rest ABR Ambulation Diet NPO NPO NPO NPO NPO NPO NPO Explanation *Continuous ambulatory peritoneal dialysis; Human chorionic gonadotropin; Computed tomography; Ultrasonography; Antibody to hepatitis B surface antigen; Enzyme immunoassay; # Hepatitis Bsantigen; ** Blood urea nitrogen; ALanine transaminase; ASpartate transaminase; Differential count; Kidney, ureter & bladder; Eendoscopic retrograde cholangiopancreatography; ## Endoscopic sphincterectomy; *** Nasogastric tube; Absolute bed rest; Nothing by mouth.
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