@article{c10aa2b5d3a4451fac31e5f7cb197d7c,
title = "CLEARED (Chemicals and Litmus testing with Effective Alkaline Range for Eye Damage): A Prospective, Interventional Study",
abstract = "Objectives: While immediate diagnosis and irrigation is standard chemical eye burn practice, it is unknown to what extent specific pH measurements influence management, given the frequent clinical availability of narrow-spectrum nitrazine pH strips. We hypothesize that exclusive broad-spectrum pH strip implementation leads to more accurate measurement and expedited ophthalmologic consultation. Methods: At a Level I trauma center over 25 months, all emergent adult ophthalmology consultations for chemical burns were included in a pre-intervention (n = 22) and post-intervention (n = 20) study design. During this time, narrow-spectrum nitrazine pH strips available to non-obstetric emergency department (ED) staff were exclusively replaced by broad-spectrum strips. Causative chemical, time from triage to ophthalmology consultation, examination findings, ocular pH by ED and ophthalmology staff, and irrigation quantity were analyzed. Results: Most burns were alkaline. Time from triage (p = 0.043) and irrigation quantity following consultation (p = 0.047) each decreased following exclusive ED implementation of broad-spectrum pH strips. There was greater pH congruence between consulting and primary physicians after intervention (p = 0.03). Conclusions: Exclusive non-obstetric implementation of broad-spectrum pH strips may allow greater accuracy and faster management of ocular chemical burns. Availability of narrow-spectrum pH strips may be dangerous clinically by falsely reassuring the examiner with inherent inaccuracy.",
author = "Breazzano, {Mark P.} and Day, {H. Russell} and Sarah Tanaka and Uyen Tran",
note = "Funding Information: This study was supported by donation from the Vanderbilt Eye Institute's Lefkovitz Discovery Grant (MPB) and an unrestricted departmental grant from Research to Prevent Blindness (Vanderbilt Eye Institute). Institutional review board approval and Health Insurance Portability and Accountability Act compliance were satisfied for pre- and postinterventional investigation at the adult hospital of an academic Level I trauma center. On approximately October 1, 2016, all narrow-spectrum (pH 4.5–7.5) nitrazine strips (pHizatest, Micro Essential Laboratory) were replaced exclusively by broad-spectrum (pH 1–14) strips (Hydrion, Micro Essential Laboratory), for the adult ED (Figure); nitrazine strips were still immediately available as needed for obstetrics only. Consulted ophthalmologists continued to use Hydrion broad-spectrum pH strips (pH 1–14) supplied by their own department. Aside from informing ED and consultation administrators of the one change with pH testing equipment by necessity, no additional intervention such as in-service education module highlighting the change or emphasizing the emergent nature of chemical eye burns to clinical staff was made within the emergency or ophthalmology departments. All emergent adult ophthalmology consultations for chemical ocular burns were identified and grouped into a pre-intervention cohort (between October 1, 2015, and September 30, 2016) and post-intervention cohort (October 1, 2016, to October 31, 2017) study design. Cases were cumulatively gathered using regularly performed search queries of all adult ophthalmology consultations for “chemical burn” within the trauma center's in-house electronic medical record system during the entire duration of the study, both before and after intervention. Collection data were obtained for each case using standard ophthalmology consultation and ED physician history and physical forms. Timing information was gathered using immediately recorded time stamps in the same medical record system that are automatic for both ED triage (when the ED physician was made first aware of the patient) and placement of ophthalmology consultation (when the ophthalmologist was made first aware of the patient); timing of first contact between the patient and each physician was not performed. Physicians and other staff were unaware that collection of data regarding each case were being gathered. A minimum two of three different investigators (MPB, HRD, and ST) independently reviewed and verified the data for each case without any discrepancies. This study only included cases of chemical eye burns where an ophthalmologist was consulted. Causative chemical agent classification, age, sex, laterality, time interval from ED triage to ophthalmology consultation, irrigation management per eye before and after consultation, ocular surface pH values obtained by consulting ED staff and consulted ophthalmologists, visual acuity (VA) in logMAR ([logarithm of the minimum angle of resolution] given recent studied advantages over Snellen; briefly, 20/20 Snellen is equivalent to 0.00 logMAR, and a lower logMAR value represents a superior VA), and ophthalmologic examination findings (including corneal epithelial defect [KED] and limbal ischemia) both at consultation and at last follow-up were recorded. KED and limbal ischemia were recorded and converted from clock hours or diametric values to percentages, based on approximate normal adult corneal diameter of 12 mm, by using standard area formula calculation. Statistical analyses were performed with simple t-test, Fisher's exact test, and Pearson's chi-square test when appropriate. This study was supported by donation from the Vanderbilt Eye Institute's Lefkovitz Discovery Grant (MPB) and an unrestricted departmental grant from Research to Prevent Blindness (Vanderbilt Eye Institute). Funding Information: This study was supported by donation from the Vanderbilt Eye Institute{\textquoteright}s Lefkovitz Discovery Grant (MPB) and an unrestricted departmental grant from Research to Prevent Blindness (Vanderbilt Eye Institute). Publisher Copyright: {\textcopyright} 2018 by the Society for Academic Emergency Medicine",
year = "2019",
month = jul,
doi = "10.1111/acem.13622",
language = "English (US)",
volume = "26",
pages = "796--802",
journal = "Academic Emergency Medicine",
issn = "1069-6563",
publisher = "Wiley-Blackwell",
number = "7",
}