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Supplement to
Annals of Emergency Medicine
An International Journal
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 
 
ACEP RESEARCH FORUM
October 5-6, 2009
Boston Convention and Exhibition Center
Hall B2
Boston, MA
3A
19A
S1
S4
Schedule of Presentations
Index of Presenters
Oral Presentations
Poster Presentations
www.annemergmed.com
SEPTEMBER 2009
VOLUME 54 NUMBER 3
Supplement to
Annals of Emergency Medicine
Journal of the
American College of
Emergency Physicians
ACEP
RESEARCH
FORUM
October 5-6, 2009
Boston Convention and Exhibition Center
Hall B2
Boston, MA
Annals of Emergency Medicine is owned by
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Emergency Medicine, the American College
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2009 Research Committee/Research Forum Steering
Subcommittee
Charles B. Cairns, MD, FACEP, Research Committee Chair
Debra E. Houry, MD, MPH, Research Forum Co-Director;
Research Committee/Research Forum Subcommittee Chair
Brian J. O’Neil, MD, FACEP, Research Forum Co-Director
Steven B. Bird, MD, FACEP
Deborah B. Diercks, MD, FACEP
2009 Research Forum Abstract Reviewers
Vikhyat S. Bebarta, MD
Michelle Blanda, MD, FACEP
Keith Borg, MD, PhD
Edward Boyer, MD, PhD
Carlos Camargo, Jr, MD, DrPH
Brendan Carr, MD
Shu B. Chan, MD, MS, FACEP
D. Mark Courtney, MD, FACEP
Francis M. Fesmire, MD, FACEP
Michelle Garcia, MD, FACEP
Robert T. Gerhardt, MD, MPH, FACEP
Seth W. Glickman, MD
Edward C. Jauch, MD, FACEP
Alan E. Jones, MD, FACEP
Amy H. Kaji, MD, MPH, PhD
Phillip D. Levy, MD, FACEP
Roger J. Lewis, MD, PhD, FACEP
Matthew Lyon, MD, FACEP
Lawrence A. Melniker, MD, MS, FACEP
David Morgan, MD, FACEP
James E. Olson, PhD
Peter R. Panagos, MD, FACEP
Jesse H. Pines, MD, MDA
Eileen C. Quintana, MD, FACEP
Maria R. Ramos Fernandez, MD
Michael Roshon, MD, PhD, FACEP
Luis A. Serrano, MD
Anand Shah, MD
Adam J. Singer, MD, FACEP
Jonathon M. Sullivan, MD, PhD
Richard L. Summers, MD
Selim Suner, MD, FACEP
RESEARCH FORUM EDUCATIONAL PROGRAM 2009
MONDAY, OCTOBER 5, 2009
MONDAY, OCTOBER 5, 2009
1:00 - 1:30 PM
State of the Art Presentation
8:00 - 9:00 AM
Poster Session 1
Administration
Cardiology—Judd E. Hollander, MD, FACEP—
Room TBA, Boston Exhibition and Convention Center
9
Does a Clinical Productivity Incentive Plan Work for Emergency
Medicine Faculty?
Richerson PJ, Texas A&M University Health Science Center,
Temple, TX
1:30 - 2:30 PM
Oral Presentations
10
Does a Team Triage Service Affect Patient Satisfaction in an Urban
Academic Emergency Department?
Saef SH, Medical University of South Carolina, Charleston,
SC
11
Impact of Triage Physician and Clinical Operation Management
Consultant Implementation on Emergency Department
Throughput at a Tertiary Care Center
AlDarrab A, King Faisal Specialist Hospital & Research
Center, Riyadh, Saudi Arabia
12
When the Emergency Department Is Packed Can Physician
Assistants Pick Up the Pace? An Analysis of Physician Assistant
Productivity Related to Patient Volume
Brook C, Albany Medical College, Albany, NY
13
Utilizing Time-Driven Activity-Based Costing in the Emergency
Department
Bank DE, Phoenix Children’s Hospital, Phoenix, AZ
14ⴱ
An Analysis of Emergency Department Flow, Severity and
Congestion Factors That Are Associated With Decreases in the Left
Without Being Seen Rate
Sattarian M, George Washington University, Washington, DC
15
Satisfaction of Emergency Department Hallway Patients
Stiffler KA, Summa Health System/NEOUCOMP, Akron, OH
16†
Emergency Department Consultation Practices and Documentation
Vary Widely Across Hospitals
Schuur J, Brigham and Women’s Hospital, Boston, MA
17
Emergency Department Rapid Assessment Unit at the Cambridge
Hospital: Why and How?
Lobon LF, The Cambridge Hospital/Cambridge Health
Alliance, Cambridge, MA
Cardiology—Moderator: Judd E. Hollander, MD, FACEP—
Room TBA, Boston Exhibition and Convention Center
1ⴱ
†
A Clinical Prediction Model to Estimate Risk for 30-Day Adverse
Events in Emergency Department Patients With Symptomatic Atrial
Fibrillation
Barrett TW, Vanderbilt University Medical Center, Nashville,
TN
2
Early Objective Identification of Chest Pain Patients at Very Low
Risk of 30-Day Adverse Outcomes
Peacock W, The Cleveland Clinic, Cleveland, OH
3
Quality of Care for Acute Myocardial Infarction in 58 US
Emergency Departments
Tsai C, Massachusetts General Hospital, Harvard Medical
School, Boston, MA
4
The Impact of a Statewide ST-segment Myocardial Infarction
Regionalization Program on Treatment Times for Women,
Minorities, and Elderly Patients at Hospitals Without Percutaneous
Coronary Intervention Capability
Glickman S, University of North Carolina, Chapel Hill, NC
TUESDAY, OCTOBER 6, 2009
8:00 - 8:30 AM
State of the Art Presentation
Infectious Diseases—Gregory J. Moran, MD, FACEP—
Room TBA, Boston Exhibition and Convention Center
Cardiology
8:30 - 9:30 AM
Oral Presentations
Infectious Diseases—Moderator: Gregory J. Moran, MD,
FACEP—Room TBA, Boston Exhibition and Convention
Center
18
Fibrinolytics for Acute Myocardial Infarction in Emergency
Departments
Niska RW, Centers for Disease Control, Hyattsville, MD
19
Prescription of Non-Steroid Anti-Inflammatory Drugs in
Emergency Department Patients With Acute Coronary Syndrome/
Myocardial Infarction
Zito JA, Stony Brook University, Stony Brook, NY
5
Mass Screening of Children During a Pandemic Influenza Drill
Fertel BS, University of Cincinnati, Cincinnati, OH
20†
Can Point-of-Care Assays Deliver Lab Quality Accuracy?
Peacock W, The Cleveland Clinic, Cleveland, OH
6ⴱ
Effect of Hyperlactatemia on the Likelihood of In-Patient Mortality
for Patients With a Normal and Abnormal Anion Gap
Green J, New York Hospital Medical Center of Queens,
Flushing, NY
21
Oral Anticoagulation Quality Index as a Predictor for Bleeding
Pazin-Filho A, Medical School of Ribeirao Preto - University
of Sao Paulo, Ribeirao Preto, Brazil
22
Error in Body Weight Estimation Leads to Inadequate Parenteral
Anticoagulation
Pazin-Filho A, Medical School of Ribeirao Preto - University
of Sao Paulo, Ribeirao Preto, Brazil
23
Typical Angina Is Not Predictive of the Presence of Inducible
Cardiac Ischemia in Emergency Department Chest Pain Patients
Hermann LK, Mt Sinai School of Medicine, New York, NY
7
How Reliable Is Urinalysis to Predict Urinary Tract Infections?
Waseem M, Lincoln Hospital, Bronx, NY
8EMF
The Effect of Etomidate on Hospital Length of Stay of Patients
With Sepsis: A Prospective, Randomized Study
Tekwani K, Advocate Christ Medical Center, Oak Lawn, IL
Volume , .  : September 
Annals of Emergency Medicine 3A
Research Forum Educational Program 2009
MONDAY, OCTOBER 5—cont’d
24
Initiating Medical Therapies in the Cardiac Catheterization Lab
Decreases Door-To-Balloon Time for Acute ST Elevation
Myocardial Infarction
Bastani A, William Beaumont Hospital, Troy, MI
39
25
Additional Diagnostic Utility of Upright T-Wave in V1 and TWave V1 Vs. T-Wave in V6 in Differentiating Acute Anterior STSegment Elevation Myocardial Infarction From Benign Early
Repolarization
Smith SW, Hennepin County Medical Center, Minneapolis,
MN
Pain Management
26
When “Good” Is Below Average
Kiefer CS, Mayo Clinic, Rochester, MN
27
An Assessment of Resident Training in Emergency Department
Administration
Farley HL, Christiana Care Health Systems, Newark, DE
40
Comparison of Analgesic Practices in Pregnant and Non-Pregnant
Emergency Department Patients
Bloch RB, Maine Medical Center, Portland, ME
41†
A Qualitative Study Assessing the Information Needed to Manage
Adults in the Emergency Department With Sickle Cell Disease
Tanabe P, Northwestern University, Chicago, IL
42†
The Emergency Department Pain Experience for Adults With Sickle
Cell Disease
Tanabe P, Northwestern University, Chicago, IL
43
How Does Use of a Statewide Prescription Monitoring Program
Affect Emergency Department Prescribing Behaviors?
Sinha S, University of Toledo College of Medicine, Toledo,
OH
44
Risk Factors for Delayed Analgesia in Patients Presenting to the
Emergency Department With Long Bone Fractures
Mejia J, New York Hospital Queens, Flushing, NY
45
A Clinical Study to Evaluate the Efficacy of 4% Liposomal
Lidocaine as Compared to Placebo for Pain Reduction of
Nonemergent Venipuncture in Adults
Rusczyk G, New York Hospital Queens, Flushing, NY
Education
28ⴱ
The Use of Video Laryngoscopy in Massachusetts Emergency
Departments
Raja AS, Brigham and Women’s Hospital, Boston, MA
29
Evaluating Applicants to a New Emergency Medicine Residency
Program: Characteristics of Applicants Who Used the Electronic
Residency Application Service Versus Applicants Who Did Not
Groke S, University of Utah School of Medicine, Salt Lake
City, UT
30ⴱ
Characteristics of Emergency Medicine Residency Curricula That
Affect Board Performance
Babcock C, University of Chicago, Chicago, IL
31
Evaluation of Different Teaching Modalities for EKG Interpretation
Among Emergency Medicine Residents
Das D, New York Hospital Queens, Flushing, NY
32
The Perceived Impact of Precepting Medical Students on Residents’
Clinical Work and Education
Barcomb T, Albany Medical College, Albany, NY
33
Direct Observation Evaluations by Emergency Medicine Faculty Do
Not Provide Unique Information Over That Provided by
Summative Quarterly Evaluations by the Same Faculty
Barlas D, New York Hospital Queens, Flushing, NY
Imaging 2 (Other Imaging)
34
35ⴱ
Assessing Inter-Rater Reliability and Agreement Between Two
Methods of Noninvasive Hemodynamic Monitoring in Clinically
Stable Emergency Department Patients
Napoli A, Rhode Island Hospital/Brown University,
Providence, RI
Value of Noninvasive Measurement of Contractility to Predict
Mortality in Emergency Department Patients Undergoing Early
Goal-Directed Therapy for Severe Sepsis
Napoli A, Rhode Island Hospital/Brown University,
Providence, RI
36
Ionizing Radiation From Computed Tomography During
Evaluation of Intermediate-Risk Trauma Patients
Thompson K, Mayo Clinic, Rochester, MN
37ⴱ
New Generation CT Scanners Demonstrate Higher Sensitivity for
Subarachnoid Hemorrhage
Phanthavady T, University of Utah, Salt Lake City, UT
38
The “Triple Rule-Out” 64-Section Coronary Computed
Tomographic Angiography Protocol: Coronary and Extra-Coronary
Findings of Emergency Department Patients
Takakuwa KM, Thomas Jefferson University Hospital,
Philadelphia, PA
4A Annals of Emergency Medicine
Intussusception in Adults: A 148-Patient Experience
Lindor RA, Mayo Medical School, Mayo Clinic College of
Medicine, Rochester, MN
Pediatrics
46
The Pediatric Experience in the Emergency Department, 2000-2006
Thode HC, Stony Brook University, Stony Brook, NY
47
Delayed Repeat Enema Management of Failed Initial EnemaReduction Intussusception
Losek JD, Medical University of South Carolina, Charleston,
SC
48ⴱ
Anaphylaxis Management in the Pediatric Emergency Department:
Opportunities for Improvement
Russell S, Medical University of South Carolina, Charleston,
SC
49†
Recombinant Human Hyaluronidase-Facilitated Subcutaneous vs
Intravenous Hydration Therapy in Infants and Children
Hahn B, Staten Island University Hospital, Staten Island, NY
50ⴱ
Emergency Department Prescriptions for Long-Term Inhaled
Corticosteroids for Children With Asthma: Are We Following
Recommendations?
Garro A, Rhode Island Hospital and Alpert School of
Medicine at Brown University, Providence, RI
51
Spontaneous Pneumomediastinum in Children: A 10-Year
Experience
van Tonder RJ, Mayo Clinic, Rochester, MN
52
Endotracheal Tube Cuff Pressures in Pediatric Patients Intubated
Prior to Aeromedical Transport
Tollefsen WW, Harvard University, Boston, MA
53ⴱ
Does Sex Delay the Diagnosis of Appendicitis in Female Patients
With Abdominal Pain?
Baquero A, Lincoln Medical Center, Bronx, NY
Public Health
54
Characteristics and Risk Factors of Patients Who Refuse Routine
HIV Testing in an Urban Emergency Department
Calderon Y, Jacobi Medical Center, Bronx, NY
Volume , .  : September 
Research Forum Educational Program 2009
MONDAY, OCTOBER 5—cont’d
55
STEP-DC: Stop Emergency Department Visits for Hyperglycemia
Project -DC
Dubin J, Washington Hospital Center, Washington, DC
70
A Regional Study of Emergency Department Visits for Acute
Exacerbation of Chronic Obstructive Pulmonary Disease
Faig O, Morristown Memorial Hospital, Morristown, NJ
56
A Performance Improvement Audit to Assess Airway
Documentation: How Well Do Emergency Physicians Document
Confirmation of Endotracheal Tube Placement?
Phelan MP, Cleveland Clinic, Cleveland, OH
71
Does the Pulmonary Embolism Severity Index Identify Patients at
Risk for Short Term Clinical Deterioration?
Hariharan P, Massachusetts General Hospital, Boston, MA
57
Copperhead (Agkistrodon Contortrix) Snakebites in the United
States: 2000-2007
Bhakta NS, Scott and White Memorial Hospital, Temple, TX
Resuscitation
58
Epidemiology of Prolonged Emergency Department Length of Stay
Heins A, University of South Alabama College of Medicine,
Loxley, AL
59
Multicenter Study of Internet Use by Emergency Department
Patients in Boston
Sullivan AF, Massachusetts General Hospital, Boston, MA
60
The Prevalence of Tobacco and Alcohol Use in Immigrant
Emergency Department Patients in Queens, NY
Gupta S, New York Hospital Queens, Flushing, NY
61
National Survey of Preventive Health Services in United States
Emergency Departments
Delgado MK, Stanford-Kaiser Emergency Medicine
Residency, Palo Alto, CA
369‡
A Randomized Controlled Trial of the Effect of Energy Drinks on
Exercise Performance, Dexterity, Reaction Time and Vital Signs
Before and After Exercise
O’Neil BD, Everest Academy, Clarkston, MI
72
Outcome of Cardiac Arrest After Accidental Hypothermia and
Indication for Cardiopulmonary Bypass
Mori K, Sapporo Medical University, Sapporo, Japan
73
Effects of the Low Dose Radiation on Nerve Cells as a Method to
Increase the Survival Rate of Emergency Patients
Kim S, Chungnam National University Hospital, Daejeon,
Republic of Korea
74
Heat Loss From IV Fluids During the Administration of PreWarmed Normal Saline
Lyng J, SUNY Upstate Medical University, Syracuse, NY
75EMF
Time to Invasive Airway Placement and Resuscitation Outcomes
After Inhospital Cardiopulmonary Arrest
Wong ML, UMDNJ-Robert Wood Johnson Medical School,
New Brunswick, NJ
76
Early Goal-Directed Therapy for Severe Sepsis/Septic Shock: Which
Components of Treatment Are More Difficult to Implement in a
Community-Based Emergency Department?
O’Neill R, Genesys Regional Medical Center, Grand Blanc,
MI
77†
Rebound Hyperthermia After Cessation of Mild Therapeutic
Hypothermia in Patients With Successful Resuscitation From
Cardiac Arrest
Park E, Ajou University School of Medicine, Suwon, KyoungGi Do, Republic of Korea
Respiratory 1 (Airway)
62
Comparison of the Airtraq® to Direct Laryngoscopy by Flight
Nurses and Respiratory Therapists in the Simulated Airway
Suozzi JC, Hartford Hospital, Hartford, CT
63
Respiratory Isolation Rooms in the Emergency Department
Pazin-Filho A, Medical School of Ribeirao Preto - University
of Sao Paulo, Ribeirao Preto, Brazil
78
Risk of Death in Emergency Department Patients Needing
Intubation
Irvin MM, St. John Hospital and Medical Center, Detroit, MI
64
Intubator Recall of Hypoxia and Number of Attempts Is Often
Inaccurate Compared to Video Review
Hill CH, Hennepin County Medical Center, Minneapolis, MN
EMF-2‡
65
Emergency Physician Ability to Predict Difficult Endotracheal
Intubations
Shum L, University of Pittsburgh Medical Center, Pittsburgh,
PA
Induced Mild Hypothermia Modulates Akt Phosphorylation and
Hsp27 Expression in Mouse Hemorrhagic Shock
Das A, University of Chicago, Chicago, IL
See page S28
66
Airway Characteristics of Patients With Difficult Airways
Wong E, Singapore General Hospital, Singapore, Singapore
EMF-1‡
Characteristics of Patients Undergoing Mechanical Ventilation in
US Emergency Departments
Easter B, Harvard Medical School, Boston, MA
See page S28
Trauma
79
Establishment of a Prospective Burn Registry
Taira BR, Stony Brook University, Stony Brook, NY
80ⴱ
Epidemiology of Trampoline-Related Injuries in Children Attending
the Emergency Department
Dhillon RJ, Mayo Clinic, Rochester, MN
81ⴱ
Use of a Clinical Sobriety Assessment Tool With the NEXUS LowRisk Cervical Spine Criteria to Reduce Cervical Spine Imaging in
Blunt Trauma Patients With Acute Alcohol or Drug Use: A Pilot
Study
Mahler SA, LSUHSC-Shreveport, Shreveport, LA
Respiratory 3 (Pulmonary)
67
Pulmonary Effects of Atropine in Humans
Ly S, University of Massachusetts, Worcester, MA
82
68ⴱ
Spontaneous Pneumomediastinum: A Ten-Year Experience
Beatty N, Mayo Medical School, Rochester, MN
Beyond Boxer’s: Bony Injuries Sustained From Punching
Jeanmonod R, Albany Medical College, Albany, NY
83
69
Patient Outcomes and Resource Utilization for Emergency
Department Patients With Suspected Pulmonary Embolism and
Initial Chest Computed Tomography Angiography Studies Deemed
Suboptimal for Interpretation
Burton J, Albany Medical Center, Albany, NY
Utility of Additional Radiographs in Emergency Department
Patients With Extremity Injuries
Mirhadi M, UC Irvine, Orange, CA
84
Alcohol-Related Sexual Assault Victimization Among Adolescents
Oostema A, MERC/Michigan State University Program in
Emergency Medicine, Grand Rapids, MI
Volume , .  : September 
Annals of Emergency Medicine 5A
Research Forum Educational Program 2009
MONDAY, OCTOBER 5—cont’d
85
Penile Fracture: Evaluation and Management
Hawkins D, Michigan State University College of Human
Medicine, Grand Rapids, MI
10:45 - 11:45 AM
Poster Session 2
Cardiology
Education
102
Does Correlation of Faculty Assessment of Emergency Medicine
Residents’ Medical Knowledge Competency with Performance on
the In-Training Examination Improve With Advancement Through
the Program?
Barlas D, New York Hospital Queens, Flushing, NY
103
Is There a Doctor in the House? The Experience of Medical
Students as Responders to Out-of-Hospital Emergency Medical
Situations
Greene T, Mount Sinai School of Medicine, New York, NY
104†
Performance of an Ultrasound-Guided Thoracentesis Teaching
Model
Nomura JT, Christiana Care Health System, New Castle, DE
105ⴱ
Evaluation of Quantity-Based Credentialing: The Need for
Competency Metrics
Wu TS, Orlando Health, Orlando, FL
106
Improved Resident Knowledge and Adherence to Care Guidelines
Using an Algorithm for Ectopic Pregnancy Evaluation
Nelson BP, Mount Sinai School of Medicine, New York, NY
86
Use of New Cardiac Biomarkers as Diagnostic Tools in the
Emergency Department
Battista S, San Giovanni Battista Hospital of Turin, Turin,
Italy
87
Prognostic Significance of an Estimated Glomerular Filtration Rate
for Long-Term Mortality in Patients With Syncope
Suzuki M, Keio University, Tokyo, Japan
88†
Acute Heart Failure Mortality Prediction Using Copeptin: Results
of the Biomarkers in ACute Heart Failure Trial
Peacock W, The Cleveland Clinic, Cleveland, OH
89
Abstract Withdrawn
90
A Randomized Comparison of Continuous IV Infusion of
Furosemide Versus Repeated IV Bolus Furosemide in Acutely
Decompensated Congestive Heart Failure
Cienki JJ, Jackson Memorial Hospital, Miami, FL
107
Continuous Non-Invasive Hemodynamic Monitoring Using Novel
Finger-Cuff Technology in Emergency Department Patients: A Pilot
Study
Sen A, Henry Ford Hospital, Detroit, MI
Assessing Reaction Time Among Emergency Medicine Residents
Working Different Shift Hours
Berios I, Christus Spohn Memorial Hospital, Texas A&M
University, Corpus Christi, TX
108
The Effect of Video Demonstration to Improve the Quality of
Dispatcher-Assisted Chest Compression-Only Cardiopulmonary
Resuscitation Amongst Middle-Aged Persons
You Y, Ajou University, Suwon, Republic of Korea
91†
92ⴱ
Out-of-Hospital Electrocardiogram Interpretation and Early
Activation for ST-Segment Elevation Myocardial Infarction Patients
Reduces Door-to-Balloon Times and Hospital Length of Stay
Miller A, Lehigh Valley Hospital, Allentown, PA
93ⴱ
Cost-Effectiveness Analysis of Out-of-Hospital 12-Lead
Electrocardiogram Programs
Gross T, University of Pennsylvania, Philadelphia, PA
Emergency Medical Services
Diagnosis/Treatment
109
Airway Management by Critical Care Teams Is Not Associated With
Physiologic Decompensation
Starr GA, University of Oklahoma School of Community
Medicine, Tulsa, OK
Diagnostic Accuracy of Non-Contrast Computed Tomography for
Appendicitis in Adults: A Systematic Review
Hlibczuk V, New York Presbyterian Hospital, New York, NY
110
The Impact of Unit Hour Utilization on Out-of-Hospital
Interventions
Myers LA, Mayo Clinic Medical Transport, Rochester, MN
96
Comparison of Traditional Pediatric-Age, Nontraditional PediatricAge and Adult-Age Patients With Intussusception: A Case Series
Cochran AM, Maine Medical Center, Portland, ME
111
Insurance Status as a Predictor of Mode of Arrival for Patients Who
Present to the Emergency Department With Chest Pain
Weiner SG, Tufts Medical Center, Boston, MA
97
An Analysis of Emergency Department Utilization by Intellectually
Disabled Adults
Venkat A, Allegheny General Hospital, Pittsburgh, PA
112
98
Management of the Bariatric Surgery Patient in the Emergency
Department
Kiebel W, Michigan State University College of Human
Medicine, Grand Rapids, MI
Knowledge of Self-Injectable Epinephrine Technique Among
Emergency Medical Services Providers
Davis JE, Georgetown University Hospital & Washington
Hospital Center, Washington, DC
113
Clinical Features of Acute Diverticulitis in Very Young Patients
Oosterhouse T, Michigan State University College of Human
Medicine, Grand Rapids, MI
The Treatment of Motion Sickness in the Out-of-Hospital Setting:
A Comparison of Metoclopramide and Diphenhydramine to
Placebo
Weichenthal LA, UCSF-Fresno, Fresno, CA
114
Fecal Occult Blood Testing Does Not Predict Major
Gastrointestinal Bleeding in Heparinized Patients
Bennett CJ, University of Maryland, Baltimore, MD
A Comparison of Out-of-Hospital Rapid Sequence Intubation
Success to Non-Paralyzed Patients
Felderman H, Morristown Memorial Hospital, Morristown, NJ
115
The Predictive Value of Arrival With EMS
Felderman H, Morristown Memorial Hospital, Morristown, NJ
116
Postural Hypotension in the Elderly: Predictors for Intervention
Chan W, Tan Tock Seng Hospital, Singapore, Singapore,
Singapore
94
Spontaneous Retroperitoneal Hematoma: Etiology, Characteristics,
Management, and Outcome
Sunga KL, Mayo Clinic, Rochester, MN
95
99
100
101
The Utility of Routine Reticulocyte Count in Uncomplicated VasoOcclusive Crisis Due to Sickle Cell Disease
Garman A, Medical College of Georgia, Augusta, GA
6A Annals of Emergency Medicine
Volume , .  : September 
Research Forum Educational Program 2009
MONDAY, OCTOBER 5—cont’d
Infectious Diseases
117ⴱ
Do HIV-Positive Patients With Severe Sepsis Receive Adequate
Initial Antibiotics in the Emergency Department When Compared
With HIV-Negative Patients?
McGrath ME, Boston Medical Center, Boston, MA
118
External Site Testing of an Instrument to Predict Endocarditis in
Injection Drug Users With Fever
Romero K, University of California, San Francisco, San
Francisco, CA
119
Diagnostic Testing and Site-of-Care Assigned to 608 Pneumonia
Patients Admitted to the Hospital After Evaluation at the
Emergency Department
Ferre C, Bellvitge Universitary Hospital, L’Hospitalet de
Llobregat, Spain
120
How Many Methicillin-Resistant Staphylococcus aureus Infections
Are Missed Upon Admission to the Emergency Department?
Akpunonu P, University of Toledo College of Medicine,
Toledo, OH
121
Prognosis of Urosepsis Patients Who Are Treated by Inappropriate
Initial Antimicrobial Therapy in the Emergency Department
Imamura T, Shonan Kamakura General Hospital, Kamakura,
Japan
122
Vancomycin Minimum Inhibitory Concentration Values ⬎1.0 ␮g/mL
Do Not Predict a Worse Clinical Outcome in Non-ICU, Adult,
Methicillin-Resistant Staphylococcus aureus-Positive Patients
Virk PS, University of Nevada School of Medicine, Las
Vegas, NV
123
124
134ⴱ
Does a Novel Abscess Drainage Technique Differ in Procedural
Times and Times to Discharge From Traditional Incision and
Drainage at a Level I Pediatric Trauma Center?
Ladde J, Orlando Regional Medical Center, Orlando, FL
135
Provider Compliance With the Food and Drug Administration
Recommendation to Avoid the Use of Over the Counter
(Nonprescription) Cough and Cold Medications in Children Under
Two Years Old
Goo R, Tripler Army Medical Center, Honolulu, HI
136ⴱ
Fever in Children Less Than 60 Days Old: What Are Current
Cerebrospinal Fluid, Blood, and Urine Culture Positive Rates in the
Vaccination Era?
Morley EJ, SUNY Upstate Medical University, Syracuse, NY
137
Frequency of Preschoolers Positive for Drugs or Alcohol After
Suffering Traumatic Injuries
Eadeh H, St. John Hospital and Medical Center, Detroit, MI
Practice Management
Nausea and Vomiting: Are We Treating the Patients or Ourselves?
Garra G, Stony Brook University, Stony Brook, NY
139
The Significance of Lactate Clearance Rate as a Predictor of Organ
Failure
Cho YD, Korea University Medical Center, Seoul, Republic of
Korea
Comparison in the Management of Inhalational Injuries Presenting
to a Tertiary Hospital Emergency Department
Ngo AS, Singapore General Hospital, Singapore, Singapore
140†
A Prospective Observational Study of Medication Errors in a
Tertiary Care Academic Emergency Department
Patanwala A, University of Arizona, Tucson, AZ
Rapid HIV Testing in a Large Urban Emergency Department
Harper JB, Rush University, Chicago, IL
141EMF
Patient Satisfaction of Emergency Department Boarders With
Inpatient Hallway Admission
Zito JA, Stony Brook University, Stony Brook, NY
142
Medication Errors Recovered by Emergency Department
Pharmacists
Rothschild JM, Brigham and Women’s Hospital, Boston, MA
143
Materials Management of a Busy Emergency Department
Richardson D, Lehigh Valley Hospital, Allentown, PA
144
Evaluating Predictors of Door-to-EKG Times
Borquez EA, Los Angeles County/University of Southern
California, Los Angeles, CA
125
Trauma Care Access for Road Traffic Injuries in Hanoi City
Nagata T, Himeno Hospital, Hirokawa-city, Japan
126
Road Traffic Injury Hot Spots in Yerevan, Armenia
Lynch CA, Yale School of Medicine, New Haven, CT
127†
Comparison of Acidosis Markers Associated With Law Enforcement
Applications of Force
Ho JD, Hennepin County Medical Center, Minneapolis, MN
128
Radiation Exposure in Emergency Physicians Working in an Urban
Emergency Department: A Prospective Cohort Study
Gottesman B, University of Cincinnati College of Medicine,
Cincinnati, OH
129ⴱ
Emergency Department Blood Cultures Have Limited Usefulness in
the Management of Children Hospitalized for CommunityAcquired Pneumonia
Davis V, University of Alabama at Birmingham, Birmingham,
AL
138
Injury Prevention 2 (Unintentional)
ⴱ
133
Industrial Accidents: An Epidemiological Profile of 866 Emergency
Admissions in a Tertiary Care Teaching Hospital, S. India
Banala SR, Sri Ramchandra Medical College & Research
Institute, Chennai, India
Psychiatry
145
Content Validity Testing for the Agitation Severity Scale:
Development of a Measure for Use With Acute Presentation
Behavioral Management Patients
Strout TD, Maine Medical Center, Portland, ME
146
Punch Injuries and Psychiatric Comorbidity in Men and Women
Damewood S, Albany Medical College, Albany, NY
147
Psychiatric Clearance in the Pediatric Emergency Department
Waseem M, Lincoln Hospital, Bronx, NY
148
Factors Predicting Return Visits Among Emergency Department
Patients With Psychiatric Complaints
Groke S, University of Utah School of Medicine, N Salt
Lake, UT
149
Psychiatric Transfers From the Emergency Department: Factors
Associated With Length of Stay
Klope JL, Resurrection Medical Center, Chicago, IL
Pediatrics
130
Abstract Withdrawn
131ⴱ
Impact of Rapid Streptococcal Test on Antibiotic Use in a Pediatric
Emergency Department
Waseem M, Lincoln Hospital, Bronx, NY
132
Obesity in Children
Chohan JK, Stony Brook University, Stony Brook, NY
Volume , .  : September 
Annals of Emergency Medicine 7A
Research Forum Educational Program 2009
MONDAY, OCTOBER 5—cont’d
Public Health
The Effect of Access to Health Care and Socioeconomic Status on
the Availability and Effectiveness of Medical Treatment for Asthma
and Hypertension Among Patients Presenting to the Emergency
Department
Miner JR, Hennepin County Medical Center, Minneapolis,
MN
150
Emergency Department Patient Acceptance of Rapid HIV Testing
Practices, Revisited: The 2006 CDC Recommendations for NonTargeted, Opt-Out HIV Screening
Prekker ME, Hennepin County Medical Center, Minneapolis,
MN
151
152
Epidemiology of Advance Directives in Extended Care Facility
Patients Presenting to the Emergency Department
Wall JJ, The Ohio State University, Columbus, OH
153
Do Attitudes About Homosexuality Affect Emergency Medicine
Practice? Results of a Survey
Shearer P, Mount Sinai School of Medicine, New York, NY
154
Impact of Care Management on the Highest Utilizers of Camden
NJ’s Emergency Departments
Sciorra D, University of Medicine and Dentistry of New
Jersey, Camden, NJ
155
Preliminary Results of the Survivors of Torture Presenting to an
Urban Emergency Department Prevalence Study
Hexom B, Mount Sinai School of Medicine, New York, NY
156
Large Increase in Emergency Department Visits for Head Trauma
After Natasha Richardson’s Death
Campo C, Morristown Memorial Hospital, Morristown, NJ
157
Patient Perceived Alcohol and Substance Abuse Treatment Needs:
An Urban Emergency Department Pilot Study
Scott S, The University of Medicine and Dentistry of New
Jersey, Newark, NJ
165ⴱ
2:30 - 4:00 PM
Poster Session 3
Administration
166
Emergency Department Operational Improvements’ Impact on
Volume, Quality Core Measures, Patient Stay and Satisfaction
Sayah A, Cambridge Health Alliance, Cambridge, MA
167
Implementation of Crowding Solutions from the American College
of Emergency Physicians Task Force Report on Boarding
Handel DA, Oregon Health & Science University, Portland,
OR
168
Utilization of the Situation-Background-Assessment-Request,
Companion Phones, and Cell Phones Improves Communication
With Consultants in the Emergency Department
Farley H, Christiana Care Health System, Newark, DE
169
A Protocol to Improve Door-to-EKG Times in the Emergency
Department
Mostofi M, Tufts Medical Center, Boston, MA
170
Managing Patient Expectations at Emergency Department Triage
Rumoro D, Rush University Medical Center, Chicago, IL
171
Characteristics of an Emergency Medicine-Led Rapid Response
Team at an Academic Tertiary Care Hospital in the United States
Mace SE, Cleveland Clinic, Cleveland, OH
172
An Analysis of Patients Treated by a Rapid Response Team: A High
Acuity, Critically Ill Patient Population Requiring Multiple
Procedures and Transfer to a Higher Level of Care
Mace SE, Cleveland Clinic, Cleveland, OH
173
Effect of an Attending Physician Float Shift to Care for Boarding
Patients in a Crowded Emergency Department
Holt S, Advocate Christ Medical Center, Chicago, IL
174
Emergency Severity Index Triage System Correlation With
Emergency Department Evaluation and Management Billing Codes
Hendry D, Washington University St. Louis, St. Louis, MO
175ⴱ
Emergency Department Inpatient Bed Management Inventory
System
Shah S, Rush University Medical Center, Chicago, IL
Research Issues
158
Interobserver Reliability of a Novel Scar Evaluation Scale
Singer AJ, Stony Brook University, Stony Brook, NY
159
Use of the Descriptive Term “Experiment” Does Not Significantly
Influence a Potential Subject’s Decision to Participate in Research
Schroeder JW, Philadelphia College of Osteopathic
Medicine, Philadelphia, PA
Survey of Medical Decisionmaking: Ability of the Public to SelfTriage and Recognize Symptoms of Emergency Conditions
Plonk T, East Carolina University, Greenville, NC
160
ⴱ
161
Cardiology
176
Evolution of Door to Electrocardiogram Times After an Educational
Strategy in Patients Presenting With Chest Pain to the Emergency
Department in a Chilean Academic Center
Aguilera P, Pontificia Universidad Católica de Chile,
Santiago, Chile
177†
A Comparative Analysis of Screening Hypertensive Patients for Left
Ventricular Abnormality With Electrocardiograph and NT-proBNP
Chandra A, Duke University Medical Center, Durham, NC
178
The Percent of Total Emergency Department Visits for Congestive
Heart Failure Declined From 1996 to 2008
Allegra JR, Morristown Memorial Hospital, Morristown, NJ
179
Disposition and Final Diagnosis of Patients Presenting With Chest
Pain to an Academic Emergency Department in Chile
Aguilera P, Pontificia Universidad Católica de Chile,
Santiago, Chile
180ⴱ
Epidemiology of Elevated Blood Pressure in Emergency Department
Adhikari S, University of Nebraska Medical Center, Omaha,
NE
Do Prolonged Emergency Department Waiting Times Reduce
Emergency Research Consent Rates?
Limkakeng AT, Duke University, Durham, NC
Respiratory 2 (Asthma)
162
Trends and Disparities in Emergency Department Asthma Care,
1992-2006
Heins A, University of South Alabama College of Medicine,
Loxley, AL
163
Educational Intervention in Adult Asthma: A Randomized Clinical
Trial to Determine If Adult Patients With Asthma Can Learn How
to Use a Metered Dose Inhaler
Acosta JF, Yakima Regional Medical & Cardiac Center,
Yakima, WA
164†
Percutaneous Vagal Electrical Stimulation for Severe Asthma
Lewis L, Washington University, St. Louis, MO
8A Annals of Emergency Medicine
Initial Out-of-Hospital End-Tidal Carbon Dioxide Measurements
in Adult Asthmatic Patients
Lamba S, The University of Medicine and Dentistry of New
Jersey, Newark, NJ
Volume , .  : September 
Research Forum Educational Program 2009
MONDAY, OCTOBER 5—cont’d
181†ⴱ
Describing Global and Tissue Level Perfusion in Congestive Heart
Failure Patients Presenting to an Urban Emergency Department: A
Pilot Study
Sherwin R, Wayne State University, Detroit, MI
197
Endotracheal Tube and Laryngeal Mask Airway Cuff Pressures Can
Exceed Critical Values During Air Transport
Miyashiro R, University of Hawaii John A. Burns School of
Medicine, Honolulu, HI
182
Performance of a Novel Spanish-Language Chest Pain Tool for
Evaluation, Risk Stratification, and Dissection/Fibrinolysis
Screening in Spanish-Speaking Emergency Department Patients
Slattery DE, University of Nevada School of Medicine, Las
Vegas, NV
198
Injury Incidence and Predictors on a Mass Bicycle Ride
Boeke P, University of Iowa, Iowa City, IA
199
Does “Off-Hour” Presentation Contribute to Out-of-Hospital Process
Delays Among Patients With ST-Elevation Myocardial Infarction?
Agarwal A, Southern Illinois University, Springfield, IL
200
The Impact of 24-Hour Shifts on Paramedics Providing Out-ofHospital Analgesia in Patient-Reported Pain Scales
Myers LA, Mayo Clinic Medical Transport, Rochester, MN
201
Safety and Efficacy of a Novel Abdominal Aortic Tourniquet Device
for the Control of Pelvic and Lower Extremity Hemorrhage
Greenfield EM, Medical College of Georgia, Augusta, GA
202
Improvement in Bag-Mask Ventilation Performance After Training
With a Novel Terminal Feedback Manikin System
Salvucci AA, Ventura County Medical Center, Ventura, CA
203
Hospital Processes, Not EMS Transport Times, Are Crucial
Predictors of Rapid Reperfusion for ST-Segment Elevation
Myocardial Infarction Patients
Swor R, William Beaumont Hospital, Royal Oak, MI
204
Endotracheal Intubation Success in an Ambulance by Emergency
Medical Out-of-Hospital Personnel Using Direct and Glidescope®
Laryngoscopes
Toofan M, Scott & White Memorial Hospital, Temple, TX
183
Effects of Body Mass Index and B-type Natriuretic Peptide Level in
Chronic Heart Failure Patients
Phelan T, LSUHSC-Shreveport, Shreveport, LA
184
Quantitative Meaning of Common Terms Like “Very Low Risk”
and “Low Risk” for Chest Pain Patients
Menchine M, University of California, Irvine, Irvine, CA
Diagnosis/Treatment
185
Asymptomatic Bacteriuria: Is the Presence of Microscopic
Bacteriuria Without Pyuria in Asymptomatic Pregnant Females
Associated With Positive Urine Culture? A Retrospective CrossSectional Study
Hile D, Madigan Army Medical Center, Tacoma, WA
186
Tamsulosin Does Not Increase One-Week Rate of Passage of
Ureteral Stones in Emergency Department Patients
Lipe KM, William Beaumont Hospital, Royal Oak, MI
187
Value of Head CT in Syncope Patients in the Emergency
Department
Vélez I, University of Puerto Rico School of Medicine,
Carolina, PR
188
Evaluation of a Non-Contact Infrared Thermometer in an Adult
Emergency Department
Patyrak S, UT Southwestern, Dallas, TX
189
Accuracy of Point-of-Care Finger Stick Hemoglobin Compared to
Laboratory Value
Morris DF, UCSD, San Diego, CA
190ⴱ
Fear of Brain Herniation From Lumbar Puncture: Do History and
Physical Exam Indicate Abnormalities on Head Computed
Tomography?
O’Laughlin KN, Harvard Medical School, Boston, MA
Health Care Policy
205
Accountability, Transparency, and Interoperability: Developing a
Database of Federal Efforts in Emergency Medical Care
Johnson KA, Dept. of Health and Human Services,
Washington, DC
206
Poor and Sick: Do Low-Income Areas Have Fewer Emergency
Departments?
Ravikumar D, University of California, San Francisco, San
Francisco, CA
207
Penetration of Board Certified Emergency Physicians Into Rural
Emergency Departments in Iowa
House H, University of Iowa, Iowa City, IA
208
Does Having and Using a Usual Source of Care Decrease
Emergency Department Use?
Gabayan GZ, VA Greater Los Angeles Health System, Los
Angeles, CA
191ⴱ
Disease and Non-Battle Traumatic Injuries Evaluated by Emergency
Physicians in a US Tertiary Combat Hospital
Bebarta VS, Wilford Hall Medical Center, San Antonio, TX
192ⴱ
The Utility of HbA1C Screening in Low-Risk Chest Pain Patients in
the Emergency Department Observation Unit
Wiederhold H, William Beaumont Hospital, Royal Oak, MI
209
A New Study of Intraosseous Blood for CBC and Chemistry Profile
Philbeck T, Vidacare Corporation, San Antonio, TX
Determinants of Health Care Access on the US-Mexico Border
Watts S, Texas Tech University Health Sciences Center, El
Paso, TX
210
The Use of a Subcutaneous Insulin Aspart Protocol for the
Treatment of Hyperglycemia in the Emergency Department: A
Randomized Clinical Trial
Harper JB, Rush University, Chicago, IL
Severity of Illness Does Not Differ Based on Insurance Status in
Two Urban Emergency Departments
Shukla KT, University of Illinois, Chicago, IL
211
Does Pay for Performance Lead to Potential Misuse of Antibiotics
Among Patients With Congestive Heart Failure?
Duseja R, Wharton School, University of Pennsylvania,
Philadelphia, PA
212†
Resident Alertness, Stress, and Self-Reported Medical Errors in an
Urban Teaching Hospital Emergency Department
Hansen KN, University of Maryland School of Medicine,
Baltimore, MD
213
Major Barriers to Follow-Up of Emergency Department Patients at
Federally Funded Clinics: Metropolitan-Wide Survey Pilot Data
Lewis L, Washington University, St. Louis, MO
193†
194
Emergency Medical Services
195
Refusals of Medical Aid in the Out-of-Hospital Setting
Waldron R, New York Hospital Queens, Flushing, NY
196
Intubation Success Rates in Helicopter Emergency Medical Services:
A Prospective Multicenter Analysis
Howard Z, Harvard Affiliated Emergency Medicine
Residency, Boston, MA
Volume , .  : September 
Annals of Emergency Medicine 9A
Research Forum Educational Program 2009
MONDAY, OCTOBER 5—cont’d
214ⴱ
Emergency Department Boarding Is Associated With Higher
Medication-Related Errors but Fewer Laboratory Errors During the
Early Admission Period
Liu SW, Massachusetts General Hospital, Boston, MA
229
A Survey of Emergency Physician and Stroke Specialist Beliefs and
Expectations Regarding Telestroke
Moskowitz A, Mount Sinai School of Medicine, New York,
NY
230
A Comparison of Inferior Vena Cava Measurements in Emergency
Department Patients With Acute Systolic Versus Diastolic Heart
Failure
Sen A, Henry Ford Hospital, Detroit, MI
Out-of-Hospital Normobaric Oxygen Therapy in Presumptive
Acute Stroke Patients: A Preliminary Study
Chan Y, Mount Sinai School of Medicine, New York, NY
231ⴱ
Comparison of Bedside Ultrasound and Panorex Radiography in the
Diagnosis of a Dental Abscess in the Emergency Department
Adhikari S, University of Nebraska Medical Center, Omaha,
NE
Predictors of Mortality in Patients Presenting to the Emergency
Department With Stroke: A Developing Nation Scenario
Chandra S, All India Institute of Medical Sciences, New
Delhi, India
232
Emergency Department Hyperglycemia as a Predictor of Mortality
and Functional Outcome After Intracerebral Hemorrhage by
Diabetes Mellitus Status
Bellolio M, Mayo Medical School, Rochester, MN
233
Screening Electroencephalograms Are Feasible and Identify Potential
Subclinical Seizure Activity in Emergency Department Patients
Bastani A, Troy Beaumont Hospital, Troy, MI
234ⴱ
Comparison of Blunt Versus Sharp Spinal Needles Used in the
Emergency Department in Rates of Post-Lumbar Puncture
Headache
Torbati S, Cedars-Sinai Medical Center, Los Angeles, CA
Imaging 1 (Ultrasound)
215
216ⴱ
217ⴱ
INSPIRED: Instruction of Sonographic Placement of IVs by RNs in
the Emergency Department
Liteplo AS, Massachusetts General Hospital, Boston, MA
218ⴱ
Bedside Ultrasound Evaluation of Tendon Injuries
Wu TS, Orlando Regional Medical Center, Orlando, FL
219
Time to Identify Needle Tip Location Is Independent of Ultrasound
Transducer Orientation and Physician Level of Training
Cook D, Christiana Care Health Services, Newark, DE
220ⴱ
How Accurate Is the Last Menstrual Period in Dating a First
Trimester Pregnancy?
Saul T, St. Luke’s Roosevelt Hospital, New York, NY
TUESDAY, OCTOBER 6, 2009
221
Evaluation of Ectopic Pregnancy With Bedside Ultrasound by
Emergency Physicians: A Meta-Analysis
Stein JC, University of California, San Francisco, CA
9:30 - 11:30 AM
Poster Session 4
Administration
222
Nurse Utilization of Ultrasound Guidance for Peripheral IV
Placement in the Emergency Department: Does It Change Over
Time?
Lyon M, Medical College of Georgia, Augusta, GA
235
Can We Defer a Type and Screen for Pregnant Patients With
Vaginal Bleeding Who “Know” Their Blood Type?
Shah K, St. Luke’s-Roosevelt Hospital, New York, NY
236
223
Emergency Department Bedside Ultrasound Measurement of Caval
Index as Non-Invasive Determination of Low Central Venous
Pressure: A Multi-Center Validation of an Emergency Department
Protocol
Hansen AV, University of California - San Diego, San Diego,
CA
An Analysis of Prolonged Length of Stay in a Pediatric Emergency
Department
Place R, Inova Fairfax Hospital, Falls Church, VA
237ⴱ
Supplemented Triage and Rapid Treatment in the Emergency
Department
White BA, Massachusetts General Hospital, Boston, MA
238
An Analysis of Emergency Department Observation Units Impact
on Patient Satisfaction Scores
Chandra A, Duke University Medical Center, Durham, NC
239ⴱEMF
The Impact of Emergency Department Boarding on Hospital
Revenues
Pines JM, University of Pennsylvania, Philadelphia, PA
240ⴱ
Primary and Specialty Care Follow-Up for Uninsured Emergency
Department Patients
Ginde AA, University of Colorado Denver School of Medicine,
Aurora, CO
241
A Multifaceted Quality Improvement Program Improves Hand
Hygiene Compliance in the Emergency Department
Schuur J, Brigham and Women’s Hospital, Boston, MA
242
Validating an Emergency Medicine-Specific Tool to Estimate
Cognitive Impairment
Birkhahn R, New York Methodist Hospital, Brooklyn, NY
243ⴱ
The Use of an Expeditor and Its Impact on Emergency Department
Length of Stay
Handel DA, Oregon Health & Science University, Portland,
OR
244
Environmental Predictors of Hand Hygiene Compliance in the
Emergency Department
Venkatesh A, Brigham and Women’s Hospital, Boston, MA
224
Teaching the Focused Assessment With Sonography in Trauma
Exam: Is an Ultrasound Mannequin Simulator as Good as or Better
Than Using Live Models for Practical Training?
Damewood S, Albany Medical Center, Albany, NY
Neurology
225
Should This Stroke Patient Be Transferred? Computed
Tomographic Angiography Predicts Use of Tertiary Interventional
Services
Thomas LE, Massachusetts General Hospital, Boston, MA
226
Nonaneurysmal Subarachnoid Hemorrhage: Clinical Course and
Outcome in Two Distinct Hemorrhage Patterns
Gilmer M, Michigan State University College of Human
Medicine, Grand Rapids, MI
227
Examination of Adherence to Evidence-Based Practices and 30-Day
Outcomes for Emergency Department Patients Treated for
Transient Ischemic Attack
Baumann MR, Maine Medical Center, Portland, ME
228ⴱ
Cephalgia in Emergency Department Patients Responds to Oxygen,
Decreasing Time to Relief, Length of Stay, Computed Tomographic
Utilization, and Need for Pharmacotherapy
Veysman BD, UMDNJ-Robert Wood Johnson Medical School,
New Brunswick, NJ
10A Annals of Emergency Medicine
Volume , .  : September 
Research Forum Educational Program 2009
TUESDAY, OCTOBER 6—cont’d
Emergency Medical Services
245
246
247
Should the Deeply Comatose Trauma Patient Be Intubated by
EMS?
Walters J, St. John Hospital and Medical Center, Detroit, MI
Admission Rates for Walk-In Patients Differ Between Suburban and
Urban Emergency Departments While Admission Rates for
Emergency Medical Services Arrivals Show No Significant
Difference
Matthews P, Christiana Care Health Services, Newark, DE
Baseline Carboxyhemoglobin Levels in Firefighters Using the
Masimo Rainbow SET Rad-57 Pulse CO-Oximeter
Black A, University of Texas Southwestern Medical Center,
Dallas, TX
248ⴱ
Predictors of Ambulance Use for Emergency Department Patients
Over 45 With Chest Pain
Meisel ZF, University of Pennsylvania, Philadelphia, PA
249ⴱ
Type of Insurance Is Associated With Ambulance Use for Transport
to Emergency Departments in the United States
Meisel ZF, University of Pennsylvania, Philadelphia, PA
250
Collaborative to Decrease Ambulance Diversion: The California
Emergency Department Diversion Project
Castillo EM, University of California, San Diego, San Diego,
CA
261
Restraint Use in the Elderly Emergency Department Patient
Swickhamer C, Resurrection Medical Center, Chicago, IL
262
Yield of Head Computed Tomography in the Alcohol-Intoxicated
Patient
Shah K, St. Luke’s-Roosevelt Hospital, New York, NY
263
Assessing Three-Month Fall Risk for Geriatric Emergency
Department Patients
Carpenter CR, Washington University in St. Louis, St. Louis,
MO
264
Has Grandma Been Drinking?
Kott I, St. John Hospital and Medical Center, Detroit, MI
265
Guided Medication Dosing for Elderly Emergency Department
Patients Using a Real-Time, Computerized Decision Support Tool
Griffey RT, Washington University School of Medicine,
Barnes-Jewish Hospital, St. Louis, MO
Health Care Policy
266
Do Non-English-Speaking Patients With an Admitting Diagnosis of
Pneumonia Experience a Systematic Delay in Time to Antibiotics?
Green JP, New York Hospital Queens, Flushing, NY
267ⴱ
Emergency Department Nurse Workloads and Their Contributors
Rabin E, Mount Sinai School of Medicine, New York, NY
268ⴱ
Change in Acuity of Emergency Department Visits After
Massachusetts Health Care Reform
Smulowitz PB, Beth Israel Deaconess Medical Center,
Boston, MA
251ⴱ
Pharmacist Implementation in the Emergency Department
Hong AL, Memorial Hermann Katy Hospital, Katy, TX
252
Provider Impression of Cervical Spine Injury and Its Effects on
Quality of Out-of-Hospital Immobilization Techniques
Dailey M, Albany Medical Center, Albany, NY
269ⴱ
The C.I.N. Study: Is Contrast-Induced Nephropathy a Problem in
High-Risk Emergency Department Patients?
Su M, North Shore University Hospital, Manhasset, NY
The Impact of Declining Emergency Department Subspecialty
Availability
Ladde J, Orlando Regional Medical Center, Orlando, FL
270ⴱ
Epidemiology of Out-of-Hospital Emergencies in Andhra Pradesh,
India, 2007
Mahadevan SV, Stanford University School of Medicine,
Palo Alto, CA
The Impact of Health Care Reform in Massachusetts on Emergency
Department Use by Uninsured and Publicly Subsidized Individuals
Smulowitz PB, Beth Israel Deaconess Medical Center,
Boston, MA
271ⴱ
Accidents Waiting to Happen: Decreasing Access to Emergency
Departments in Rural Areas in the US, 2001-2005
Hsia RY, University of California at San Francisco, San
Francisco, CA
272
Are Public Hospitals More Efficient in Providing Health Care?
Roberts RR, Stroger Hospital of Cook County, Chicago, IL
273
Hospitalizations of Older Human Immunodeficiency Virus Patients
in the United States from 2000-2006
Tadros A, West Virginia University, Morgantown, WV
Association Between Emergency Department Crowding on the
Appropriateness of Resuscitation Room Utilization: An Expert Panel
Study in a Single Emergency Center
Kim J, Seoul National University Hospital, Seoul, Republic of
Korea
274
Cognitive Impairment and Comprehension of Emergency
Department Discharge Instructions in Older Patients
Bryce SN, Vanderbilt University School of Medicine,
Nashville, TN
Multi-Center Study of Left Without Treatment Rates From
Emergency Departments Serving a Large Metropolitan Region
Lev R, Scripps Mercy Hospital, San Diego, CA
275
A Classification System for Emergency Departments: Massachusetts,
2008
Camargo CA, Massachusetts General Hospital, Boston, MA
258ⴱ
Preliminary Results of a Multidisciplinary Falls Evaluation Program
for Elderly Fallers Presenting to the Emergency Department
Wong EM, Tan Tock Seng Hospital, Singapore, Singapore
Imaging 1 (Ultrasound)
259
Occult Cognitive Impairment in Admitted Older Emergency
Department Patients Is Not Identified by Admitting Services
Heidt JW, Washington University in St. Louis, St. Louis, MO
253
254
Geriatrics
255
256
257EMF
260
The Outcome of Out-of-Hospital Cardiopulmonary Arrest in the
Over 85-Year-Old Japanese Population Taken to the Emergency
Department
Umezawa K, Shounan Kamakura General Hospital,
Kamakura, Japan
Geriatric Syndrome Screening in Emergency Medicine: A Geriatric
Technician Acceptability Analysis
Carpenter CR, Washington University in St. Louis, St. Louis,
MO
Volume , .  : September 
276
Nurse-Operated Ultrasound for Difficult Intravenous Access:
A Randomized Trial
River G, UCSF School of Medicine, San Francisco, CA
277ⴱ
Teaching Focused Obstetric Ultrasound to Midwives in Rural Zambia
Kimberly H, Massachusetts General Hospital, Boston, MA
278ⴱ
Comparative Extravasation Rates of 1.75-Inch and 2.5-Inch
Ultrasound-Guided Peripheral Vascular Catheters
Bauman MJ, Christiana Care Health System, Newark, DE
Annals of Emergency Medicine 11A
Research Forum Educational Program 2009
TUESDAY, OCTOBER 6—cont’d
279ⴱ
Optic Nerve Sheath Ultrasound for the Evaluation of Children
With Suspected Ventriculo-Peritoneal Shunt Failure
Hall MK, Oregon Health & Science University, Portland, OR
280ⴱ
Comparison of Web- Versus Classroom-Based Basic Ultrasound and
Extended Focused Assessment With Sonography for Trauma
Training in Two European Hospitals
Platz E, Brigham and Women’s Hospital, Boston, MA
281
Impact of Image Processing on the Pleural Sliding Sign
Holm M, Hennepin County Medical Center, Minneapolis, MN
282
Correlation of Bedside Ultrasound Measurement of the Respiratory
Variation of Internal Jugular Venous Diameter With Invasive
Central Venous Pressure Measurement in Patients With Severe
Sepsis
Bigler JB, University of Nevada School of Medicine, Las
Vegas, NV
283ⴱ
284
Utility of Bedside Biliary Ultrasound in the Evaluation of
Emergency Department Patients With Isolated Epigastric Pain
Adhikari S, University of Nebraska Medical Center, Omaha,
NE
Intra-Articular Foreign Body Evaluation: Ultrasound Versus
Fluoroscopy
Lyon M, Medical College of Georgia, Augusta, GA
Pediatrics
285
The Significance of Peripheral White Blood Cell Count in Cases of
Acute Otitis Media in Children Between 2 to 17 Years of Age
Nibhanipudi KV, NY Medical College Metropolitan Hospital
Center, New York, NY
286
Evaluation of Emergency Medicine Discharge Instructions in
Pediatric Head Injury
Sarsfield MJ, SUNY Upstate Medical University, Syracuse,
NY
287
288
289ⴱ
295
What Happens at the 72-Hour Mark? Physical Findings in Sexual
Assault Cases When Victims Delay Reporting
Burger C, Michigan State University College of Human
Medicine, Grand Rapids, MI
296
Early Treatment of Hypertonic Saline and Arginine Is Important in
Restoration of T Cell Dysfunction
Choi S, Korea University Guro Hispital, Seoul, Republic of
Korea
297
Injury Patterns Are Different for Older and Younger Patients in
Equestrian Accidents
Allegra JR, Morristown Memorial Hospital, Morristown, NJ
298ⴱ
Admission Fibrin Degradation Product Level Predicts the Need for
Massive Transfusion and Mortality in Adult Blunt Trauma Patients
MAEKAWA K, Sapporo Medical University, Sapporo, Japan
299
Can Coagulation Markers on Arrival Predict Neurological Outcome
in Patients With Traumatic Brain Injury?
Shimizu T, Teine Keijinkai Hospital, Sapporo, Japan
300
Fishing-Related Infections in the United States
Krieg C, Resurrection Medical Center, Chicago, IL
301
The Effect of the Repeal of the Pennsylvania Helmet Law on the
Severity of Head and Neck Injuries Sustained in Motorcycle
Accidents
Eberhardt M, St. Luke’s Hospital, Bethelehem, PA
302
Characteristics of Fragment Wounds in a Combat Setting
Givens ML, Carl R Darnall Army Medical Center, Fort Hood,
TX
1:00 - 2:30 PM
Poster Session 5
Administration
303
Does Insurance Status Make a Difference in Pediatric Trauma
Patients?
Hakmeh W, St. John Hospital and Medical Center, Detroit,
MI
An Analysis of Emergency Department Revisit Rates Based on
Patient Satisfaction Scores
Yang A, UMDNJ-Robert Wood Johnson, New Brunswick, NJ
304ⴱ
A Rise in Emergency Department Visits of Pediatric Patients for
Renal Colic From 1999-2008
Kairam N, Morristown Memorial Hospital, Morristown, NJ
The Use of Scripting at Triage and Its Impact on Elopements
Handel DA, Oregon Health & Science University, Portland,
OR
305
Ultrasound Assessment of Dehydration in Children With
Gastroenteritis
Levine AC, Brigham and Women’s Hospital, Boston, MA
Reliability of Emergency Severity Index Version 4
Choi M, Seoul National University Hospital, Seoul, Republic
of Korea
306
Video Technologies in Emergency Health Research in Assessing
Quality of Care: A Study of Trauma Resuscitation Milestones
Sen A, Henry Ford Hospital, Detroit, MI
307
Customer Service and Communication Training Initiative for
Emergency Physicians Improves Patient Satisfaction Despite
Crowding in the Emergency Department
Katz GR, The Ohio State University, Columbus, OH
308
A Lean-Based Triage Redesign Process Improves Door-to-Room
Times and Decreases Number of Patients at Triage
Farley H, Christiana Care Health Systems, Newark, DE
309
Validation of Modified Emergency Severity Index Version 4
Lee J, Seoul National University Hospital, Seoul, Republic of
Korea
310EMF
Impact of Mandated Nurse-Patient Ratios on Time to Antibiotic
Administration in the Emergency Department
Chan TC, University of California, San Diego, San Diego, CA
311
Care Plan Program Reduces the Number of Visits for HighUtilizing Psychiatric Patients in the Emergency Department
Abello A, University Medical Center at Brackenridge, Austin,
TX
290
A Teaspoon of Medication: How Much Is Really in It?
Mir M, Wycoff Heights Hospital, Brooklyn, NY
291
Spectrum of Bacterial Pathogens Seen in a Community Pediatric
Emergency Department
Kondamudi N, The Brooklyn Hospital Center, Brooklyn, NY
292
Perceptions and Practices of Fever: Survey for Parents With Febrile
Child Visiting Pediatric Emergency Department
Kim D, Seoul National University Hospital, Seoul, Republic
of Korea
293ⴱ
Respiratory Distress Assessment Instrument as a Predictor of
Hospital Admission and Severity in Children With Bronchiolitis
Dhillon RK, Mayo Clinic, Rochester, MN
Trauma
294
The Effects of Skin Pigmentation on the Detection of Genital Injury
From Sexual Assault: A Population-Based Study
Rechtin C, MERC/Michigan State University Program in
Emergency Medicine, Grand Rapids, MI
12A Annals of Emergency Medicine
Volume , .  : September 
Research Forum Educational Program 2009
TUESDAY, OCTOBER 6—cont’d
312
Patient Satisfaction Is Associated With Clinical Quality and
Hospital Outcomes in Acute Myocardial Infarction
Glickman S, University of North Carolina, Chapel Hill, NC
Basic Science
313
Effect of IV Deferoxamine on Burn Wound Progression
Lim T, Stony Brook University, Stony Brook, NY
314†
Effect of IV Pentoxifylline on Burn Wound Progression
Lim T, Stony Brook University, Stony Brook, NY
315
Catecholamines in Simulated Arrest Scenarios
Lundin EJ, University of Louisville, Louisville, KY
316
Visualization of Intraosseous Flow Paths by Angiography,
Computed Tomography and Vital Dye Techniques
De Lorenzo RA, Brooke Army Medical Center, Fort Sam
Houston, TX
317
A Manometric Method for Evaluating Flow Dynamics and
Thrombus Burden of Intraosseous Devices: Theory and Application
Rubal BJ, Brooke Army Medical Center, Fort Sam Houston,
TX
318†
Fetuin Protects Mice Against Lethal Sepsis by Modulating Bacterial
Endotoxin-Induced HMGB1 Release and Autophagy
Wang H, North Shore University Hospital, Manhasset, NY
319
Intracranial Constructive Interference of Low Frequency
Ultrasound: An In-Vitro Pilot Study of Parameter Dependence
Shaw GJ, University of Cincinnati, Cincinnati, OH
EMF-3‡
Inhibition of Trx Nitrative Modification as a Means of Attenuating
Myocardial Ischemia/Reperfusion Injury in a Diabetic Model
Lau WB, Thomas Jefferson University, Lansdale, PA
See page S116
327ⴱ
Correlation of ␤-hCG and Ultrasound Diagnosis of Ectopic
Pregnancy in the Emergency Department
Bloch AJ, MCG, Augusta, GA
328ⴱ
Thromboembolic Events During Venous Compression Ultrasound
of the Lower Extremity in Patients With Deep Venous Thrombosis
Adhikari S, University of Nebraska Medical Center, Omaha,
NE
329
Bedside Urinary Bladder Duplex Ultrasonography for the Detection
of Obstructing Ureteral Calculi in the Emergency Department
Chin E, University of California, Irvine Medical Center,
Orange, CA
Infectious Diseases
330
Antibiotic Prescription by Emergency and ICU Physicians in
Patients Admitted to the Intensive Care Unit With the Diagnosis
of Septic Shock
Capp R, Massachusetts General Hospital, Boston, MA
331†ⴱEMF Prospective Randomized Trial of Trimethoprim-Sulfamethoxazole
vs Placebo on 30-Day Recurrence Rates for Uncomplicated Skin
Abscesses in Patients at Risk for Community-Acquired MethicillinResistant Staphylococcus aureus Infection: An Interim Analysis
Schmitz GR, Wilford Hall Medical Center, San Antonio, TX
332ⴱ
A Survey of Provider Opinions Regarding Implementing Rapid HIV
Testing in the Emergency Department of a Safety Net Hospital
Schechter-Perkins E, Boston University School of Medicine,
Boston, MA
333
Screening Strategies for Early Identification of Spine Infections in
Patients Presenting to Emergency Departments With Severe Back or
Neck Pain
Shroyer SR, Greater San Antonio Emergency Physicians,
San Antonio, TX
EMF-4‡
Regulation of the Neuronal Taurine Transporter Protein
Reese A, Wright State University, Dayton, OH
See page S117
334
EMF-5‡
Combination Therapy for Ischemic Brain Injury After Cardiac
Arrest
Lagina A, Wayne State University, Detroit, MI
See page S117
A Two-Year Experience of Patients Receiving Non-Occupational
Post-Exposure Prophylaxis Against HIV in a NYC Emergency
Department
Egan D, St. Luke’s Roosevelt Hospital Center, New York, NY
335EMF
Double-Blind, Randomized, Controlled Multi-Center Trial of
Antibiotic Treatment for Uncomplicated Skin Abscesses in Patients
at Risk for Community-Acquired Methicillin-Resistant
Staphylococcus aureus Infection: An Interim Analysis
Olderog CK, Brooke Army Medical Center, San Antonio, TX
336
Respiratory Syncytial Virus Is Not Protective of Urinary Tract
Infections in Febrile Infants Less Than 90 Days Old
Muñiz AE, The University of Texas Health Sciences Center
at Houston, Houston, TX
337
Significant Bacterial Infections in Febrile Children Less Than 2
Years of Age With Influenza A
Muñiz AE, The University of Texas Health Science Center at
Houston, Houston, TX
Imaging 1 (Ultrasound)
320ⴱ
Asepsis in Ultrasound-Guided Central Venous Access: A New
Technique
Jain A, University of Rochester, Rochester, NY
321
Out-of-Hospital Critical Care Providers’ Retention of Ultrasound
Skills for Diagnosis of Pneumothoraces: A Nine-Month Follow-Up
Walton P, Medical College of Georgia, Augusta, GA
322ⴱ
Rate and Outcome of First Trimester Indeterminate Pelvic
Ultrasounds in an Urban Emergency Department
Phillips C, Washington Hospital Center, Washington, DC
323ⴱ
Technical and Interpretive Error Rates for the Focused Assessment
With Sonography in Trauma Exam
Montoya AM, University of Massachusetts Medical School,
Worcester, MA
338
The Significance of the Wall Echo Shadow Triad on
Ultrasonography in Emergency Department Patients
Singla A, New York Hospital Queens, Flushing, NY
Emergency Medicine Versus Pediatric Emergency Medicine
Physicians in the Management of Febrile Infants ⬍ 1 Month of Age
Muñiz AE, The University of Texas Health Science Center at
Houston, Houston, TX
339
Characteristics of Patients Undergoing Rapid HIV Testing in a
NYC Emergency Department
Egan D, St. Luke’s Roosevelt Hospital Center, New York, NY
324ⴱ
325
Access to Immediate Bedside Ultrasound in the Emergency
Department
Talley B, Denver Health Medical Center, Denver, CO
326
Ultrasound of the Inferior Vena Cava Can Assess Volume Status in
Pediatric Patients
Ayvazyan S, Maimonides Medical Center, Brooklyn, NY
Volume , .  : September 
Informatics
340
Automated Referral for Elevated Blood Pressure Has No Impact on
Patient Knowledge of Referral
Robinson JA, Wilford Hall Medical Center, San Antonio, TX
Annals of Emergency Medicine 13A
Research Forum Educational Program 2009
TUESDAY, OCTOBER 6—cont’d
341
Change in Staff Opinions After Initiation of Emergency
Department Full Electronic Health Record
Norton RL, Oregon Health & Science University, Portland,
OR
342
Two Troponins: Defining and Characterizing a Resource-Intensive
Emergency Department Cohort Using a Clinical Datamart
Genes N, Mount Sinai School of Medicine, New York, NY
343ⴱ
Emergency Department Information System Adoption in the
United States
Landman AB, Yale University, New Haven, CT
344
Impact of the Implementation of an Electronic Hand-Off Tool on
Patient Safety and Clinician Satisfaction in an Academic Emergency
Department
Little JH, Maine Medical Center, Portland, ME
345†
Development of a Technology for the Estimation of ScVO2 in
Individual Patients
Summers RL, University of Mississippi Medical Center,
Jackson, MS
346
Usability Comparison of 9 Methods of Preparing Patient Discharge
Instructions and Prescriptions
Nielson JA, Summa Health System, Akron, OH
347
Performance of a Chief Complaint Classifier for Syndromic
Surveillance for Three Gastrointestinal Sub-Syndromes
Cochrane DG, Morristown Memorial Hospital, Kinnelon, NJ
348†
Assessing the Satisfaction of Emergency Department Patients Who
Used PatientTouch™ to Provide a Medical History Prior to
Physician Contact
Arora S, Keck School of Medicine of USC, Los Angeles, CA
358ⴱ
Electrocardiographic Changes in Spontaneous Intracerebral
Hemorrhage
Jain A, University of Rochester, Rochester, NY
Toxicology & Pharmacology
359
Stonefish Envenomation Presenting to a Singapore Hospital
Ngo AS, Singapore General Hospital, Singapore, Singapore
360
A Prospective, Randomized, Double-Blind, Placebo-Controlled
Trial to Evaluate 4% Liposomal Lidocaine Cream on Pain and
Anxiety During Venipuncture in Pediatric Patients Who Present to
the Emergency Department
Boucher J, Lehigh Valley Hospital, Allentown, PA
361
Medication Errors Occurring in Fomepizole Administration
Wong S, University of Texas Southwestern Medical Center,
Dallas, TX
362
Coagulopathy in Pediatric Copperhead Snakebites
Anderson BW, Washington University School of Medicine,
St. Louis, MO
363
Obese Dosing Adjustments for Selected Antimicrobials in the
Emergency Department
Fuentes JM, Washington University School of Medicine in
St. Louis, St. Louis, MO
364
Acid Base Status as a Predictor of Severity in Salicylate Toxicity
Levine M, Banner Good Samaritan Medical Center, Phoenix,
AZ
365
Fatal Toxicity from Nucleoside Reverse Transcriptase Inhibitor Use:
Factors Implicated With Symptomatic Hyperlactemia Emergencies
Leung L, Mount Sinai School of Medicine, New York, NY
366†
Clinical Experience of Continuous Renal Replacement Therapy as
an Extracorporeal Elimination Performed by Emergency Physicians
in Patients With Poisoning
Park E, Ajou University Medical Center, Suwon, Kyoung-Gi
Do, Republic of Korea
Neurology
349
Serum Interleukin-6 as a Marker of Functional Outcome After
Acute Ischemic Stroke
Stead LG, University of Rochester, Rochester, NY
350
Circulating Levels of Pro-Inflammatory Cytokines After Acute
Ischemic Stroke as Markers of Stroke Severity
Stead LG, University of Rochester, Rochester, NY
367
Are Venous Carboxyhemoglobin Levels Being Utilized by
Physicians?
Fiesseler F, Morristown Memorial Hospital, Morristown, NJ
351
Association of Interleukin 1b and Volume of Acute Ischemic Infarct
on Magnetic Resonance Imaging
Stead LG, University of Rochester, Rochester, NY
368
Diphenhydramine Increases Lethality in a Porcine Model of
Intravenous Rattlesnake Envenomation
Sekhon N, Brody School of Medicine, Greenville, NC
352
Relationship Between Early Blood Pressure Parameters and
Intraventricular Extension After Emergency Department
Presentation for Intracranial Hemorrhage
Stead LG, University of Rochester, Rochester, NY
369
See page 5A
353
354
355ⴱ
Number of Headache Patients/Day in New York City Public
Hospitals: Relation to Time, Weather, Air Pollution and Economic
Variables
Low RB, New York City Health and Hospitals, New York, NY
Relationship Between Ambient Temperature and Emergency
Department Visits for Headaches
Gee SW, Morristown Memorial Hospital, Morristown, NJ
Anti-Coagulant, Anti-Platelet Use in Intra-Cerebral Hemorrhage
Patients: Does Reversal of International Normalized Ratio Translate
to Improved Outcome?
Jain A, University of Rochester, Rochester, NY
2:30 - 3:30 PM
Poster Session 6
Cardiology
370
Coronary CT Angiography Versus Stress Testing in Predicting
Long-Term Adverse Events: Two-Year Follow-Up of a Randomized
Controlled Trial
O’Neil BJ, Wayne State University, Detroit, MI
371
Prognostic Importance of Elevated Cardiac Troponin-t in Patients
With Acute Supraventricular Tachycardia
Marinsek M, Celje General Hospital, Celje, Slovenia
372ⴱ
Initial Troponin as a Predictor of Adverse Outcome in Patients
With Syncope
Serrano LA, Mayo Clinic, Rochester, MN
356ⴱ
Do Not Resuscitate Orders in Spontaneous Non-Traumatic IntraCerebral Hemorrhage: What Is the Difference?
Jain A, University of Rochester, Rochester, NY
373ⴱ
Electrocardiographic Intervals and One-Year Cardiovascular
Outcomes in Syncope
Serrano LA, Mayo Clinic, Rochester, MN
357ⴱ
The Mayo ICH Score: Evaluating Patients With Non-Traumatic
Intra-Cerebral Hemorrhage
Jain A, University of Rochester, Rochester, NY
374ⴱ
Prospective Observational Trial of Carotid Intima-Media Thickness
in the Evaluation of Patients With Acute Chest Pain
Khan T, NY Methodist Hospital, Brooklyn, NY
14A Annals of Emergency Medicine
Volume , .  : September 
Research Forum Educational Program 2009
TUESDAY, OCTOBER 6—cont’d
375†
Using a Rapid Cardiac Disposition Protocol to Improve Patient
Flow
Birkhahn R, New York Methodist Hospital, Brooklyn, NY
376†EMF
Evaluation of a Heart Failure Mortality Prediction Model for PostDischarge Outcomes
Hiestand BC, The Ohio State University, Columbus, OH
392
Can Total and Motor Glasgow Coma Scale Predict Mortality in
Penetrating Trauma?
Duemling KE, St. John Hospital and Medical Center, Detroit,
MI
Education
Diagnosis/Treatment
ⴱ
377
Characteristics of Waiting Patients With Abrupt Deterioration in
the Emergency Department
Ode Y, Juntendo University Urayasu Hospital, Urayasu City,
Japan
378
Diverticulitis in Taiwan: A Different Story to Western Countries
Liu C, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
379ⴱ
OB/GYN Emergencies in the Emergency Department: Ovarian
Torsion
Walker TN, New York Presbyterian Hospital, New York, NY
380
381
Blatchford Clinical Risk Stratification Score May Be Used in an
Observation Unit Setting to Risk Stratify Patients With
Gastrointestinal Bleeding
Chandra A, Duke University Medical Center, Durham, NC
Erythrocyte Sedimentation Rate Compared to C-Reactive Protein as
a Screening Marker of Inflammation in the Emergency Department
Vilke GM, University of California, San Diego, San Diego, CA
382
Glycemic Control Is Improved in Emergency Department Patients
With an Identifiable Primary Care Provider
Horwitz D, Washington University, St. Louis, MO
383
To Scan or Not to Scan: Predicting Appendicitis in Adult and
Pediatric Patients
Melville LD, New York Methodist Hospital, Brooklyn, NY
384ⴱ
Symptom Recurrence and Biphasic Reactions in Patients Presenting
to the Emergency Department With Anaphylaxis
Manivannan V, Mayo Clinic, Rochester, MN
393
Objective Structured Clinical Examination Performance Versus
Faculty Evaluation of Resident Performance
Shih RD, Morristown Memorial Hospital, Morristown, NJ
394
A Prospective Study of Cardiopulmonary Resuscitation Training in
7th Grade Students Using a Take-Home Self-Instruction
Cardiopulmonary Resuscitation Kit
Faccio K, Lehigh Valley Hospital, Allentown, PA
395
Bedside Teaching in an Academic Emergency Department
Beckmann B, Brooke Army Medical Center, San Antonio, TX
396
Repetitive Questions in the Emergency Department: Patients’
Perspectives
Ha J, University of Toledo College of Medicine, Toledo, OH
397
Code-Blue as a Teaching Moment: Re-Evaluation of Medical
Student Experiences Following Curriculum Changes
Milzman DP, Georgetown University School of Medicine/
Georgetown WHC EM Residency, Washington, MD
398
Sports Medicine Fellowship Training for Emergency Medicine
Residency Graduates: Interest, Availability and Practice: A Niche
Not Being Filled
Milzman DP, Georgetown University School of Medicine,
Washington, DC
EMF-6‡
The EMCAPs Training Method for Procedural Competency Among
Emergency Medicine Residents
Van Roo J, Northwestern University, Chicago, IL
See page S144
EMF-7‡
The Northwestern University Rotating Resident Curriculum: A
Novel Web-Based Didactic Program for Rotating Residents in the
Emergency Department
Branzetti J, Northwestern University, Chicago, IL
See page S144
Disaster/Nuclear, Biological, or Chemical Event
385
Implementing an Electronic Point-of-Care Medical Record at an
Organized Athletic Event: Challenges, Pitfalls and Lessons Learned
Wells HJ, Maine Medical Center, Portland, ME
386
Accuracy of EMS Identification of ST-Elevation Myocardial
Infarctions and Its Effect on Door-to-Balloon Time
Ardolic B, Staten Island University Hospital, Staten Island,
NY
387†
Evaluation of Time Required for Water-Only Topical
Decontamination of an Oil-Based Agent
Moffett P, Madigan Army Medical Center, Tacoma, WA
388ⴱ
Imaging Utilization During Explosive Multiple Casualty Incidents
Raja AS, The 445th Aeromedical Staging Squadron, WrightPatterson Air Force Base, Dayton, OH
389
A Mass Medication Distribution Emergency Response Exercise
Using Vaccination, Not Simulation
Martens KA, Loyola Medicine, Maywood, IL
390
In a Major Disaster, How Do You Allocate Hospital Resources?
Messman A, St. John Hospital and Medical Center, Detroit,
MI
391
The Impact of Emergency Department Size on Pandemic Influenza
Preparedness in US Emergency Departments
Morton MJ, Johns Hopkins University School of Medicine,
Baltimore, MD
Volume , .  : September 
Injury Prevention 1 (Intentional)
399
Improving Coordinated Responses for Victims of Intimate Partner
Violence: Law Enforcement Compliance With State Mandated
Intimate Partner Violence Documentation
Edwardsen EA, University of Rochester, Rochester, NY
400ⴱ
Predictors of Being Unsafe to Answer Intimate Partner Violence
Screening Questions: Findings From the Behavioral Risk Factor
Surveillance System 2006
Ranney M, Rhode Island Hospital/Brown University,
Providence, RI
401ⴱ
The Correlation Between Adolescent-Reported Parental Driving
Behaviors and Observed Adult Driving Behaviors
Murphy S, Lehigh Valley Hospital, Allentown, PA
402
TXT Rx: Using Health Information Technology to Safely Discharge
Suicidal Patients From the Emergency Department
Larkin G, Yale University, New Haven, CT
403
College Student Alcohol Screening and Outcome From AlcoholRelated Injury and Illness: Longitudinal Study of Campus Alcohol
Problem
Ybarra MP, Georgetown University School of Medicine/
Georgetown WHC EM Residency, Washington, DC
Annals of Emergency Medicine 15A
Research Forum Educational Program 2009
TUESDAY, OCTOBER 6—cont’d
Pain Management
404
Hyaluronidase-Enhanced Subcutaneous Hydration and Opioid
Administration for Sickle Cell Disease Acute Pain Episodes
Sandoval M, Beth Israel Medical Center, NY
405†
Prophylactic Etoricoxib Prevents Yom Kippur Headache: A PlaceboControlled Double Blind Trial
Drescher MJ, Hartford Hospital/University of Connecticut,
Hartford, CT
406
Transbuccal Fentanyl for Rapid Relief of Orthopedic Pain in the
Emergency Department
Nelson SW, Brigham and Women’s and Massachusetts
General Hospital, Boston, MA
420ⴱ
Clinical Features of Fitz-Hugh-Curtis Syndrome and Length of the
Emergency Department Stay
Moon S, Korea University, Ansan City, Kyunggido, Republic
of Korea
421
Self-Removal of Sutures by Emergency Department Patients
Albert M, Michigan State University College of Human
Medicine, Grand Rapids, MI
422ⴱ
A Comparison of Rates of Emergency Department and Observation
Unit Adverse Drug Events
Chandra A, Duke University Medical Center, Durham, NC
423
Variation in the Practice of Emergency Department Handoffs
Cheung DS, Carepoint, Denver, CO
407†
Pain Management during Intraosseous Infusion Through the
Proximal Humerus
Philbeck T, Vidacare Corporation, San Antonio, TX
424EMF
Association Between Length of Emergency Department Boarding,
Mortality and Length of Hospital Stay
Singer AJ, Stony Brook University, Stony Brook, NY
408ⴱ
Randomized Double-Blind Placebo-Controlled Trial Comparing
Room Temperature and Heated Lidocaine for Local Anesthesia and
Digital Nerve Block
Papa MK, Sri Ramchandra Medical College & Research
Institute, Chennai, India
425
Physican Sex Bias in Evaluating Emergency Department Patients
With Chest Pain: A Pilot Study
Wilkie L, Stony Brook University, Stony Brook, NY
426
Strangulation in Sexual Assault
Sun M, UCLA Emergency Medicine, Los Angeles, CA
409ⴱ
410
The Efficacy and Adverse Events of Morphine Versus Fentanyl on a
Physician-Staffed Helicopter
Smith MD, MetroHealth Medical Center, Cleveland, OH
Public Health
427†
An Emergency Department Intervention for Tobacco Cessation
Among Patients and Visitors Utilizing Pre-Health Professional
Students as Research Associates
Bradley K, St. Vincent’s Medical Center, Bridgeport, CT
428
Child Car Seat Safety Knowledge Among Caregivers in Puerto Rico:
Is More Education Needed?
Martinez Martinez CJ, University of Puerto Rico Emergency
Medicine Residency, Carolina, PR
The Routine Use of Local Anesthetics in Pediatric Lumbar
Punctures: Are We There Yet?
Gorchynski JA, JPS Health Network, Fort Worth, TX
Pediatrics
411ⴱ
Correlation of Pediatric Asthma Severity Score and End Tidal CO2
Values With Asthma Severity in the Pediatric Population
Dhillon RK, Mayo Clinic, Rochester, MN
429
412
An Observational Study of Cutaneous Abscess Management in a
Pediatric Emergency Department Setting
Ramirez J, Orlando Health: Arnold Palmer Hospital for
Children, Orlando, FL
Demographic and Clinical Variables Associated With Follow-Up of
Emergency Department Patients at Federally Funded Clinics:
Metropolitan-Wide Survey Pilot Data
Dziuba D, Washington University, St. Louis, MO
430
413ⴱ
Assessing Competency of the Broselow-Luten Pediatric
Resuscitation Tape: A Prospective, Cross Sectional, Analytical Study
of 15,000 South Indian School Children
Cattamanchi S, Sri Ramchandra Medical College &
Research Institute, Chennai, India
The SAVED Study: A Six-Year Consecutive Review of Factors
Associated With Loss of Consciousness Among Sexual Assault
Survivors in the Emergency Department
O’Donnell MB, North Shore University Hospital, Manhasset,
NY
431ⴱ
414
Pacifier Use for SIDS Prevention: Extent of Caregiver Awareness
and an Educational Intervention
Vieth TL, Kern Medical Center, Bakersfield, CA
Describing the Characteristics of Non-Border Patient Populations
That Utilize Cross Border Health Services
Arora S, Keck School of Medicine of USC, Los Angeles, CA
432ⴱ
415
Does Inferior Vena Cava/Aorta Ratio Correlate With Fluid Therapy
in Clinically Dehydrated Children?
Barata I, North Shore University Hospital, Manhasset, NY
Comparison of the Health Care Utilization of Resettled Hurricane
Katrina Victims
Okafor N, University of Texas - Health Science Center at
Houston, Houston, TX
416
Ambulatory Prescription Errors in a Pediatric Emergency Department
Place R, Inova Fairfax Hospital, Falls Church, VA
433
417
Cardiovascular Abnormalities Among Children Presenting With Chest
Pain to a Community Hospital and Compliance to Follow-Up
Kondamudi N, The Brooklyn Hospital Center, Brooklyn, NY
A Health Needs Assessment Conducted at the Kausay Wasi Clinic
in Coya, Peru
Arora S, Keck School of Medicine of USC, Los Angeles, CA
434
Parental Expectation to Receive Anti-Tussive Medications for Their
Coughing Children Presenting to the Emergency Department:
Impact on Satisfaction
Kondamudi N, The Brooklyn Hospital Center, Brooklyn, NY
Describing Prevalence, Health and Demographics of Emergency
Department Patients With Diabetes
Arora S, Keck School of Medicine of USC, Los Angeles, CA
Respiratory 1 (Airway)
418
435
Changes in Emergency Department Airway Management Over the
Last 12 Years
Sakles JC, University of Arizona, Tucson, AZ
436
Time to Successful Intubation Has a Similar Correlation to Hypoxia
as Number of Attempts in Rapid Sequence Intubation
Hill C, Hennepin County Medical Center, Minneapolis, MN
Practice Management
419
Work-Induced Memory Decline in Emergency Medicine Attending
Physicians
Machi MS, University of Pittsburgh, Pittsburgh, PA
16A Annals of Emergency Medicine
Volume , .  : September 
Research Forum Educational Program 2009
TUESDAY, OCTOBER 6—cont’d
437ⴱ
Glottic View Using Direct and Glidescope® Laryngoscopes in the
Hands of Emergency Physicians
Drigalla D, Scott & White Memorial Hospital, Temple, TX
450
Factors Affecting Time to Head CT in Trauma Patients With
Intracerebral Hemorrhage
Owen K, University of California Davis, Sacramento, CA
438ⴱ
Successful Endotracheal Intubation by Experienced Emergency
Physicians Using Direct and Glidescope® Laryngoscopes
Drigalla D, Scott & White Memorial Hospital, Temple, TX
451
Beta-adrenergic Blockade Prevents Myocardial Oxidative Stress Due
to Traumatic Brain Injury
Larson B, University of Vermont, Burlington, VT
439
Effects of Emergent Intubation on Heart Rate Using Three
Different Medication Regimens for Rapid Sequence Intubation:
A Retrospective Video Review
Hill C, Hennepin County Medical Center, Minneapolis, MN
452
Continuous Out-of-Hospital Vital Signs Acquisition Improves
Trauma Triage
Sen A, Henry Ford Hospital, Detroit, MI
453ⴱ
The Efficacy of Factor VIIa in Emergency Department Patients
With Warfarin Use and Traumatic Intracranial Hemorrhage
Nishijima DK, UC Davis Medical Center, Sacramento, CA
454
Serum Lactate Is Not Predictive of Major Injuries in Pediatric Blunt
Trauma
Muñiz AE, The University of Texas Health Science Center at
Houston, Houston, TX
455
The Prevalence and Prognostic Value of Hyperglycemia and
APACHE II Scores Among Adult Sepsis Patients in the Emergency
Department
D’Amore J, North Shore University Hospital, Manhasset, NY
440
Out-of-Hospital Intubations: Are Patients Well Ventilated on
Emergency Department Arrival?
Peng JS, UC Davis Medical Center, Sacramento, CA
Resuscitation
441ⴱ
442
443
Comparison of Chest Compression Quality Between the Floor and
the Bed Using Backboard
Jang J, Chung-Ang University Hospital, Seoul, Republic of
Korea
Alpha (2B)-Adrenergic Receptor Gene Polymorphism and the
Response to Epinephrine in Cardiopulmonary Resuscitation
Rivas F, Instituto Mexicano del Seguro Social, Guadalajara,
Mexico
Feasibility of Intraosseous Infusion of Iced Saline to Induce
Therapeutic Hypothermia After Cardiac Resuscitation
Walterscheid JK, Baystate Medical Center/Tufts University
School of Medicine, Springfield, MA
444
Intraosseous Infusion of Crystalloid Fluid Immediately After
Intraosseous Infusion of Nitroglycerin in the Proximal Tibia of a
Swine (Sus Scrofa) Model
Miller J, Wilford Hall Medical Center, San Antonio, TX
445ⴱ
Out-of-Hospital Cardiac Arrest: Are We Getting Our Money’s Worth?
Sasson C, University of Michigan, Ann Arbor, MI
446
ECG Analysis in Accidental Urban Hypothermia
Urdang MS, Los Angeles County ⫹ USC Medical Center,
Los Angeles, CA
447
Metabolic Profiles, Coagulopathy and Survivorship in Accidental
Urban Hypothermia
Shoenberger JM, Los Angeles County ⫹ USC Medical
Center, Los Angeles, CA
Trauma
448
Utility of Computed Tomography of the Thorax, Abdomen and
Pelvis in Patients Presenting After Ground-Level Falls
Marynowski M, Allegheny General Hospital, Pittsburgh, PA
449ⴱ
Identification of Occult Shock Using Out-of-Hospital Lactate
Guyette F, University of Pittsburgh, Pittsburgh, PA
Volume , .  : September 
TUESDAY, OCTOBER 6, 2009
4:00 - 5:30 PM
Cutting Edge: Highlights of Emergency Medicine Research
Moderator: Brian J. O’Neil, MD, FACEP
Panelists: Charles B. Cairns, MD, FACEP; Debra E. Houry,
MD, MPH, FACEP; Ian G. Stiell, MD; and
Donald M. Yealy, MD, FACEP
A panel of experts will focus on the most interesting
abstracts of Research Forum and the take-home
message for practitioners and researchers alike. No
badge or ticket is required to attend this event.
†
In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and the policy of the American College of Emergency
Physicians, the presenters noted with an (†) have indicated they have a relationship
which, in the context of their presentation, could be perceived by some as a real or
apparent conflict of interest (eg, ownership of stock, honoraria, or consulting fees),
but these presenters do not consider that it will influence their presentations.
EMF
Supported by an Emergency Medicine Foundation grant.
*Young Investigator.
‡
These abstracts were recategorized after acceptance.
Annals of Emergency Medicine 17A
INDEX OF PRESENTERS
Abello A, 311
Acosta JF, 163
Adhikari S, 180, 216, 283, 328
Aguilera P, 176, 179
Akpunonu P, 120
Albert M, 421
AlDarrab A, 11
Allegra JR, 178, 297
Anderson BW, 362
Ardolic B, 386
Arora S, 348, 431, 433, 434
Ayvazyan S, 326
Babcock C, 30
Banala SR, 129
Bank DE, 13
Baquero A, 53
Barata I, 415
Barcomb T, 32
Barlas D, 33, 102
Barrett TW, 1
Bastani A, 24, 233
Battista S, 86
Bauman MJ, 278
Baumann MR, 227
Beatty N, 68
Bebarta VS, 191
Beckmann B, 395
Bellolio M, 232
Bennett CJ, 100
Berios I, 107
Bhakta NS, 57
Bigler JB, 282
Birkhahn R, 242, 375
Black A, 247
Bloch AJ, 327
Bloch RB, 40
Boeke P, 198
Borquez EA, 144
Boucher J, 360
Bradley K, 427
Branzetti J, EMF-7
Brook C, 12
Bryce SN, 257
Burger C, 295
Burton J, 69
Calderon Y, 54
Camargo CA, 275
Campo C, 156
Capp R, 330
Carpenter CR, 260, 263
Castillo EM, 250
Cattamanchi S, 413
Chan TC, 310
Chan W, 116
Chan Y, 230
Chandra A, 177, 238, 380, 422
Chandra S, 231
Cheung DS, 423
Chin E, 329
Cho YD, 123
Chohan JK, 132
Choi M, 305
Choi S, 296
Cienki JJ, 90
Cochran AM, 96
Cochrane DG, 347
Cook D, 219
D’Amore J, 455
Dailey M, 252
Damewood S, 146, 224
Das A, EMF-2
Das D, 31
Davis JE, 112
Davis V, 133
De Lorenzo RA, 316
Delgado MK, 61
Dhillon RK, 293, 411
Dhillon RJ, 80
Drescher MJ, 405
Drigalla D, 437, 438
Dubin J, 55
Duemling KE, 392
Duseja R, 211
Dziuba D, 429
Eadeh H, 137
Easter B, EMF-1
Eberhardt M, 301
Edwardsen EA, 399
Egan D, 334, 339
Faccio K, 394
Faig O, 70
Farley HL, 27, 168, 308
Felderman H, 114, 115
Ferre C, 119
Fertel BS, 5
Fiesseler F, 367
Fuentes JM, 363
Gabayan GZ, 208
Garman A, 101
Garra G, 138
Garro A, 50
Gee SW, 354
Genes N, 342
Gilmer M, 226
Ginde AA, 240
Givens ML, 302
Glickman S, 4, 312
Goo R, 135
Gorchynski JA, 410
Gottesman B, 128
Green J, 6, 266
Greene T, 103
Greenfield EM, 201
Griffey RT, 265
Groke S, 29, 148
Gross T, 93
Gupta S, 60
Guyette F, 449
Volume , .  : September 
Ha J, 396
Hahn B, 49
Hakmeh W, 287
Hall MK, 279
Handel DA, 167, 243, 304
Hansen AV, 223
Hansen KN, 212
Hariharan P, 71
Harper JB, 124, 194
Hawkins D, 85
Heidt JW, 259
Heins A, 58, 162
Hendry D, 174
Hermann LK, 23
Hexom B, 155
Hiestand BC, 376
Hile D, 185
Hill CH, 64, 436, 439
Hlibczuk V, 95
Ho JD, 127
Holm M, 281
Holt S, 173
Hong AL, 251
Horwitz D, 382
House H, 207
Howard Z, 196
Hsia RY, 271
Imamura T, 121
Irvin MM, 78
Jain A, 320, 355, 356, 357, 358
Jang J, 441
Jeanmonod R, 82
Johnson KA, 205
Kairam N, 288
Katz GR, 307
Khan T, 374
Kiebel W, 98
Kiefer CS, 26
Kim D, 292
Kim J, 273
Kim S, 73
Kimberly H, 277
Klope JL, 149
Kondamudi N, 291, 417, 418
Kott I, 264
Krieg C, 300
Ladde J, 134, 269
Lagina A, EMF-5
Lamba S, 165
Landman AB, 343
Larkin G, 402
Larson B, 451
Lau WB, EMF-3
Lee J, 309
Leung L, 365
Lev R, 274
Levine AC, 289
Levine M, 364
Lewis L, 164, 213
Lim T, 313, 314
Limkakeng AT, 161
Lindor RA, 39
Lipe KM, 186
Liteplo AS, 217
Little JH, 344
Liu C, 378
Liu SW, 214
Lobon LF, 17
Losek JD, 47
Low RB, 353
Lundin EJ, 315
Ly S, 67
Lynch CA, 126
Lyng J, 74
Lyon M, 222, 284
Mace SE, 171, 172
Machi MS, 419
Maekawa K, 298
Mahadevan SV, 254
Mahler SA, 81
Manivannan V, 384
Marinsek M, 371
Martens KA, 389
Martinez Martinez CJ, 428
Marynowski M, 448
Matthews P, 246
McGrath ME, 117
Meisel ZF, 248, 249
Mejia J, 44
Melville LD, 383
Menchine M, 184
Messman A, 390
Miller A, 92
Miller J, 444
Milzman DP, 397, 398
Miner JR, 150
Mir M, 290
Mirhadi M, 83
Miyashiro R, 197
Moffett P, 387
Montoya AM, 323
Moon S, 420
Mori K, 72
Morley EJ, 136
Morris DF, 189
Morton MJ, 391
Moskowitz A, 229
Mostofi M, 169
Muñiz AE, 336, 337, 338, 454
Murphy S, 401
Myers LA, 110, 200
Nagata T, 125
Napoli A, 34, 35
Nelson BP, 106
Nelson SW, 406
Ngo AS, 139, 359
Nibhanipudi KV, 285
Nielson JA, 346
Annals of Emergency Medicine 19A
Index of Presenters
Nishijima DK, 453
Niska RW, 18
Nomura JT, 104
Norton RL, 341
O’Donnell MB, 430
O’Laughlin KN, 190
O’Neil BD, 369
O’Neil BJ, 370
O’Neill R, 76
Ode Y, 377
Okafor N, 432
Olderog CK, 335
Oostema A, 84
Oosterhouse T, 99
Owen K, 450
Papa MK, 408
Park E, 77, 366
Patanwala A, 140
Patyrak S, 188
Pazin-Filho A, 21, 22, 63
Peacock W, 2, 20, 88
Peng JS, 440
Phanthavady T, 37
Phelan MP, 56
Phelan T, 183
Philbeck T, 193, 407
Phillips C, 322
Pines JM, 239
Place R, 236, 416
Platz E, 280
Plonk T, 160
Prekker ME, 151
Rabin E, 267
Raja AS, 28, 388
Ramirez J, 412
Ranney M, 400
Ravikumar D, 206
Rechtin C, 294
Reese A, EMF-4
Richardson D, 143
Richerson PJ, 9
Rivas F, 442
River G, 276
Roberts RR, 272
Robinson JA, 340
Romero K, 118
Rothschild JM, 142
Rubal BJ, 317
Rumoro D, 170
Rusczyk G, 45
Russell S, 48
Saef SH, 10
Sakles JC, 435
Salvucci AA, 202
Sandoval M, 404
Sarsfield MJ, 286
Sasson C, 445
Sattarian M, 14
Saul T, 220
Sayah A, 166
Schechter-Perkins E, 332
Schmitz GR, 331
Schroeder JW, 159
Schuur J, 16, 241
Sciorra D, 154
Scott S, 157
Sekhon N, 368
Sen A, 91, 215, 306, 452
Serrano LA, 372, 373
Shah K, 235, 262
Shah S, 175
Shaw GJ, 319
Shearer P, 153
Sherwin R, 181
Shih RD, 393
Shimizu T, 299
20A Annals of Emergency Medicine
Shoenberger JM, 447
Shroyer SR, 333
Shukla KT, 210
Shum L, 65
Singer AJ, 158, 424
Singla A, 324
Sinha S, 43
Slattery DE, 182
Smith MD, 409
Smith SW, 25
Smulowitz PB, 268, 270
Starr GA, 109
Stead LG, 349, 350, 351, 352
Stein JC, 221
Stiffler KA, 15
Strout TD, 145
Su M, 253
Sullivan AF, 59
Summers RL, 345
Sun M, 426
Sunga KL, 94
Suozzi JC, 62
Suzuki M, 87
Swickhamer C, 261
Swor R, 203
Tadros A, 256
Taira BR, 79
Takakuwa KM, 38
Talley B, 325
Tanabe P, 41, 42
Tekwani K, 8
Thode HC, 46
Thomas LE, 225
Thompson K, 36
Tollefsen WW, 52
Toofan M, 204
Torbati S, 234
Tsai C, 3
Umezawa K, 255
Urdang MS, 446
Van Roo J, EMF-6
Van Tonder RJ, 51
Vélez I, 187
Venkat A, 97
Venkatesh A, 244
Veysman BD, 228
Vieth TL, 414
Vilke GM, 381
Virk PS, 122
Waldron R, 195
Walker TN, 379
Wall JJ, 152
Walters J, 245
Walterscheid JK, 443
Walton P, 321
Wang H, 318
Waseem M, 7, 131, 147
Watts S, 209
Weichenthal LA, 113
Weiner SG, 111
Wells HJ, 385
White BA, 237
Wiederhold H, 192
Wilkie L, 425
Wong EM, 258
Wong E, 66
Wong ML, 75
Wong S, 361
Wu TS, 105, 218
Yang A, 303
Ybarra MP, 403
You Y, 108
Zito JA, 19, 141
Volume , .  : September 
Research Forum Abstracts
From the American College of Emergency Physicians
2009 Research Forum
October 5-6, 2009
Boston Exhibition and Convention Center, Hall B2
The presenting author’s name is listed in italic type.
Volume , .  : September 
1
A Clinical Prediction Model to Estimate Risk for 30-Day
Adverse Events in Emergency Department Patients With
Symptomatic Atrial Fibrillation
Barrett TW, Martin AR, Storrow AB, Jenkins CA, Russ S, Darbar D/Vanderbilt
University Medical Center, Nashville, TN
Study Objectives: One percent of all emergency department (ED) visits are
related to atrial fibrillation and 70% of these patients are admitted. Our objective was
to develop a clinical prediction model that would predict 30-day adverse outcomes in
patients presenting to the ED with symptomatic atrial fibrillation. We hypothesized
that data available within the first 2 hours of ED management can assess a patient’s
risk of experiencing an adverse event within 30 days of their ED visit.
Methods: In this retrospective cohort study, we systematically reviewed the
electronic medical records of all ED patients presenting with atrial fibrillation
between August 2005 and July 2008 at an urban academic medical center. We
defined symptomatic atrial fibrillation as patients with a new or established diagnosis
of atrial fibrillation or atrial flutter that required ED evaluation for a complaint
thought related to their rhythm disturbance. The predetermined adverse outcome
measures included failing to achieve successful ventricular rate control (pulse less than
100 bpm) at time of ED disposition; 30-day ED return visit for an atrial fibrillationrelated complaint; 30-day hospital admission for an atrial fibrillation-related
complaint; 30-day cardiovascular complication, and patient death secondary to an
atrial fibrillation-related problem. We selected 12 predictor variables for inclusion in
the model based on clinical relevance and review of baseline descriptive statistics. We
performed a proportional odds logistic regression analysis and validated the model
using 150 bootstrap replications. We calculated the c index, which generalizes area
under the receiver operator curve, to test the model’s predictive ability.
Results: During the 3-year study period, 914 patients accounted for 1228 ED
visits. We included only the patient’s first ED visit in the analysis and 80 patients
were excluded for non-atrial fibrillation related complaints. The median age was 68
years, 46% were male and 77% were admitted. New atrial fibrillation was diagnosed
in 36%; 43% had paroxysmal atrial fibrillation and 21% had permanent atrial
fibrillation. Twenty-seven percent of patients had at least one of the 30-day atrial
fibrillation-related adverse events. The odds ratios and 95% confidence intervals for
the selected predictors impact on risk of 30-day adverse event in ED patients with
symptomatic atrial fibrillation are presented in the Table. The prediction model
showed that increasing age, higher ED maximum pulse rate, ED complaint of
dyspnea, cigarette smokers, and patients not taking outpatient digoxin were
independently associated with increased odds of higher risk for 30-day adverse events.
The model’s c-index was 0.75.
Conclusion: In patients presenting to the ED with symptomatic atrial fibrillation,
this study suggests that patients with increased age, smoking history, complaint of
dyspnea, higher maximum pulse rates in the ED and no home treatment with digoxin
are more likely to experience an atrial fibrillation-related adverse event within 30 days.
Annals of Emergency Medicine S1
Research Forum Abstracts
2
Early Objective Identification of Chest Pain Patients at Very
Low Risk of 30-Day Adverse Outcomes
Peacock IV W, Hoekstra J, Krucoff M, Diercks D, Fermann G, Clark C, Grines C,
Jois-Bilowich P/The Cleveland Clinic, Cleveland, OH; Wake Forest School of
Medicine, Winston-Salem, NC; Duke University, Durham, NC; University of
California, Davis, Sacramento, CA; University of Cincinnati, Cincinnati, OH;
William Beaumont Hospital, Royal Oak, MI; University of Florida, Gainsville, FL
Study Objectives: There are no objective early emergency department (ED) measures
that identify chest pain patients at sufficient low risk so that immediate discharge is
clinically reasonable. Our purpose was to determine if the combination of a normal
creatinine, negative troponin, and negative 80 lead ECG (PRIME ECG, Heartscape, Inc.,
Columbia, MD) could identify patients at very low risk for 30-day adverse events.
Methods: The Optimal Cardiovascular Diagnostic Evaluation Enabling Faster
Treatment of Myocardial Infarction (OCCULT-MI) trial was a multicenter prospective
observational study of moderate-to-high risk patients, ⬎39 years old, presenting to the
ED with chest pain or symptoms suspicious for acute coronary syndrome. Moderate-tohigh risk for adverse cardiovascular outcomes was defined as chest pain and either 1)
ischemic 12 lead ECG abnormalities, 2) known coronary artery disease, or 3) 3 or more
cardiac risk factors (diabetes, hypertension, current smoking, family history of coronary
artery disease, or hypercholesterolemia). Patients received simultaneous 12 lead and 80
lead ECGs as part of their initial evaluation, and were treated according to the standard of
care, with clinicians blinded to the 80 lead ECG results. For this analysis patients were
included if both troponin and creatinine levels were measured, and they received an 80
lead ECG in the ED. Endpoints were defined as death, myocardial infarction, or rehospitalization within 30 days of the index visit.
Results: OCCULT enrolled 1816 patients meeting all inclusion criteria. Patients were
excluded for elevated Tn (n⫽217, 11.9%) or a creatinine ⬎ 2.0 mg/dL (n⫽52, 2.9%),
leaving 1288 with evaluable 80 lead ECGs. Patients with abnormal 80 lead ECGs were
excluded for ST elevation (n⫽72, 5.6%), ST depression (n⫽19, 1.5%), and T wave
inversion (n⫽65, 5.0%). The remaining 1132 (87.9%) patients make up the analysis
cohort and had an 80 lead ECG without ST deviation or T wave inversion, an initial
troponin below the institutional myocardial infarction cutpoint, and a creatinine ⬍ 2.0
mg/dL. Overall, 36 (3.2%) of patients were lost to follow-up. The 30-day outcomes
included death in 5 (0.4%, 95% CI ⫽ 0.1 to 1.0), myocardial infarction in 9 (0.8%, 95%
CI ⫽ 0.3 to 1.5%), and re-hospitalization in 27 (2.4%, 95% CI ⫽1.6 to 3.4).
Conclusion: In patients at moderate to high risk of acute coronary syndromes,
the combination of a single initial negative troponin, the absence of renal
dysfunction, and a negative 80 lead ECG, identifies those for whom 30-day death
and myocardial infarction occur at very low rates. A prospective study is warranted.
3
Quality of Care for Acute Myocardial Infarction in 58 US
Emergency Departments
Tsai C, Magid DJ, Sullivan AF, Gordon JA, Kaushal R, Blumenthal D,
Camargo Jr CA/Department of Emergency Medicine, Massachusetts General
Hospital, Harvard Medical School, Boston, MA; Institute for Health Research,
Kaiser Permanente Colorado and the Departments of Emergency Medicine and
Preventive Medicine and Biometrics, University of Colorado Health Science
Center, Aurora, CO; Weill Medical College of Cornell University and New YorkPresbyterian Hospital, New York, NY; Department of Medicine, Massachusetts
General Hospital, Harvard Medical School, Boston, MA
Study Objectives: Little is known about quality of emergency department (ED)
care for patients with acute myocardial infarction (AMI). The objectives of the study
S2 Annals of Emergency Medicine
were (1) to determine concordance of ED management of AMI with 1996 American
College of Cardiology/American Heart Association (ACC/AHA) guidelines, and (2)
to identify ED characteristics predictive of higher guideline concordance.
Methods: We conducted a chart review study of AMI as part of the National
Emergency Department Safety Study. Using a primary hospital discharge diagnosis of
AMI (ICD-9 code 410.XX), we identified ED visits for AMI in 58 urban EDs across
20 US states between 2003 and 2006. Concordance with guideline recommendations
was evaluated using five individual quality measures (electrocardiogram within 10
minutes of ED arrival, aspirin use in the ED, ␤-blocker use in the ED, fibrinolytic
therapy within 30 minutes of ED arrival, and ED disposition for cardiac
catheterization or transfer within 60 minutes of ED arrival) and a composite
concordance score. Concordance scores were calculated as the percentage of eligible
patients with AMI who received guidelines-recommended care. Clinically indicated
deviations from guideline-recommended care were not counted as discordant (eg,
beta-blockers withheld for hypotension; aspirin withheld for bleeding). These
percentage scores were rescaled from 0 to 100, with 100 indicating perfect
concordance.
Results: The cohort consisted of 3,819 subjects; their median age was 65 years
and 62% were men. The mean ED composite concordance score was 60 (standard
deviation, 8), with a broad range of values (40 to 81). Except for aspirin use in the
ED (mean concordance, 82), ED concordance scores of other quality measures were
low (␤-blocker use, 54; timely electrocardiogram, 41; timely fibrinolytic therapy, 26;
timely ED disposition for cardiac catheterization or transfer, 43). A factor analysis
revealed two distinct clusters of AMI processes of care (use of medications [aspirin,
␤-blocker] vs. the 3 timeliness-related care processes). In a multivariable analysis
adjusting for aggregate patient mix (age, sex, race/ethnicity, prior myocardial
infarction, rales ⬎50% of lung fields at ED presentation), and several hospital
characteristics (number of beds in the ED, region, and affiliation with an emergency
medicine residency program), southern EDs were independently associated with
lower ED composite concordance scores (␤ coefficient, ⫺10; 95% confidence
interval, ⫺20 to ⫺1), compared to northeastern EDs.
Conclusion: Overall ED concordance with treatment recommendations in the
ACC/AHA guidelines was low. We identified substantial variations in ED quality of
care for AMI, with lower guideline concordance in the South. Future quality
improvement efforts should continue to focus on AMI management in the ED.
4
The Impact of a Statewide ST-segment Myocardial Infarction
Regionalization Program on Treatment Times for Women,
Minorities, and Elderly Patients at Hospitals Without
Percutaneous Coronary Intervention Capability
Glickman S, Cairns C, O’Brien S, Ou F, Lytle B, Granger C, Jollis J/University of
North Carolina, Chapel Hill, NC; Duke University, Durham, NC
Background: Disparities in time to reperfusion for ST-segment myocardial
infarction has been shown for women and elderly patients who receive primary
fibrinolysis and those who are transferred for primary percutaneous intervention
(PCI). Regionalization has been shown to improve overall ST-segment myocardial
infarction treatment times, although the impact on disparities in care in non-PCI
centers has not been evaluated.
Study Objective: To assess the impact of a statewide system of care for STsegment myocardial infarction (Reperfusion of Acute Myocardial Infarction in North
Carolina Emergency Departments [RACE]) on reperfusion times and change in
baseline treatment disparities according to sex and age at non-PCI hospitals.
Methods: ST-segment myocardial infarction treatment times were determined
before (7/05–9/05) and after (1/07–3/07) a year-long implementation of RACE.
RACE implemented tailored reperfusion plans and quality interventions at 65
hospitals, including 55 non-PCI and 10-PCI centers. Treatment times in the pre- and
post- intervention periods at non-PCI hospitals were compared using Wilcoxon tests
and disparities were analyzed using a linear mixed effects model which adjusted for
patient demographics and co-morbidities.
Results: Six hundred thirteen patients at non-PCI hospitals were analyzed. At
baseline, older patients and women had longer delays in door-to-needle, door-toEKG, and door-in-door-out times among patients transferred for primary PCI. Doorto-needle, door-to-EKG, and door-in-door-out times all decreased among the elderly
(age⬎70) and women (113 to 78, 15 to 9, and 48 to 36 minutes respectively for the
elderly, and 114 to 65, 13 to 8, and 42 to 30 minutes respectively for women,
p⬍0.05 for all subgroups). Yet, elderly patients still had relatively longer treatment
times than younger patients after implementation of the RACE program. While there
were no changes in baseline treatment disparities in the elderly, the baseline disparity
Volume , .  : September 
Research Forum Abstracts
in door-in-door-out times between women and men was reduced at non-PCI
hospitals (pre: 36 min, post: 10 min, p⫽0.07). Hospital and EMS RACE factors
associated improvement in treatment times included: use of out-of-hospital
electrocardiography, emergency physicians having the authority to implement
reperfusion without consulting cardiology, and stocking/reconstituting thrombolytics
in the ED versus the pharmacy.
Conclusion: A statewide STEMI regionalization program was associated with
overall improvements in treatment times for women and elderly patients. Disparities
remained in elderly patients, suggesting the need for further study and intervention.
5
Mass Screening of Children During a Pandemic Influenza Drill
Fertel BS, Kohlhoff SA, Roblin PM, Parker CE, Augenbraun MH, Arquilla B/
University of Cincinnati, Cincinnati, OH; SUNY Downstate Medical Center,
Brooklyn, NY
Study Objectives: Tools for mass screening have been developed to separate
symptomatic from asymptomatic patients during outbreaks of contagious infectious
illnesses, such as pandemic influenza, in emergency departments (EDs). We sought to
evaluate the effectiveness of one such tool in identifying symptomatic children, to
assess the impact of such screening on children and family units and to identify
pitfalls in the screening and quarantine of pediatric patients during a pandemic.
Methods: In a prospective, observational, multicenter, pandemic influenza
simulation exercise, we assessed the disposition of patients (actors) who self-presented
for treatment at 3 hospital EDs (a tertiary care university hospital, a community
hospital and an academic, urban, municipal, level 1 trauma center). Eight sequential
public health alerts identifying the outbreak and case definition were issued over a
number of weeks by the local health department and sent to hospital clinicians. Each
patient was randomly assigned to a pre-identified influenza or non-outbreak-related
case scenario and screened at the hospital entrance. Mass screening officers used a
Mass Screening, Triage and Isolation (MSTI) tool based on clinical signs and
symptoms of influenza for adults and children and CDC interim guidance documents
on pandemic influenza. Victims meeting the case definition for influenza were
isolated in a separate area of the hospital. Actual disposition of participants was
recorded by trained observers using standardized forms and compared with intended
outcomes. Descriptive statistics and chi square test were performed.
Results: A total of 171 adults and 113 children (ages 0 –5, n⫽15; ages 6 –12,
n⫽40; and ages 13–17, n⫽58 ) were screened by ED physicians and nurses using the
MSTI. Of victims whose assigned scenario met the influenza case definition, 20%,
23%, 33%, and 46% of adults, children 13–17y, children 6 –12y, and children 0 –5y,
respectively, were incorrectly identified as not having influenza. There was a
significant correlation between decreasing age and difficulty recognizing influenza
symptoms (p ⫽ 0.005). There were 45 families that consisted of at least one adult
and one or more children. Of these, 26 families (58%) had a child with symptoms
that differed from those of their parent resulting in one individual meeting the case
definition and the other not. Fourteen of these family units (54%) received
discordant dispositions that resulted in the separation of children from parents despite
existing recommendations to the contrary.
Conclusion: This drill identified the challenge of correctly applying pandemic
influenza case definitions to young children receiving ED-based care, which is
consistent with clinical studies during current influenza season. As the clinical case
definition of infectious diseases often varies with age, just-in-time-training of ED
personnel should incorporate and highlight the different age-specific presentations of
the identified outbreak. Mass screening protocols, tools and disaster plans should pay
careful attention to younger children, account for the challenge of treating family
units with discordant symptoms and identify strategies to minimize the impact on
affected children.
6
Effect of Hyperlactatemia on the Likelihood of In-Patient
Mortality for Patients With a Normal and Abnormal Anion
Gap
Green J/New York Hospital Medical Center of Queens, Flushing, NY
Study Objective: Hyperlactatemia (serum lactateⱖ4.0 mmol/L) is a marker of
increased short-term mortality in adult septic patients and is an enrollment criterion
for early goal-directed therapy (EGDT). Prior studies have shown that lactic acidosis
(serum lactateⱖ4.0 mmol/L, blood pH⬍7.35) is predictive of short-term mortality,
but that hyperlactatemia with a normal blood pH (7.35–7.45) is less predictive. We
Volume , .  : September 
sought to determine whether hyperlactatemia is predictive of short-term mortality
both in patients with a normal corrected anion gap and in patients with an abnormal
corrected anion gap (⬎12 mEq/L).
Methods: This was a prospective observational cohort. Setting: Urban tertiary
care teaching hospital (90,000 annual ED visits) with an active severe sepsis screening
protocol (serum lactate checked when clinician suspects infection likely to require
admission). Inclusion criteria: Patients ⱖ 21 years of age with an admitting diagnosis
of suspected or confirmed infection that were screened for severe sepsis during a 1year period (2/1/2007–1/30/2008) Exclusion criteria: Repeat patient visits during the
study period were excluded. Statistical Analysis: The calculated anion gap was
corrected for hypoalbuminemia via the Figge equation. The primary outcome was
in-patient 28-day mortality stratified by anion gap and serum lactate. Chi-square was
used for categorical data, t-test for continuous parametric data.
Results: One thousand eight hundred thirty-eight patients were screened for
severe sepsis during the study period, of which 1430 (77.8%) were admitted with an
infectious diagnosis. Complete records were available for 1308 patients (91.5%). The
most common admitting diagnosis was lower respiratory infection (n⫽667, 51%),
followed by urogenital tract infection (n⫽262, 20%). Mean age was 73.3 years, 52%
were female. In-patient 28-day mortality was 12.5% (95%CI 10.1 to 13.4%). One
hundred seventy four patients had a serum lactateⱖ4.0 mmol/L (13%, 95%CI 11.3
to 14.9%); 361 patients had a corrected anion gap⬎12 mEq/L (27.6%, 95%CI 25.2
to 30.0%). 28-day in-patient mortality for patients with a normal vs. elevated
corrected anion gap was 9.8% vs. 18.9% (OR 2.16, 95%CI 1.53 to 3.05). Twenty
eight-day in-patient mortality for patients with a serum lactate⬍4 mmol/L vs.
lactateⱖ4 mmol/L was 9.4% vs. 28.7% (OR 3.90, 95%CI 2.66 to 5.71). Among
patients with a normal corrected anion gap, 28-day in-patient mortality for lactate⬍4
mmol/L vs. lactateⱖ4.0 mmol/L was 8.8% vs. 23.3%, (OR 3.16, 95%CI 1.50 to
6.65). Among patients with a corrected anion gap ⬎12 mEq/L, 28-day in-patient
mortality for lactate⬍4 mmol/L vs. lactateⱖ4.0 mmol/L was 12.9% vs. 30.8% (OR
3.01, 95%CI 1.76 to 5.13). Hyperlactatemia had a similar effect on the likelihood of
28-day in-patient mortality for patients with a normal corrected anion gap vs.
patients with an elevated anion gap (p⫽0.917).
Conclusion: In this cohort of adult ED patients with suspected infection
requiring admission, both an elevated corrected anion gap and hyperlactatemia
significantly increased the likelihood of 28-day in-patient mortality. Hyperlactatemia
had a similar effect on the likelihood of 28-day in-patient mortality for patients with
a normal corrected anion gap and patients with an abnormal corrected anion gap.
Hyperlactatemia can be used to risk stratify patients for 28-day in-patient mortality
regardless of the anion gap.
7
How Reliable Is Urinalysis to Predict Urinary Tract
Infections?
Waseem M, Paudel G, Sharma N/Lincoln Hospital, Bronx, NY; Lincoln Medical &
Mental Health Center, Bronx, NY
Background: Urinary tract infection (UTI) has a prevalence of up to 5.3% among
febrile infants and young children. In the emergency department, results of urinalysis
are often used to guide management of febrile patients with suspected UTI. Specific
attention is paid to the leukocyte esterase (LE) and nitrite tests in order to determine
the likelihood of UTI, and thus begin antibiotic treatment pending urine culture
results. It has, however, been noted that UTI may be confirmed by urine culture even
in the presence of a negative urinalysis.
Study Objective: To determine whether a negative urinalysis is predictive of a
negative urine culture in febrile children.
Methods: A retrospective review of all patients under 2 years of age with cultureproven UTI was performed from January 2004 to December 2007 in an inner city
teaching hospital. For study purposes, urinalysis results were reviewed by two
independent emergency physicians, blinded to urine culture results, and to the
patient’s clinical presentation. Physicians were asked to predict UTI based on
urinalysis results. Based on the physician’s prediction, the results of urinalysis were
classified into three groups; high, intermediate and low probability. Urine cultures
were obtained for a definite diagnosis of UTI. A chi-square analysis was performed.
Results: Over the study period, 749 patients were identified with culture-proven
UTI. Of these, 206 (27.5%) had urinalysis with less than 5 WBCs, negative LE &
nitrite, and were therefore classified in low probability group. 478/749 (63.8%) had
⬎15 WBCs and positive LE & nitrite, and were determined to be in the high
probability group. 65 (8.7%) were in the intermediate probability group (5–15
WBCs with minimal/or trace LE or nitrite) (P ⬍ .001).
Annals of Emergency Medicine S3
Research Forum Abstracts
Conclusion: Urinalysis is a poor predictor for UTI, especially if negative. Almost
one in four urinalysis with culture proven UTI was classified in the low probability
group. A negative urinalysis therefore does not rule out UTI and should be
interpreted with caution in the young febrile children. Urine cultures should be
obtained to evaluate the possibility of UTI.
8
The Effect of Etomidate on Hospital Length of Stay of
Patients With Sepsis: A Prospective, Randomized Study
Tekwani K, Watts H, Sweis R, Rzechula K, Kulstad E/Advocate Christ Medical
Center, Oak Lawn, IL
Study Objectives: Etomidate is a widely used induction agent for rapid sequence
intubation in the emergency department (ED) that has been demonstrated to cause
measurable adrenal suppression after a single bolus dose. The clinical significance of
this adrenal suppression in septic patients remains controversial. We sought to
determine the difference in hospital length of stay (LOS) of septic patients intubated
in our ED given etomidate compared to patients given midazolam, hypothesizing at
least a 4-day increase in LOS in patients given etomidate.
Methods: We performed a prospective, double blind, randomized study of septic
patients intubated in our ED over a 16-month period. Eligible patients who were
critically ill and suspected to be septic were randomized to either etomidate or
midazolam prior to intubation. We recorded times of patient presentation,
intubation/extubation, administration of first antibiotic, intensive care unit (ICU)
LOS, discharge and/or death, as well as the presence of sepsis criteria and the use of
corticosteroids. We also recorded relevant laboratory and demographic variables to
determine severity of illness using the Mortality in Emergency Department Sepsis
(MEDS) score in addition to vital signs and lactate levels.
Results: A total of 116 patients were enrolled over the study period, of which 92
(79%) completely fulfilled sepsis criteria, while 24 initially thought to be septic were
found to have alternative etiologies for their illness. Of the 92 patients with
confirmed sepsis, 49 received midazolam and 43 received etomidate. Age in years
(mean 71, SD ⫾ 14), sex (56% male), MEDS score (mean 12.1, SD ⫾ 4.6), need for
vasopressors (48%), need for blood transfusion (6.5%), mean arterial pressure (mean
75, SD ⫾ 25), pulse rate (mean 111, SD ⫾ 28), respiratory rate (mean 26, SD ⫾ 9),
lactate (median 2.8, IQR 1.7 to 4.1) and receipt of supplemental corticosteroids
(46%) were statistically similar between the two groups. In-hospital mortality of
patients given etomidate (42%, 95% CI 28% to 57%) was similar to those receiving
midazolam (35%, 95% CI 23% to 49%). There were no significant differences in
median hospital LOS (9.2 vs. 10.8 days), median ICU LOS (3.1 vs 4.2 days), or
median ventilator days (2.2 vs. 2.8) between patients who received etomidate and
patients who received midazolam.
Conclusions: Our results do not support the contention of significant effects on
outcome from the use of etomidate for the intubation of patients with sepsis.
Suggestions to discontinue the use of etomidate for intubation in the ED may not be
warranted.
9
Does a Clinical Productivity Incentive Plan Work for
Emergency Medicine Faculty?
Richerson PJ, Morgan DL, Burr MF, Stone CK/Texas A&M University Health
Science Center, Temple, TX; Scott and White, Temple, TX
Study Objectives: There is growing financial pressure to maximize clinical
productivity for academic physicians. Although incentive plans based on relative value
unit (RVU) productivity have been studied in other academic departments, their use
in emergency medicine departments have not been widely studied for effectiveness.
Our goal was to determine if the implementation of an RVU-based incentive plan
significantly increased the productivity of the emergency medicine faculty at a
teaching hospital.
Methods: Design: Retrospective analysis for the 6-month control period (1 year
prior to implementation of the incentive plan) and the 6-month study period
immediately after the incentive plan began. The incentive plan was a “base ⫹
incentive” model with the incentive payment to be distributed every 6 months to
those faculty members who achieved the targeted RVUs/hour. This study analyzed
total RVUs, patients seen, and hours worked for each faculty member. Setting:
Academic teaching hospital and a Level I Trauma Center affiliated with a medical
school located in a small city. The ED treats over 75,000 patients annually and has 30
emergency medicine residents. Type of Participants: 14 EM board-certified faculty
S4 Annals of Emergency Medicine
members with 1–25 years experience. Part-time faculty and full-time faculty who left
the department during the study were excluded.
Results: The emergency medicine faculty saw 30,263 patients during the control
period and 33,474 (⫹ 10.6%) for the study period. The fraction of patients who left
without being seen decreased from 2.6% to 2.0%. The total faculty time increased
from 8,925 hours to 9,185 (⫹2.9 %) due to decreases in part-time faculty coverage.
The total RVUs increased from 62,654 to 66,199 (⫹5.7%), but the total charges
increased by 15.3%. The RVUs/patient decreased from 2.1 to 2.0 (⫺4.5%), but
there was an increase in RVUs/hour from 7.02 to 7.2 (⫹2.7%).
Conclusion: There was a large increase in patients seen by the faculty. This may
have been due to factors other than the incentive plan. Although the RVUs/patient
decreased (probably due to seeing more patients with less acuity), the RVUs/hour
increased. The significant increase in total charges indicates this incentive plan may
increase clinical productivity in an academic emergency department.
10
Does a Team Triage Service Affect Patient Satisfaction
in an Urban Academic Emergency Department?
Saef SH, Gist A, Carr CM, Headden G, Lukasavage JN/Medical University of
South Carolina, Charleston, SC
Study Objectives: Compare patient perceptions of emergency care delivered by a
team triage service in the hallway of a busy emergency department (ED) with the care
provided in the regular treatment rooms of the same ED.
Methods: The study setting was an urban level I trauma and tertiary care center
at a southeastern academic medical center. The study design was a prospective, selfadministered, anonymous survey. The study site offers a “team triage” (TT) service in
which patients receive expedited care by an expert emergency physician (EEP)
working independently with an experienced emergency nurse and ED technician. TT
patients were selected by the EEP or triage nurse and were seen separately from
regular ED patients in a wide central hallway within the ED. Patient satisfaction
surveys consisted of 4 questions which were validated prior to the study and addressed
patient perceptions regarding (1) excellence of care, (2) MD hurriedness, (3) empathy
of staff, and (4) waiting time. Survey forms were placed in wall files in the TT and
regular treatment areas and were easily accessible to all patients. Surveys were
submitted anonymously into drop-boxes at exit points from the ED. All questions
were answered using a 5 point Likert scale. Results were compared using Student’s
t-test.
Results: 274 patients submitted surveys; 197 regular ED and 77 TT. No
significant differences were noted in excellence of care (p⫽0.64), MD hurriedness
(p⫽0.69), staff empathy (p⫽0.87), or waiting time (p⫽0.57).
Conclusion: Patients perceived equivalent quality of care, hurriedness of
physicians, empathy of staff, and waiting times between TT and the regular ED. In
this data, being seen quickly in the hall did not impact the studied measures of
patient satisfaction. A team triage service, even when run in a busy ED hallway,
appears to be a valid mechanism to provide expedited care in an urban academic ED.
11
Impact of Triage Physician and Clinical Operation
Management Consultant Implementation on Emergency
Department Throughput at a Tertiary Care Center
AlDarrab A, Abuhaimed K, Alabdullah T, Alshabanah H, Almogbil M, Gletsu S/
King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
Study Objectives: Emergency department (ED) crowding is recognized to be a
major, international concern that affects patients and providers. ED crowding causes
are multifactorial and divided into 3 ED functions: input, throughput and output. In
February 2008; 2 interventions were implemented in our ED: 1- Triage physician
from 0800 –1600, to assist triage nurses and to initiate treatment for low acuity
patients in a separate designated area. 2- Clinical operation management consultant
on duty from 0800 –1400, to manage ED flow and administration, answer medical
calls, assist charge nurses and act as a liaison with admitting services to ensure optimal
care and expedite in-patient flow for boarded patients in the ED. We seek to evaluate
the effect of implementing these 2 interventions on throughput at an ED of a tertiary
care center.
Methods: A before-after intervention administrative database review was
completed for 6 months (March–August 2007) and same 6 months (March–August
2008). Outcome of interest was average monthly length of stay (LOS) (⫹/⫺ SD) for
all patients presenting to our ED from arrival until disposition (discharge home for
discharged patient and decision to admit for admitted patient).
Results: During the study periods, 22987 were seen in 2007 compared to 24314
Volume , .  : September 
Research Forum Abstracts
in 2008. 2008 patients were admitted in 2007 compared to 2522 patients in 2008.
LOS of admitted patients from decision to admit until they leave the department
increased from 551 minutes (⫹/⫺105) in 2007 to 979 minutes (⫹/⫺ 89) in 2008.
LOS of patients from arrival till disposition reduced from 279 minutes (⫹/⫺ 28) in
2007 to 270 minutes (⫹/⫺ 22) in 2008.
Conclusion: Despite the significant increase in input and output, implementation
of triage physician and clinical operation management consultant provided benefits to
throughput of crowded ED. The results strongly suggest that the implementation of
this intervention could provide significant improvement to the delivery of emergency
medical care in a tertiary care ED.
12
When the Emergency Department Is Packed Can
Physician Assistants Pick Up the Pace? An Analysis of
Physician Assistant Productivity Related to Patient
Volume
Brook C, Chomut A, Jeanmonod R/Albany Medical College, Albany, NY; St.
Luke’s Hospital, Bethlehem, PA
Background: The volume of patients seen in an emergency department (ED) is
highly variable. It has been determined that resident productivity is not highly
correlated with volume, but the relationship between physician assistant (PA)
productivity and volume has not been studied.
Study Objective: To determine whether PA productivity varies with ED census.
Methods: A retrospective review was conducted of all ED visits at a level one
trauma center during June and July 2007. The PA who first signed up for the patient
and dictated the patient’s chart was considered to be the primary caregiver. All
patients seen by PAs were included in the study. The hour during which care was
initiated was defined as the hour that a PA electronically signed up for a patient.
Productivity was calculated as the number of patients upon which care was initiated
each hour. Data was collected regarding the total number of patients registered in the
ED from 0700 to 2359 each day of the study period, as PAs do not work overnights
at our institution. This was then broken down to patients registered per hour to
determine ED volume per hour. Regression analysis was used to determine the
relationship that hourly and daily volume had on PA productivity. Monthly Relative
Value Units (RVUs) were also collected for the PAs during the study period.
Results: During June and July 2007, there were 160 PA shifts. The number of
patients seen in the ED per hour ranged from 0 –22 patients (Mean: 9.4 Standard
Deviation: 3.9). Anywhere from 133–198 patients were seen daily (Mean: 160.4,
Standard Deviation: 14.8). Regression analysis examining shift productivity related to
daily volume showed a R2 of 0.01. Regression analysis of productivity per hour
plotted against volume per hour yielded a R2 of 0.02. Productivity in terms of mean
RVUs per hour during the study period was calculated as 2.35 RVUs/hour (95%
CI ⫽ 1.98 –2.72).
Conclusion: PA productivity does not correlate with the total or hourly volume
of patients seen in the ED.
13
Utilizing Time-Driven Activity-Based Costing in the
Emergency Department
Bank DE, McIlrath T/Phoenix Children’s Hospital, Phoenix, AZ
Study Objectives: Traditionally employed health care costing methods may not
accurately reflect actual costs of emergency department (ED) service. The
introduction of a practical costing tool using a time driven activity-based costing
(TDABC) model allows ED directors to understand the costs of ED service and make
decisions on the allocation of resources.
Methods: This study was conducted using data from a high volume pediatric ED
in a free-standing children’s hospital. The TDABC model was utilized to estimate
costs of provider resources and apply them to three specific clinical scenarios common
to any ED service: a simple laceration repair of an extremity (⬍2.5cm), a mild asthma
exacerbation requiring respiratory therapy, and acute gastroenteritis with mild
dehydration requiring intravenous fluid therapy. We compared our calculated costs
for each of these three clinical scenarios with the standard Medicaid Outpatient
Prospective Payment System (OPPS) and physician fee reimbursement schedules for
2008. The total direct and indirect costs to the ED were obtained from 2008 hospital
accounting. Costs of medications and supplies were obtained from hospital materials
management and pharmacy accounting and were treated as separate entities.
Results: In each of the 3 clinical scenarios, combined 2008 OPPS and physician
reimbursement was greater than the total ED costs derived using TDABC. In
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Scenario 1: a simple laceration repair of an extremity (⬍2.5cm), the Medicaid
reimbursement was $581.77 and the estimated actual cost was $365.53 (profit
margin 37%). In Scenario 2: a child with mild asthma exacerbation requiring
respiratory therapy, the Medicaid reimbursement was $501.87 versus the estimated
actual cost of $491.61 (profit margin 2%). In Scenario 3: a child with acute
gastroenteritis and mild dehydration requiring intravenous fluid therapy, the
Medicaid reimbursement was $523.00 versus the estimated actual cost of $491.43
(profit margin 6%).
Conclusion: TDABC may be utilized as an effective and accurate tool to estimate
the true cost of ED service. For any given patient encounter, the costs of service vary
greatly based on the proportion and time of resources utilized. TDABC analysis can
be used by ED directors to help determine the allocation of ED clinical resources.
TDABC analysis of service can be used as a tool to help development professional and
facility reimbursement strategies with commercial payers.
14
An Analysis of Emergency Department Flow, Severity
and Congestion Factors That Are Associated With
Decreases in the Left Without Being Seen Rate
Sattarian M, Shesser R/George Washington University, Washington, DC
Study Objective: During the last 3 years, the overall left without being seen
(LWBS) rate in our academic, urban emergency department (ED) decreased from
4.6% (2006) to 3.2 % (2008) despite an increase in ED census and the absence of
specific process change that focused on LWBS rate reduction. This analysis examines
the strengths of association between the LWBS rate and a group of standard ED flow,
congestion, and severity parameters.
Methods: Data on all visits during calendar years 2006 – 8 to the GW Hospital
ED were tracked with an EMR application that required assignment of a specific
discharge category for every arrival. The LWBS category included all registrants who
left either before or after nursing triage, but before being seen by a physician. Data
were analyzed by hour for each of the 26,304 hours in the study period. The LWBS
patient number for each hour during this period was compared to the mean arrivalbed (waiting) times for ambulatory patients arriving that same hour who successfully
completed their evaluation, their mean Emergency Severity Index scores, the number
of patient arrivals during that hour, and the total number of patients in the ED
treatment area and lobby at each hour’s end.
Results: During the analysis period, 187,663 patients were registered; 128,430
walk-ins (68.4%) and 59,233 ambulance arrivals (31.6%). 7,543 patients LWBS,
6,705 (88.9%) of whom were walk-ins and 838 (11.1%) arrived by EMS. LWBS
rates for the three year analysis period were 4.0% overall, 5.2% for walk-ins and 1.4%
for ambulance arrivals. The LWBS rate for walk-ins decreased by 36% from 5.5%
(July–December, 2006) to 3.5% (July–December 2008) (P ⬍ 0.001). During the
analysis period, mean waiting times for ambulatory arrivals decreased from 61.4
minutes (2006) to 52.6 minutes (2008); mean total hourly arrival volume increased
from 6.9 patients (2006) to 7.5 patients (2008); and mean, total end-hourly ED
census increased from 36.5 patients (2006) to 39.5 patients (2008). Measuring the
strength of association between the hourly LWBS patients and that same hour’s
waiting times, arrival volume, Emergency Severity Index acuity, and total end-hourly
ED census demonstrated highly significant relationships between LWBS and waiting
times (P ⬍ 0.001, r: 0.48) and total ED census (P ⬍ 0.001, r: 0.34). There was a
weaker relationship with arrival intensity (P ⬍ 0.001, r: 0.26), and no relationship
with mean patient acuity.
Conclusion: ED process improvements that lead to a modest decrease in patient
waiting time, may achieve larger, proportional decreases in the ED’s LWBS rate.
Although decreased waiting time in our setting was achieved by “front-end” process
improvement, “back-end” strategies that reduce total ED census may have a greater
effect on reducing the LWBS rate due to the strong association between LWBS and
total ED census. It is still possible to lower LWBS rates during periods of increasing
ED census and congestion.
15
Satisfaction of Emergency Department Hallway Patients
Stiffler KA, Wilber ST, Blanda M, Nielson J, Winot S, Kline J/
Summa Health System/NEOUCOMP, Akron, OH
Study Objectives: Emergency department (ED) crowding is recognized as a
national problem and has reached epidemic proportions. During times of acute ED
crowding, patients experience their most significant delay while waiting for an ED
bed. Many EDs attempt to ameliorate this problem by treating non-urgent conditions
in hallway treatment areas instead of regular treatment rooms. Many studies are
Annals of Emergency Medicine S5
Research Forum Abstracts
available on patient satisfaction, but none specifically address the satisfaction of
patients who are assigned hallway beds in the ED. We conducted a study to evaluate
patients’ opinions, concerns, and satisfaction about being placed in hallway treatment
spaces for their ED care.
Methods: A cross-sectional study of patients assigned to a hallway treatment space
at Akron City Hospital ED, a 72,500 adult visit urban community teaching hospital,
was performed. Sequential patients who were placed in hallway treatment spaces
during peak volume hours were asked to complete a confidential, self-administered
survey regarding hallway treatment issues. The initial questions asked how patients
felt about various issues pertaining to being treated in the hallway using a 5-point
Likert scale. The second portion of the survey used 100mm visual analog scale
questions (0⫽not satisfied, 100⫽satisfied) to determine satisfaction levels with regard
to treatment location, medical care, and overall satisfaction. Data are reported as
means and proportions with 95% confidence intervals (mean 95% CI).
Results: A total of 100 patients with a mean age of 41.6⫾16.4 years completed
the survey. Fifty nine percent were female. Areas of greatest concern for patients
included feeling in the way (60%, 95% CI 49.7– 69.7), having no room for visitors
(57%, 95% CI 46.7– 66.9), and a lack of privacy (56%, 95% CI 45.7– 65.9). Forty
two percent (95% CI 32.2–52.3) identified safety as a concern. Overall visit
satisfaction scores were 52.77 (95% CI 46.9 –58.6), while satisfaction with regard to
medical care revealed 70.27 (95% CI 65.0 –75.5). Satisfaction with regard to hallway
treatment location scored 46.31 (95% CI 39.7–52.9). Thirty-four percent of patients
(95% CI 24.8 – 44.1) surveyed were less likely to recommend our ED to others based
on treatment location, while 26% (95% CI 17.7–35.7) were less likely to recommend
this hospital system. When questioned about willingness to wait any longer for a
treatment room, 75% (95% CI 65.3– 83.1) preferred to be treated in the hallway
immediately. The most common Emergency Severity Index score of surveyed hallway
patients was 3 (72%, 95% CI 62.1– 80.5). Emergency Severity Index category 4
patients represented 25% (95% CI 16.9 –34.7) of the population. The remaining 3
patients had an Emergency Severity Index of 5 (95% CI 0.62– 8.5).
Conclusion: Overall satisfaction and satisfaction with treatment area are low for
patients treated in the hallway. Patients feel as if they are in the way, and cite lack of
visitor space, lack of privacy, and a fear for safety. Despite these issues, most patients
would prefer to be treated in the hallway as opposed to waiting any longer in the
waiting room.
16
Emergency Department Consultation Practices and
Documentation Vary Widely Across Hospitals
Schuur J, Moreau J, Bohan J, Fauchet G, Lobon L, Lyn E, Nathanson L, Stack A,
Temin E, Tibbles C/Brigham and Women’s Hospital, Boston, MA; Cambridge
Health Alliance, Cambridge, MA; North Shore Medical Center, Salem, MA; Beth
Israel Deaconess Medical Center, Boston, MA; Children’s Hospital Boston,
Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: Emergency department (ED) specialty consultation carries
significant patient safety and medico-legal risk, as it involves information transfer
between multiple providers. We aimed to determine the frequency that information
considered critical to consultations is documented and the prevalence of informal
consults.
Methods: We conducted retrospective chart review at 6 hospitals (2 community
teaching hospitals [CHs] and 4 academic/urban Level 1 trauma centers [AHs]) in a
Northeastern metro area. At each hospital, we consulted with ED and consultant
service leaders to determine critical elements of consults. We identified the following
time points: consult called, consult acknowledged, and consult completed. Other
elements identified as critical to document included: reason for consult, supervision of
trainees, and real-time “closed-loop” communication between the consultant and the
emergency physician at the beginning and completion of the consultation. Each ED
reviewed 20 charts from each of 4 commonly consulted services for documentation of
the critical elements of consultation (80 – 87 charts at each AH and 10 and 75 charts
at CHs). To determine the prevalence of informal (ie, “curbside”) consults, we
reviewed 100 –200 consecutive ED charts at each hospital (n⫽737). We identified
documented mentions of specialty consults within emergency physician
documentation and matching consultant documentation. We determined the percent
of informal consults from all services by calculating the ratio between explicit consult
mentions and written consult notes.
Results: Documentation of critical elements varied widely across services and
hospitals (Table). Time consult requested was logged 100% of the time at one ED
with a dashboard that logged consults, and two other hospitals had high percentages
of documented consult request time due to formal recording policies (55% and 100%
S6 Annals of Emergency Medicine
compliance). Time consult acknowledged was rarely recorded (8% across all
hospitals), except at the ED with the electronic dashboard (25%). Documentation of
other critical communication elements also varied across hospitals: reason for consult:
37–96%; role of supervising MD: 38 –78%; and real-time closed loop
communication at consult completion: 19 – 88%. Evidence of informal consultation
in ED documentation was common, with 17– 43% of consult mentions
unaccompanied by consultant documentation. There was significant variation in all
measures between services at each hospital (see table).
Conclusion: Consultation practice varied significantly across 6 hospitals in a
metropolitan area and within each hospital by service. Timeliness, supervision and
communication between emergency physicians and consultants is not routinely
documented in the medical record, and informal ED consults (“curbsides”) are
common. There is an opportunity to standardize communication and
documentation, which may improve patient safety and reduce medico-legal risk.
17
Emergency Department Rapid Assessment Unit at the
Cambridge Hospital: Why and How?
Lobon LF, Sayah AJ, Rivard L, Brady M, Skura S/The Cambridge
Hospital/Cambridge Health Alliance, Cambridge, MA
Background: Before having contact with a provider and receiving medical
treatment the majority of emergency department (ED) patients in the US are
screened by clinical and non-clinical staff. This screening follows a sequential process
including triage, registration and initial assessment which requires patients to move
through different areas of the ED.
Our model at The Cambridge Hospital ED (TCH ED) followed that operational
structure until 4/2/08.
We believe that delays in patient care were caused by the factors described above
and contributed to:
● Increase in time for provider evaluation and management
● Increase total length of stay with long “waiting room” times
● Crowding/ambulance diversion situations
● Very low patient satisfaction scores
Study Objectives: Rapid Assessment Unit (RAU) implementation on 4/2/08
impact on time-to-provider (TTP), turn-around-times (TAT) and ED quality
indicators: Press Ganey scores (PG) and left without been seeing (LWBS). RAU has 5
dedicated front-end multipurpose treatment areas and is staffed 10am-10pm by 1 PA
(supervised by an ED attending), 2 RNs, 1 ED tech and 1 patient partner (PP).
Immediately upon arrival to the ED reception area patients are greeted by our PP
and entered into our electronic record system. Subsequently they are escorted into the
RAU where the clinical team assesses their condition and determines based on the
Emergency Scale Index (ESI) if:
1. the patient can stay in RAU for treatment and release
2. the patient needs to be evaluated immediately in the acute care area due to the
severity of the presentation
3. management will start in RAU and will continue in the acute care area when
appropriate.
Registration and triage are brought to the patient’s bedside avoiding delays and
uncomfortable transfers.
Methods: Retrospective data analysis includes ED visits pre-implementation of a
RAU in Jan 08 and post-implementation in Jan 09, during the hours that RAU is
operational, 10am-10pm.
We will compare mean values for time -to-provider and turn-around-times.
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A comparison of quality indicators such as PG scores and LWBS will also be
evaluated around the time periods selected.
Results:
1. Time Indicators:
TTP down from 37 minutes in Jan 08 to 23 minutes in Jan 09
TAT down from 160 minutes in Jan 08 to 137 minutes in Jan 09
2. Quality Indicators:
PG scores up 80.9 Q2FY08 to 85.6 Q2FY09
LWBS down from 61 Q2FY08 to 28 Q2FY09
Conclusion:
Budget neutral operational changes such as implementation of the RAU at TCH
ED can have significant impact on the efficiency of the department.
Reduction in key time intervals in emergency medicine such as time-to-provider
and turn-around-time seems to correlate with improved scores in patient satisfaction
surveys and other quality indicators such as LWBS.
The improvement in efficiency indicators provided by the implementation of the
RAU at TCH ED has increased our competiveness in a demanding health care
market where patients choose their providers based on quality of care and expeditious
service.
18
Fibrinolytics for Acute Myocardial Infarction in
Emergency Departments
Niska RW/Centers for Disease Control, Hyattsville, MD
Study Objectives: In 2006, the American College of Emergency Physicians
proposed measures to improve quality of emergency medical care, including the use
of fibrinolytics in acute myocardial infarction. This investigation is important because
it studies the extent of emergency department use of fibrinolytic agents for myocardial
infarction in response to recent clinical guidelines, and the factors associated with
using fibrinolytics.
Methods: The National Hospital Ambulatory Medical Care Survey (NHAMCS)
is an annual nationally representative cross-sectional survey of hospitals with
emergency and outpatient departments. This study examines fibrinolytic use in the
treatment of acute myocardial infarction in emergency departments, using data from
the NHAMCS for 2000 –2006. From 2000 to 2006, there were 661 unweighted
visits from patients with acute myocardial infarction (weighted national estimate of
297 thousand annual visits) without contraindications to fibrinolytics.
The prevalence of fibrinolytic therapy was determined and cross-tabulated against
independent variables that might influence compliance with fibrinolytic guidelines,
including age, sex, ethnicity, triage acuity, ambulance arrival, transfer to another
facility, primary payment source, metropolitan statistical area, and annual visit
volume. Bivariate associations were analyzed with chi-square test of significance at
alpha less than 0.05. Odds ratios with 95 percent confidence intervals were derived
for each independent variable from logistic regression, adjusting for other
independent variables.
Results: Fibrinolytic agents were given at 7.6 percent of visits. Adjusting for all
independent variables in a logistic regression model, fibrinolytic therapy was about
seven times more likely to be given to patients who were then transferred to another
facility, and about four times more likely to be to patients triaged as needing to be
seen in less than 15 minutes. Fibrinolytics were less than a tenth as likely to be given
to non-white, non-Hispanic patients, and about a tenth as likely to be given to
Medicaid patients as to those who were privately insured.
Conclusion: Relatively few acute myocardial infarction patients are receiving
fibrinolytics when indicated, and there is evidence of socioeconomic disparities in
their use. This analysis is timely as a reminder to clinicians to understand and
implement fibrinolytic guidelines. More research is needed to define disparities in
fibrinolytic use more precisely, as well as to determine whether other interventions are
being used as an alternative to fibrinolytics.
19
Prescription of Non-Steroid Anti-Inflammatory Drugs in
Emergency Department Patients With Acute Coronary
Syndrome/Myocardial Infarction
Zito JA, Garra G, Thode Jr HC, Singer AJ/Stony Brook University, Stony Brook,
NY
Study Objectives: There is mounting evidence that use of non-steroid antiinflammatory drugs (NSAID) is associated with increased cardiovascular risk.
Recent American Heart Association guidelines discourage the use of NSAIDs in
Volume , .  : September 
patients with acute coronary syndrome/myocardial infarction. We determined
trends in NSAID prescriptions for ED patients with acute coronary syndrome/
myocardial infarction who presented to US emergency departments over the last
decade.
Study Design: Retrospective analysis of National Hospital Ambulatory Medical
Care Survey for the years 1998 –2005. Subjects: Primary diagnosis of acute coronary
syndrome/myocardial infarction based on ICD-9-CM codes.
Methods: Demographic and clinical characteristics and prescription of NSAIDs in
ED based on medication codes. Analysis: Patients’ weights were used to obtain estimated
national values. Univariate and multivariate analyses used to determine association
between predictor variables and NSAID prescriptions and trends over time.
Results: The number of acute coronary syndrome/myocardial infarction
patients decreased from 320,000 and 360,000 in 1998 to 177,000 and 264,000
in 2005 respectively, while the number of ED visits increased from 100 to 115
million. Acute coronary syndrome/myocardial infarction patients were similar in
mean age (65 vs 63) and sex (55% vs 53% male). There was a significant but
nonlinear increase in NSAIDs prescribing in acute coronary syndrome patients
over time (P⫽0.003): 17% from 1998 to 2000, then increasing from 17% in
2000 to 37% in 2005. The rate of NSAID prescribing in myocardial infarction
patients varied widely from year to year (min 20% in 1999, max 31% in 2002)
but there was no trend over time. By comparison, there was an increasing linear
trend (P⬍0.001) in NSAIDs usage over time in patients without acute coronary
syndrome/myocardial infarction from 15% in 1998 to 20% in 2005. Multivariate
analysis indicated there was no relation between NSAIDs use and age, sex or
geographic region for either acute coronary syndrome or myocardial infarction
patients.
Conclusion: The rates of NSAID prescription in acute coronary syndrome but not
myocardial infarction patients increased over time. Education of emergency physicians
regarding the risks of NSAIDs in acute coronary syndrome may be required.
20
Can Point-of-Care Assays Deliver Lab Quality Accuracy?
Peacock IV W, Diercks D, Hollander J, Singer A, Birkhahn R,
Shapiro N, Lewandrowski E, Nagurney J/The Cleveland Clinic, Cleveland, OH;
University of California, Davis, Sacramento, CA; University of Pennsylvania,
Philadelphia, PA; Stony Brook University and Medical Center, Stony Brook, NY;
New York Methodist Hospital, Brooklyn, NY; Beth Israel Deaconess Medical
Center, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: Troponin I (TnI) point-of-care (POC) assays historically
suffer greater inaccuracy than lab-based assays. Our purpose was to compare the
diagnostic accuracy of a contemporary POC TnI assay to a lab-based platform.
Methods: From healthy normal banked samples, we determined the 99th%ile
TnI reference value with the POC Cardio3 TnI (Biosite, Inc, San Diego, CA)
and the lab-based DxI TnI (Beckman Coulter, Inc, Fullerton, CA), termed the
“derivation cohort.” The Myeloperoxidase In the Diagnosis of Acute coronary
syndromes Study (MIDAS) was a multicenter study that collected plasma from
patients presenting to the emergency department with suspected acute coronary
syndromes in whom the emergency physician planned an objective cardiac
ischemia evaluation (eg, exercise stress testing, myocardial perfusion imaging,
etc). In the MIDAS study, gold standard diagnoses were adjudicated by the site
principal investigator at the end of hospitalization, using all available data.
Applying the reference ranges from the derivation cohort, we determined assay
performance to diagnose non-ST segment myocardial infarction (NSTEMI) in a
validation cohort from the MIDAS study, enriched to provide a 50% acute
coronary syndrome rate.
Results: The derivation cohort (n⫽997) provided TnI reference ranges of 0.05ng/mL
for both the lab and POC platforms. The final diagnosis distribution of the validation
cohort was non-cardiac chest pain (n⫽176, 50.7%), unstable angina (n⫽74, 21.3%),
NSTEMI (n⫽72, 20.7%), and STEMI (n⫽25, 7.2%). In the validation cohort, after
exclusion of STEMI patients, there were no performance differences between the lab or
POC tests when comparing patients with and without NSTEMI (see table).
Conclusion: In ED suspected ACS patients, the Cardio3 TnI POC platform
provides similar diagnostic performance for the outcome of NSTEMI as a
contemporary laboratory-based Troponin I assay.
Annals of Emergency Medicine S7
Research Forum Abstracts
23
Typical Angina Is Not Predictive of the Presence of
Inducible Cardiac Ischemia in Emergency Department
Chest Pain Patients
Hermann LK, Weingart S, Yoon Y, Shearer P, Henzlova M, Duvall WL/Mt Sinai
School of Medicine, New York, NY; Elmhurst Hospital, New York, NY; Mt Sinai,
New York, NY
21
Oral Anticoagulation Quality Index as a Predictor for
Bleeding
Franciscon A, Machado J, Schmidt A, Pazin-Filho A/Medical School of Ribeirao
Preto - University of Sao Paulo, Ribeirao Preto, Brazil
Study Objectives: To evaluate the impact of the oral anticoagulation quality
index over the emergency department visits for patients regular taking warfarin in a
tertiary reference hospital.
Methods: Two groups of patients taking warfarin on a regular basis were
identified - Group I (57,4⫾10,4 years; 30% male) constituted by patients with atrial
fibralation and a RNI target 2–3 and Group II (41,3⫾13,7 years; 37% male) of
patients anticoagulated due to methalic valve prosthesis and a RNI target 2.5–3.5.
Both groups were free of bleeding events prior enrollment and were followed through
a median of 11 years (interquartil range 2.5 – 15 years). Outcome was defined as a
bleeding event over moderate severity or those in need of blood transfusion, fresh
frozen plasm or vitamin K administration. Exposure was defined as the oral
anticoagulation quality index, determined by the percentage of the RNI values in the
target range devided by the total RNI values obtained. Survival analysis techniques
were employed to calculate events rate and Cox proportional analysis for adjusting for
potential confounders. To exclude the erratious RNI levels during anticoagulation
start, we used a lag time analysis.
Results: Group I quality index did not differ from the Group II (0,60⫾0,20 x
0,62⫾0,10 ⫺ p 0,54) in univariate analysis. Group I (23 events) showed an incidence
rate of 86.7 per 100.000 patients/year (48.5 – 143.0 95% CI) while Group II (28
events), an incidence rate of 58.2 per 100.000 patients/year (38.0 – 85.2 95% CI) ⫺
Log Rank test 0.1518. In multivariate analysis, only the quality index was associated
with a hazard ratio for Group II ⫺ 15.5 (1.31 – 181.8 95% CI).
Conclusion: Keeping the RNI in the recommended range is of extreme
importance to avoid significant bleeding events. In our study, the intensity of the
RNI range was not associated with greater hazard ratio for bleeding, while a
significant difference was shown for the quality of the anticoagulation.
22
Error in Body Weight Estimation Leads to Inadequate
Parenteral Anticoagulation
Macedo LG, Pazin-Filho A/Medical School of Ribeirao Preto - University of Sao
Paulo, Ribeirao Preto, Brazil
Study Objectives: To evaluate the adequacy of parenteral anticoagulation with
enoxaparin, mensurated by anti-Xa (⬎ 0.5 and ⱕ 0.5 UI/ml), according to body
weight estimation error (⬎ 10% and ⱕ 10 %).
Methods: 28 patients (13 men; age 59.3⫾13.9 years) initiating enoxaparin due to
cardiovascular emergency conditions (acute coronary syndromes, pulmonary
embolism or intracardiac thrombus) were prospectively enrolled. The initial
enoxaparin dose was based on subjective estimation by the attending physician or on
information provided by the patient. Objective measured body weight was obtained
24 hours after admission and the patients were classified in group 1 (body weight
error ⬎ 10%) or 2 (ⱕ 10 %). The activity of anti-Xa factor was measured before and
after the first dose of enoxaparin and after the second dose for every patient and the
values compared between the groups.
Results: Group 1 (21 patients; 59.3⫾14.2 years) had anti-Xa levels within the
therapeutic range for all the patients, while 4 patients (14.3%) of Group 2 (7
patients; 59.2⫾14.2 years) had anti-Xa levels ⬍ 0.5 Ul/mL. Anti-Xa levels were
normal before starting enoxaparin for both groups and there was no difference
referring to creatinine levels between the groups. Group 1 had an estimated weight of
63.3⫾12.0 kg and a mensurated of 76.2⫾10.3 kg (p non-significant), while Group 2
had an estimated weight of 75.0⫾5.0 kg and a mensurated of 95.6⫾4.6 kg.
Conclusion: Body weight estimation error greater than 10% is frequent,
associated to patients with greater measured body weight and leads to undertherapeutic anti-Xa levels.
S8 Annals of Emergency Medicine
Study Objectives: To assess the value of the presenting symptom of typical anginal
pain, atypical/non-anginal pain, or lack of chest pain in predicting the presence of
inducible myocardial ischemia via cardiac stress testing in emergency department (ED)
patients being evaluated for possible acute coronary syndrome (ACS).
Methods: This was a retrospective observational study of adult patients who were
evaluated for ACS in an ED chest pain unit from March 2004 to May 2008. Patient
presenting symptom was categorized based on the presence of: 1) substernal chest
pain or discomfort that is 2) provoked by exertion or emotional stress and 3) relieved
by rest and/or nitroglycein. Chest pain was classified as “typical” angina if all three
descriptors were present and atypical or non-anginal if less than three descriptors were
present. All patients underwent serial biomarker and cardiac stress testing prior to
discharge.
Results: 2525 patients, aged 22–97, met eligibility criteria. Inducible ischemia on
stress testing was found in 33 (14%) of the 231 patients who had typical anginal pain,
238 (11%) of the 2,140 patients presenting with atypical/non-anginal chest pain; and
25 (16%) of the 153 patients who had no complaint of chest pain at presentation.
The presence of typical chest pain had a likelihood ratio positive of 1.25 (95% CI
0.89 –1.78) and negative 0.98 (95% CI 0.94 –1.02). The presence of any form of
chest pain when compared to the absence of pain had a likelihood ratio positive of
0.97 (95% CI 0.94 –1.01).
Conclusion: In our study, patients who presented with typical angina were no
more likely to have inducible myocardial ischemia by stress testing than other
presenting symptoms. Our data suggests that presenting symptoms are not helpful in
identifying which patients have a high probability of obstructive coronary artery
disease and therefore should be used with caution to determine disposition and the
need for further testing.
24
Initiating Medical Therapies in the Cardiac
Catheterization Lab Decreases Door-To-Balloon Time for
Acute ST Elevation Myocardial Infarction
Bastani A, Anderson W, Rocchini A, Newman S, Lazarus J, Ishioka N, Cholette K,
Hercula J, Hunt-Walch R, Kraft P/William Beaumont Hospital, Troy, MI
Study Objective: The national standard for door-to-balloon time (DBT) is 90
minutes as recommended by the American Heart Association/American College of
Cardiology guidelines for ST-elevation myocardial infarction (STEMI). In 2007 39%
of STEMI patients at our institution did not meet this recommendation. A STEMI
multidisciplinary team consisting of emergency physicians, cardiologists, cardiac
catheterization lab (CCL) and emergency department (ED) personnel was assembled
to identify areas of delay in our DBTs. This team identified that the timeframe
between STEMI team notification by the emergency physician and transfer to the
CCL accounted for a significant portion of the delay. This time period consisted of
the 2 main procedures: 1) the initiation of all anti-platelet, anti-thrombotic and
vasoactive therapies and 2) the preparation of the patient for transport to the CCL.
Our objective was to shorten this time period by prioritizing the ED personnel to
prepare and transfer the patient to the CCL rather than focusing on the initiation of
medical therapies. By focusing the ED personnel to immediately transfer the patient
to the CCL after STEMI team notification, the patient would be able to
simultaneously receive medical therapies and prepare for angiography, thus decreasing
our DBTs.
Methods: To evaluate the outcome of our new protocol on DBTs, we conducted
a before and after study from January 2007 to Feb 2009. In Feb 2008, the acute
STEMI protocol at our institution was revised to focus on immediate transport of the
patient to the CCL before all medical therapies had been initiated. No other
significant changes were made to the protocol during the study period. Our primary
outcome was the mean DBT for the 13 months prior to our intervention, compared
to the mean DBT for the following 13 months. DBT was then subdivided to
elucidate the effect of our protocol modification on the time between STEMI team
notification and time of transfer to the CCL. Means were reported with standard
deviations and significance was analyzed by an unpaired two-tailed t-test (␣⫽ 0.05).
Results: During the 13-month period prior to protocol revision, the mean DBT
was 91.70 minutes (⫹/⫺SD ⫽ 32.57). After the protocol was revised, the mean
Volume , .  : September 
Research Forum Abstracts
DBT decreased to 66.84 minutes (⫹/⫺SD ⫽ 19.76). By implementing this protocol
change DBT was decreased an average of 25 minutes (p⬍0.0001). Furthermore, the
mean CCL transfer time was 38.17 minutes (⫹/⫺ SD 12.49). After the protocol was
revised, the mean CCL transfer time was 26.73 minutes (⫹/⫺ SD 9.04); with an
absolute reduction of 11.44 minutes (p⬍0.0001).
Conclusions: Immediate transport of the patient to the CCL prior to initiation of
all medical therapies in the ED significantly decreases DBTs for acute STEMI.
25
Additional Diagnostic Utility of Upright T-Wave in V1
and T-Wave V1 Vs. T-Wave in V6 in Differentiating
Acute Anterior ST-Elevation Myocardial Infarction From
Benign Early Repolarization
Smith SW/Hennepin County Medical Center, Minneapolis, MN
Background: Using logistic regression, we previously derived, then later validated,
a predictive rule to differentiate benign early repolarization (BER) from subtle acute
anterior ST elevation myocardial infarction (STEMI) due to acute left anterior
descending (LAD) coronary artery occlusion. The logistic regression rule (LRR) uses
the mean R wave (RA) amplitude in V2-V4, mean ST elevation at the J-point (STEJ)
in V2-V4, and Bazett corrected QT interval (QTc-B) in milliseconds (ms) such that
if (1.553 x mean STEJ) ⫹ (.0546 x mean QTc-B in ms) – (0.3813 x mean RA) ⬎
21, vs. ⬍/⫽ 21, then anterior STEMI was predicted. It has been suggested that an
upright T-wave (TW) in lead V1 (TV1) is predictive of acute myocardial infarction,
especially when the amplitude of TV1 ⬎ TV6.
Study Objective: We sought to determine how the addition of this latter TW rule to
the LRR would improve the utility of the LRR alone in the diagnosis of anterior STEMI.
Methods: Retrospective study combining the derivation and validation sets for
the previous study. The study group comprised consecutive anterior STEMI sent for
primary percutaneous coronary intervention who had proven LAD occlusion. The
control group comprised consecutive ED chest pain patients whose ECGs were coded
as BER and who had 3 negative serial troponins. ECGs were excluded if MI was
obvious: this was defined if there was inferior ST depression, STE ⬎ 5mm, anterior
TW inversion, terminal QRS distortion, or a single straight or convex ST segment in
any of leads V2-V6. Computerized QTc-B, and hand measured RA and STEJ in
leads V2-V4 were measured to the nearest 0.5mm relative to the PR interval. In
addition, TV1 was scrutinized and deemed inverted if either the entire T, or just the
terminal portion of it, was inverted. It was coded as upright if there was no inversion.
An upright TV1 was ⬎ TV6 if it was at least 1.0 mm greater in amplitude. Statistics
were by two-tailed Chi square and Fisher exact test.
Results: There were 292 ECGs; 125 with anterior STEMI and 167 with BER.
78/167 BER (47%) and 88/125 anterior STEMI (70%) had an upright TW in V1
(p⬍ .0001). 24/167 (14%) BER and 51/125 (41%) anterior STEMI had TV1⬎TV6
(p⬍.0001). Sensitivity (Sens), specificity (Spec), and accuracy (Acc) of upright TV1,
and TV1 ⬎ TV6 for MI were, respectively, 70%, 47%, and 61%, and 41%, 86%,
and 66%. Sens, Spec, and Acc of the LRR value ⬎ 21 was 91%, 83%, and 87%.
Sens, Spec, and Acc of the LRR value ⬎ 21 or upright TW in V1, vs. neither, was
97% (p⫽0.11 vs. LRR alone), 42% (p⬍.0001), and 65% (p⬍.0001). Sens, Spec,
and Acc of the LRR value ⬎ 21 or TV1 ⬎ TV6, vs. neither, was 96% (p⫽0.20 vs.
LRR alone), 72% (p⫽.01), and 82% (p⫽0.17).
Conclusion: An upright TW in V1, and TV1⬎TV6, are both significantly more
common in anterior STEMI than BER. Neither rule performed as well as the LRR
which uses RA, STEJ, and QTc-B. The addition of upright TW in V1, or
TV1⬎TV6, minimally and nonsignificantly improved sensitivity of the LRR for
LAD occlusion at the expense of significant decrement in specificity and accuracy.
26
When “Good” Is Below Average
Kiefer CS, Colletti JE, Bellolio M, Thomas KB, Woolridge DP/Mayo Clinic,
Rochester, MN; University of Arizona, Tucson, AZ
Study Objectives: The Medical Student Performance Evaluation (MSPE) is a
summarative evaluation composed by a student’s medical school dean that takes into
account the student’s performance during pre clinical and clinical years.
The aim of this study was to determine if there was a relationship between usage
of the term “good” in the descriptive paragraph of the MSPE and academic
performance in medical school as described by the ranking within the class.
Methods: The final paragraph of the MSPE contains a summary statement in
which the writer of the evaluation often uses a descriptive term such as “good,”
Volume , .  : September 
“outstanding,” or “excellent” in order to summarize a student’s overall performance.
All MSPEs submitted to 3 different residency programs were reviewed. Each MSPE
was examined to determine the presence or absence of the descriptive term “good” in
either the summary statement or the appendices accompanying the MSPE.
For institutions using the term “good,” the percentile ranking of students in the
class receiving “good” as a descriptive term was noted. Following tabulation, the data
was dichotomized in “bad” for institutions describing students in the bottom 25%
and “intermediate” for the rest of the institutions, and analyzed with Wilcoxon test
according to its non-normal distribution.
Results: MSPEs were collected from122/125 accredited medical schools. Overall,
34 (27.9%) of institutions sampled used the term “good,” 86 (70.5%) of schools had
no mention or category of students that was classified as “good,” and the use of the
term “good” was unclear in 2 institutions.
Of the 34 institutions utilizing “good” to describe students, all used the term to
classify students in either the bottom 50%. Specifically, 25 schools used the term to
classify students in the bottom quartile (0 –25%), 4 schools to students in the bottom
33%, 4 schools to students ranked between the 20 and 40th percentile, and in 1
institution “good” was applied to students in the bottom half of the class (0 –50%).
There was a significant difference in the use of the term “good” among different
medical schools when comparing those in the bottom 25% versus those with
intermediate scores (p⬍0.0001). Students described by “good” could be anywhere
between the 1st and 50th percentile.
Conclusion: In the MSPE, the term “good” was utilized to describe students in
the bottom 50% of the class. This makes a “good” medical student, a code for a
below average medical school performance.
27
An Assessment of Resident Training in Emergency
Department Administration
Farley HL, Buehler G/Christiana Care Health Systems, Newark, DE; Christiana
Care Health Systems, Newark, DE
Background: Emergency department (ED) administration encompasses a wide range
of topics which residents spend a variable amount of time learning during training.
Study Objective: To examine the curricula of emergency medicine (EM)
residency programs with regards to ED administration.
Methods: An electronic survey was sent to all U.S. EM residency coordinators to
evaluate resident training in ED administration. Data included which post-graduate
year (PGY) residents completed the rotation, the amount of time dedicated to ED
administration, and administrative topics covered. Possible administrative topics
covered included ED operations, billing/coding, quality assurance/performance
improvement, risk management/medical-legal, EMTALA, contracts, budget
planning/financing, scheduling, marketing, public policy/political advocacy, and an
option to specify other topics.
Results: 55/140(39.3%) of coordinators completed the survey. Of programs that
completed the survey, 73.6% reported having ED administration as part of the
curriculum, and 57.7% had a dedicated rotation block for ED administration. Of
those with dedicated administration rotations, 77.4% occurred during the PGY-3
year. The most common length of an administration rotation was 4 weeks (41.9%).
However, about half (51.6%) reported having ED administration combined with
another rotation, such as EMS, research, or toxicology. The most common topics
covered included ED operations (93.8%), quality assurance/performance
improvement (84.4%), and risk management(87.5%). Other topics covered included
billing/coding (62.5%), EMTALA (56.3%), contracts (34.4%), budget planning/
financing (46.9%), scheduling (28.1%), marketing (9.4%), and public
policy/political advocacy (43.8%).
Conclusions: The amount of time dedicated to ED administration and the
administrative topics covered vary widely among training programs.
28
The Use of Video Laryngoscopy in Massachusetts
Emergency Departments
Raja AS, Sullivan AF, Pallin DJ, Bohan J, Camargo Jr CA/Brigham and Women’s
Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA
Study Objectives: Video laryngoscopy decreases time to intubation, diminishes
cervical spine motion, and increases the chance of first pass success during difficult
intubations when compared to direct laryngoscopy. We sought to determine how
many emergency departments (EDs) in Massachusetts were using video laryngoscopy,
the characteristics of user and non-user EDs, and the reasons why non-users do not
use video laryngoscopy.
Annals of Emergency Medicine S9
Research Forum Abstracts
Methods: Surveys were mailed to the medical directors of all non-federal EDs in
Massachusetts (n⫽74). Non-responders received repeat mailings, and then ED
clinical directors or nurse managers were contacted via telephone or email. Data
regarding annual ED visit volume was obtained from the National Emergency
Department Inventory - USA (www.emnet-usa.org).
Results: 63 (85%) of 74 EDs responded. 43% (27/63) had video laryngoscopy
available in the ED. EDs with video laryngoscopy had a higher mean annual visit
volume than EDs without video laryngoscopy (49,043 vs. 38,093, respectively;
P⫽0.04). EDs with and without video laryngoscopy reported similar percentages of
American Board of Emergency Medicine, American Osteopathic Board of Emergency
Medicine, or American Board of Pediatrics certified intubating physicians (93% vs
92%, P⫽0.89), mean intubations per week (4.5 vs. 4.4, P⫽0.97), and mean surgical
airways per year (0.7 vs 1.1, P⫽0.19). 50% (5/10) of EDs affiliated with emergency
medicine residency programs had video laryngoscopy available. Amongst all EDs with
video laryngoscopy, the technology had been available for ⬍ 1 year in 52% (14/27),
between 1 and 5 years in 48% (12/27), and for ⬎5 years in 4% (1/27). EDs without
video laryngoscopy felt that it was too expensive [69% (25/36)], believed that it
showed no improvement over standard direct laryngoscopy [17% (6/36)], or were
unwilling to invest in technology that might soon become outdated [14% (5/36)].
None of the EDs without video laryngoscopy believed that it was too difficult to use.
Conclusion: At present, 57% of Massachusetts EDs, including 50% of emergency
medicine residency-affiliated EDs, do not have video laryngoscopy available. EDs
with and without video laryngoscopy perform the same number of intubations per
week. In addition, while 69% of ED directors not using video laryngoscopy do not
do so because of its cost, an additional 17% of directors believed that it showed no
improvement over direct laryngoscopy, despite peer-reviewed evidence to the
contrary. Nevertheless, the tide appears to be turning; while available since 2001,
video laryngoscopy was adopted by 52% of users only within the past year. Efforts to
further disseminate this proven technology should focus on incorporating it into
residency training, evaluating its cost-effectiveness, and educating providers regarding
its proven clinical benefits over direct laryngoscopy.
29
Evaluating Applicants to a New Emergency Medicine
Residency Program: Characteristics of Applicants Who
Used the Electronic Residency Application Service Vs.
Applicants Who Did Not
Groke S, Knapp S, Dawson M, Strate L, Stroud S, Davis V, Hartsell S,
Madsen T/University of Utah School of Medicine, Salt Lake City, UT
Study Objectives: One previous study has compared differences in applicants
between years in which the Electronic Residency Application Service (ERAS) was
used and years in which ERAS was not used. To date, no study has compared
applicant characteristics in the first two years of a new residency program. Because of
the Accreditation Council for Graduate Medical Education (ACGME) approval
timelines, new residency programs cannot use ERAS during their first year of
applicants. We compared applicant characteristics in an emergency medicine (EM)
residency program’s first year (in which ERAS was not used) vs. applicant
characteristics in year two (using ERAS).
Methods: The University of Utah Emergency Medicine Residency Program received
approval from the ACGME in 2004 and began accepting applicants for its first class, to
begin in 2005. We retrospectively reviewed the applications to the residency program for
the entering classes of 2005 (year one) and 2006 (year two). Because of the ACGME
residency approval timeline, applicants in year one did not use ERAS and were required to
complete a separate application for the University of Utah residency program, while those
in year two used ERAS for the application. Applicant characteristics, board scores,
previous residency application history, and characteristics from the medical school record
were recorded. Chi square and t-test statistics were used to compare groups, with p⬍0.05
considered statistically significant.
Results: A total of 130 and 458 applications were received in year one and year
two, respectively. Applicants were similar in age (30.9 yrs vs. 30.3 yrs; p⫽0.225),
while year one had a higher percentage of male applicants (77.3% vs. 67.2%;
p⫽0.028). Applicants in year one and year two were similar in average Step 1 score
(211.8 vs. 212.4; p⫽0.791), previously failed Step 1 or Step 2 attempt (12.1% vs.
11.0%; p⫽0.729), previous failure to match in a residency program (8.6% vs. 4.6%;
p⫽0.083), previous residency training (18.8% vs. 14.9%; p⫽0.288), and the percent
who had completed an EM clerkship (95.3% vs. 93.0%; p⫽0.342). Applicants in
year one were more likely to have been remediated in medical school (13.2% vs.
4.2%; p⬍0.001) and to have a standardized letter of recommendation (SLOR) (87%
S10 Annals of Emergency Medicine
vs. 78%; p⫽0.024). Applicants in year two were more likely to have a SLOR match
estimate of “very competitive” (38.2% vs. 54.1%; p⫽0.004).
Conclusion: In addition to an increased number of applicants once ERAS use was
initiated, the applicant pool in year two of a new emergency medicine residency
program had a higher percentage of applicants who were estimated as “very
competitive” on the SLOR and a lower percentage of applicants who had been
remediated during medical school. These results may provide a guide to new
emergency medicine residency programs in terms of applicant numbers and potential
characteristics.
30
Characteristics of Emergency Medicine Residency
Curricula That Affect Board Performance
Ahn J, Christian MR, Patel SR, Allen NG, Theodosis C, Babcock C/University of
Chicago, Chicago, IL
Study Objectives: With emergency medicine (EM) maturing as a specialty, there
is no consensus regarding the best model for training competent emergency
physicians. There is a paucity of validated research regarding how to appropriately
structure EM curricula. This study aimed to identify whether certain characteristics of
residency program curricula correlate with improved first-time pass rates on written
and oral emergency medicine boards after residency completion.
Methods: A survey tool was developed and disseminated to all EM residency
program directors (PDs) using the Council of Residency Directors listserv. Personal
emails were then sent to PDs who did not initially participate in the survey. 149
programs were contacted and 115 partially completed the survey (77.2%). 69
completed the entire survey (46.3%). PDs were asked questions regarding the format
of their residency program and curricula, as well as historical written and oral board
exam first-time passage rate (⬎95% vs ⬍95%). Correlations between program
characteristics and board pass rates were analyzed using STATAv10.
Results: As expected, written board pass rates correlate strongly with oral board
pass rates (p⫽0.000). In addition, programs with greater than one half of residents
honored by Alpha Omega Alpha score higher on written (p⫽0.001) and oral boards
(p⫽0.023). Higher oral board pass rates were demonstrated if greater than 4 faculty
members routinely attend weekly conferences (p⫽0.054). No relationship was noted
for written boards (p⫽0.145). Lack of a required reading curriculum trended toward
a higher written board pass rate (p⫽0.063), but did not influence oral board
performance (p⫽0.34). Finally, semi-annual mock oral board simulations trended
toward higher written (p⫽0.053) and oral board pass rates (p⫽0.063). No
correlation was identified between board performance and other factors studied
including; length of training program (PGY1-3, 1-4, 2-4), frequency of curriculum
repetition, percent of conference lectures given by residents versus faculty, resident
attendance requirements, frequency of written quizzing, and curriculum format.
Conclusion: In summary, factors that improve board pass rates were those that
encourage verbal communication between faculty and residents including increased
faculty conference attendance and semi-annual mock oral boards. Medical school
Alpha Omega Alpha recipients continued to excel after residency. Interestingly, no
correlation existed between board performance and program structure, curriculum
structure, readings, quizzing, or resident lecture attendance. This study is limited by
an incomplete survey completion rate and PD opinion bias. Clearly, additional
research regarding optimal EM education components is necessary.
31
Evaluation of Different Teaching Modalities for EKG
Interpretation Among Emergency Medicine Residents
Das D, Garg N, Green JP, Gupta S, Suarez AE/New York Hospital Queens,
Flushing, NY
Study Objectives: To determine whether a Web-based teaching module is more
effective in teaching residents to identify and manage wide-complex tachycardic
rhythms as compared to a traditional didactic lecture format.
Background: Accurate EKG interpretation is a vital component in the
management of patients. Previous research reveals that traditional forms of teaching
fail to adequately enforce the ability to interpret critical EKG diagnoses in emergency
medicine residents. Further, independent Web-based resources can be an effective
method of education. The demands of the resident work schedule coupled with the
abundance of medical knowledge to be acquired in the short years of residency make
it necessary to incorporate newer, more innovative means of individualized education.
Methods: Prospective, observational study conducted in an urban Level I
emergency department with over 100,000 visits per year. The subjects were 14
emergency medicine residents. The participants were randomly assigned to two
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groups: a didactic session or a Web-based interactive learning module. Each group
was composed of nearly equal number of residents with a comparable level of
training. Each group was administered a 30-minute pretest that included 25 multiple
choice questions regarding the recognition and management of wide complex
tachycardic rhythms. The duration of each session was 30 minutes and both covered
the recognition and management of wide complex tachycardic rhythms. The
participants were then administered a 30-minute test composed of the same 25
questions they were initially given on the pretest. Analysis of test results was
performed utilizing the paired T test and ANOVA.
Results: There is no difference in the mean pretest scores between the Web-based
(55%) and lecture groups (62%), p⫽0.063. There is a significant improvement in
mean test scores for all subjects, 59% pretest and 71% test, p⫽0.002. There is a trend
for improvement in mean test scores in the lecture group, 62% pretest to 72% test,
p⫽0.118. There is a statistically significant improvement in test scores in the Webbased group, 55% pretest and 69% test, p⫽0.005. The difference in the mean pretest
scores stratified according to postgraduate year (PGY) level was significant, PGY-1
49%, PGY-2 66%, PGY-3 64%, p⫽0.042. The difference in the mean test scores
stratified according to PGY level did not achieve significance, PGY-1 67%, PGY-2
69%, PGY-3 81%, p⫽0.133. The change in the residents’ scores stratified by PGY
level did not achieve significance, p⫽0.153.
Conclusion: Web-based resources may be used effectively for teaching EKG
interpretation for emergency medicine residencies.
32
The Perceived Impact of Precepting Medical Students
on Residents’ Clinical Work and Education
Barcomb T, Jeanmonod R, Pattee J/St. Luke’s Hospital, Bethlehem, PA; Albany
Medical College, Albany, NY
Study Objectives: This study aims to evaluate the impact precepting medical
students has on both resident education and clinical work as perceived by the
residents. We hypothesized that precepting students would have a larger negative
impact on second year residents (PGY2s) compared to third year residents (PGY3s),
as PGY3s have more experience with teaching and prioritizing tasks. We also
hypothesized that the perceived impact of precepting students on PGY2s would
diminish over the study period as they became more comfortable in their roles as
teachers and physicians.
Methods: This is a prospective study of PGY2 and PGY3 emergency medicine
(EM) residents during 6 months beginning July 1st, 2008. The study was performed
at a tertiary care emergency department with a census of 70,000. The hospital is
affiliated with a medical school, and EM is a mandatory rotation for all 4th year
students. While in the ED, students are assigned to residents for day and evening
shifts.
Residents involved in precepting turned in monthly surveys evaluating the impact
teaching medical students had on their education and clinical work. The questions
were designed by drawing on previously validated educational surveys given to
medical students and residents in inpatient settings to evaluate clinical educators. In
addition, these surveys are based on educational research from the EM literature
regarding specific goals of EM education. Responses were scored on a 10 cm visual
analog scale (VAS). PGY3s had a previous year of precepting students prior to the
start of the study. PGY2s first precepted students in August 2008. Changes in answers
over time for all residents were analyzed using Friedman’s test. PGY2 and PGY3 data
were compared on a month-by-month basis using Mann Whitney, with particular
attention paid to comparisons of the first month and the last month. The study
protocol was approved by the IRB.
Results: In the first month of the study, PGY2s and PGY3s had similar attitudes
toward precepting students. They had similar enthusiasm for teaching (7.29 ⫾ 1.01
vs. 6.73 ⫾ 1.32, p⫽0.5) and rated their ability to teach as similar (6.62 ⫾ 1.12 vs
5.39 ⫾ 1.68, p⫽0.18). All other survey items were not significantly different between
the two classes with the exception that PGY2s were significantly less likely to think
that students appreciated their teaching (6.9 ⫾ 1.21 vs. 5.06 ⫾ 1.35, p⫽0.046). At
the end of the 6-month study period, however, survey items showed differences
between the 2 classes as PGY2 VAS scores fell and PGY3 VAS scores remained stable
or increased. Specifically, there were differences in PGY3 vs. PGY2 scores on the
statement “Teaching medical students is an important role of the resident physician”
(8.01 ⫾ 0.93 vs. 5.24 ⫾ 2.22, p ⫽ 0.029), “If busy, I still find time to teach” (6.6 ⫾
0.81 vs. 4.5 ⫾ 1.77, p ⫽ 0.023), “Students do not interfere with my ability to
effectively see patients” (5.67 ⫾ 1.55 vs. 2.8 ⫾ 1.63, p ⫽ 0.015), “There is adequate
time for teaching during a shift” (6.1 ⫾ 1.62 vs. 2.63 ⫾ 1.53, p ⫽ 0.006), and “I feel
well qualified to teach” (6.87 ⫾ 0.92 vs. 4.44 ⫾ 1.87, p ⫽ 0.033).
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Conclusion: In the first 6 months of the PGY2 year, residents find precepting
students interferes with their ability to effectively perform clinical work. They are also
less likely than PGY3s to think teaching students is an important role of the resident
physician. PGY3s feel better able to handle the time constraints of clinical practice
while precepting students.
33
Direct Observation Evaluations by Emergency Medicine
Faculty Do Not Provide Unique Information Over That
Provided by Summative Quarterly Evaluations by the
Same Faculty
Barlas D, Ryan JG/New York Hospital Queens, Flushing, NY
Study Objectives: Shift-based direct observation evaluations (DOE) are used by
many emergency medicine residency programs for faculty evaluations of residents on
the 6 core competencies, but it is unclear if these provide any unique data over that
provided by summative quarterly evaluations (QE). The purpose of this study is to
determine if and how well DOE correlates with QE submitted by the same faculty
during the same evaluation period.
Methods: This observational, cohort study was performed at a 3-year emergency
medicine residency with 10 residents/year. QE and DOE with 8 identical corecompetency based questions and identical discrete, 1–9 rating scales (1⫽Level of a
medical student and 9⫽Level of an attending) were completed by emergency
medicine attending physicians over 4 years for 39 emergency medicine residents. We
collected 1) All direct observation evaluations completed by the faculty pertaining to
performance on specific shifts and patient encounters, and 2) Quarterly summative
evaluations that were submitted by faculty members who had also submitted direct
observation evaluations for the same residents. Pearson correlation coefficients were
performed across these groups of evaluations.
Results: 297 complete data sets were available for analysis. When there were
greater than 4 DOE, there was excellent correlation between scores on DOE and QE
by faculty who completed both (r⫽0.973, p⬎.001). When there were less than 3
DOE per QE, the correlation dropped to (r⫽0.739; p⬎.001).
Conclusion: Direct observation evaluations of EM residents are highly correlated
with paired quarterly summative evaluations when there are more than 4 observations
available, but the correlation drops significantly when the number of direct
observations is below 3. Hence, as the number of DOE increases per resident and
faculty pair, the data that is gained becaomes more and more similar to that which
appears in the QE.
34
Assessing Inter-Rater Reliability and Agreement
Between Two Methods of Noninvasive Hemodynamic
Monitoring in Clinically Stable Emergency Department
Patients
Napoli A, Forcada A, Corl K, Machan J/Rhode Island Hospital/Brown University,
Providence, RI; Rhode Island Hospital, Providence, RI
Study Objectives: Noninvasive hemodynamic monitoring is becoming more
frequent. Transcutaneous doppler ultrasonagraphy (TCDU) and impedance
cardiography (IC) are two technologies available for use in the emergency department
setting. Limited studies have indicated some operator variability, particularly with
novice users of TCDU. We sought to evaluate the inter-rater reliability of two devices
based on these technologies and compare them in clinically and hemodynamically
stable ED patients. We hypothesized a high inter-rater reliability for each device, as
well as a high level of agreement between the devices.
Methods: We enrolled 30 low acuity ED patients over a 2-day period. Patients
had 3 consecutive simultaneously blinded measurements recorded by TCDU
(USCOM, Sydney, Australia) and IC (Cardiodynamics, San Diego, CA). 2
physicians, with basic familiarity and no clinical experience with either device, made 3
measurements of pulse rate (HR) and stroke volume (SV) with each device within 1
minute of each other. After 3 minutes, operators switched devices and 3 more
measurements were recorded. Inter-rater reliability was assessed using intra-class
correlation coefficients (ICC). Mixed linear models for repeated measures were used
to estimate the relationship between measures using a compound symmetry variancecovariance structure, with different parameters for each device operator. In addition,
Bland-Altman plots were used for further assessing instruments for bias and nonlinearity.
Results: Both devices had excellent inter-rater reliability as assessed by ICC. The
ICC for TCDU was 0.96 for HR and 0.95 for SV. The ICC for IC was 0.93 for HR
Annals of Emergency Medicine S11
Research Forum Abstracts
and 0.98 for SV. Measures of HR from the two devices were significantly related
(p⬍.0001 for all slopes), but biased in the first 50 trials, with both slope and intercept
differing from ideal: slope 0.48 (0.27– 0.68) and intercept 35.80 (21.56 –50.04).
However, by the final 26 trials, both slope and intercept were not statistically
different from their ideals: slope 1.02 (0.71–1.33) and intercept ⫺0.35 (⫺22.37–
21.67). In contrast, the relationship between device measures of SV failed to reach
statistical significance except in the first 50 trials (t(94.2)⫽2.72, p⫽0.0077), where
there were several points of high leverage that may have created that effect. There was
fair agreement of individual measures of HR (bias ⫺0.9, limits of agreement ⫺16.9 –
15.1) but poor agreement in SV (bias ⫺3.8, limits of agreement (⫺57.6 – 50).
Conclusion: Both TCDU and IC have very good inter-rater reliability and this
reliability appears not to be limited by clinical experience. A statistically significant
relationship exists between the two devices but this does not appear to produce
predictable values. Over time comparative results become less biased but are still
limited by a great degree of variability. Further study in patients with a larger range of
HR and SV may clarify this relationship further.
35
Value of Noninvasive Measurement of Contractility to
Predict Mortality in Emergency Department Patients
Undergoing Early Goal-Directed Therapy for Severe
Sepsis
Napoli A, Corl K, Forcada A, Gardiner F/Rhode Island Hospital/Brown University,
Providence, RI
Study Objectives: Research on severe sepsis and septic shock has demonstrated
that increases in cardiac output and decreases in systemic vascular resistance are often
accompanied by a depression of myocardial contractility. Prior ICU-based studies of
ejection fraction (EF), a commonly used surrogate for contractility, have shown a
significantly depressed EF in septic patients vs. controls as well as in survivors vs.
nonsurvivors. The prognostic significance of assessing this myocardial depression and
decreased inotropic state in emergency department patients remains ill-defined. The
severity of myocardial depression and contractility is difficult to measure in the ED.
Impedance cardiography (Bio-Z™, Cardiodynamics, San Diego, CA), utilizing the
accelerated cardiac index (ACI) or an estimated EF (by the modified Capan
equation), represents a technology with the potential to noninvasively measure
myocardial contractility in the ED. Previous research has shown that the modified
Capan equation and the ACI index are strong measures of cardiac contractility. We
hypothesized that reduced cardiac contractility, as defined by the ACI index and a
refined Capan mathematical model of ejection fraction, will predict mortality in ED
patients undergoing early goal-directed therapy for severe sepsis and septic shock.
Methods: This is a prospective observational cohort study of 49 patients age⬎ 18
who met criteria for early goal-directed therapy (lactate ⬎4, SBP⬍90 after 2L normal
saline); none were lost to follow-up. 43 patients were screened but excluded due to
inability to consent. Continuous measurements of left cardiac work index (LCWI)
and ACI, as well as measures required for calculation of the Capan EF, were obtained.
APACHE scores and MEDS scores were calculated on each patient. Prior studies
demonstrated a greater than 30% difference in EF in nonsurvivors vs. survivors. To
detect a 15% difference (␣⫽0.05, ␤⫽0.2, 2 tailed) a sample size of 17 in each group
is necessary. AUROC was calculated using the Wilcoxon method.
Results: The average age was 66 ⫾ 18.7 years. APACHE II and MEDS scores
were 18⫾7.9 and 10⫾4.3, respectively. The mortality rate was 29%. None of the
study variables (LCWI, modified Capan, APACHE, MEDS score) predicted
mortality with the exception of the ACI. The ACI had the highest and only
statistically significant AUROC⫽0.67 (CI 0.51– 0.83). The mean ACI for survivors
and nonsurvivors was 124.8 and 84.3, respectively. An ACI of ⬎50 was 75%
sensitive and 45% specific for predicting survival.
Conclusion: Noninvasive measurement of cardiac contractility using ACI significantly
predicted mortality in ED patients undergoing early goal-directed therapy. A larger sample
size and further studies are necessary to examine the clinical significance of this
relationship particularly as it pertains to its role in ongoing resuscitation.
36
Ionizing Radiation From Computerized Tomography
During Evaluation of Intermediate-Risk Trauma Patients
Thompson K, Laack N, Kofler J, Bellolio M, Sawyer M, Laack T/Mayo Clinic,
Rochester, MN
Study Objectives: Computerized tomography (CT) is used extensively in the
initial evaluation of trauma patients. CT studies are responsible for the majority of
S12 Annals of Emergency Medicine
ionizing radiation exposure in medical populations. Because ionizing radiation
exposure is associated with long-term risks of cancer mortality, much attention has
been given to reducing unnecessary CT scans. In severely injured trauma patients, the
risk of radiation exposure is negligible in comparison to that of the acute injuries.
However, the balance of risk versus benefit in trauma patients with less severe injury
is unknown. To our knowledge, this is the first study to compare mortality from
trauma with estimated mortality from CT ionizing radiation in intermediate-risk
trauma patients.
Methods: This observational cohort study included patients over a one-year
period with blunt trauma who presented to a trauma center and were prospectively
triaged to an intermediate risk group (level II). Patients were triaged based on criteria
that included the initial EMS report, mechanism of injury, and patient risk factors.
Level 1 (high risk) patients were excluded from the study. The number and type of
CT scans performed during the initial evaluation (first 24 hours) were recorded.
Individual and median cumulative radiation doses were calculated using an average
dosage for each type of CT received based on International Commission on
Radiological Protection (ICRP) 60 weighting factors for typical size patients.
Attributable radiation risk was calculated using Biologic Effects of Ionizing Radiation
(BEIR) VII data.
Results: A total of 642 eligible patients presented to the emergency department
between August 2006 and September 2007. The mean age was 43.8 years with 64%
males. The median Injury Severity Score (ISS) was 8 {interquartile range (IQR) 4 to
12}. The median radiation effective dose from CT was 24.7 (IQR 6.2 to 26.6)
milliSieverts (mSv). Dose by age is shown in Table 1. Higher ISS was associated with
greater total radiation dose (p⬍0.0001). There were 4 deaths secondary to trauma
(0.6%); patients who died were older (median 90 vs. 41 years, p⬍0.001), and all had
intracranial injuries. The cumulative estimated risk of cancer death attributable to CT
exposure in the ED for all patients was 0.00106 (IQR 0.00043 to 0.00139) or 0.1%,
with the risk by age shown in Table 2.
Conclusion: In our study population of intermediate severity trauma patients, the
risk of mortality from trauma is 6 times higher than the estimated risk of radiationinduced cancer mortality. The mortality due to trauma is greatest in older patients,
suggesting lower clinical suspicion is needed to warrant CT studies in this population.
Clearly, the risk of death from trauma outweighs the long-term risk of mortality from
radiation-induced neoplasia in older patients, but this gap narrows with younger
patient age and less serious trauma. Further investigation to evaluate the benefits of
CT in preventing mortality may help determine a possible crossing point between
these two mortality risks.
37
New Generation CT Scanners Demonstrate Higher
Sensitivity for Subarachnoid Hemorrhage
Gee CA, Phanthavady T, McGuire T, Madsen T/University of Utah, Salt Lake City,
UT
Study Objective: Previous studies have reported inadequate sensitivity of
computed tomography (CT) to rule out subarachnoid hemorrhage (SAH). These
studies have typically been performed using 4-slice or lower CT scanners. We aimed
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Research Forum Abstracts
to evaluate the sensitivity of CT scan for subarachnoid hemorrhage using highergeneration CT scanners.
Methods: We performed a retrospective chart review of all patients who had a
non-contrast head CT scan and were diagnosed with subarachnoid hemorrhage
between January 1, 2005 and December 31, 2008 at the University of Utah Medical
Center. This included patients who were transferred from outside hospitals as well as
those who were seen initially in the University of Utah emergency department. CT
scanner type from outside hospitals was not known, but the University of Utah CT
scanner was upgraded from a 16-slice CT scanner to a 64-slice scanner in early 2005.
Patients were included only if they presented with a non-traumatic mechanism. We
calculated the sensitivity of CT for SAH based on those diagnosed by CT vs. those
with a negative head CT and positive lumbar puncture (LP).
Results: 134 patients were diagnosed with SAH during the study period. Average
age was 53.6 years old, and 62.2% of patients were female. 130 patients (97%) had a
non-contrast head CT demonstrating SAH. 4 patients (3%) who had a negative head
CT were diagnosed with SAH by LP. Of these 4 patients, two were diagnosed with
aneurismal SAH, while the other two patients had no aneurysm and were discharged
without intervention. Sensitivity of CT for SAH was 97% (95% CI: 92.1%–99%).
Including only those patients who had a negative head CT with later diagnosis of
aneurismal SAH, sensitivity of CT was 98.5% (94.1%–99.7%). One of these two
patients had an initial CT scan done at an outside hospital, where the generation of
scanner was not known.
Conclusion: Our results demonstrate a higher sensitivity of CT for SAH than has
been previously reported. Still, the sensitivity of CT may not be high enough to
warrant the use of CT scanning as the sole modality for diagnosis of SAH. Further
study of newer generation CT scanner sensitivity and patient stratification by
presentation is warranted.
38
The “Triple Rule-Out” 64-Section Coronary Computed
Tomographic Angiography Protocol: Coronary and ExtraCoronary Findings of Emergency Department Patients
Takakuwa KM, Estepa AT, Halpern EJ/Thomas Jefferson University Hospital,
Philadelphia, PA
Study Objectives: To determine the frequency of coronary and extra-coronary
diagnoses that explain the patient presentation among emergency department (ED)
patients with acute chest pain or symptoms suggestive of acute coronary syndrome
(ACS) evaluated with a coronary CT angiography (CCTA) “triple rule-out” (TRO)
protocol.
Methods: This was a prospective cohort study (10/06 –3/09) at a single academic
ED. Patients judged to be at low to intermediate risk of having ACS based on nonacute ECGs, initial normal myoglobin and troponin I, and TIMI risk scores were
studied with a CCTA TRO protocol that evaluated for coronary disease, aortic
dissection and pulmonary embolism. We performed our study with a 64-slice scanner
(Brilliance Pro, Philips Medical Systems) using 100ml of iodinated contrast material.
Structured data collection included demographics, laboratory test data, treatment
provided, CCTA findings and 30-day clinical outcomes.
Results: 466 patients were studied. Mean age was 49.6 ⫹ 11 years. 44% were
men; 50% were black, 44% were white. Of 168 patients with detectable coronary
lesions, 113 (24%) had minimal-mild coronary artery disease (CAD with ⬍50%
diameter reduction), 36 (8%) had moderate CAD (50 –70%) and 19 (4%) had severe
CAD (⬎70%). ACS was ultimately diagnosed in 11 (2.4%) of patients: 9 had severe
CAD, 1 had moderate CAD and 1 had minimal CAD. There were 74 patients (16%)
with extra-coronary findings that explained their symptoms. These diagnoses
included pneumonia (n⫽15), pulmonary embolis (n⫽11), cardiomyopathy (n⫽10),
chronic obstructive pulmonary disease (n⫽8), hiatal hernia (n⫽6), metastatic cancer
(n⫽4), congestive heart failure (n⫽3), anomalous coronary artery (n⫽3), aortic
aneurysm (n⫽2), Barretts esophagitis (n⫽2), aortic dissection (n⫽1), breast cancer
(n⫽1), lung cancer (n⫽1), lymphoma (n⫽1), myocarditis (n⫽1), pancreatitis
(n⫽1), pneumomediastinum (n⫽1), sarcoidosis (n⫽1), thyroid cancer (n⫽1) and
thyroid mass (n⫽1).
Conclusion: A majority of patients were safely discharged based upon normal
coronary arteries or CAD ⬍ 50% with no extra-coronary findings. Many more
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patients with ACS symptoms had extra-coronary findings that explained their
symptoms than actual ACS. Only 9 of 11 patients with ACS had severe CAD.
39
Intussusception in Adults: A 148-Patient Experience
Lindor RA, Bellolio M, Sadosty AT, Earnest IV F, Cabrera D/Mayo Medical
School, Mayo Clinic College of Medicine, Rochester, MN; Mayo Clinic College of
Medicine, Rochester, MN; Mayo Clinic College of Medicine, Rochester, MN
Study Objective: Intussusception is a predominantly pediatric diagnosis that is
not well characterized in adults. Undiagnosed cases can result in significant
morbidity, making early recognition important for clinicians. We describe the clinical
characteristics, management, and outcome of adult patients diagnosed with
intussusception during a 12-year period.
Methods: Observational cohort study of consecutive adult patients diagnosed
with intussusception at a tertiary academic center from 1996 to 2008. Cases were
identified using ICD-9 codes. Data was abstracted in duplicate by 2 independent
authors. Parametric and non-parametric tests were used according to the data type
and distribution. Results are presented as percentages and relative risks (RR) with
confidence intervals (CI).
Results: Of 196 identified patients, 148 were eligible for inclusion; the most
common reason for exclusion was diagnosis at an outside facility or prior to the study
period. The mean age at diagnosis was 48 years (SD 16.6) with females making up
the slight majority (56.8%).
The most common symptoms at diagnosis were abdominal pain (71.6%), nausea
(48.7%), vomiting (35.8%), diarrhea (18.9%), and bloody stools (11.5%); 20.3%
were asymptomatic. The causes of intussusception included malignancy (14.9%),
benign neoplasm (12.8%), adhesions (9.5%), inflammation (8.1%), and other
identifiable causes (15.5%); an unknown etiology accounted for 39.9%. Symptomatic
patients were more likely to have a determined cause for the intussusception (RR
2.57, p⬍.0001).
The most common method of diagnosis was computed tomography which was
positive for intussusception in 128/138 patients (92.8%). The majority of cases were
enteroenteric (80.4%), followed by ileocolonic (10.8%). A total of 88 patients
(59.5%) were admitted to the hospital. Seventy-seven (52.0%) underwent surgery
within 1 month while 71 (48%) were either managed conservatively or received no
specific treatment. Predictors of surgery included the presence of abdominal pain (RR
1.46), nausea (RR 1.73), vomiting (RR 1.65), or bloody stool (RR 6.91) and cases
that were ileocolonic location (RR 6.45).
A total of 46 patients (31.1%) presented to the emergency department (ED).
There was no difference in age (p⫽0.62) or sex (p⫽0.29) between patients presenting
to the ED and those diagnosed elsewhere. Those presenting to the ED were more
likely to have abdominal pain (RR 1.51, p⬍0.0001), nausea (RR 2.1, p⬍0.0001),
vomiting (RR 2.9, p⬍0.0001), and diarrhea (RR 2.2, p⫽0.016); those presenting
outside the ED were 13 times more likely to be asymptomatic (p⬍0.0001). Patients
presenting to the ED were more likely to have intussusceptions caused by malignancy
(RR 2.66) or inflammation (RR 4.43) and to be admitted to the hospital (RR 2.32)
and require surgical intervention (RR 1.75).
There were 10 cases of recurrent intussusception within 1 year, with a median
time to recurrence of 2 months. There were no clinical predictors of recurrence.
Conclusions: The majority of adult intussusceptions present with abdominal
pain, are enteroenteric in nature, have an unknown etiology, and require surgical
management. Predictors for surgery include the presence of abdominal pain, nausea,
vomiting, or bloody stool and an ileocolonic location. Patients presenting to the ED
are more likely to be symptomatic, have an underlying malignancy, and be admitted
for surgery than patients diagnosed elsewhere.
40
Comparison of Analgesic Practices in Pregnant and
Non-Pregnant Emergency Department Patients
Bloch RB, Strout TD, Pierson EA/Maine Medical Center, Portland, ME; University
of Vermont College of Medicine, Burlington, VT
Study Objective: Disparities in the treatment of pain exist for vulnerable groups
such as the elderly, minorities, and indigent populations. It is generally recognized
that the use of medication in pregnancy requires careful consideration as not all
agents are safe. We sought to determine whether pregnancy status affects prescribing
practices for the treatment of pain.
Methods: This IRB-approved study is a retrospective health records survey of
female patients treated for acutely painful conditions: dental pain, minor burns,
Annals of Emergency Medicine S13
Research Forum Abstracts
extremity fractures, and renal colic in the emergency department over a 5-year period.
Records were systematically reviewed, and data pertaining to pregnancy, pain, and
treatment were abstracted. Data were analyzed to compare pain treatment in pregnant
vs. non-pregnant patients.
Results: 1419 records were reviewed. Mean age was 29.3 yrs ⫹/⫺ 9.4 yrs and 63
subjects (4.4%) were pregnant. The mean self-reported pain score was 8.04 ⫹/⫺
2.23, 95% CI: 7.93– 8.16. 802 subjects (56.5 %) received narcotics in the ED. 1019
subjects (71.8%) were prescribed narcotics for home. 780 subjects (55.0%) received
non-narcotic medication in the ED and 853 (60.1%) were prescribed non-narcotic
analgesics for home. In comparing the use of narcotics in the ED for pregnant and
non-pregnant subjects, a significant difference was not noted (p⫽0.919); however,
pregnant subjects were significantly less likely to be prescribed a narcotic for home
(p⫽0.038). When examining the use of non-narcotic analgesics in the ED or when
prescribed for home, no significant differences were noted (p⫽0.374 and p⫽0.450,
respectively).
Conclusions: Narcotic medications can be used safely during pregnancy, and
our data suggest that practitioners are equally likely to use them to treat pain in
the ED for pregnant and non-pregnant patients. However, we demonstrate that
pregnant patients are less likely to be prescribed narcotics for home use,
suggesting that pregnant women may face a health disparity when confronting
pain at home.
41
A Qualitative Study Assessing the Information Needed
to Manage Adults in the Emergency Department With
Sickle Cell Disease
Tanabe P, Lyons JS, Reddin CJ, Thornton VL, Wun T, Todd KH/Northwestern
University, Chicago, IL; United States Naval Nurse Corp, Chicago, IL; Duke
University, Durham, NC; University of California, Davis, Sacramento, CA; Albert
Einstein College of Medicine, New York, NY
Study Objectives: A decision support tool may guide emergency clinicians in
recognizing assessment, analgesic and overall management and health service
delivery needs for patients with sickle cell anemia (SCA) in the emergency
department (ED). We aimed to identify data elements and resulting decisions to
providing optimal care and analgesic management to adult patients with painful
episodes in the ED.
Methods: Qualitative methods using a series of focus groups and grounded
theory were used. Eligible participants included adult clients with SCA and ED
physicians and nurses with a minimum of one year of experience providing care
to patients with SCA in emergency medicine. Patients were recruited in
conjunction with annual SCA meetings, and providers included clinicians who
were and were not affiliated with sickle cell centers. Groups were conducted until
saturation was reached and included a total of two client groups, three physician
groups, and two nurse groups. Focus groups were held in New York, Durham,
Chicago, New Orleans and Denver. Clinician participants were asked the
following two questions to guide the discussion: (1) What information do you
need to provide care to a patient with SCA and (2) What should you do with the
information and what kind of decisions do you need to make? Client participants
were asked the same questions with re-wording to reflect what they believed
providers should know to provide the best care and what they should do with the
information. All focus groups were audiotaped and transcribed. The constant
comparative method was used to analyze the data. Two coders independently
coded participant responses and identified focal themes based on the key
questions. The investigator and assistant independently reviewed the transcripts
and later met four times until the final coding structure was determined.
Results: 47 individuals participated (14 clients, 16 physicians and 17 nurses) in a
total of seven different groups. Two major themes emerged: acute management and
health care utilization. Major sub-themes included the following: physiologic
findings, diagnostics, assessment and treatment of acute painful episodes, and
disposition. The most common minor sub-themes which emerged included: past
medical history, presence of a medical home (physician or clinic), individualized
analgesic treatment plan for treatment of painful episodes, history of present illness,
medical home follow-up available, patient reported analgesic treatment that works,
and availability of analgesic prescription at discharge. Additional important elements
in treatment of acute pain episodes included the use of a standard analgesic protocol,
need for fluids and non-pharmacologic interventions, and the assessment of typicality
of pain presentation. The patients’ interpretation of the need for hospital admission
also ranked high.
S14 Annals of Emergency Medicine
Conclusion: Participants identified several areas which are important in the
assessment, management and disposition decisions which may help guide best
practices in SCA patients in the ED setting.
42
The Emergency Department Pain Experience for Adults
With Sickle Cell Disease
Tanabe P, Hafner JW, Courtney DM, Martinovich Z, Zvirbulis E, Artz N/
Northwestern University, Chicago, IL; University of Illinois, Peoria, IL; University
of Chicago, Chicago, IL
Study Objectives: To report baseline patient characteristics, health services
utilization, and analgesic management practices of emergency department (ED)
patients with sickle cell disease.
Methods: A multi-center, prospective, longitudinal surveillance study enrolled
patients from three academic medical centers (rural and urban). All ED patients ⬎18
years with a chief complaint of a sickle cell pain episode were eligible for inclusion.
All records for all visits with a chief complaint of sickle cell pain were reviewed at all
three sites, and at two sites, patients participated in a structured interview within 7
days of emergency department (ED) visit (1 interview per month). The study period
was 10 months for Sites 1 & 2 and 3.5 months for Site 3. Outcome variables
examined collectively and between sites included the number of patients, number of
visits, mean number of visits/patient/month, ED discharge rate, time to initial
analgesic (from arrival, controlled for the individual patient due to repeat visits), pain
score documented in the medical record within 45 minutes of discharge, compared
with discharge pain score desired at discharge as reported by the patient on follow-up
interview. Time to analgesic is reported as median with intra-quartile range (ICR).
For patients discharged home, the Wilcoxon test with z score analyzed differences
between the highest tolerable pain score at ED discharge (reported during a follow-up
interview) with the score documented in the medical record (when documented).
Results: 703 eligible ED visits were made by 157 different patients [50% male,
median age 32 (ICR 24, 40)]. The mean number of ED visits per individual patient
per site per month was 0.55, 1.0 and 0.58 respectively. For the entire cohort, 72% of
patients had between 1–3 visits to the ED during the study period, 14% had between
4 –9 visits, and 14% of patients had greater than 10 visits. The discharge rate to
home/site were 47%, 76% & 54% respectively. The median and ICR time to initial
analgesic per site was; Site #1 ⫽ 90 (62, 141), Site 2 ⫽ 70 (49, 84), and Site 3 ⫽ 172
(86, 278). On follow-up interview patients reported a significantly lower desired
targeted discharge pain score (median ⫽ 4, ICR ⫽ 3, 5) when compared with the
actual documented discharge pain score within 45 minutes of discharge (median ⫽ 5,
ICR ⫽ 3, 7), (z score ⫽ ⫺3.2, p ⬍.001, n⫽43).
Conclusion: These data show that the range of patient visits per month was as
low as 0.5 but only as high as 1.0 visits/patient/month. Baseline data demonstrate
individual differences between study sites. Site 2 achieved faster time to analgesia and
a higher proportion of discharged patients (primarily accounted for by one patient).
Data support the need for individual case management for the few patients at each
site for patients with multiple visits and opportunities to improve analgesic
management at all sites.
43
How Does Use of a Statewide Prescription Monitoring
Program Affect Emergency Department Prescribing
Behaviors?
Sinha S, Callan EM, Akpunonu P, Baehren D, Marco C/University of Toledo
College of Medicine, Toledo, OH
Background: Prescription opioid dependence and abuse are public health
problems of national importance. The state of Ohio recently instituted an online
prescription monitoring program (PMP), The Ohio Automated Rx Reporting System
(OARRS) to monitor controlled substance prescriptions within the state of Ohio.
Study Objectives: This study was undertaken to identify the influence of OARRS
data on clinical management of emergency department patients with painful
conditions.
Methods: This prospective quasi-experimental study was conducted at the
University of Toledo Medical Center Emergency Department during June and July
of 2008. Eligible participants included ED patients with painful conditions
(including dental, neck, back, head, joint, or abdominal pain). After clinical
evaluation, attending physicians answered a set of questions regarding planned opioid
prescription for the patient. Following the intervention of presentation of OARRS
data, attending physicians again responded to the questions regarding opioid
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prescription. Outcome measures included changes in opioid prescription, and other
potential factors that influenced opioid prescription.
Results: Among 174 (90% of eligible) participants, OARRS data revealed high
numbers of narcotics prescriptions filled in the most recent 12 months (18.9 mean
prescriptions ⫹/⫺ 26.6, range 0 –128). Numerous physicians prescribed narcotics for
patients (mean 5.6 physicians per patient ⫹/⫺ 7.6, range 0 – 40). Patients had filled
narcotics prescriptions at numerous pharmacies (mean 3.5 ⫹/⫺4.4).
Following review of the OARRS data, physicians changed the clinical
management in 41% of cases. In cases of altered management, the majority (63%)
resulted in fewer or no opioid medications prescribed than originally planned. The
most common reasons for change in management, as cited by physicians, included
the number of previous prescriptions filled (41%) and number of physicians writing
prescriptions (31%). Other reasons for change in management included number of
pharmacies filling prescriptions (26%), number of addresses (16%), physical exam
(10%), and patient statements (6%).
Conclusion: In our patient population, the use of prescription opioids within the
past twelve months was common. The use of data from a statewide narcotic registry
frequently altered clinical management of ED patients with complaints of pain. In
addition to information from the registry, information from the physical examination
and statements by the patients also altered management in some cases.
44
Risk Factors for Delayed Analgesia in Patients
Presenting to the Emergency Department With Long
Bone Fractures
Mejia J, Bautista F, Garg N, Reddy V, Radeos MS, Caligiuri AC/New York
Hospital Queens, Flushing, NY
Study Objectives: Oligoanalgesia has been identified as a problem area in
emergency medicine. We sought to determine the causes for delayed administration
of analgesics in adults presenting to the emergency department (ED) with long bone
fractures.
Methods: Retrospective review of consecutive adult patients presenting to an
urban level I Trauma Center ED with a long bone fracture. Patients were excluded if
they were age 17 or less or involved in a major trauma. We examined demographic
and clinical data, mode of arrival and time to analgesic administration. Data were
analyzed using chi-square and Kruskal-Wallis test for non-parametric data as needed.
Logistic regression was performed and odds ratios (OR) with 95% confidence
intervals (95% CI) were used. Alpha was set at 0.05 by convention.
Results: 615 total patients were enrolled between 7/1/06 and 11/30/06. 407
(66.2%) were female, age groups were 18 –39 (75 [12.2%]), 40 – 64 (168 [27.3%])
and 65 and above 372 (60.5%). More than a dozen languages were represented in our
patient population, with 393 (63.9%) speaking English as their primary language.
338 (55.1%) were white, 40 (6.5%) were Black, 63 (10.3%) were Latino 123
(20.0%) were Asian or Pacific Islander and 50 (8.1%) were other race. 402 (66.0%)
of our patients arrived via ambulance. 301 (65.4%) patients experienced a delay in
getting analgesia. Delay was statistically significantly related to age (209 (74.1%) of
those 65 and older): OR 1.84 (95% CI [1.35,2.50]) p⬍0.001. There was no delay
associated with either race or English-speaking ability. Neither was delay associated
with sex or mode of arrival. The effect remained quite significant even when adjusting
for sex, age, race, English language preference and mode of arrival.
Conclusion: There does appear to be a delay in older emergency department
patients getting timely analgesia when they have suffered a long bone fracture. Future
studies should focus on how to overcome barriers to rapid pain relief for all of our
patients, especially the elderly.
45
A Clinical Study to Evaluate the Efficacy of 4%
Liposomal Lidocaine as Compared to Placebo for Pain
Reduction of Nonemergent Venipuncture in Adults
Rusczyk G, Bhatt S, Amodeo D, Cregin R, Green JP/New York Hospital Queens,
Flushing, NY
Study Objectives: There is a multitude of literature describing the benefits of
topical anesthetics for pain reduction during venipuncture in children, but no study
to date has shown a pain reduction from topical anesthetic use during venipuncture
in adults. This study was a randomized, double-blind, placebo-controlled trial to
assess the efficacy of an existing topical anesthetic- 4% liposomal lidocaine (LMX-4
®) already in use for children, for pain relief in adult patients during non-emergent
venipuncture procedures.
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Methods: This was a randomized, double-blind, placebo-controlled trial. Setting:
ED urgent care and outpatient surgery of a 500 bed, urban, tertiary care hospital.
Subject Enrollment: During specified enrollment periods consecutive adult patients
(ⱖ 21 years of age) at the 2 sites requiring non-emergent venipuncture were
approached, and all consenting patients enrolled. Subjects were randomized via
random number generator to LMX® or placebo application for 30 minutes prior to
venipuncture. Subject allocation was concealed and research staff, clinicians and
subjects were blinded to groups. The placebo was a cream with the same color and
consistency as the LMX® product, but containing no anesthetic. Inclusion criteria:
Adult patients ⱖ 21-years of age requiring non-emergent venipuncture. Exclusion
criteria: Inability to obtain IV access, allergy to topical anesthetic or cream. Statistical
analysis: Data was analyzed following an intention-to-treat basis. The primary
outcome was the patient’s rating of pain immediately after venipuncture as compared
to baseline pain pre-procedure using the visual/verbal analogue pain scale. Chi-square
was used to analyze categorical data, t-test for continuous parametric data and MannWhitney-U for continuous non-parametric data.
Results: 95 adult patients were enrolled in the study. Complete records were
available for 93 patients (98 %). There were no baseline differences between groups
in terms of age, sex or baseline pain. The LMX® group contained 63% females and
had a mean age of 47.1 years. The placebo group was 60% female and had a mean
age of 42.3 years. Mean baseline pain score (pre-cannulation) in the placebo group
was 2.46 (95% CI 1.48 –3.44) and 2.05(95% CI 1.06 –3.03) in the LMX® group.
Mean post IV cannulation pain in the placebo group was 4.02 (95%CI 3.26 – 4.78)
and 4.12 (95% CI 3.25– 4.98) in the LMX® group. The primary outcome (mean
change in pain score after IV cannulation), was 1.56 (95%CI 0.38 –2.74) for the
placebo group and 2.07 (95%CI 0.97–3.12) for the LMX® group, P⫽0.628.
Conclusion: This study did not demonstrate statistically significant pain
reduction with the use of LMX® or placebo in adult subjects. The study was limited
by a small sample size, which should be addressed in future studies.
46
The Pediatric Experience in the Emergency Department,
2000 –2006
Thode Jr HC, Garra G/Stony Brook University, Stony Brook, NY
Study Objectives: Determine the characteristics of pediatric visits to emergency
departments (EDs) with the purpose of identifying focuses of research needs.
Methods: Retrospective analysis of The National Hospital Ambulatory Medical
Care Survey (NHAMCS) data for 2000 –2006. Pediatric patients were defined as
⬍18 years old. Trends over time were evaluated using linear regression; comparisons
to adults were also performed.
Results: From 2000 to 2006 pediatric ED visit characteristics were uniform.
There were about 28 million visits per year, 25% of all ED visits. Mean age was 7
years, 75% were ⬍ 13 years. More than half were male, 40% were injury related with
injury rate increasing with age. More than 50% of visits occurred between 4 PM and
midnight. There was a slight increase in pediatric visits on Sundays; no seasonal
variation was seen. Thirty percent of patients received antibiotics and 40% received
analgesics during their visit. Fewer than 7% arrived by ambulance. 40% of all
pediatric patients were located in the southern geographic region, and 25% were in
the Midwest. About 4% of patients were admitted, with the admission rate highest
for patients ⬍ 2 years old (⬎ 5%) and lowest for those between 2 and 4 (⬃3%).
Some differences between pediatric and adult ED populations included: 15% of
adults arrived by ambulance, 15% admitted, and a third were due to injury. Twenty
five percent of patients ⬍ 6 years had an imaging study done, with imaging increasing
with age to almost 50% for adults. The most common reasons for visits were fever,
cough and vomiting (pediatrics) vs abdominal and chest pain (adults). Similarities
between older and younger patients included race and geographic distribution.
Conclusion: There has been no change in the characteristics of the pediatric ED
population over the 7-year study period. The nature of pediatric ED visits is different
than that of adults, which requires a different focus on diseases and treatments.
Relatively few pediatric cases arrive by ambulance, limiting the availability of subjects
to conduct out-of-hospital research in this population.
47
Delayed Repeat Enema Management of Failed Initial
Enema-Reduction Intussusception
Pazo A, Hill J, Losek JD/Medical University of South Carolina, Charleston, SC
Study Objectives: Air enema reduction under fluoroscopic guidance has
become the treatment of choice for intussusception. Although surgery is the
Annals of Emergency Medicine S15
Research Forum Abstracts
recommended management for failed enema patients, successful reduction has
been reported with delayed repeat enemas. The purpose of this study is to
describe the demographic and clinical characteristics of children managed by
delayed repeat enema reduction for failed initial enema attempts and identify
predictors of delayed repeat enema success.
Methods: This is a retrospective cross-sectional study of children diagnosed with
intussusception who received care at an urban 110 bed children’s hospital. Patients
with initial failed enema attempts who were managed by delayed repeat enemas made
up the study population. The primary outcome variable was success of delayed repeat
enema reduction. Predictor variables included duration of presenting symptoms (⬍
24 hours vs equal to or greater than 24 hours), gross bloody stools, dehydration,
altered mental status, radiographic ileus and lack of partial reduction to the ileocecal
valve and clinical improvement with the first enema.
Results: Over a 6-year period (March 2003 – Feb 2008) 16 patients with 17
intussusception events managed by delayed repeat enemas were identified. Of the 16
patients there were 11 (69%) males. Race was 7 (43%) Caucasians, 5 (31%) African
Americans and 4 (25%) Hispanics. The mean age (months) at the time of
intussusception was 16.1, SD 13.8, median 8 and range 2 to 43 months.
Of the 17 delayed repeat enemas 9 (53%) were successful. Of the 8 unsuccessful
attempts 4 had a second delayed repeat enema attempt and 3 were successful. Overall
delayed repeat enemas were successful in 12 (71%). Surgical reduction was performed
in 5 (29%) patient events. Of these manual reduction was performed in 3 and
surgical incision in 2 with one requiring resection of 7 cm of the distal ileum. There
were 15 (88%) ileo-colic and 2 (12%) ileo-ileo-colic intussusceptions. There were no
pathologic lead points.
In comparing the successful vs failed delayed repeat enema groups there was
no significant difference in demographic or clinical characteristics or time from
initial enema to 1st repeat enema. However, there was a trend towards a
significant difference in regard to the failed group having a greater rate of rectal
bleeding, dehydration and altered mental status. There was a significant
difference for the degree of partial reduction achieved on the initial enema. For
the successful vs failed delayed repeat enema groups the location of the lead point
of the intussusceptum post the initial enema was at the ileocecal value for 9
(90%) vs 2 (40%) respectively. Although not significantly different the successful
delayed repeat enema group had trends for significance in regard to fewer patients
with radiographic ileus and more patients with clinical improvement post initial
enema.
Conclusion: Delayed repeat enemas were successful in 12 (71%) patients thus
avoiding the need for standard surgical management. Therefore with the
coordinated care of emergency medicine, surgery and radiology services delayed
repeat enema appears to be a safe and effective management option for clinically
stable children when partial reduction to the ileocecal value on the initial enema
attempt is achieved.
48
Anaphylaxis Management in the Pediatric Emergency
Department: Opportunities for Improvement
Russell S, Monroe K, Losek JD/Medical University of South Carolina,
Charleston, SC; University of Alabama-Birmingham, Birmingham, AL
Study Objective: To determine the rate of anaphylaxis, review the immediate
(out-of-hospital and emergency department (ED)) management of anaphylaxis, and
identify opportunities for improving anaphylaxis management of children receiving
care in a pediatric emergency department.
Methods: Retrospective cross-sectional descriptive study of children (21 years
of age or younger) who received care for anaphylaxis over a 5-year period in an
urban children’s hospital emergency department with an annual census of
55,000. The diagnostic criteria for anaphylaxis were: symptoms and/or signs
involving two or more organ systems (dermatologic, respiratory, gastrointestinal
and cardiovascular), hypotension for age, one organ system involvement with
admission to the hospital, and/or dermatologic system involvement treated with
intramuscular epinephrine.
Results: There were 124 patient visits by 103 patients (4.5 events/10,000 ED
patient visits) who met the diagnostic criteria for anaphylaxis. This included 114
(92%) who had two or more organ system involvement. There were 66 (64%)
males. The most common organ system involvement was dermatologic 121
(98%), followed by respiratory 101 (81%), gastrointestinal 33 (27%) and
cardiovascular 11 (9%). Intramuscular epinephrine was administered to 69 (56%)
patients. Interventions other than epinephrine included administration of H1
S16 Annals of Emergency Medicine
and/or H2 antihistamine 114 (93%), corticosteroids 97 (79%), albuterol
nebulization 37 (30%) and intravenous fluid bolus 15 (12%). Food was the most
common inciting allergen 45 (36%). Hospitalization occurred in 33 (27%)
patient visits and 91 (73%) were managed as outpatients. Compared to the
children managed as outpatients, those hospitalized had a significantly greater
rate of cardiovascular system involvement and of receiving 3 or more
interventions other than epinephrine. When compared to those not treated with
intramuscular epinephrine, patients treated with intramuscular epinephrine had a
significantly greater rate of hospitalization and of receiving 3 or more
interventions other than epinephrine. Of the 91 children managed as outpatients,
auto-injection epinephrine was prescribed to 57 (63%) and referral to an allergist
was recommended to 30 (33%). There were no patient deaths.
Conclusion: This study is the first to describe the management of anaphylaxis in a
pediatric emergency department. The results revealed opportunities for improvement.
Although our ED treatment and outpatient management of children with anaphylaxis
did not meet recommended standards of care in regard to administering
intramuscular epinephrine, prescribing auto-injection epinephrine, or referral to
allergist for all patients diagnosed with anaphylaxis, we do report higher concordance
with published recommendations than those reported in previous studies performed
in adults.
49
Recombinant Human Hyaluronidase-Facilitated
Subcutaneous vs Intravenous Hydration Therapy in
Infants and Children
Hahn B, Mace SE, Maher G, Harb G/Staten Island University Hospital, Staten
Island, NY; Cleveland Clinic Lerner College of Medicine of Case Western
Reserve University, Cleveland, OH; Memorial Children Hospital/Memorial
Medical Group, South Bend, IN; Baxter Health Care Corporation, New
Providence, NJ
Study Objectives: Clinical trials have demonstrated the safety, efficacy, and
tolerability of recombinant human hyaluronidase (rHuPH20)-facilitated
subcutaneous (SC) hydration therapy in adults and children. The objective of the
Increased Flow Utilizing Subcutaneously Enabled Pediatric Rehydration Study II
(INFUSE II) is to evaluate whether rHuPH20-facilitated SC fluid administration can
be given safely and effectively in clinically appropriate volumes no less than that
delivered via the intravenous (IV) route in infants and children with mild to moderate
dehydration.
Methods: In this ongoing phase 4, open-label, randomized, stratified study,
eligible patients are otherwise healthy children aged 1 month to ⬍3 years in the
emergency department or pediatric inpatient unit with mild to moderate dehydration
(Gorelick scores 1 to 6). Patients are stratified based on body weight (⬍10 kg and
ⱖ10 kg) and dehydration severity (Gorelick score 1 to 2 [mild] and 3 to 6
[moderate]), then randomly assigned (1:1 ratio) to receive rehydration therapy (20
mL/kg isotonic fluid over 1 hour and additional fluid as needed until deemed
clinically rehydrated up to 72 hours) via rHuPH20-facilitated SC or IV
administration. One mL of rHuPH20 (150 U) is administered SC through an
angiocatheter or needle placed in the upper back or other suitable region,
immediately followed by SC isotonic fluid administration. The primary study end
point is the total volume of fluids administered at a single infusion site. Secondary
end points include the percentage of patients successfully hydrated; time to urine
output; total volume infused over all infusion sites; safety evaluations (adverse events
[AEs]), and health care provider ease of use assessment.
Results: An interim data analysis was conducted on 41 subjects (20
randomized to SC; 21 randomized to IV), mean age (standard deviation [SD])
1.6 (0.7) years. Baseline Gorelick score indicated mild dehydration in 45% in the
SC group vs 71% in the IV group, and moderate dehydration in 55% in the SC
group vs 29% in the IV group. The primary efficacy outcome, mean total volume
(SD) infused over a single site, was 329.4 (216.7) mL for SC vs 560.2 (799.4)
mL for IV (Table 1). The mean total volumes, adjusted for duration of infusion,
were 466 mL for SC and 429 mL for IV. Mean volumes per body weight were
28.3 (17.2) mL/kg (SC) and 52.1 (77.2) mL/kg (IV). Secondary end point results
are provided in Table 2.
Conclusions: Preliminary results reveal that rHuPH20-facilitated SC infusions
were safe and resulted in a higher percentage of patients who were successfully
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hydrated compared with IV. Duration-adjusted mean volume of fluids infused was
comparable for both routes of administration.
was younger for possible compared to definite asthma patients (6 vs. 8 years;
p⬍0.0001). Long-term ICS were prescribed more frequently at visits for definite vs.
possible asthma (5.5 vs. 0.1%; p⬍0.0001). Patients with a greater odds of being
prescribed a long-term ICS in the ED were those with definite vs. possible asthma
(OR 49.4; 95% CI: 18.4 –132.5); those triaged to be seen immediately vs. later (OR
6.1; 95% CI 1.1 – 33.6); and those who received a short-acting ␤-agonist and oral
steroid vs. neither medication while in the ED (OR 4.8; (95% CI: 1.7–13.7).
Conclusion: Long-term ICS are prescribed from EDs, although very infrequently.
Children with definite asthma were more likely to receive a long-term ICS, despite
presenting complaints similar to those with possible asthma. Our findings suggest that
unrecognized asthma in children with presenting complaints consistent with possible
asthma contributes to the already low rate of long-term ICS prescribing from EDs.
51
Spontaneous Pneumomediastinum in Children:
A 10-Year Experience
van Tonder RJ, Beatty NC, Bellolio MF, Colletti JE/Mayo Clinic, Rochester, MN
50
Emergency Department Prescriptions for Long-term
Inhaled Corticosteroids for Children With Asthma: Are
We Following Recommendations?
Garro A, Asnis L, Merchant R, McQuaid E/Rhode Island Hospital and Alpert
School of Medicine at Brown University, Providence, RI; Brown University,
Providence, RI; Rhode Island Hospital and Alpert School of Medicine at Brown
University, Providence, RI; Bradley/Hasbro Research Center, Alpert Medical
School at Brown University, Providence, RI
Study Objectives: Emergency departments (EDs) are a unique component of the
health care system involved in treating childhood asthma. EDs in the US are visited
by underserved populations disproportionate to other health care settings. These
populations are more likely to have poorly controlled asthma and less likely to be
using an appropriate asthma controller medication. National Heart, Lung, and Blood
Institute (NHLBI) asthma guidelines recommend that children with persistent
asthma be prescribed long-term inhaled corticosteroids (ICS). Our first objective was
to determine how frequently US ED providers prescribe long-term ICS to children
with definite or possible asthma. Our second objective was to examine clinical and
demographic factors associated with children being prescribed these medications.
Methods: This study examined data from the 2005 and 2006 National Hospital
Ambulatory Medical Care Survey for US ED visits for children between 0 and 21 years
old. For this study, ED visits for definite asthma were defined as visits with presenting
patient complaints consistent with a potential asthma exacerbation (eg, wheezing,
dyspnea/shortness of breath, cough) and ICD-9 code of 493. ED visits for possible asthma
were defined as visits with the same presenting complaints, but excluded visits for definite
asthma and those with an alternative definitive diagnosis (eg, heart failure). Summary
statistics on long-term ICS prescriptions were calculated for definite and possible asthma.
Logistic regression modeling was used to identify demographic, clinical, and temporal
variables associated with prescriptions for long-term ICS. Odds ratios (ORs) and
corresponding 95% confidence intervals (CIs) were calculated.
Results: There were 1,841,551 ED visits for definite asthma, and 5,899,192 for
possible asthma for children 0 –21 years old during the study period. The mean age
Volume , .  : September 
Study Objectives: To examine demographic characteristics, clinical presentation,
workup for diagnosis, treatment and outcome of children presenting with
spontaneous pneumomediastinum (SPM) to the emergency department.
Methods: Observational cohort study of all consecutive patients less than 19,
presenting with SPM between 1998 and 2007 to an academic ED. The medical
records were reviewed and demographics, risk factors, symptoms, treatment, and
outcomes were collected. The statistical analyses were performed according to the
distribution and the characteristics of the variables collected.
Results: A total of 22 children were seen with SPM over the 10-year period,
90.9% were male. The median age was 15 years (range 6 to 17 years). A total of 16
(72.7%) children had chest pain, 63.6% had neck pain or sore throat, and 5 (22.7%)
children complaint of shortness of breath. Nine children (40.9%) had asthma, 14%
reported drug use and 13.6% were active smokers.
Patients with asthma were as likely to have chest pain as those without asthma
(Relative risk 0.87, 95%CI 0.5–1.5, p⫽0.655). A trigger for the SPM was identified
in 12 children (55%) and the most common trigger was cough in 11 children (50%
of the cohort) and Valsalva in one. Overall 15 (68.2%) were admitted to the hospital,
with a median length of stay of 1 day (range 1 to 4 days).
Age (p⫽0.75) and asthma (p⫽0.99) were not predictors of hospital admission. All of
the patients had a chest X-ray, 31.8% had a chest CT, and 22.7% had an esophagogram
performed. Three SPM were missed on the initial chest X-ray (13.6%).
Having a CT done or not did not affect the final disposition of the patient;
71.4% of those with CT were admitted vs 66.7% of those without CT were admitted
(p⫽0.99). All 5 patients having an esophagogram were admitted to the hospital. One
patient had a concomitant pneumothorax, and chest tube was not required. Overall
86.4% had more than 30 days of follow-up, for a median follow-up of 3 years, and
none of them had a recurrent episode of SPM.
Conclusion: SPM is a rare benign condition seen primarily in older male children.
Most patients will either have chest pain or neck pain. SPM appears to be strongly
associated with asthma with near half of the cohort having past history of asthma.
Although SPM may be spontaneous, an identifiable trigger is present most of the time.
CT of the chest does not change disposition. No recurrences of SPM were found during
our study.
52
Endotracheal Tube Cuff Pressures in Pediatric Patients
Intubated Prior to Aeromedical Transport
Tollefsen WW, Chapman J, Frakes M, Gallagher M, Shear M, Thomas SH/
Harvard University, Boston, MA; Massachusetts General Hospital, Boston, MA;
Boston MedFlight, Boston, MA; University of Oklahoma School of Community
Medicine, Tulsa, OK
Study Objectives: Prolonged endotracheal tube cuff pressures (ETTCP) greater
than 30 cm H2O can cause complications. Significantly elevated cuff pressures in an
emergency setting have been demonstrated to be commonplace in adults. With
increasing utilization of cuffed endotracheal tubes (ETT) in pediatric patients comes
the risk of overinflation. This study’s goals were to assess pediatric patients intubated
with cuffed ETTs undergoing transport by a critical care transport (CCT) service to
ascertain ETTCP and whether elevated ETTCP was associated with factors such as
patient demographics, diagnostic category and intubator credentials.
Methods: In this prospective study, CCT protocols were modified and crews
educated to assess ETTCP in all patients intubated (with cuffed ETTs) upon their
arrival at the bedside. The study focused on a consecutive sample of the first year
Annals of Emergency Medicine S17
Research Forum Abstracts
(FY08) of pediatric (⬍18 years) patients undergoing CCT, with cuffed ETTs placed
prior to CCT arrival. All patients had cuff pressures assessed by the same cuff
manometry device (Posey® Cufflator #8199), and recorded at time of arrival at the
patient. (Pressures found to be above 30 cm H2O were corrected by the CCT crew.)
Results: It is found that 41% met the a priori defined cutoff for elevated ETTCP of
30 cm H2O, and 18% met twice that cutoff. There were no associations between any of
the demographic variables, or between physician and nonphysician intubators, or between
intubation location (ie, scene vs. ED vs. ICU), in the risk of high ETTCP.
Conclusion: A significant number of pediatric patients requiring intubation prior to
transport by an aeromedical service were found to have elevated cuff pressures.
Furthermore, there was no clear risk factor for elevated cuff pressures. This is further
evidence that regardless of patient demographic or intubator credentials, cuff pressures
should be measured in all patients. Further research should focus on the effect of
educational intervention, and on the possible clinical results of elevated ETTCPs.
53
Does Sex Delay the Diagnosis of Appendicitis in Female
Patients With Abdominal Pain?
Baquero A, Reynolds T, Waseem M, Leber M/Lincoln Medical Center, Bronx, NY
Study Objectives: We believe female patients, especially those who are sexually
active, presenting with lower abdominal pain undergo more ancillary testing. These
additional tests may lead to a delay in diagnosis and subsequent surgery, placing these
patients at higher risk of perforation or increased morbidity and mortality. This study
looks at the present day’s pediatric population and attempts to determine any surgical
delay in male versus female patients diagnosed with appendicitis as well as looks at
what adjuvant studies do in the emergency department before surgery.
Methods: We designed a retrospective chart review study at an urban academic
pediatric ED. Subjects were patients under 22 years of age. Two hundred and twenty
five consecutive retrospective records of subjects with the diagnosis of appendicitis as
per surgical pathology were reviewed. Patients were divided into two groups, female
(study population) and male (control). Inclusion criteria included patients presenting
to the pediatric ED and positive post-surgical pathological specimen showing
appendicitis. Exclusion criteria include patients with unstable vital signs at time of
presentation. We collected the following data: sex, age, time to OR from ED triage,
whether CT was done and whether an abdominal and/or pelvic ultrasound was
performed. Length of hospital stay, whether patient were admitted to the ICU and
duration of symptoms before ED presentation were also noted. Data underwent
univariate, bivariate, Kaplan Meier Survival, and Cox regression analysis. Significance
was set at p⫽0.05 and 95% confidence intervals (95% CI) were calculated.
Results: 223 consecutive charts meeting inclusion criteria where analyzed. 95 (43%)
were female. Mean age was 12.7 years with minimum of 3 and maximum of 21. 64% of
the patients had CT scan performed. Ultrasound was performed in 29.8% of patients.
There were more CT scans (74% versus 54%, P⫽0.005) and ultrasound (42% versus
20%, P⬍0.0001) in females versus males. 33% of females had both ultrasound and CT
scans as part of their evaluation compared to only 15% of males. Patients with combined
studies had a longer time from triage to OR (P⫽.08). Performing CT scan caused the
mean time to go from 564 minutes to 999 minutes (P⫽.04) while performing ultrasound
doubled mean time to OR from 661 minutes to 1289 minutes. However, there were no
significant differences between sex using as far as sex and time to OR from triage, hospital
stay, age, duration of symptoms, and ICU stay. It is important to note that the standard
deviation of time to OR from triage was extremely high making it difficult to attain
statistical significance. Statistical differences between performance of ultrasound and
incidence of complicated appendicitis 44% vs. 25% (P⫽.006). Using Kaplan Meier
Survival Analysis there is statistical differences in time to OR between men and women
(P⫽.03).
Conclusion: More ancillary tests were used in evaluation of females versus males.
In addition, there was an increased incidence of complicated appendicitis in those
patients undergoing ultrasound. Although these tests increased the amount of time to
the operating room, it was difficult to determine significance in terms of sex due to
high standard deviation. Further studies should focus on increasing sample size.
54
Characteristics and Risk Factors of Patients Who
Refuse Routine HIV Testing in an Urban Emergency
Department
Calderon Y, Cowan E, Fettig J, Hannon M, Leider J/Jacobi Medical Center,
Bronx, NY
Study Objectives: CDC guidelines recommend routine HIV screenings in locations
including emergency departments (EDs). Characteristics of patients who refuse testing in
S18 Annals of Emergency Medicine
the ED have not been thoroughly investigated. This study examines the characteristics and
risk factors of patients who refused ED-based rapid HIV testing.
Methods: A prospective cross-sectional study of patients recruited into an EDbased rapid HIV testing program was conducted for 39 months. Demographics and
risk factors were collected from patients who both agreed to and refused testing. Data
was analyzed using STATA.
Results: 19,454 patients were offered routine HIV testing and 1669 (8.6%) were
ineligible. Of the 17,785 eligible patients 16,688 (93.8%) agreed to test and 1097
(6.2%) refused. Characteristics of those who refused testing: 51.2% females, 14.3%
Hispanic, 39.8% black, 18.9% married, and 70.8% aged over 30; all characteristics
had a p-value ⬍ 0.01 compared to those who agreed to test. Bivariate analysis
demonstrated that blacks (OR 1.24, 95% CI: 1.10 to 1.41), women (OR 1.02, 95%
CI: 1.01 to 1.03), patients over 30 (OR 1.97, 95% CI: 1.73 to 2.26) and married
persons (OR 1.37, 95% CI: 1.17 to 1.61) were more likely to refuse testing. Most
refusals (49.6%) felt they were not at risk for HIV infection; their risk factors are in
Table 1. Additionally, 12.0% refused testing because they felt they had “no time” and
8.6% refused because they were “afraid.”
Conclusion: Patients who refused testing were more likely to be older, black,
married and female. The majority of patients who refused testing perceived
themselves to be “not at risk” even though they exhibited multiple HIV risk factors.
Further studies are needed to assess the generalizability of this issue and evaluate
interventions that can effectively target this group.
55
STEP-DC: Stop Emergency Department Visits for
Hyperglycemia Project -DC
Dubin J, Nassar C, Sharretts J, Youssef G, Curran J, Magee M/Washington
Hospital Center, Washington, DC; MedStar Diabetes Institute, Washington, DC
Study Objectives: Due to a variety of socioeconomic factors, greater numbers of
patients both with known diabetes and undiagnosed diabetes present to the
emergency department (ED) with uncontrolled hyperglycemia. This interventional
study evaluates the implementation of survival skills diabetes self-management
education (DSME) and medication management to achieve better control of diabetes
and reduce the frequency of repeat emergency department visits for hyperglycemia.
Methods: Diabetics with a blood sugar level over 200 mg/dl whom were suitable
for discharge were enrolled in this IRB-approved study. The patients received formal
DSME (4 sessions over 4 weeks) which included instruction on use of a glucometer
and how to self inject insulin if indicated; meal planning; prevention and treatment of
hypoglycemia; and medication information. Diabetes medications were initiated and/
or adjusted using an algorithm that provided guidelines for initiating and/or titrating
upwards oral agents and/or insulin. Patients with blood glucose over 300 mg/dl were
given an injection of glargine insulin prior to discharge from the emergency
department. All education was performed by certified diabetes educators who were
nurses or registered dieticians. Baseline and follow-up HgA1C and glucose levels were
checked on enrollment and at follow-up visits.
Results: Of 86 patients enrolled, 60% completed all four follow-up study visits,
21% completed at least two or three visits. 19% did not follow up after enrollment.
No patients had hypoglycemia on day one (after therapy initiation). Overall
hypoglycemia rate was only 1.6% based on 34 episodes in 2,148 patient days
measured. At 2 week follow-up mean blood glucose for 51 patients tested was
reduced by 48.9% from 356 (95% CI: 325–387) to 183 mg/dl (95% CI: 153 to
212), p⬍.001. Baseline hemoglobin A1C levels were tested on 81 study patients of
whom 52% had levels above 13%. Hemoglobin A1C was tested on 46 patients at
week two and mean HgA1C levels decreased 3.3% from a pre intervention mean
12.0% (95% CI: 11.6 –12.5) to mean POST 11.6% (95% CI:11.1–12.1%), p⬎0.05.
The proportion of patients with HgA1C ⬎13% trended down from 54.35% PRE to
43.48% POST intervention, but this was not statistically significant (Chi Squared
⫽1.09, p⫽0.29.) Total number of ED visits/hospitalizations for hypo/hyperglycemia
among the study group patients were reduced by 78% from 42 in the six months
before the index visit to nine in the six months following study visit one.
Conclusion: Formal diabetes teaching and medication management introduced in
the ED can significantly reduce hyperglycemia and reduce the frequency of ED visits
for uncontrolled diabetes. The diabetes medication management algorithm utilized,
which included starting basal insulin in the ED, was safe and effective.
Volume , .  : September 
Research Forum Abstracts
56
A Performance Improvement Audit to Assess Airway
Documentation: How Well Do Emergency Physicians
Document Confirmation of Endotracheal Tube
Placement?
Phelan MP, Wickline D, Glauser J, Peacock WF, Meredith R, Joyce M, Martin C,
Sturges Smith L/Cleveland Clinic, Cleveland, OH; MetroHealth Medical Center,
Cleveland, OH
Study Objectives: Documentation of correct endotracheal tube (ET) placement is
poorly described in patients arriving to the emergency department (ED) already
intubated. We sought to determine the rate at which emergency physicians document
correct ET location in patients arriving to the ED already intubated.
Methods: The study was performed at an urban tertiary referral hospital with an
emergency medicine residency and an annual census of 60,000. Using our quality
improvement airway registry of all patients presenting to the ED with an ET in place,
over a 21-month period (1/1/06 –9/9/07) trained research assistants reviewed the
medical records specifically looking for physician confirmation and documentation of
ET placement. Consistent with the American College of Emergency Physician
guidelines, ET confirmation was defined as end tidal CO2 (ETCO2) measurement,
direct laryngoscopy (DL), or bulb aspiration (BA).
Results: 152 patients arrived intubated; 88 (57.9%) were hospital transfers, with
the remainder intubated by EMS in the field. Overall, physician documentation of
ET placement was found in only 52 (34.3%). In the EMS intubated cohort, 40
(63%) had ET confirmation; 5 (8%) by ETCO2, 35 (55%) by DL, and 24 (38%)
had no ET confirmation documentation. Of the transfer patients, 12 (13.6%) had
ET confirmation documented in the physician medical record; 7 (8%) by ETCO2, 5
(6%), by DL; 76 (86%) had no physician confirmation documented. Patients
transferred from other hospitals were 2.25 times less likely to have physician
documentation of correct ET placement than those intubated by EMS, 86% (95%
CI⫽ 0.774 to 0.928) vs 38% (95% CI ⫽ 0.257 to 0.505), respectively.
Conclusion: Physician documentation of correct ET placement is poor for
patients arriving intubated, and is worst when patients are transferred between
hospitals.
57
Copperhead (Agkistrodon Contortrix) Snakebites in the
United States: 2000 –2007
Bhakta NS, Morgan DL, Borys DJ/Scott and White Memorial Hospital, Temple,
TX; Texas A&M University Health Science Center, Temple, TX; Central Texas
Poison Center, Temple, TX
Background: Bites from copperhead snakes (Agkistrodon contortrix) are the
second most common snake envenomation in the United States. There are 5
subspecies of this copperhead that inhabit 27 states. The effects from copperhead
bites (such as pain, tissue necrosis, and coagulation abnormalities) are generally
considered less severe than those of other pit vipers. However, there have been no
large national studies of copperhead bites published.
Study Objectives: Our goal was to describe the characteristics of copperhead bite
victims reported to all US poison centers.
Methods: Retrospective, observational study of telephone calls to all US poison
centers (National Poison Data System) for copperhead snakebites to human victims
of any age from 2000 to 2007.
Results: There were 7,748 total copperhead bites. The annual number of bites
reported increased by 65.3% during the 8-year study period. Copperhead bites were
reported every month including the nadir in January (0.2%) and the peak in July
(21.4%). Copperhead bites occurred in all but 7 states (AK, ID, HI, ND, SD, UT,
WY). Seventeen states had only 1 to 3 bites over the 8-year period (AZ, CA, IA, ME,
MA, MI, MN, MT, NE, NV, NH, NM, OR, RI, VT, WA, WI). Ten states (TX,
NC, MO, GA, VA, KY, OK, TN, LA, WV) accounted for 80.0% of all bites. Most
victims were male (71.0%). The average age of all victims was 34.1 years. There were
1,754 (22.6%) children under the age of 18 years, and there were only 481 (6.2%)
victims over the age of 65 years. There were 3,135 victims (40.5%; 95%CI: 39.4% –
41.6%) who did not have any or had only minimal clinical effects (“dry bites”).
Almost half (46.3%; 95%CI: 45.2% – 47.4%) of the victims had moderate effects,
and 249 (3.2%; 95%CI: 2.8% – 3.6%) had major effects. Poison centers were unable
to record an outcome for 706 victims (9.1%). There was a single death, a 51-year-old
male in Maryland. The major limitation of this study is the volunteer reporting of
information to poison centers.
Conclusion: This is the largest analysis of copperhead snakebites in the US. Very
few victims suffered major effects from these bites. Eighty percent of all bites occurred
Volume , .  : September 
in just 10 states. These results may be useful for snakebite prevention and the
planning for snakebite management in each state.
58
Epidemiology of Prolonged Emergency Department
Length of Stay
Heins A, Liang S, Richardson LD/University of South Alabama College of
Medicine, Loxley, AL; University of Maryland, Baltimore, MD; Mt. Sinai School of
Medicine, New York, NY
Study Objectives: Emergency department (ED) boarding of admitted patients for
excessive lengths of time is one of the key determinants of ED crowding, a serious
and growing problem for U.S. hospitals. While some studies of patient-level health
outcomes have shown considerable harm to patients, no population-based studies
have directly examined the public health impact of ED boarding. We designed the
present study to describe the epidemiology of prolonged ED length of stay (LOS) in
the US and to determine the effects of ED LOS on hospital LOS and in-hospital
mortality.
Methods: This study was a secondary analysis of data from the 2006 National
Hospital Ambulatory Medical Care Survey (NHAMCS), which uses a 4-stage
probability sample design to collect a nationally representative sample of visits to
emergency departments in non-federal general acute care hospitals. Independent
study variables included patient demographics, characteristics of the ED visit,
including ED LOS and disposition; outcome variables were hospital LOS and inhospital mortality. Descriptive and regression methods were used to examine
predictors of and disparities in outcomes for ED patients admitted to the hospital.
Results: The study cohort represents 15,207,497 admitted patients, including
2,242,547 patients admitted to an ICU, out of over 119 million ED visits for 2006.
Notable results include the finding that admitted patients in the 3-⬍6 hour, 6-⬍9
hour and the 9⫹ hour ED LOS categories had hospital LOS 0.43, 0.91 and 0.55
days longer than the cohort with ED LOS less than 3 hours. For the ICU cohort, the
ED LOS 3-⬍6 hour group had similar hospital LOS to the ⬍3 hour group, but the
6-⬍9 and 9⫹ groups had hospital LOS 0.74 and 1.33 days longer than the cohort
with ED LOS ⬍ 3 hours. Admitted patients with lower initial triage priority
experienced more prolonged ED LOS. Females, blacks, and self-pay patients were
held in the ED for prolonged periods more frequently than males, whites, and
privately insured patients. Regression analysis of predictors of in-hospital mortality
showed that patients with more acute triage assessments and those recommended for
critical care admission were more likely to die in the hospital. Females were less like to
die than males. Whites and blacks died more often than those in the other race
category. Contrary to previous studies, prolonged ED LOS did not contribute to
worsened survival.
Conclusion: Prolonged length of stay in the ED for admitted patients is a serious
operational problem for EDs and may contribute to multibillion dollar increases in
medical care costs through extension of hospital length-of-stay for the 15 million
patients admitted through the ED each year. Elimination of ED boarding might yield
substantial reductions in cost and increases in efficiency.
59
Multicenter Study of Internet Use by Emergency
Department Patients in Boston
Sullivan AF, Ginde AA, Weiner SG, Pallin DJ, Betz ME, Oldfield JH,
Camargo Jr CA/Massachusetts General Hospital, Boston, MA; University of
Colorado Denver School of Medicine, Aurora, CO; Tufts Medical Center, Boston,
MA; Brigham and Women’s Hospital and Children’s Hospital Boston, Boston,
MA; Beth Israel Deaconess Medical Center, Boston, MA
Study Objectives: The Internet is an important source of health information. We
sought to examine emergency department patients’ Internet use for health
information and its relation with ED utilization. We also sought to determine
patients’ willingness to use the Internet for participation in future research.
Methods: We surveyed consecutive patients age 18⫹ years for two 24-hour
periods at 4 Boston EDs, excluding patients with severe illness or altered mental
status. Data analysis used descriptive statistics and multivariate logistic regression.
Results: We enrolled 530 patients (73% of those eligible). Overall, 67% (95%
confidence interval [CI], 63–71%) used the Internet over the past 12 months. While 31%
(CI 26–36%) looked on the Internet at least monthly for health information or advice,
24% (CI 20–29%) never did. Patients were less likely to report any use of the Internet for
health information if they were aged ⱖ65 years (compared to age 18–26 reference group:
OR 0.15 [95%CI, 0.06–0.37]), were black (compared to white: OR 0.47 [95%CI,
0.23–0.96], and did not have a primary care provider (OR 0.35 [95%CI, 0.17–0.70]).
Annals of Emergency Medicine S19
Research Forum Abstracts
Before going to the ED, 21% (95%CI 17–26%) of Internet users sought information or
advice on the Internet about their health condition; the information they found on the
internet made them more likely to go to the ED: yes 46% (95%CI 34–59%), no 40%
(95%CI 28–53%), and unsure 14% (95%CI 7–25%). Among patients who used the
Internet, 65% (95%CI 60–70%) would be very or somewhat willing to communicate by
email if enrolled in a research project that required follow-up and provide health
information for research via a secure online form.
Conclusion: The majority of ED patients in Boston use the Internet for health
information. Older age, black race, and no primary care provider were all associated
with less use of the Internet for health information. Email and the Internet may be
effective tools for communication with ED research subjects.
60
The Prevalence of Tobacco and Alcohol Use in
Immigrant Emergency Department Patients in Queens,
NY
Gupta S, Anderson C, Henkel K, Garg N/New York Hospital Queens, Flushing,
NY
Study Objective: To determine the prevalence of tobacco use in immigrant and
non-immigrant emergency department patients. To determine the prevalence of
alcohol use and alcoholism using the CAGE questionnaire in immigrant and non
immigrant ED patients.
Methods: The study is prospective, observational, and survey based in an urban
100K visit ED in Queens, NY, postulated to be the most ethnically diverse county in
the USA. Trained volunteer research assistants interviewed a convenience sample of
ED patients over 16 months with a 3-page survey regarding demographic
information, tobacco and alcohol use, and knowledge of current male or female
preventive health recommendations as offered by the U.S. government’s Agency for
Health care Research and Quality. The CAGE questionnaire is positive with ⱖ2
affirmative answers. Translation services were available for all non-English speaking
subjects. Data management was performed through Microsoft Access and statistical
analysis through SPSS version 13, using Chi-squared analysis and Fisher Exact test for
significance.
Results: A total of 1380 surveys were collected; 640 male, 217 being immigrant
males, 740 female, 256 being immigrant females. Of the men surveyed, 28% of
immigrants and 46% of non-immigrant men drink alcohol, P⫽ ⬍0.001. CAGE was
positive in 8/60 immigrant and in 13/196 non-immigrant drinkers, P ⫽ 0.166. In
tobacco smoking, 13% of immigrant and 23% of non-immigrant men smoke
tobacco, P ⫽ 0.008. Smoking counseling was done on 67% of immigrant and 85%
of non immigrant smokers, P ⫽ 0.157. All male smokers know tobacco causes
disease, and 67% of immigrants and 90% of non-immigrants have tried to quit, P ⫽
0.028. Of the female subjects, 8% of immigrants and 19% of non-immigrants drink
alcohol, P ⫽ ⬍0.001. CAGE was positive in 2/21 immigrant and in 6/91 nonimmigrant drinkers, P ⫽ 1.00. In tobacco smoking, 5.6% of immigrant and 17.7%
of non-immigrant women smoke tobacco, P ⫽ ⬍0.001. Smoking counseling was
done on 75% of immigrant smokers, and 85% non-immigrant smokers. 100% of
immigrant and 94% of non-immigrant smokers know tobacco causes disease, and
83% of immigrants and 80% non-immigrants have tried to quit. No significance was
achieved in these categories.
Conclusion: In this population, immigrant men and women tend to drink
alcohol and smoke tobacco less than the native population, but immigrant men and
women may receive less counseling on tobacco cessation.
61
National Survey of Preventive Health Services in United
States Emergency Departments
Delgado MK, Wang N, Acosta C, Khandwala Y, West AM, Strehlow MC,
Ginde AA, Camargo Jr CA/Stanford-Kaiser Emergency Medicine Residency, Palo
Alto, CA; Stanford University School of Medicine, Palo Alto, CA; University of
Colorado Denver School of Medicine, Denver, CO; Massachusetts General
Hospital, Harvard Medical School, Boston, MA
Study Objectives: Emergency departments (EDs) see a high proportion of
patients with unmet primary care needs and who present with illnesses related to
unhealthy behaviors. Although various ED-based preventive health services have been
reported, nationwide data are sparse. Our goals are to determine: 1) the availability of
11 different preventive health services in U.S. EDs; 2) ED directors’ opinions
whether these services could be provided with existing funding and staff; 3) ED
directors’ preferences of services to implement; and 4) perceived barriers to offering
preventive services in the ED.
S20 Annals of Emergency Medicine
Methods: 350 (7%) of the 4,828 U.S. EDs were randomly selected from the
2005 National Emergency Department Inventory (NEDI)-USA database. A survey
was sent to ED directors to determine the prevalence of: 1) screening, intervention,
and referral programs for alcohol, tobacco use, geriatric falls, intimate partner
violence, HIV, diabetes, and hypertension; 2) vaccination programs for influenza and
pneumococcus; and 3) linkage programs to primary care and health insurance. ED
directors were asked to rank the 3 services they would most like to implement given
their patient population and rate 5 potential barriers to offering preventive services on
a 5-point Likert scale.
Results: The authors have collected responses from 257 institutions (75%
response rate). In this random sample of EDs, the median annual patient visit volume
was 21,682 (interquartile range 8,543–37,674); 54% [95% confidence interval - CI
51– 63] were urban, 18% [CI 14 –23] suburban, and 23% [CI 19 –30] rural; 24%
[CI 19 –29] participated in the Critical Access Hospital program; and 8% [CI 4 –11]
were teaching hospitals. The three most commonly offered preventive services were
for: intimate partner violence (66% of hospitals [CI 60 –72]), primary care linkage
(55% [CI 49 – 61), and hypertension (51% [CI 44 –57]). The least commonly offered
services were for HIV (19% [CI 14 –24]) and tobacco (19% [CI 14 –24]). If not
currently offered, the services ED directors perceived could be offered most with
existing staff and funding were for: diabetes (an additional 30% [CI 24 –36] of
hospitals) pneumococcal vaccines (28% [CI 22–34]), and tobacco 27% [CI 22–33]).
The lowest potential capacity was for: geriatric falls (15% [CI 9 –21]). If not currently
available, ED directors most wanted to provide services for primary care linkage (38
% [CI 29 – 47]), insurance linkage (19% [CI 13–26]), and tobacco (17% [CI 12–
22]). ED directors “strongly agree” that the following are barriers to offering
preventive services: cost (39%), increased patient length of stay (30%), lack of
primary care follow-up (27%), resource shifting leading to worse patient outcomes
(22%), and philosophical opposition (12%).
Conclusion: EDs offer different types of preventive services at varying rates. The
perceived capacity to offer new preventive services with existing funding and staff varies by
type of service. The service that ED directors would most like to provide is primary care
linkage. The three services that have the most capacity for expansion based on utilizing
existing resources are: diabetes screening and referral, pneumococcal vaccines, and
smoking cessation counseling. Overall, ED directors perceive cost to be a large barrier to
offering preventive services, while only a small proportion appear to be philosophically
opposed to offering preventive care in the ED.
62
Comparison of the Airtraq® to Direct Laryngoscopy by
Flight Nurses and Respiratory Therapists in the
Simulated Airway
Suozzi JC, Bolton L, Nowicki TA, Ventriglia R, Donahue S, Robinson KJ/Hartford
Hospital, Hartford, CT
Study Objectives: Emergent in-flight endotracheal intubation is an infrequent
event that carries additional challenges due to a confined space environment and
limited patient/practitioner positioning. The purpose of this study was to compare
intubation utilizing the Airtraq® with direct laryngoscopy in the manikin model
given both normal and difficult airway scenarios in the helicopter setting. We
evaluated the number of attempts, time to successful ventilation, Cormack-Lehane
view and the Airtraq’s® learning curve.
Methods: This was a randomized crossover study involving flight nurses and
respiratory therapists. Each subject was given a standardized lecture and a
demonstration of the Airtraq® device including a set of instructions regarding its use.
Participants were then allowed a 5-minute practice session on a Laerdal Airway
Management Trainer® with the Airtraq® and direct laryngoscopy using a Macintosh
#3 blade. Subjects then managed the following scenarios in the aircraft on a Laerdal
SimMan® manikin: (1) normal airway; (2) tongue edema; (3) c-spine
immobilization; (4) normal airway. Results were analyzed utilizing Wilcoxon Signed
Ranks Test.
Results: 21 flight personnel participated in this study. For scenario #1 (normal airway)
there were no significant differences in either the number of attempts or time to
ventilation between the devices. A significantly lower grade view with use of the Airtraq®
was reported (p⫽.009). For scenario #2 (tongue edema) the median time to ventilation
using direct laryngoscopy was 47.41s and using the Airtraq® was 27.25s with a difference
of 20.16s (p⫽.001). There were also significantly fewer intubation attempts (p⫽.05) and
a lower grade view (p⫽⬍.001) with the Airtraq® in this scenario. There were no
significant differences in time to ventilation and number of attempts for c-spine
immobilization. A significant lower grade view was also reported for this scenario
(p⫽⬍.001). For scenario #4 (normal airway) there were no significant differences in time
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Research Forum Abstracts
to ventilation or number of attempts. There was a significantly lower grade view with the
Airtraq® for this scenario (p⫽.001). There were no differences in time to ventilation
between scenario #1 and #4 (normal airway).
Conclusion: The Airtraq® was shown to be equal or faster than direct
laryngoscopy with the Macintosh #3 blade for easy and difficult airway scenarios in
this manikin model. The Airtraq® also required fewer intubation attempts than
direct laryngoscopy in the tongue edema scenario. Use of the Airtraq® resulted in
significantly lower Cormack-Lehane airway views compared with direct laryngoscopy
for all scenarios.
63
Respiratory Isolation Rooms in the Emergency
Department
Lobo R, Borges Md, Neves FF, Pazin-Filho A/Medical School of Ribeirao Preto University of Sao Paulo, Ribeirao Preto, Brazil
Study Objectives: To analyze the use of other performance parameters in
planning isolation room capacity and to evaluate the impact of installing an
exclusively dedicate respiratory isolation room in a tertiary emergency department
predicted by a time-to-reach facility method.
Methods: Two groups of patients with suspected tuberculosis admitted to a
tertiary emergency department were evaluated prior and after the implementation of
the exclusively dedicated respiratory isolation room. Group I (2004; 29 patients;
44.1⫾3.4 years; 68.9% male) and Group II (2007; 50 patients; 43.4⫾1.8 years;
41.2% male) were gathered in the same period of the year. We recorded demographic
and functional parameters. Unadjusted crude incidence rates for respiratory isolation
were obtained by survival methods. Cox proportional hazard models adjusted for age,
gender and in-hospital respiratory isolation room availability were obtained.
Results: Increasing the isolation room decreased the time from arrival to
indication of respiratory isolation (27.5⫾9.3 x 3.7⫾2.0; p ⫽ 0.0180) and from
indication to effectively respiratory isolation (13.3⫾3.0 x 2.94⫾1.06; p ⫽ 0.003) but
not the respiratory isolation duration and total hospital stay. The impact on crude
isolation rates were very significant (8.9 x 75.4/100.000 patients ⫺ p⬍0.001). The
hazard ratio for effectively respiratory isolation was 26.8 (95% CI 7.42 – 96.9) ⫺
p⬍0.001 greater for 2007.
Conclusion: Implementing an exclusively dedicated negative-pressure respiratory
isolation room in a tertiary emergency department reduced significantly the time to
respiratory isolation in suspected tuberculosis patients. Planning capacity based on
time-to-isolation could be a better strategy than the traditional occupation rate.
64
Intubator Recall of Hypoxia and Number of Attempts Is
Often Inaccurate Compared to Video Review
Hill CH, McGill J, Reardon R, Falvey D/Hennepin County Medical Center,
Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN
Study Objective: Most emergency intubation literature uses intubator recall of
the procedure as the method of data collection. This study evaluated the accuracy of
intubator recall with regard to hypoxia and number of attempts by comparing video
recordings of airway procedures to intubator charting.
Methods: This was a retrospective review of emergency intubations at an urban
level one trauma center. All emergency intubations were recorded using video cameras
Volume , .  : September 
from three distinct angles with the cardiac monitor information recorded alongside
these images. During video review the lowest oxygen saturation was recorded as the
lowest value from medication administration through the minute following successful
intubation. Saturations were not recorded if there was no agreement between the
pulse obtained from the oxygen saturation probe and the cardiac monitor leads.
Hypoxia was defined as oxygen saturation under 90%. The number of attempts was
obtained by direct visualization of the video by two reviewers following an agreed
upon definition of “attempt.” An electronic procedure note was created with spaces to
record the number of attempts and lowest oxygen saturation for the procedure.
Retrospective review of the electronic health record was conducted and the
corresponding values for low oxygen saturation and number of attempts were
obtained from this procedure note.
Results: 104 intubations over a three-month period were reviewed. All procedures
had a corresponding computerized procedure note; however, not all notes recorded
the low oxygen saturation and the number of attempts. In 8 patients no saturation
was recorded by the cardiac monitor due to ongoing CPR (n ⫽ 6) or due to emergent
intubation that occurred before the cardiac monitor was applied (n ⫽ 2). Excluding
these, 45/96 patients (47%) became hypoxic. This was correctly recognized in the
chart in 15/45 times (33%). In 11/45 cases (24%) satutration was not recorded in the
procedure note, in 28 /45 (62%) the recorded low saturation was greater than 5
points higher than the true low saturation. In 11/45 cases (24%) the low saturation
was recorded as above 90 when video review revealed hypoxia. The number of
attempts were charted correctly in 66/104 cases (63%). In 27 (25%) the number of
attempts was not charted and in 12 cases (11%) were charted incorrectly. In patients
who required one attempt 57/81 (70%) were charted correctly, 5/81 (6%) were
charted incorrectly and 19/81 (23%) were not charted. In patients who required two
attempts 9/13 (69%) were charted correctly, 2/13 (15%) were charted incorrectly and
2/13 (15%) were not charted. In patients who required more than two attempts, 0/10
were charted correctly, 5/10 (50%) were charted incorrectly and 5/10 (50%) were not
charted.
Conclusions: Intubator recall performs poorly when compared to video review of
intubations, especially in cases where patients become hypoxic or require multiple
intubation attempts.
65
Emergency Physician Ability to Predict Difficult
Endotracheal Intubations
Shum L, Guyette F, Emlet L/University of Pittsburgh Medical Center, Pittsburgh,
PA
Study Objective: We examined the ability of emergency physicians to predict
difficult endotracheal intubations in patients requiring immediate airway
management.
Methods: We prospectively collected data on both medical and trauma
intubations in the emergency department of a university affiliated, Level 1 trauma
hospital. Following intubation, emergency physicians were asked to fill out a data
form which included reasons for intubation, airway management technique, number
of attempts, level of training, utilization of airway adjuncts, medications used to
facilitate intubation, and whether the emergency physician thought the intubation
would be difficult. We also collected data on traditional predictors of a difficult
airway; including patient anatomy, Mallampati score, thyromental distance, and
mouth opening. Data were then extracted from all recorded difficult intubations,
defined as ⱖ3 intubation attempts, use of any adjunct airway device, or a CormackLehane grade III or IV.
Results: Two hundred forty intubations were recorded during the study period
including 89 trauma and 151 medical intubations. 27/240 (11%) intubations were
classified as difficult intubations. 14/27 (52%) were trauma and 13/27 (48%) were
medical intubations. This represents 14/89 (15%) of all traumas and 13/151 (8%) of
all medical intubations. 14/27 (52%) required ⱖ3 intubation attempts, 19/27 (70%)
had a Cormack-Lehane grade III or IV, and 6/27(22%) had both. 9/27 (33%)
required the use of an airway adjunct including cricothyrotomy 4/27 (15%), bougie
3/27 (11%), video laryngoscopy 1/27 (3%), and fiberoptic intubation 1/27 (3%).
Rapid sequence induction was utilized in 24/27 (89%) difficult intubations.
Mallampati was grade 3 or 4 in 8/27 (30%) while there was no assessment made in
15/27 (56%) of difficult intubations. Thyromental distance was not assessed in 13/27
(48%) and mouth opening in 6/27 (22%). Emergency physicians made the
prediction of a difficult airway in 77/240 (32%) of intubations. Among difficult
intubations, physicians accurately predicted 17/27. This represents a sensitivity of
Annals of Emergency Medicine S21
Research Forum Abstracts
63% (CI 42%– 81%) and specificity of 71% (CI 65%–77%). In the correctly
predicted difficult airways, emergency physicians most often listed obesity/big neck
9/17 (53%) and facial trauma/bloody secretions 5/17 (29%) as factors leading them
to predict a difficult airway.
Conclusion: Difficult airways are frequently encountered in the emergency
department and occur more often in trauma versus medical airway management.
Emergency physician assessment is moderately effective at predicting difficult
intubations. However, emergency physicians did not assess many of the traditional
predictors of a difficult airway. Instead, successful difficult airway prediction relied on
a clinical evaluation of multiple patient characteristics including body size, secretions,
facial trauma, and neck size.
66
Airway Characteristics of Patients With Difficult
Airways
Wong E, Ngo A/Singapore General Hospital, Singapore, Singapore
Study Objectives: The difficult airway is a challenge to most emergency
physicians and its incidence is rare. In this study, we attempt to document the airway
characteristics of patients with difficult airways.
Methods: The department of emergency medicine has an ongoing airway
registry from 2000. From 1 October 2008, the emergency department
prospectively collected data on airway management with particular emphasis on
the difficult airway. Data captured included patient demographics, airway
characteristics, diagnoses, indications for intubation, personnel and discipline of
the physician performing the intubations, reasons for difficult intubation, rescue
methods, success rate, complications and disposition. A difficult airway was
defined as at least 3 attempts at intubation by an attending emergency physician
or a failed intubation or is deemed difficult by the attending physician after the
intubation attempt.
Results: There were 172 patients who received advanced airway management
from 1 October 2009. There were 117 (68%) men. The mean age was 62 years.
The main diagnoses were cardiac arrest (67, 39%), congestive heart failure (27,
15.7%) and cerebrovascular accidents (15, 8.7%). Twenty-four (14%)
intubations were felt to be difficult by the practitioners. Twelve cases (7%)
had three attempts or more. Five of these cases required the use of the bougie (2)
and glidescope (3) as rescue devices. There was no failed intubation or failed
airway. The patient characteristics associated with the difficult airway were as
follows:
Difficult intubations were associated with more complications (OR 8.944, CI
5.322, 15.033).
Conclusion: The difficult airway seemed to be more prevalent than in previous
studies when the data collection form placed emphasis on describing airway
characteristics of intubated patients. Maxillofacial trauma, small mouth opening,
thyromental and thyroid spaces, obesity, oral obstruction and neck immobility are
associated with difficult intubation.
67
Pulmonary Effects of Atropine in Humans
Ly S, Lindberg J, Dershwitz M, Walz M, Gaspari R/University of Massachusetts,
Worcester, MA
Study Objectives: Atropine increases ventilation by decreasing pulmonary
secretions and dilates pulmonary airways but it is unclear if atropine affects
pulmonary vascular tone. Animal studies indicate that atropine’s effect on
pulmonary vascular tone causes a dose dependant ventilation-perfusion (V–Q)
S22 Annals of Emergency Medicine
mismatch and resultant hypoxia. We hypothesize that atropine causes a V–Q
mismatch in humans.
Methods: An interventional human study of patients undergoing general
anesthesia at a tertiary care center was performed to get pilot data for a later larger
study. Patients were consented to receive 0.02– 0.03 mg/kg intravenous atropine with
arterial blood gas measurement at baseline and 2 minutes following IV atropine. A
comparison of paO2, paCO2 and A-a gradient was made pre- and post-atropine.
This study was approved by our IRB.
Results: Nine patients were enrolled with complete data sets. The average FiO2 at
baseline was 63% and remained unchanged throughout the study with initial paO2,
paCO2 and A-a gradient of 222 mmHg, 40.2 mmHg and 180 mmHg respectively.
Post-atropine the paO2 increased to 235 mmHg and paCO2 increased to 43.3
mmHg. For all patients the A-a gradient decreased an average of 17.47 mmHg after
atropine was given, but 4 of the 5 patients demonstrated the opposite effect with an
increase in A-a gradient an average of 7.42 mmHg with an average decrease in paO2
of 13.75 mmHg.
Conclusion: Atropine improves gas exchange and oxygenation in most
patients but in some patients there is a paradoxical decrease in oxygenation and
gas exchange.
68
Spontaneous Pneumomediastinum: A Ten-Year
Experience
Beatty N, Van Tonder R, Bellolio M, Colletti J/Mayo Medical School, Rochester,
MN; Mayo Clinic, Rochester, MN
Study Objectives: To assess the clinical presentation, triggers, evaluation
and outcomes of patients presenting with spontaneous pneumomediastinum
(SPM).
Methods: We performed an observational cohort study of 142 consecutive cases
from 1998 to 2007. We excluded cases involving trauma and procedures.
Results: The final cohort was 84 patients, 65.5% were male, with a median age of
24.5 years. Twenty-two (26.2%) were children less than 18 years. Fourteen (16.7%)
had history of drug use, and 22 (26.2%) were active tobacco smokers. Sixteen (19%)
had history of obstructive lung disease. Symptoms at presentation are displayed in the
Table.
Seventy-one subjects (84.5%) had a chest radiograph, and SPM was missed on 17
(21%) of them. Fifty-seven (67.9%) subjects had a chest CT. Twenty-eight (33.3%)
had an esophagogram, and 3 of these (12%) had a positive study for esophageal leak.
Eight (9.5%) subjects had interventions associated with the SPM, and 17 (26.1%)
had an associated pneumothorax. A total of 64 patients (76.2%) were admitted. The
median hospital length of stay was 2 days (IQR 1 to 6.5).
Children were twice as likely to present with chest pain compared to adults (73%
vs 37%; RR 1.96, 95%CI 1.30 –2.96, p⫽0.004), and 4 times more likely to present
with sore throat or neck pain (64% vs 16%; RR 3.94, 95%CI 2.06 –7.55,
p⬍0.0001). There was no difference in fever at presentation (9% vs 8%, RR 1.12,
95%CI 0.23 to 5.39, p⫽1.0).
Obstructive lung disease was more common in children (n⫽9, 41%) compared
to adults (n⫽7, 11.3%), RR 3.62, 95%CI 1.53– 8.56, p⫽0.002. Cough was a trigger
in 50% of the children and 30% of adults. There was 1 child with SPM secondary to
valsalva/vomiting as compared to 29% of adults.
All the children (n⫽22, 100%) and 49 adults (69%) had a chest radiograph in
the initial evaluation (p⫽0.02), SPM was missed in 14% of children vs 24% adults,
p⫽0.38.
Children were half as likely to undergo chest CT (n⫽7, 31.8%) compared to
adults (n⫽50, 80.6%), RR 0.39, 95%CI 0.21– 0.74, p⬍0.0001. Children were as
likely as adults to have an esophagogram, 22.7% vs 37.1%, p⫽0.22.
Patients were followed for up to 1 year, and there were no recurrences of SPM in
this cohort.
Conclusion: SPM is an uncommon disease. Children are more likely to have
history of obstructive lung disease, present with chest pain, sore throat and neck pain.
Children are more likely to have a chest radiograph whereas adults are more likely to
have a chest CT during evaluation for SPM. While esophagogram is frequently
obtained in evaluation of etiology of SPM, it infrequently reveals esophageal leak even
when esophageal leak is strongly suspected.
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69
Patient Outcomes and Resource Utilization for Emergency
Department Patients With Suspected Pulmonary Embolism
and Initial Chest Computed Tomography Angiography
Studies Deemed Suboptimal for Interpretation
Weinstein J, Burton J, Katz B/Albany Medical Center, Albany, NY
Study Objective: Chest computerized tomography angiography (CTA) has
become a standard study for the radiological evaluation of emergency department
(ED) patients with suspected pulmonary embolism (PE). Previous studies have
described CTA in these patients to be interpreted as “suboptimal” for PE diagnosis in
as many as one-third of patients imaged. To date there have been no investigations
addressing the medical decisionmaking, resource utilization, and patient outcomes in
these patients with suboptimal studies. The objective of this study was to examine the
subsequent treatment, additional imaging modalities, resource utilization, and clinical
outcomes associated with suboptimal ED CTA studies to exclude PE.
Methods: This retrospective health record review investigated a consecutive cohort of
ED patients who underwent chest CTA for suspected PE during a predefined four-month
period in an academic tertiary care medical center. All health records were reviewed by
trained personnel for predefined variables including radiological imaging studies, medical
therapy and patient outcomes after 30 days. This study was conducted with approval from
the institutional review board. Data were analyzed using descriptive statistics.
Results: A total of 274 patient encounters occurred and were reviewed during the
study period. There were 83 (30%) chest CTAs interpreted as suboptimal in this dataset.
Additional imaging studies or interventions in these patients included 9 patients receiving
repeat intravenous contrast bolus for an immediate repeat chest CTA, 10 patients
undergoing lower extremity duplex ultrasound, 6 patients with ventilation/perfusion scans
done the same or next day, and 1 patient with repeat chest CTA within 24 hours of the
initial study. Three patients were admitted to hospital solely for further PE consideration.
Medical management for suboptimal interpretation patients included 2 patients treated
with heparin for anticoagulation prior to further imaging studies with one of these
patients having repeat chest CTA the next day and one with heparin treatment and repeat
chest CTA 14 days later. None of these additional treatments or imaging modalities
yielded a diagnosis of PE. Thirty-day outcomes of patients with suboptimal chest CTA
findings demonstrated no diagnosis, morbidity or mortality associated with PE.
Conclusion: In this cohort of ED patients with suboptimal chest CTA studies,
patients incurred additional imaging studies, medical therapy and in some cases
hospital admission for further consideration of PE diagnosis. Suboptimal chest CTA
interpretations in ED patients suspected of PE appear to have a substantial impact on
health care resource utilization given that many of these patients undergo additional
imaging and treatment which may represent an elevated risk for this patient
population as well as escalated health care costs. The implications of not pursuing
further diagnostic workup or therapy in patients suspected of PE with suboptimal
chest CTA interpretations also represent an area for concern.
70
A Regional Study of Emergency Department Visits for
Acute Exacerbationof Chronic Obstructive Pulmonary
Disease
Faig O, Allegra JR, Eskin B/Morristown Memorial Hospital, Morristown, NJ
Study Objective: Recent advances have been made in the treatment of chronic
obstructive pulmonary disease (COPD), including the use of corticosteroids and
noninvasive positive pressure ventilation. However, a recent study using a national
database demonstrated no change from 1993 to 2005 in the rates of visits to the
emergency department (ED) for acute exacerbations of COPD, of hospital admission
and of intubation. Our objective was to examine whether the trend in rates in our
local region were similar to those found in the national database.
Volume , .  : September 
Methods: Design: Retrospective cohort. Setting: Consecutive patients seen by ED
physicians in 28 hospitals in New Jersey and New York between 1/1/1996 and 12/
31/08. Protocol: We classified patients as having COPD exacerbations based on
ICD9 codes. Data Analysis: We compared the annual COPD visits to total ED visits
and, for the COPD visits, the annual hospital admission and intubation rates using
regression analyses and the Student t test with alpha ⫽ 0.05.
Results: Of the 7,567,002 ED visits, there were 47,285 visits (0.6%) with an ED
diagnosis of COPD. Mean age was 71 ⫹/⫺ 12 years and 54% were female. The
mean age and percent female were similar for all years. There was no statistically
significant correlation in percent of total ED visits for COPD versus year (R2 ⫽ 0.08,
p ⫽ 0.35) and in the percent of COPD patients intubated versus year (R2 ⫽ 0.21,
p ⫽ 0.11). The percent of COPD patient admitted to the hospital increased from
62% in 1996 to 76% in 2008 (difference ⫽ 14%, 95% CI: 11%, 16%, p ⬍0.001).
The correlation coefficient for this upward trend was R2 ⫽ 0.91 (p⬍0.0001).
Conclusion: Similar to a previous study, we found no statistically significant change in
the rate of visits to the emergency department (ED) for acute exacerbations of COPD or
of intubation. However, contrary to that study, and despite availability of newer
treatments, hospitalization rates for COPD patients in our area have increased.
71
Does the Pulmonary Embolism Severity Index Identify
Patients at Risk for Short Term Clinical Deterioration?
Hariharan P, Kabrhel C/Massachusetts General Hospital, Boston, MA
Study Objectives: The Pulmonary Embolism Severity Index (PESI) aims to
differentiate patients with pulmonary embolism (PE) who are at risk for clinical
deterioration from those who can safely be treated as outpatients. Previous studies
have shown that the PESI predicts 30 and 90 day mortality after PE. However, the
decision to admit a patient may incorporate outcomes other than mortality, and the
relevance of delayed endpoints to clinical deterioration occurring during an average
hospitalization is not known. We sought to determine whether the PESI predicts
clinical deterioration during an average length hospitalization for PE.
Methods: Retrospective analysis of emergency department patients with
radiographically proven acute PE from May 2006 to April 2008. We reviewed the
medical record for demographics, data needed to calculate the PESI and our composite
outcome. Our outcome was designed to identify hospitalized patients who had any
cardiopulmonary instability or required a hospital-based medical intervention (other than
anticoagulation). Patients were considered to have the composite outcome if, within the
first five days after diagnosis, they: 1) had two consecutive systolic blood pressures below
100mmHg; 2) had an oxygen saturation ⬍90%; 3) had a new cardiac arrhythmia; 4) had
recurrent symptomatic PE; 5) required advanced cardiac life support (ACLS); 6) required
respiratory support with more than 2L/min of oxygen; 7) were treated with vasopressors;
8) received thrombolysis or thrombectomy; 9) returned to the hospital after discharge; 10)
died. Sensitivity, specificity, NPV and PPV were calculated using SAS 9.1 (Cary, NC).
The Partners Human Research Committee approved the study.
Results: We identified 249 patients diagnosed with acute PE during the study
period. Complete data were available for 244. Of these, 116 (46%) were male, 203
(83%) were white, 16 (7%) black, 14 (6%) Hispanic and 23 (9%) were of other race/
ethnicity. The mean age was 57⫾17 years. One hundred thirty eight (57%) had
private insurance. The PESI identified 107 (44%) as low risk and 137 (56%) as high
risk. Among high risk patients, the most common PESI risk factors (apart from age)
were: malignancy (73, [53%]), hypotension (67, [49%]), male sex (65, [47%]) and
tachycardia (55, [40%]). There were 131 (54%) patients with the composite
outcome. The PESI correctly identified 94 (72%) of these patients as high risk, while
37 (35%) of 107 patients characterized by the PESI as low risk had the composite
outcome. Test characteristics were as follows (95%CI): sensitivity 72% (64%–79%);
specificity 62% (53%–71%); NPV 65 (56%–74%) and; PPV 79% (61%–76%).
Conclusion: The PESI identifies most patients who clinically deteriorate during
the first five days after a diagnosis of acute PE. However, 35% of patients categorized
as safe by the PESI clinically deteriorated or required a hospital-based intervention
within five days of their PE. The PESI is insufficiently sensitive to use when
determining whether a patient should be hospitalized for PE.
72
Outcome of Cardiac Arrest After Accidental
Hypothermia and Indication for Cardiopulmonary Bypass
Mori K, Sawamoto K, Maekawa K, Warabi R, Tanno K, Uemura S, Nara S,
Asai Y/Sapporo Medical University, Sapporo, Japan
Study Objectives: Cardio pulmonary bypass (CPB) is effective for resuscitation in
cases of cardiac arrest after accidental hypothermia (AH), but the indications for CPB
Annals of Emergency Medicine S23
Research Forum Abstracts
have not yet been clarified properly. The purpose of this study was to investigate the
outcome of cardiac arrest after AH and to clarify the indications for CPB by a
retrospective review.
Methods: Out of 133 patients carried to our emergency department between
May 1994 and April 2008, there were 24 for whom CBP was performed for
resuscitation from AH with cardiac arrest. We reviewed the prognostic factors (age,
cause of AH, core temperature, electrocardiography, cardiac arrest time, time to
introduce CPB, time to restart heart beat) and the values of the blood gas analysis
(PH, serum base excess, serum potassium, lactate, glucose, PaCO2, PaO2).
Neurological prognosis was measured by the Glasgow Outcome Scale (GOS) at the
time of discharge from hospital.
Results: The average age of the patients was 43.3⫹/⫺21.4 years, 16 were male
and 8 were female. The causes of AH were drowning 11, mountaineering and
exposure to cold air 13. The body temperature was 24.1⫹/⫺3.6 C.
Electrocardiography findings were ventricular fibrillation 5, Asystole 14, pulseless
electrical activity 5. The mean interval from discovery of patients to carrying to ED
was 44.1⫹/⫺29.5 minutes. The mean interval from admission to rewarming with
CPB was 29.5⫹/⫺22.5 min, and all of the 24 patients obtained spontaneous heart
beats, and the mean interval from CPB to the restart of heart beat was 28.1⫹/22.3
min. Nine of 24 patients had neurological recoveries, and neurological prognosis were
Good Recovery 8, Moderate Disability 1, Vegetative State 1, and dead 7. The
findings of ECG and core temperature at admission did not relate to prognosis at the
time of discharge. The patients who had mild acidemia (PH⬎7.0, SBE⬎-20mmol/L,
lactate⬍150mg/dl, potassium⬍6.0mEq/L) improved in neurological outcome.
Conclusion: CPB improved prognosis of AH, and was particularly beneficial for
patients whose AH was caused by exposure to cold air and whose acidosis had not
progressed.
73
Effects of the Low Dose Radiation on Nerve Cells as a
Method to Increase the Survival Rate of Emergency
Patients
Kim S/Chungnam National University Hospital, Daejeon, Republic of Korea
Study Objectives: When ischemic neuronal cell damage inducing acute
cardiopulmonary arrest occurs, treatment by emergency personnel is limited other
than cardiopulmonary cerebral resuscitation, defibrillation, tracheal intubation, and
specific vasopressor injection. In this research, low dose radiation (LDR) was applied
to delay ischemic damaged neuronal necrosis and apoptosis. I did isolate and
characterize some biofactors having protective and recovery effects for ischemic
damaged neuronal cells by LDR, which may role important function of the delaying
neural necrosis and the promoting neuroprotection.
Methods: Ischemia was induced in PC12 cells by irradiation with the 6 MV linear
accelerator. After 0.1 Gy, total mRNA was isolated from PC12 cells. DD-PCR was
performed from the total mRNA to find the differentially expressed genes and DNA chip
analysis was carried out to compare with the data from DD-PCR. Then, RT-PCR and
Northern blotting were executed to confirm the differentially expressed genes.
Results: In this study, low doses of radiation at 0.1 Gy clearly showed
neuroprotection effect in neuronal cells. Also, it has been demonstrated that all
protective responses to single exposures tend to be expressed maximally after about
0.1 Gy dose radiation. From the data, 21 genes were found. I tested these with RTPCR and Northern blot analysis and compared with the data from DNA chip assay.
Conclusion: The effect of radiation on neuroprotection seems to be different at
low dose levels of irradiation. The mechanism of adaptive responses to low dose
radiation is explained by a cell-survival adaptive response with a genotoxic adaptive
response. Cells exposed to low dose radiation in vitro or in vivo can develop high
resistance to subsequent high dose radiation induced gene mutation, DNA damage,
and cell death. Also, ED stress induction by LDR was observed in the results,
suggesting that ED chaperones may involve in LDR. If introducing low dose of
radiation, it may be possible to ameliorate or rescue individuals at risk from a variety
of types of neuronal ischemic injury. And then the results can be directly applied to
some fields of emergency medicine.
74
Heat Loss From IV Fluids During the Administration of
Pre-Warmed Normal Saline
Lyng J, Cooney DR, Scott J, Grant W/SUNY Upstate Medical University,
Syracuse, NY
Study Objectives: This study was designed to evaluate the amount of heat lost
during the administration of pre-warmed normal saline (NS) through IV tubing in
S24 Annals of Emergency Medicine
two different thermal environments during acute resuscitation. Infusion of warmed
IV fluids in hypothermic and trauma patients is considered to have significant benefit.
Operating room studies have suggested that administering pre-warmed fluids through
standard IV tubing results in a significant amount of heat loss between the source and
terminal ends of the tubing. This has led to recommendations for development of
techniques/devices designed to reduce this heat loss. No IV fluid heat loss studies
have been performed in the emergency department (ED) or out-of-hospital settings.
Methods: One liter NS fluid bags were heated to 40°C and connected to IV tubing.
A 16-gauge hypodermic needle was attached to the terminal end and inserted into an
empty 1 L bag for collection. Fluid was run at a “wide-open” flow rate to simulate acute
resuscitation. Temperature measurements were made every 1-second using hypodermic
thermocouple probes inserted into the source bag and terminal end of the tubing. The
ambient air temperature proximate to the IV tubing was measured using an additional
probe. Evaluations were performed in both room temperature and sub-freezing
environments.
Results: At a mean room temperature of 20.44°C (68.79°F), the mean heat loss
between the proximal and terminal end of the IV tubing of was 1.8°C, with a maximal
loss of 4.25°C. The maximum and minimum terminal temperatures were 38.01°C and
34.46°C respectively. At a mean sub-freezing ambient temperature of ⫺9.21°C, the mean
heat loss was 4.20°C, with a maximal loss of 8.58°C. The maximum and minimum
terminal temperatures were 36.04°C and 29.89° respectively.
Conclusion: Administration of 40°C NS through IV tubing at a “wide open” flow
rate in a room temperature environment does not seem to result in significant reduction
in temperature at the terminal end of the IV tubing. Administration of 40°C NS through
IV tubing in a sub-freezing environment results in more heat loss than in a room
temperature environment, but the mean total reduction in fluid temperature does not
appear to be clinically significant. This study appears to contradict previous studies that
suggested a significant amount of heat was lost as warmed NS was administered through
standard IV tubing. Therefore, we do not recommend pursuit of potentially time
consuming and/or costly techniques designed to reduce this heat loss for patients receiving
warm saline “wide-open” in either environment.
Table 1: Mean, maximum, and minimum temperatures in a room
temperature environment
Table 2: Mean, maximum, and minimum temperatures in a cold
environment
75
Time to Invasive Airway Placement and Resuscitation
Outcomes After Inhospital Cardiopulmonary Arrest
Wong ML, Carey S, Mader TJ, Wang HE, The American Heart Association
National Registry of Cardiopulmonary Resuscitation Investigators/UMDNJ-Robert
Wood Johnson Medical School, New Brunswick, NJ; Johns Hopkins Medicine,
Baltimore, MD; Baystate Medical Center/Tufts University School of Medicine,
Springfield, MA; University of Pittsburgh, Pittsburgh, PA
Study Objectives: Clinicians often emphasize early invasive airway placement
during resuscitation from cardiopulmonary arrest (CPA). We examined the
association between time to invasive airway (TTIA) placement and patient outcomes
after inhospital CPA.
Methods: We analyzed data from the National Registry of Cardiopulmonary
Volume , .  : September 
Research Forum Abstracts
Resuscitation (NRCPR) for the 2003 to 2007. We evaluated adult patients receiving
an invasive airway (endotracheal intubation, laryngeal mask airway, tracheostomy,
and cricothyrotomy) after the onset of inhospital CPA but before return of
spontaneous circulation or termination of resuscitation. Patients with weights less
than 20kg or more than 250kg were excluded for presumed non-standard airway
management. We defined TTIA as the elapsed time from CPA recognition to invasive
airway establishment. The primary outcome was return of spontaneous circulation.
Secondary outcomes were 24-hour survival, survival to hospital discharge, and
favorable neurological outcome (Cerebral Performance Category 1 or 2) at discharge.
Using logistic regression we evaluated the association between TTIA (early (⬍5
minutes) versus late (ⱖ5 minutes)) and outcomes, adjusting for hospital location,
patient age and sex, first documented pulseless ECG rhythm, precipitating etiology,
and witnessed arrest.
Results: We analyzed the 25,006 CPA that met the inclusion criteria of the total
82,649 CPA in the registry. Observations were most commonly excluded for not
having a documented TTIA. Patient outcomes were: return of spontaneous
circulation 50.3% (95% CI: 49.7–51.0%), 24-hour survival 33.7% (33.1–34.3%),
survival to discharge 15.3% (14.9 –15.8%), and favorable neurological outcome
70.5% (69.1–72.0%). The mean time to invasive airway placement was 5.9 minutes
(95% CI: 5.8 – 6.0 min). Early TTIA was not associated with return of spontaneous
circulation (adjusted OR 0.96, 95% CI: 0.91–1.01), but was associated with
improved 24-hour survival (adjusted OR 0.94, 0.89 – 0.99). The relationships
between TTIA and survival to discharge and CPC could not be determined due to
poor model fit.
Conclusions: Early invasive airway placement is not associated with return of
spontaneous circulation, but is associated with slightly improved 24-hour survival. The
clinical benefit of early invasive airway placement during CPA resuscitation is limited.
76
Early Goal-Directed Therapy for Severe Sepsis/Septic
Shock: Which Components of Treatment Are More
Difficult to Implement in a Community-Based Emergency
Department?
O’Neill R, Morales J, Jule M/Genesys Regional Medical Center, Grand Blanc, MI
Study Objectives: We evaluated the severe sepsis/septic shock protocol at our
institution to determine which specific treatment elements were more difficult to
implement in a community-based emergency department.
Methods: Our community-based teaching hospital developed a severe
sepsis/septic shock protocol based on criteria defined by the Surviving Sepsis
Campaign 2008 International Guidelines. We conducted a retrospective analysis of
adult patients entered into the protocol. Exclusion criteria included age ⬍ 18,
pregnancy, trauma, burns, acute coronary syndrome, acute cerebral vascular event,
drug overdose, do-not-resuscitate orders, contraindication to central venous catheter
insertion, and need for immediate surgery. Charts were reviewed by the principal
investigator to determine if the patient had met criteria for severe sepsis/septic shock
as well as whether the following had been completed: a fluid resuscitation (defined as
a two liter fluid bolus within one hour of identification), antibiotics within one hour
of identification, a central venous catheter insertion (subclavian or internal jugular
vein) with an initial central venous pressure reading, an arterial line insertion, a
vasopressor infusion if indicated, a central venous oxygen saturation measurement (a
venous blood gas off the central line), and if the patient was admitted with a
standardized order set. Ten percent of the charts were analyzed by an outside reviewer
and the inter-rater reliability compared to assess consistency.
Results: A total of 98 patients presented over a nine-month period; thirteen were
excluded. Median age was 65 years (IQR 55 to 78 years) with 56% female. A total of
79 out of 85 cases (93%, 95% CI: 86 –92%) were correctly identified as severe sepsis/
septic shock. An appropriate initial fluid bolus was given in 58 of 85 patients (68%,
95% CI: 58 –78%). Patients received antibiotics within one hour of identification in
66 of 85 cases (78%, 95% CI: 68 – 85%). An internal jugular or subclavian line was
placed in 55 of 85 patients (65%, 95% CI: 54 –74%), with only 23 of 85 cases (27%,
95% CI: 18 –36%) obtaining a central venous pressure. An arterial line was placed in
36 of 85 patients (42%, 95% CI: 32–52%). Vasopressor administration was given in
50 of the 63 patients (79%, 95% CI: 69 – 89%) that required such support. Only 13
of 85 patients (15%, 95% CI: 7–23%) had an initial central venous oxygen
saturation measurement. Fifty-nine of 85 patients (69%, 95% CI: 59 –79%) were
admitted with the standardized order set. The kappa value for inter-rater reliability
was calculated at 0.95 among the principal investigator and outside reviewer.
Conclusion: The implementation of a severe sepsis/septic shock protocol in our
community emergency department was met with variable success. There was high
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compliance (ⱖ 70%) with antibiotic administration, and vasopressor utilization.
Moderate compliance (50 – 69%) was seen with fluid resuscitation, central venous
catheter insertion and use of a standardized order set. Low compliance (⬍ 50%) was
observed with central venous pressure calibration, arterial line placement, and initial
central venous oxygenation saturation measurement. This study highlights areas
where community hospitals implementing EGDT programs in their emergency
departments may have difficulty with compliance.
77
Rebound Hyperthermia After Cessation of Mild
Therapeutic Hypothermia in Patient With Successful
Resuscitation From Cardiac Arrest
Park E/Ajou University School of Medicine, Suwon, Kyoung-Gi Do, Republic of
Korea
Study Objectives: Hyperthermia in patients with successful resuscitation from
cardiac arrest may have deleterious effects upon cerebral prognosis especially during
the acute stage. We investigate the incidence and risk factors for post-rewarming
“rebound hyperthermia” (RH) after cessation of therapeutic induced hypothermia in
patients with successful resuscitation from cardiac arrest.
Methods: 34 patients admitted to the intensive care unit from January 2007 to
December 2008 following out-of-hospital cardiac arrest underwent mild induced
hypothermia (MIH) using cooling blanket for 24 hours. After MIH, passive
rewarming was conducted. Core temperature was monitored continuously using
rectal temperature probe for 48 hours after initiation of MIH. We also recorded the
mechanism of cardiac arrest, the APACHE II score on admission, standard biological
variables.
Results: Among the 34 patients who completed the period of MIH, postrewarming “rebound hyperthermia,” defined as a temperature of 38.0°C or greater,
was observed in 10 patients (29.4%) during the first 24 hours after cessation of MIH.
60% of RH were observed from six to seven hours after cessation of MIH. And
among 10 patients with RH, nine patients (90%) have SIRS (systemic inflammatory
response syndrome). But no SIRS were observed in patients without rebound
hyperthermia. AST and ALT levels of patients with RH were significantly lower than
those of patients without RH (147.40130.486 vs 506.92628.855, 106.40412.71.)
Conclusion: RH was observed in 29.4% of patients during the first 24 hours after
cessation of MIH. Most of cases may be associated with SIRS.
78
Risk of Death in Emergency Department Patients
Needing Intubation
Irvin MM, Meisner C, Nouhan PP, Irvin CB/St. John Hospital and Medical Center,
Detroit, MI
Background: Providing outcome information when a patient needs emergent
emergency department intubation is important to help families make informed
decisions and anticipate potential adverse outcomes. Useful information includes
overall mortality rate, proportion that will die in the first 24 hours, and the
probability patients will need to be discharged to a nursing home (NH) facility at
discharge.
Study Objective: To determine outcome estimates including the mortality rate
(MORT) in adult patients needing emergent ED intubation based on age, arrival
status (Home or NH), arrival blood pressure (BP), and reason for intubation.
Methods: A retrospective review of all consecutive patients (Age 18 –39⫽Young,
age 40 – 64⫽MidAge, and age ⬎64 yrs⫽Senior) needing ED intubation from a large
urban teaching ED (90,000ED visits/yr) from 10/07–3/09 was performed. Data on
arrival BP, admission location (from a nursing home (NH) or home), ED diagnosis,
and outcome (alive/dead) was recorded. Patients arriving without vital signs were
excluded.
Results: Of the 587 patients intubated, (43% were Senior, 42% were MidAge,
and 14% were Young) 36% died. The MORT rate for Seniors was 48%, MidAge was
29% and Young was 16%, p⬍.001. The MORT rate for the 21% (125/587) NH
patients was 44%, compared to 33% (153/462) who came from home, p⬍.04.
Patients with arrival Mean Arterial Pressure ⬍70 had very high MORT rate of 62%
(78% (29/37) MORT in Seniors, 53% (21/40) MORT in MidAge, and 38% (3/8)
MORT in Young, p⬍.04). In the first 24 hours, 39% (82/212) died. Of the 212
patients who died, 44% had comfort care. Of the 309 patients coming from home
and discharged (d/c) alive, 24% were discharged to a NH (33% Seniors from home
and d/c alive went to a NH, 24% MidAge, and 13% Young, p⬍.02). Of the ED
diagnosis, cardiac arrest in the ED had the highest MORT rate at 67% (29/43),
followed by intracranial bleed (64% 29/45) and altered mental status (56%, 41/73).
Annals of Emergency Medicine S25
Research Forum Abstracts
Intubated septic patients had an overall MORT rate of 47% (43/92) with Seniors
MORT 60% (30/50), MidAge MORT of 31% (12/39) and Young at 33% (1/3),
p⬍.04. Intubated congestive heart failure and chronic obstructive pulmonary disease
patients had the lowest MORT rates (chronic obstructive pulmonary disease⫽22%
(15/69) and CHF⫽24% (16/66), possibly reflecting the rapidly reversible nature of
these conditions.
Conclusion: Families of patients needing ED intubation are often distraught and
in great need of possible outcome information. Providing some estimates of what to
expect may help them anticipate future challenges. Providing rough age related to
overall MORT, and potentially diagnosis specific MORT information may assist
families in preparing for the potential death of their loved one. About 1/3 of patients
needing intubation in the ED die, and this death rate is much higher in Seniors
(almost 50% die). Understanding the high (almost 40%) death rate in the first 24
hours may also be helpful information for patients’ families asking for some general
idea of the severity of the situation. Finally, information about the possibility of NH
placement (1/3 Seniors were placed in a nursing home if they survived) may be
valuable in understanding how this emergency may affect the overall functional status
of their loved one. Although these discussions are never easy, empowering the family
with this information and helping them anticipate potential outcomes may improve
their ability to cope with this serious situation.
79
Establishment of a Prospective Burn Registry
Taira BR, Singer AJ, Cassara G, Salama M, Rodriguez R,
Sandoval S/Stony Brook University, Stony Brook, NY
Study Objectives: Most published burn registries are retrospective and based in
large urban centers. We established a prospective hospital and outpatient-based burn
registry to determine patient and burn characteristics in a suburban setting.
Methods: Study Design - Prospective, observational study. Setting - Suburban
academic medical center with a regional burn unit. Subjects - Burn patients seen by
the burn service between 1/08 and 3/09. Measures & Outcomes - Demographic,
clinical and burn characteristics. Data Analysis - Descriptive statistics used to
characterize the population.
Results: 230 burn patients were entered in the registry during the study period.
Mean age was 26.7 ⫹/⫺ 22.3 years, 55.3% were male; 43.5% were children (⬍18
years old). 71.9% were White, 16.7% were Hispanic, 6.6% were Black. 64.1% had
only high school or less education and 8.9% were uninsured. 16.7% of burns were
work-related and 30.6% were transported by ambulance. 95.6% were thermal burns
from scalds (49.8%), flame (25.1%), and contact with hot objects (23.7%). Most
burns were on the extremities (29.6%) and trunk (18.7%). Mean total body surface
area (TBSA) was 4.4% (⫹/⫺ 6.3). Burn depth was 1st (3.9%), superficial 2nd
(53.9%), deep 2nd (33.9%) and 3rd degree (12.2%). Inhalation injury (1.3%) and
associated trauma (4.4%) were rare. 11% reported a previous history of trauma and
6.2% a previous history of burn.
Conclusion: Most burns in the suburban setting are caused by contact with hot
liquids, flame, and hot objects. Mean TBSA is less than 5%. Inhalation injury and
associated trauma are rare. More than 1 in 10 patients reported a history of previous
trauma suggesting that burn patients should be included in studies of trauma
recidivism. Burn prevention and education focused on scald injuries and children are
recommended.
80
(62%) followed by lower limb injuries in 18%. Out of the upper limb injuries, 41%
had forearm injuries and 10% had supracondylar elbow fractures. The most common
mechanism was direct fall off the trampoline in 78%. Nineteen (66%) patients had a
procedure done under general anesthesia while 8 (28%) were managed conservatively
in plaster, 1 was transferred and 1 unknown. Of the 19 patients who had general
anesthesia, 9 (48%) had manipulation under anesthesia and plaster, 5 (26%) had
plating, 4 (21%) had manipulation under anesthesia and k-wiring and 1 (5%) had
manipulation under anesthesia and screw fixation.
There were 19 children who had surgery (67.9%). There was no difference in age
between those with conservative management (mean age 9.9 years) versus surgical
management (mean age 9.5; p⫽0.80). Boys were as likely as girls of having surgical
management (RR 1.29, 95%CI 0.74 to 2.24; p⫽0.43).
Length of hospital stay was 2 days (range 1 to 4 days). There was no difference in
length of stay between those who had limb injuries (mean 2.4 days) versus those with
spine/chest injuries (mean 2.0 days; p⫽0.33). Children having surgical management
were more likely to have longer length of hospital stay (mean 2.5 days) versus
conservative management (mean 1.9 days; p⫽0.060).
Conclusion: There is an increase in ED visits related to trampoline injuries
secondary to their increased popularity for recreational purposes. Trampoline can
cause injuries particularly in the upper and lower limbs of children. Up to 68% of
children admitted to the hospital will require surgical management, increasing the
length of stay and costs.
The importance of having safety guidelines for the use of trampolines is
emphasized. We strongly advocate the need for prominently displayed warning labels
and guidelines on safe and responsible use of domestic trampolines.
Key points to enhance safety are:
1) Reinforcement of safety mechanisms (nets) on the trampoline.
2) Adult supervision at all times for under 16 year olds.
3) Parents advice not to allow their children less than 6 years of age to use
trampoline.
4) Use of trampoline by only one person at a time.
Epidemiology of Trampoline-Related Injuries in Children
Attending the Emergency Department
Dhillon RJ, Dhillon RK, Maqsood MQ/Mayo Clinic, Rochester, MN; Lincoln
County Hospital, Lincoln, Lincolnshire, United Kingdom
Study Objective: Epidemiological analysis of trampoline-related injuries in
children attending an urban emergency department (ED) and subsequent admission
to the hospital.
Methods: Observational cohort study of consecutive children attending the ED
and admitted to the county hospital with injuries related to trampoline use over 1year period (April 2006 to May 2007) in Lincoln City, England.
Results: There were 29 children, 17 boys and 12 girls with a mean age of 9 years
5 months (range 3 to 16 years) and median age of 10 years. Of those, 7 (24%) were
under six years of age. There were 24 children with limb injuries (83%), and 5 had
spine/chest injuries (17%). There was no difference in age between those who had
limb injuries (mean age 9.2 years) versus those with spine/chest injuries (mean age
11.6 years; p⫽0.25). Boys were as likely as girls of having limb injuries (Relative risk
0.99, 95%CI 0.71 to 1.38; p⫽0.945). Upper limb injuries were the commonest
S26 Annals of Emergency Medicine
81
Use of a Clinical Sobriety Assessment Tool With the
NEXUS Low-Risk Cervical Spine Criteria to Reduce
Cervical Spine Imaging in Blunt Trauma Patients With
Acute Alcohol or Drug Use: A Pilot Study
Mahler SA, Pattani S, Caldito G, Conrad SA, Arnold TC/LSUHSC-Shreveport,
Shreveport, LA; University of Maryland, Baltimore, MD
Study Objectives: To determine if a clinical sobriety assessment tool (CSAT)
utilizing objective and reproducible measures of alertness, speech, ability to follow
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Research Forum Abstracts
commands, coordination, and conduct can identify reliable patients despite
intoxicant use and facilitate clinical exclusion of cervical spine injury.
Methods: A convenience sample of blunt trauma patients presenting to the
emergency department at Louisiana State University Health Sciences Center-Shreveport,
aged 18–65, with acute drug or alcohol use, were prospectively enrolled. Patients were
identified as having acute alcohol or drug use by self admission, smell of alcohol, or
behavior consistent with intoxication. Only blunt trauma patients with a mechanism of
injury severe enough to necessitate cervical spinal immobilization, as decided by an
emergency physician or emergency medical technician, were enrolled. Each subject was
assessed by an emergency physician using the CSAT and four of the NEXUS low risk
criteria (no distracting injuries, no focal deficits, no midline spinal tenderness, and normal
alertness). Following clinical assessment cervical spine computed tomography was
completed on all subjects. Patients were assigned to two groups for data analysis: group 1;
patients reliable by CSAT that meet all 4 NEXUS low risk criteria and group 2; patients
not reliable by CSAT or did not meet all NEXUS low risk criteria. The number of
fractures in each group was recorded and the predictive value of the CSAT with NEXUS
was calculated. Potential cervical imaging reduction was determined by calculating a
percentage using the number of patients in group 1 without a fracture divided by the total
number of subjects enrolled.
Results: 202 blunt trauma patients with evidence of acute intoxicant use were
enrolled. Patients in group 1, reliable by CSAT and low risk by remaining NEXUS
criteria, had no cervical spine fractures (0/84). Frequency of cervical spine fractures in
group 2 was 2.5%, (3/118). The CSAT used with the NEXUS criteria had a 100%
predictive value (84/84) in excluding cervical spine injury. Use of the CSAT could
have resulted in a 42% (84/202) 95%CI (32–53%) reduction of cervical imaging.
Conclusion: The CSAT combined with the NEXUS low risk cervical spine
criteria had a 100% predictive value for excluding cervical spine fractures in blunt
trauma patients with acute alcohol or drug use. Due to the low frequency of cervical
spine fractures a much larger study is required to confirm the utility of the CSAT.
82
Beyond Boxer’s: Bony Injuries Sustained From Punching
Perry C, Powers M, Damewood S, Jeanmonod D, Jeanmonod R/
Albany Medical College, Albany, NY; St. Luke’s Hospital, Bethlehem, PA
Study Objective: To define the spectrum of bony injuries sustained from a punch
mechanism beyond the classic Boxer’s fracture (a fracture to the distal 5th
metacarpal).
Methods: This is a retrospective study of hand injuries evaluated by plain films at an
academic emergency department with a census of 72,000. The Patient Archiving and
Communication System (PACS) was queried for each hand radiograph performed from
July 2007 to June 2008. The mechanism of injury was obtained from the radiology
requisition and verified with the electronic medical record. The specific injury was
obtained from the attending radiologist read. If the radiologist read was ambiguous, the
final clinical diagnosis from the medical record was used. All data points were recorded
into a standard spreadsheet. Children under age 13 were excluded. 8% of the collected
data was confirmed by a second investigator with a kappa value of 1.0 for identifying
punch as the mechanism as well as for the specific injury sustained.
Results: Of 1292 patients receiving hand x-rays, 4 had no dictated note available,
and were excluded from the study. 172 patients were evaluated (13.3%) secondary to
self-inflicted punch mechanisms. There were 76 (40%) identified fractures in 70
patients (41%). Of all the fractures identified, 61% (46) of them were 5th metacarpal
fractures. However, the classic Boxer’s fracture represented only 20 (26%) of these
fractures, with the remaining being mid- or proximal metacarpal fractures. 13.3%
(10) of the fractures were of the 4th metacarpal, 4% (3) were of the 3rd metacarpal,
2.7% (2) were of the 2nd metacarpal, and 1.3% (1) were of the 1st metacarpal. Other
injuries noted were 9 phalanx fractures, 3 carpal fractures and 1 radius/ulna fracture.
In addition, there were 9 dislocations: 3 of the 5th metacarpal, 3 of the 4th
metacarpal, 1 of the 3rd metacarpal, and 2 of phalanges.
Conclusion: There are significant injuries sustained as a result of punching.
Although the greatest proportion are to the fifth metacarpal bone, only 1 in 4
fractures meets the definition of a classic Boxer’s fracture, while 40% of injuries
involve other bones of the hand, wrist, and forearm.
83
Utility of Additional Radiographs in Emergency
Department Patients With Extremity Injuries
Mirhadi M, Suchard J, Leung A, Chang R/UC Irvine, Orange, CA
Study Objectives: Emergency department (ED) patients with extremity injuries
are typically evaluated with X-rays based on signs or symptoms suggesting potential
Volume , .  : September 
skeletal injuries. However, a common teaching is get X-rays “above and below”
identified bony injuries. When surgical consultation is requested, additional X-rays
may be obtained regardless of clinical signs. We were unable to identify prior studies
evaluating the utility of such additional X-rays. Our objectives were to determine the
incidence of positive radiographic findings found on additional X-rays ordered by the
consulting surgeon in cases of extremity trauma seen in the ED, and to find if these
newly identified injuries impacted clinical care.
Methods: This study was a retrospective chart review in a suburban academic ED
with annual census ⬃38,000. Extremity trauma cases with surgical consultation were
identified from a list obtained from radiology of all ED patients with extremity X-rays
(from hip to toe, or from shoulder to finger) from 6/1/08 to 11/30/08. “Trauma
activation” patients, those with only one X-ray, those getting multiple X-rays of noncontiguous body parts, and patients with no positive radiographic findings were
excluded. Medical records of the remaining subjects were reviewed for evidence of
orthopedic or plastic surgical consultation, the timing of consultation and all X-rays,
whether additional X-rays were obtained by consultant request, and whether findings
on these X-rays resulted in splinting, reduction, surgery, or admission. Descriptive
statistics were used.
Results: 1979 patients had 3719 extremity X-rays during the six-month study
period. 200 patients had positive radiographic findings and multiple X-rays of
contiguous body parts; 142 of these (7.1% of total) also had evidence of surgical
consultation, prompting further chart review. 32 patients had additional X-rays
ordered by, or at the request of, the consultant (22.5% of consults). These films
revealed 4 injuries not detected on initial X-rays (2.8% of consults), 2 of which
resulted in an additional intervention (splinting, surgery). It was not possible to
determine if these interventions weren’t already indicated by initial X-ray findings.
Conclusion: We found a 2.8% incidence of injuries discovered by additional Xrays ordered by consultants for ED patients with isolated extremity injury. The
impact of these X-rays on clinical care is not clear. While obtaining X-rays “above and
below” the site of identified bony injury is common, this practice may be of minimal
clinical utility.
84
Alcohol-Related Sexual Assault Victimization Among
Adolescents
Oostema A, Jones JS, Rossman L, Wynn B/MERC/Michigan State University
Program in Emergency Medicine, Grand Rapids, MI; Grand Rapids MERC/
Michigan State University, Ada, MI; YWCA West Central Michigan Nurse
Examiner Program, Grand Rapids, MI; MERC/Michigan State University Program
in Emergency Medicine, Spectrum Health Hospital, Grand Rapids, MI
Background: Alcohol is commonly present in sexual assault incidents with
approximately one- to two-thirds of rape incidents involving alcohol use by offenders
and/or victims. However, only a few studies of national samples have explored the
role of alcohol use in sexual assaults against young women in relation to rape and
injury outcomes and the severity of sexual assault.
Study Objective: To document the rates of alcohol-related sexual assault among
adolescents using a community-based sample and to examine the distinctions between
alcohol-related and non-alcohol-related assault.
Methods: This retrospective cohort trial evaluated consecutive female patients (⬍ 18
years old) presenting to a community-based Nurse Examiner Program (NEP) during a
10-year study period. Sexual assault victims presenting directly to four downtown
emergency departments are routinely referred to the NEP for evaluation after triage and
initial assessment. The clinic is associated with a university-affiliated emergency medicine
residency program and is staffed by forensic nurses trained to perform medical-legal
examinations. Patient demographics, assault characteristics, and injury patterns were
recorded using a standardized classification form. For the purposes of this study, injury
was defined as any tissue trauma visible on inspection which was then subsequently
classified using the TEARS (tears, ecchymoses, abrasions, redness and swelling)
classification system. Primary outcome of interest was the relationship between injury
from sexual assault and alcohol use by the victim prior to the assault. Chi-square and
ANOVA tests were used to compare anogenital findings in victims examined.
Results: A total of 895 adolescent cases (⬍ 18 years old) were identified;
representing 32% percent of all women assault victims. 528 (59%) of adolescents
reported alcohol and/or drug use immediately prior to the sexual assault, of which
399 (45%) involved alcohol only. Over the ten-year study period, the annual
incidence of alcohol use by adolescent victims remained stable (43% to 47%).
Victims who reported alcohol consumption were more likely to be white, victim of
multiple assailants, and sleeping prior to the assault. Although this cohort had a
smaller incidence of vaginal penetration, they had a greater number of documented
Annals of Emergency Medicine S27
Research Forum Abstracts
genital injuries (68% vs. 59%, p⬍.01). In contrast, adolescents who denied alcohol
consumption were more likely to be virgins, assaulted in their own home, and file a
police report. This group reported a higher incidence of weapon use by the assailant
but had fewer non-genital injuries (25% vs. 37%, p⬍.01) when compared to victims
of alcohol-related sexual assault.
Conclusions: Alcohol consumption remains an important risk factor in sexual
assault, with 45% of rape incidents involving alcohol use by adolescent victims. Preassault alcohol use by victims was associated with more non-genital and genital injury
to the victim. The epidemiology and injury patterns in this group are unique and
pose special challenges to emergency health care providers.
85
Penile Fracture: Evaluation and Management
Hawkins D, Jones JS, Bush C/Michigan State University College of Human
Medicine, Grand Rapids, MI; MERC/ Michigan State University, Grand Rapids,
MI; MERC/Michigan State University Program in Emergency Medicine, Grand
Rapids, MI
Background: Fracture of the penis is a relatively uncommon form of urologic
trauma. It is a disruption of the tunica albuginea of one or both corpus cavernosum
due to blunt trauma to the erect penis. Unfortunately it is often misdiagnosed and
may therefore be mistreated.
Study Objective: The purpose of this study was to review the predisposing
factors, injury patterns, and treatment of penile fracture in a cohort of patients who
presented to the emergency department (ED).
Methods: The design was a retrospective analysis of patients presenting to the ED
of an urban U.S. academic medical center over a 4-year study period. Patient
demographics, presenting complaints, co-morbidity, radiographic studies, treatment
in the ED, final disposition, and complications were recorded using a standardized
abstraction form. CT reports and procedure or operative notes were reviewed to
define the extent of penile injuries and time and type of definitive treatment. To
assess accuracy of the data collection, 10% of the records were randomly selected and
reexamined by one investigator. Descriptive statistics (frequency tables, confidence
intervals) were used to summarize the data.
Results: From August 2004 to July 2008, 16 patients presented to the ED with a
penile fracture. The mean age was 33.2 ⫹7.8 years (range, 14 – 47). Mechanism of
injury included sexual maneuvers (75%), accidental manipulation of erect penis
(19%), and fall onto erect penis (6%). Characteristically, all patients heard a cracking
sound associated with sharp pain followed by immediate loss of the erection,
deformity, discoloration and swelling of the soft tissues. Accurate identification of the
fracture site could usually be made on examination by rolling the swollen skin over a
fixed, smooth, rounded, tender lump (of clot), deep to Buck’s fascia: the rolling sign.
Blood was present at the meatus in three patients; however, urethrography
demonstrated a urethral wall tear in only one man. In all patients the tunica albuginea
of the corpora cavemosa in the proximal third of the penis was torn (range, 5 to 20
mm) but the corpus spongiosum was intact. The tear in the tunica albuginea was
unilateral and transverse in all cases, involving less than half of the circumference of
the corpus cavernosum. Defects in the tunica albuginea were repaired with sutures
and the hematoma was evacuated. Operations were performed 3 hours to 4 days after
injury. Only 6 patients were treated within 7 hours and no short-term complications
were noted.
Conclusions: The diagnosis of penile rupture does not require further
investigation when the patient presents with typical onset (during sexual intercourse)
and typical physical findings, including swelling and ecchymosis of the penis with a
deviation toward the side opposite the injury. Ultrasound and retrograde
urethrograms, especially in an atypical case, should be performed to rule out other
injury and to help determine appropriate surgical management. The management of
penile rupture includes conservative treatment and early surgical repair to avoid
complications such as persistent clot, angulation, penile abscess and fibrosis.
EMF-1
Characteristics of Patients Undergoing
Mechanical Ventilation in US Emergency
Departments
Easter B, Fischer C, Fisher J/Harvard Medical School, Boston, MA; Beth Israel
Deaconess Medical Center, Boston, MA
Study Objectives: Outside the intensive care unit and the post-operative recovery
area, the emergency department (ED) is the most common site for provision of
critical care. However, little is known about ED-based mechanical ventilation (MV).
S28 Annals of Emergency Medicine
We examined the epidemiology of ED MV, including demographic, clinical, and ED
length of stay (LOS) variables that may influence subsequent management of
mechanically ventilated patients.
Methods: We combined the 2002–2006 ED datasets of the National Hospital
Ambulatory Medical Care Survey. Patients were considered to have undergone a
period of MV if they were intubated in the ED and survived their ED course to either
hospital admission or transfer to another facility. Demographic and clinical
characteristics, ED LOS, and indications for MV were analyzed. Point estimates of
proportions with confidence intervals were calculated. To categorize indications for
MV, we used the Clinical Classifications Software (CCS) 2009 (Agency for Health
care Research and Quality) to systematically sort ICD-9 codes. CCS makes use of
seventeen predetermined categories, such as respiratory diseases or diseases of the
circulatory system. Up to three ICD-9 codes were available for each patient, and
patients were assigned multiple categories if their ICD-9 codes so indicated.
Results: The combined dataset contained 494 observations of intubations,
representing 1,473,000 visits, and 334 observations for MV, representing 994,000
visits. Approximately 0.26 % (95% CI 0.23– 0.29) of ED patients were intubated and
0.17% (0.15– 0.20) underwent MV. 58.8% of MV patients were male, 75.5%
Caucasian, and 66.1% over age 45. 9.1% received CPR. Mean LOS was 278.1
minutes (234.9 –321.3); 53.5% of visits were greater than four hours, a sufficient
amount of time to implement interventions aimed at reducing complications of MV.
Against a backdrop of increasing ED visit times nationally, LOS for MV patients
actually decreased over the study period (ptrend⬍.05). In particular, LOS fell
precipitously over the last two years of the study period, from 325.9 minutes in 2004
to 192.6 minutes in 2006. By comparison, LOS for all ED visits increased by 7.0
minutes over the same period. Based on CCS, the most frequent indications for
intubation were respiratory diseases, circulatory system diseases, and injury and
poisoning with 23.5%, 23.1%, and 21.1% of patients, respectively, having an ICD-9
code matching one of these categories. By comparison, these categories accounted for
13.5%, 10.0%, and 20.3%, respectively, of all ED visits over the study period.
Conclusions: These data provide a picture of the epidemiology of MV in US
EDs. Mean LOS appears sufficient for collaborating with critical care providers on
implementing ED-based solutions that will reduce the complications of MV, such as
ventilator-associated pneumonia, for ED patients. However, the decline in LOS from
2004 –2006 may undermine this approach if MV patients are simply not in the ED
long enough to impact outcomes. Further investigation of the LOS trend will help
determine the utility of such an ED-based approach.
EMF-2
Induced Mild Hypothermia Modulates Akt
Phosphorylation and Hsp27 Expression in
Mouse Hemorrhagic Shock
Das A, Li J, Wang H, Vanden Hoek T, Beiser D/University of Chicago, Chicago,
IL
Study Objective: We characterized the effect of induced hypothermia (HT) on
cardiac Akt and Hsp27 signaling in a mouse model of resuscitated hemorrhagic
shock.
Methods: Mice were bled and maintained at a mean arterial pressure (MAP) of
35 mmHg for 90 minutes. At 30 minutes of shock (S30), animals were randomized
to 120 minutes of HT (33⫾0.5°C, n⫽19) or continued normothermia (NT,
37⫾0.5°C, n⫽21). After 90 minutes of shock (S90) mice were resuscitated with shed
blood and lactated Ringer’s solution. Whole hearts were harvested at S30 and S90,
and at 30 (R30) and 180 (R180) minutes following resuscitation for Western blot
and immunoprecipitation analysis of Akt and Hsp27, myeloperoxidase (MPO)
activity, and TUNEL staining. Plasma myoglobin and cytochrome c were measured
as markers of cardiac and mitochondrial injury, respectively.
Results: Mice treated with HT responded with sustained improvement in postresuscitation MAP values. After 30 minutes of shock, prior to randomization, cardiac
Akt phosphorylation (p-Akt) decreased relative to baseline. At S90, p-Akt levels in the
NT group returned to baseline and were significantly higher than those in the HT
group. In the NT group, both p-Akt and total Hsp27 expression progressively
decreased following resuscitation. By contrast, HT animals displayed progressively
increased levels of p-Akt and total Hsp27 expression following resuscitation.
Immunoprecipitation analysis revealed an interaction between Akt and Hsp27 at
baseline which decreased by R30 in NT animals, but was preserved in HT animals.
HT also decreased heart MPO and TUNEL staining, as well as plasma myoglobin
and cytochrome c, by R180.
Conclusions: HT improves short-term hemodynamic outcomes and leads to
increased p-Akt and total Hsp27 within the heart following resuscitation. HT also
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maintained baseline levels of Akt-Hsp27 interaction and attenuated tissue
inflammation and cell death. Akt-Hsp27 signaling may play an important role in
mediating HT protection in the setting of hemorrhagic shock.
86
Use of New Cardiac Biomarkers as Diagnostic Tools in
the Emergency Department
Battista S, Formoso F, Maggiorotto M, Loiacono M, Mengozzi G, Gai V/San
Giovanni Battista Hospital of Turin, Turin, Italy
Study Objectives: The aim of this study was to retrospectively assess the
diagnostic performances of two novel proposed biomarkers, myeloperoxidase (MPO)
and midregional fragment of proadrenomedullin (MR-proADM), in the emergency
department (ED) workup of patients presenting with symptoms suggestive of cardiac
damage.
Methods: A cohort of 196 patients (mean age 69.3 years, 76 females) admitted to
the ED of a large tertiary referral hospital were selected over a three-week period
according to a high degree of suspicion of cardiac involvement. The study population
included 25 subjects who were discharged and taken as controls, 33 patients referred
to cardiologist counselling who did not undergo further evaluation, 31 patients with
negative findings on either ischemia tests or coronary artery examination, 34 with
coronary artery changes and stent placement, and 73 subjects with heart failure
according to the diagnosis at discharge. Plasma MPO (Abbott Diagnostics, Abbott
Park, IL, USA) and MR-proADM (B.R.A.H.M.S AG, Hennigsdorf/Berlin,
Germany) concentrations were measured by automated immunoassays.
Results: Although with some overlap among study groups, MPO levels showed a
significantly different distribution (p⫽0.014 by one-way ANOVA), higher values
being detected in patients with proven coronary artery disease (p⬍0.05 with respect
to controls and patients with negative coronary artery findings, according to
Bonferroni correction test). MR-proADM concentrations resulted significantly
increased in subjects with myocardial dysfunction and heart failure (p⬍0.0001 and
p⬍0.05 as compared to all other groups). ROC curve analysis yielded a good
diagnostic performance for MR-proADM levels in the differential diagnosis of heart
failure in our population, with an area under the curve of 0.78 (0.71 to 0.85, 95%
CI), corresponding to 79% sensitivity and 69% specificity (61% and 84% positive
and negative predictive values, respectively) at a cut-off threshold of 0.52 nmol/L.
Conclusions: Both tested biomarkers might provide an useful diagnostic aid in
the ED decisionmaking process. Automated immunoassays allow accurate results to
be available to the clinician with short turnaround time. Their diagnostic potential,
when considered individually, should be further investigated in a multimarker
strategy to be used as a biomarker profile for risk stratification as well as monitoring
and targeting therapy.
87
Prognostic Significance of an Estimated Glomerular
Filtration Rate for Long-Term Mortality in Patients With
Syncope
Suzuki M, Tatematsu S, Takeshita AS, Hori S/Keio University, Tokyo, Japan
Study Objectives: Underlying cardiovascular conditions are the determinants of
mortality for syncopal patients. Impaired renal function also affects the cardiovascular
complications. We hypothesized that glomerular filtration rate (GFR) levels is an
independent predictor of mortality for patients with syncope.
Methods: This retrospective observational study was conducted on patients seen
in an academic emergency department (ED) in Tokyo. Nine hundred and twelve
consecutive patients who presented with syncope were identified. Of those, 205
patients whose follow-up information regarding mortality was not obtained from
mailed questionnaires and/or medical records and 91 patients who had no data of
serum creatinine levels in the ED were excluded. The GFR was estimated by the
Modification of Diet in Renal Disease equation modified by Japanese coefficient, and
the remaining 616 patients were grouped according to their estimated GFR. We
compared all cause and cardiac mortality among three GFR groups.
Results: The distribution of estimated GFR was wide and normally shaped, with
a mean (⫾SD) value of 76⫾32 ml/min/ 1.73 m2 of body-surface area. Of the 616
patients, the estimated GFR was less than 60 ml/min per 1.73m2 in 196 patients
(31.8%). The reduced level of the estimated GFR was associated with the increased
incidence of cardiac syncope. The median follow-up period was 37 months (range:
0⬃132 months). During the follow-up period, 49 deaths including 5 sudden cardiac
deaths were observed. A graded association was observed between a reduced estimated
GFR and the risk of death from any cause and cardiac cause (Log-rank test: P⬍0.001,
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P⫽0.01, respectively). The Cox proportional hazards analysis indicated the level of
the estimated GFR was an independent predictor of any cause mortality (odds ratio
2.38, 95% confidence interval: 1.23 to 4.60), although the level of the estimated
GFR was not an independent predictor.
Conclusion: In patients with syncope, impaired renal function, as assessed by the
estimated GFR, was common, and the reduced level of the estimated GFR was
associated with an increased risk of death. Impaired renal function should be
considered a major risk factor for mortality after syncope.
88
Acute Heart Failure Mortality Prediction Using
Copeptin: Results of the Biomarkers in ACute Heart
Failure Trial
Peacock IV W, Nowak R, Maisel A, Di Somma S, Mockel M, Mueller C,
Xavier Neath S, Hartman O, McCord J, Anker S/The Cleveland Clinic, Cleveland,
OH; Henry Ford Health System, Detroit, MI; VA San Diego Health Care System,
San Diego, CA; Sant’Andrea Hospital, University La Sapienza, Rome, Italy;
Charite, Campus Virchow-Klinikum, Berlin, Germany; University Hospital Basel,
Basel, Switzerland; University of California, San Diego, CA; Brahm’s, Berlin,
Germany
Study Objectives: Emergency physicians have few tools providing objective
accurate prediction of short term mortality risk in patients presenting to the
emergency department (ED) with acute heart failure (AHF). Our purpose was to
describe whether plasma C-terminal pro-vasopressin fragment (Copeptin), a surrogate
for circulating arginine vasopressin (AVP), is associated with short term death rates in
ED patients presenting with AHF.
Methods: The Biomarkers in ACute Heart failure (BACH) trial was a
prospective, 15-center, international study of patients presenting to the ED with nontraumatic dyspnea. Copeptin values were blinded. All other lab testing was per
standard of care and, when used clinically at the discretion of the treating emergency
physician, employed the local hospital reference range. For copeptin, BNP and NTproBNP, a core lab was utilized. Creatinine was measured in the local hospital
laboratory. Gold standard diagnoses were determined by 2 cardiologists, blinded to
copeptin results, reviewing all data available 90 days post ED visit.
Results: Of the 1641 BACH patients, 568 (34.6 %) had a gold standard
diagnosis of AHF, 52% were male, and 36% had a prior history of HF. Overall, 21
(3.5%) died within the first 14 days, and 65 (11.4%) were dead by 90 days. Mortality
prediction is described by C- statistic; all p values ⬍0.05, except when noted by *
where p⫽NS. In a multivariable model including systolic and diastolic blood
pressure, creatinine (⬎1.6 mg/dL), and troponin (high/low), copeptin added
significantly to the base model (Chi2⫽10.5, HR 3.3, p⫽0.0012). Neither BNP nor
NT-proBNP were significant in univariate Cox regression (both p ⬎0.1).
Conclusion: Copeptin demonstrates superior short term mortality prognostic
ability when compared to natriuretic peptides, and is independent of other clinical
covariates. Objective determination of mortality risk may provide opportunities to
improve emergency department acute heart failure decisionmaking and consequent
clinical outcomes.
89
90
Abstract Withdrawn
A Randomized Comparison of Continuous IV Infusion of
Furosemide Versus Repeated IV Bolus Furosemide in
Acutely Decompensated Congestive Heart Failure
Cienki JJ, Hebert K, Ta AK, Diskin AL/Jackson Memorial Hospital, Miami, FL;
Miller School of Medicine of the University of Miami, Miami, FL
Study Objectives: Acutely decompensated congestive heart failure (CHF) is a
frequent cause of emergency department visits, accounting for over 3% of all
Annals of Emergency Medicine S29
Research Forum Abstracts
encounters. Diuretic therapy is one of the mainstays of management of CHF with
furosemide commonly given in episodes of acute decompensation. Concern exists
about intravenous (IV) bolus furosemide resulting in duretic resistance via the
braking effect as compared to IV continuous furosemide use resulting in longer
hospital stay. Previous studies have shown continuous infusion furosemide to reduce
the amount of furosemide given potentially reducing adverse effects. We sought to
determine whether continuous (IV) infusion of furosemide initiated in the ED would
lead to a more rapid resolution of symptoms than repeated IV bolus therapy.
Methods: An institutional review board-approved, prospective convenience
sample of patients with acute decompensated CHF were randomized to either
continuous IV infusion of furosemide or IV bolus therapy. Inclusion criteria were all
patients with acute decompensated CHF with New York Heart Association Class II
or above symptoms. Exclusion criteria were patients age ⬎70, acute myocardial
infarction, chronic obstructive pulmonary disease, renal failure, active chest pain,
acute cardiac dysrhythmias, or other disease processes which might prolong treatment
or length of stay unrelated to CHF. If the patient required positive pressure
ventilation or intubation they were excluded from the study. Patients were excluded
from enrollment in the study if they already received greater than 40 mg furosemide.
Preprinted order sets were used to remind ED staff to include ACE inhibitors, beta
blockers and nitroglycerin if medially indicated. Aside from the method of
administration of furosemide, the provider could treat the patient at their discretion.
Initial orders were written by the ED attending and method of administration of
furosemide was maintained throughout the hospital stay. Length of IV therapy was
used as a correlate of resolution of symptoms.
Results: Twenty patients were randomized to receive either continuous IV
infusion or IV bolus furosemide therapy. Mean age for the continuous infusion group
was 56.0 and for the IV bolus group was 57.5. Time to discontinuation of
continuous IV infusion was shorter than for IV bolus therapy 12.3 hours (95% CI:
5.5, 19.1) versus 33.6 hours (95% CI: 15.7, 59.5) (p ⬍0.05).
Conclusion: Length of treatment of continuous IV infusion of furosemide was
statistically shorter than IV bolus therapy in this study. Continuous IV infusion
merits continued investigation as an improvement over IV bolus therapy in the
treatment of acutely decompensated CHF in the ED.
91
Continuous Non-Invasive Hemodynamic Monitoring
Using Novel Finger-Cuff Technology in Emergency
Department Patients: A Pilot Study
Sen A, Nowak R, Garcia AJ, Wilkie H, Moyer M/Henry Ford Hospital, Detroit, MI
Study Objectives: Hemodynamic optimization is one of the most important endpoints of resuscitation of emergency department (ED) patients presenting with acute
heart failure, sepsis, and stroke. Various studies have explored the use and clinical
relevance of comprehensive point-of-care cardiovascular monitoring in the ED
without any one device gaining widespread acceptance. The Nexfin apparatus is a
novel, easily applied, non-invasive beat-to-beat hemodynamic cardiovascular monitor
based on the measurement principle of the volume-clamp method originally
described by Penaz to measure blood pressure at the finger. Previous studies have
shown that the trends in the Nexfin-derived variables closely reflect changes when
compared to those obtained by invasive hemodynamic measurements in the non ED
setting.Our objectives were: (1). To compare the blood pressure and pulse rate
measurements obtained by Nexfin finger cuff to those recorded by intermittent
brachial cuff in the ED setting. (2). To assess the diagnostic accuracy of the clinician
regarding estimates of cardiac output and systemic vascular resistance when compared
to those calculated by the Nexfin device in various acute ED presentations. (3). To
define the hemodynamics of patients on arrival to the ED prior to receiving any
therapy and to document the response to any treatments given.
Methods: This is a prospective, blinded, convenience sample study in adult ED
patients with suspected acute congestive heart failure, sepsis and stroke. The hospital
Institutional Review Board approved the study protocol and informed consent was
obtained for all study participants. Patients were enrolled on arrival by a trained
research coordinator and the Nexfin finger cuff applied. Conventional and Nexfin
hemodynamic measurements were obtained every 15 minutes for a minimum of 2
hours. The results of the Nexfin measurements were blinded to the treating physician.
The treating clinician was asked at baseline and after 2 hours of patient management
to estimate the cardiac output and systemic vascular resistance as to whether they
were low, normal or high. Statistical analysis was conducted using paired t-test for
comparison between groups and test of significance was set at p⬍0.05.
Results: To date, a total of 91 blood pressure and pulse rate readings in 12
patients have been analyzed to determine Nexfin device reliability. There was no
S30 Annals of Emergency Medicine
significant difference between the Nexfin finger-derived and brachial cuff systolic
(p⫽0.08) or diastolic blood pressure (p⫽0.1) and pulse rates (p⫽0.12). There was,
however, significant difference between the clinician estimation of Nexfin
hemodynamics computed from the beat-to-beat waveform analysis (p⬍0.001). The
diagnostic accuracy of ED physicians was only 48% and 50% when estimating
cardiac output and systemic vascular resistance respectively suggesting that some
patients did not reach optimal hemodynamic resuscitation.
Conclusions: Nexfin continuous non-invasive finger cuff monitoring compares
well with brachial cuff blood pressure and pulse rate measurements. The Nexfincalculated cardiac output and systemic vascular resistance can aid physicians in better
understanding the hemodynamics of ED patients and help them individualize their
strategies for therapeutic interventions. Additional studies are needed to further
evaluate the use of finger cuff derived hemodynamics in the ED setting.
92
Out-of-Hospital Electrocardiogram Interpretation and
Early Activation for ST-Segment Elevation Myocardial
Infarction Patients Reduces Door-to-Balloon Times and
Hospital Length of Stay
Miller A, Coleman G, MacKenzie R, Richardson D, Kleaveland J, Cox D,
Feldman B, Crown A, Rupp V/Lehigh Valley Hospital, Allentown, PA
Study Objectives: Current national guidelines recommend hospitals treating STelevation myocardial infarction (STEMI) patients achieve a door-to-balloon (D2B)
angioplasty time of less than 90 minutes. We have in place a myocardial infarction
(MI) alert process where emergency physicians activate the cardiac catheterization
(CC) team based on identified STEMI patients. In an effort to reduce D2B times
we initiated an out-of-hospital Myocardial Infarction Alert 3 (MI-3) process
where trained Emergency Medical Service (EMS) providers interpret a 12-lead
electrocardiogram (ECG) in the field and notify the emergency physician allowing for
earlier activation of the existing MI Alert process.
Methods: This retrospective analysis of our Institutional Review Board (IRB)approved database include all patients who present to our center with a STEMI. Our
hospital is a 600-bed academic community medical center with an annual ED census
of 56,000 patients. In this cohort study of STEMI patients, we reviewed a one-year
period (9/06 –9/07) pre-implementation of MI-3 and period (10/07–9/08) postimplementation of MI-3.
Six EMS Advanced Life Support (ALS) units took part in a 12 lead ECG and
MI-3 process training class. The trained paramedics call the ED via radio
communication with their interpretation of the ECG and initiate aspirin therapy.
The emergency physician notifies the CC team including the interventional
cardiologist prior to patient arrival. The patient stops in the ED for registration,
confirmation of STEMI, and initiation of heparin and clopidogrel. The patient is
then transported for emergent percutaneous coronary intervention (PCI).
Results: From 9/06–9/07, 127 STEMI patients had activation of the MI Alert
process. Of those, 114 underwent emergent PCI with a median D2B time of 67 minutes
(min) (86% ⬍90 min, 36% ⬍60 min). Four (3.2%) patients were classified as false
positives after PCI revealed no coronary artery disease. The remaining 9 patients
underwent emergent coronary artery bypass graft, were treated medically, or expired.
From 10/07–9/08, 173 patients presented with STEMI of whom 147 underwent
emergent PCI. The median D2B time for this group was 63 min (83%⬍90min,
45%⬍60 min, p⫽0.147). Of the 147, 65 patients (44%) had MI-3 activation and 87
(56%) had activation of the MI Alert process. In the MI-3 activated subset, the
median D2B was 42 min (97% ⬍90min, 78% ⬍60 min, p ⬍ 0.001). 5 patients
were classified by the emergency physician to not meet STEMI criteria and were not
taken for PCI, yielding a false positive activation rate of 7. 7%.
Furthermore, we found the mean length of hospital stay decreased from 5.38 days
pre-implementation to 3.78 days (p⫽0.005) post MI-3 intervention.
Conclusion: A process where trained ALS providers in the interpretation of ECGs
to identify patients with STEMI and activation prior to patient arrival leads to a
decrease in the D2B times with a low false positive rate. In addition, the patients with
this process in place appear to have a decreased length of hospital stay.
93
Cost-effectiveness Analysis of Out-of-Hospital 12-Lead
Electrocardiogram Programs
Gross T, Groeneveld P/University of Pennsylvania, Philadelphia, PA
Study Objectives: National guidelines for the treatment of acute myocardial
infarction endorse the use of out-of-hospital 12-lead electrocardiograms (PHECGs)
Volume , .  : September 
Research Forum Abstracts
to reduce delays in reperfusion therapy for patients transported by emergency medical
services (EMS). The cost-effectiveness of this technology has not been established.
This study was designed to examine the societal costs and benefits associated with a
PHECG program.
Methods: A Markov decision analytic model was constructed to model short- and
long-term outcomes for a cohort of 65-year-old patients with ST-elevation
myocardial infarction. Data was obtained from the medical literature and publicly
available sources. Costs were measured in 2006 U.S. dollars and account for EMS
capital equipment and personnel, as well as short- and long-term patient health care
costs. Effectiveness was measured in quality-adjusted life years (QALYs). Sensitivity
analyses were performed to assess the model’s robustness.
Results: For the base case, the incremental cost-effectiveness ratio of a
PHECG program was $17,525 for each additional QALY compared to no
PHECG program. The PHECG strategy remained favorable with variation of all
model parameters across plausible ranges, given a willingness-to-pay of $50,000
per QALY.
Conclusions: The cost-effectiveness of PHECG programs compares favorably
with other widely accepted medical interventions. This study demonstrates that
PHECG programs offer significant societal benefits at reasonable costs. This evidence
should support further development and implementation of PHECG programs in
U.S. EMS systems.
94
weeks as the reference standard. Two authors independently conducted the
relevance screen of titles and abstracts, selected studies for the final inclusion,
extracted data and assessed study quality. Consensus was reached by conference
and any disagreements were adjudicated by a third reviewer. Unenhanced
computed tomography test performance was assessed using summary receiver
operating characteristic (SROC) curve analysis with independently pooled
sensitivity and specificity values across studies.
Results: The search yielded 1258 publications; 7 studies met the inclusion criteria
and provided a sample of 1060 patients. The included studies were of high
methodological quality with respect to appropriate patient spectrum and reference
standard. Our pooled estimates for sensitivity and specificity were 92% (95% CI:
0.89 to 0.95) and 96% (95% CI: 0.94 to 0.97), respectively; the likelihood ratio (LR)
positive ⫽ 23 for non-contrast CT and the LR negative ⫽ 0.08.
Conclusion: We found the diagnostic accuracy of non-contrast CT for diagnosis
of acute appendicitis in the adult population to be adequate for clinical
decisionmaking in the ED setting.
Spontaneous Retroperitoneal Hematoma: Etiology,
Characteristics, Management, and Outcome
Sunga KL, Bellolio MF, Gilmore RM, Cabrera D/Mayo Clinic, Rochester, MN
Study Objectives: To describe the clinical course of patients presenting with
spontaneous retroperitoneal hematoma (SRH) during a seven-year period.
Methods: We conducted an observational cohort study of all consecutive
patients 18 years and older, diagnosed with SRH at Mayo Clinic Rochester from
January 2000 to December 2007. SRH was defined as not related to invasive
procedures, surgery, trauma, or abdominal aortic aneurysm. For statistical
analysis we used Wilcoxon, Chi-square, Fisher’s, or t-test according to data type
and distribution.
Results: Of 346 identified patients, 89 were eligible. Median age was 72 years
(interquartile range 61–79), and 56.2% were male. Fifty-nine (66.3%) were
anticoagulated, with 41.6% on warfarin, 30.3% heparin, and 11.2% low molecular
weight heparin. Twenty-seven (30.3%) were on an antiplatelet regimen, with 29.2%
on aspirin and 2.5% clopidogrel. Fourteen (15.7%) were taking both classes of
medication. Thirteen (14.6%) were on neither. Primary presentation to the
Emergency Department was seen in 36%, whereas 64% developed SRH during
inpatient anticoagulation therapy. 11.1% were initially misdiagnosed. Computed
tomography (CT) was performed in 95.5%, ultrasound in 21.3%, and magnetic
resonance imaging in 3.3%. 40.4% were managed by the intensive care unit. 24.7%
underwent interventional radiology, and 5.6% required surgical management. 75.3%
received blood transfusion. Mortality was 5.6% within 7 days, 10.1% within 30 days,
and 19.1% within 6 months. The most common symptoms were abdominal pain
(60.7%), leg pain (21.3%), hip pain (20.2%) and back pain (19.1%).
Conclusion: SRH is an uncommon but lethal entity with a non-specific
presentation that can lead to misdiagnosis. It should be suspected in patients who
present with atraumatic abdominal, leg, hip, or back pain, regardless of
anticoagulation history. CT is frequently used and effective for diagnosis. The
majority of patients will require aggressive support in the form of blood transfusion or
interventional radiology. Surgery is rarely performed.
95
Diagnostic Accuracy of Non-Contrast Computed
Tomography for Appendicitis in Adults: A Systematic
Review
Hlibczuk V, Dattaro JA, Jin Z, Falzon L, Brown MD/New York Presbyterian
Hospital, New York, NY; Columbia University, New York, NY; Mount Sinai
Medical Center, New York, NY; Michigan State University, Grand Rapids, MI
Study Objective: We sought to determine the diagnostic test characteristics of
non-contrast computed tomography (CT) for appendicitis in the adult emergency
department (ED) population.
Methods: We conducted a search of MEDLINE, EMBASE, the Cochrane
Library, and the bibliographies of previous systematic reviews. Included studies
assessed the diagnostic accuracy of non-contrast CT scans for acute appendicitis
using the final diagnosis at the time of surgery or follow-up at a minimum of two
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96
Comparison of Traditional Pediatric-Age, Nontraditional
Pediatric-Age and Adult-Age Patients With
Intussusception: A Case Series
Cochran AM, Higgins III GL, Strout TD/Maine Medical Center, Portland, ME
Study Objectives: Most medical texts cite the typical patient age range of
intussusception (INT) as being between 2 months and 6 years old. Our clinical
observations and experience suggested INT is more common in nontraditional age
groups than commonly described. We sought to determine the incidence of INT in 3
age groups (traditional pediatric-age, 0 to 6 years [T]; nontraditional pediatric-age,
⬎6 to 18 years [N]; and adult-age, ⬎18 years [A]) and to compare characteristics
among these groups.
Methods: Maine Medical Center is a 600-bed academic medical center with an
emergency medicine training program that provides care to 58,000 emergency
department (ED) patients annually. This retrospective case series used a standardized
data extraction tool to collect multiple historical, physical exam and diagnostic testing
data elements on each subject. Patients discharged with a proven diagnosis of INT
between October 1999 and June 2008 were included. This project was reviewed and
approved by the Institutional Review Board.
Results: 95 cases of INT were diagnosed: 61 T (64%), 12 N (13%), 22 A (23%).
34% T, 50% N, and 37% A patients visited a primary care provider and/or an
emergency medicine provider for related complaints prior to the diagnosis of INT
being made. The presence of bloody stool was more common in T than N and A
patients: 16% vs. 0% vs. 4% (p⫽0.016). An intermittent pain pattern was most
frequent in all groups. 70% T, but only 42% N and 50% A patients, were admitted
with a diagnosis of INT (p⫽0.015). Air contrast barium enema (36%) and
ultrasound (33%) were the most common diagnostic tests in T, while CT was the test
of choice in N (83%) and A (68%) patients. Bowel resection was required more
frequently in older patients: 23% T, 75% N, 43% A (p⫽0.001). The most frequent
causative pathologies for T, N and A patients respectively were adenitis, Peutz-Jeghers
polyp and carcinoma. 10 A patients (11% of the entire cohort) had prior gastric
bypass surgery as a cause.
Conclusions: The incidence of INT is substantially higher in nontraditional age
groups than previously reported. Older patients are more likely to have prior visits for
related complaints prior to being diagnosed, are less likely to have bloody stool, are
less likely to be admitted with a diagnosis of INT, are more likely to have causative
pathologies of concern, and are more likely to require bowel resection. Gastric bypass
surgical procedures are an emerging cause of INT in adults.
Annals of Emergency Medicine S31
Research Forum Abstracts
97
An Analysis of Emergency Department Utilization by
Intellectually Disabled Adults
Venkat A, Pastin RB, Hegde GG, Shea JM, Cook JT, Culig C/Allegheny General
Hospital, Pittsburgh, PA; Allegheny Valley School, Coraopolis, PA; University of
Pittsburgh Katz School of Business, Pittsburgh, PA; Veterans Administration
Medical Center, Pittsburgh, PA
Study Objectives: Intellectually disabled (ID) adults are a growing and rarely
studied emergency department (ED) population. To aid in their ED management,
our objectives were to identify what factors increase the likelihood of ED utilization
among ID adults and determine how their ED and hospital discharge diagnoses differ
from the general adult ED population.
Methods: This was a retrospective, observational study of all adult (age ⬎ 18 on
1/1/07) residents of an intermediate care facility (ICF) for ID individuals & their ED
visits to a tertiary center (1/1/07– 6/30/08). The investigators abstracted from the
ICF clinical database the subjects’ demographic (age, sex, race), intellectual disability
(ID degree and related diagnosis, autism and cerebral palsy presence), health (number
of prescribed medications, hearing and visual impairment, body mass index,
tracheostomy presence) and adaptive status (bowel and bladder continence,
ambulatory and feeding ability) variables and whether they required ED
care/hospitalization via an ED. We abstracted from the hospital database the
International Classification of Disease (ICD)-9 coded ED and hospital discharge
diagnoses of the study and general adult population presenting to this ED. We used
multivariate logistic regression to compute odds ratios (OR) of ED utilization and
hospitalization among the subjects from the abstracted variables and the conditional
large sample binomial test (z-statistic) to determine if the ICD-9 ED and hospital
discharge diagnoses of the study and general adult ED population were significantly
(p⬍.05) different.
Results: 433 subjects met inclusion criteria - Mean Age 45, 49.4% Male and
92.1% White. 57% had profound ID (Intelligence Quotient [IQ] ⬍25), 22.4%
significant ID (IQ 25– 40), and 20.6% mild/moderate ID (IQ 40 –70). 7.4% had
autism, 39.7% cerebral palsy. 222 subjects required ED care (741 visits, 90.6% to
this ED); 132 subjects required hospitalization via an ED (323/741 visits, 92.9% to
this ED). In the study cohort, feeding status (gastrostomy/jejunostomy: OR
4.16(95CI 1.64 –10.58)) alone increased the likelihood of ED utilization (p⬍.05);
feeding status (partial help to feed: OR 2.59(1.14 –5.88)), gastrostomy/jejunostomy:
OR 3.26(1.30 – 8.18)) and number of prescribed medications (OR 1.08(1.03–1.14))
that of hospitalization. For ED discharge diagnoses, ID adults were more likely
(p⬍.05) than the general adult ED population to have ICD-9 diagnoses in Blood (z
3.59), Mental (z 10.55), Nervous System (z 6.26) & Digestive disorders (z 3.10) and
Ill-Defined Symptoms/Signs (z 4.60), less likely in Circulatory (z ⫺3.45),
Musculoskeletal (z ⫺3.32) & Injury/Poisoning (z ⫺5.61) disorders. For hospital
discharge diagnoses, ID adults were more likely (p⬍.05) than the general adult ED
population to have ICD-9 diagnoses in Infectious (z 8.82), Mental (z 2.78), Nervous
System (z 29.42), Respiratory (z 11.58), Digestive (z 10.24), Skin (z 4.46) &
Musculoskeletal (z 14.47) disorders and Ill-Defined Symptoms/Signs (z 8.73), less likely
in Neoplastic (z ⫺6.02), Endocrine (z ⫺2.43), Circulatory (z ⫺19.66) &
Injury/Poisoning (z ⫺13.14) disorders.
Conclusion: In this study of ID adults, feeding status alone increased the
likelihood of ED utilization. Feeding status and number of prescribed medications
increased the likelihood of hospitalization. The ED and hospital discharge diagnoses
of ID adults differed significantly from the general adult ED population.
98
Management of the Bariatric Surgery Patient in the
Emergency Department
Kiebel W, Hawkins D, Meyers L, Ray D, Jones JS/Michigan State University
College of Human Medicine, Grand Rapids, MI; MERC/Michigan State University
Program in Emergency Medicine, Grand Rapids, MI
Background: Nearly two-thirds of Americans are considered overweight and half
of these individuals are considered obese. With advances in health care and
technology and the rising prevalence of the condition, bariatric surgery has become an
increasingly common procedure. As more patients have weight loss surgery, clinicians
working in the emergency department will frequently encounter complications of
these procedures.
Study Objective: To identify the complications that can arise post-operatively,
and the assessment and management of the bariatric surgery patient who presents to
the emergency department (ED).
Methods: From our hospital information system, retrospective data was obtained
S32 Annals of Emergency Medicine
on consecutive emergency department patients with a definite diagnosis relating to
bariatric surgery complications. The study took place at two urban U.S. academic
medical centers over a 3-year study period. Patients were stratified based on surgical
technique (laparoscopic vs. open) and type of surgical procedure (gastric bypass vs.
stapling). The patients were further differentiated based on when they presented to
the ED following surgery: within 30 days, 30 – 60 days, 60 –90 days, and 90 –120
days. In addition to demographic data, charts were reviewed for presenting
symptoms, clinical features, diagnostic studies and treatment modalities. Chi-square
and ANOVA tests were used to compare clinical features among the cohorts
examined. Relative risk was also calculated.
Results: During the 3-year study period, 2735 patients underwent bariatric
surgery; 519 (17%) were evaluated in the ED within 120 days of surgery. A total of
46 post-op complications were identified. Early complications (seen within 30 days of
surgery) were documented in 61% (317/519) of patients. These included post-op
pain, vomiting/dehydration, electrolyte disorders, gastrointestinal reflux/spasm,
gastric distension and pneumonia. Gastric bypass patients tended to have more
wound problems, abdominal hernias, and dumping syndrome when compared to
gastric stapling (p⬍.01). Late complications were documented in 39% (202/519) of
patients and ranged from respiratory failure to not life-threatening but clinically
important conditions such as wound infection, hernias, and pneumonia. Overall 30%
of patients were readmitted to the hospital; the most important risk factor for
admission was the presence of three or more co-morbidities. Patients who had
laprascopic surgery and/or gastric stapling were less likely to be admitted to the
hospital (RR⫽0.5, [95% CI: 0.3– 0.7]).
Conclusions: In this community-based study, 17% of patients undergoing
bariatric surgery were evaluated in the ED within 120 days of surgery. Clinicians
working in the ED should have a basic understanding of the various procedures
performed for weight loss, as well as management of common early and late
complications.
99
Clinical Features of Acute Diverticulitis in Very Young
Patients
Oosterhouse T, Loyson A, Bianco M, McNinch D, Jones JS/Michigan State
University College of Human Medicine, Grand Rapids, MI; MERC/Michigan State
University Program in Emergency Medicine, Grand Rapids, MI
Study Objective: Acute diverticulitis is relatively rare in patients younger than the
age of 40, which may lead to a delay in diagnosis. The purpose of this study was to
characterize the clinical presentation, laboratory and radiologic findings, as well as the
treatment and outcome of patients 40 years of age and younger diagnosed with acute
colonic diverticulitis.
Methods: This retrospective cohort analysis evaluated consecutive adult patients
presenting to the emergency department with a discharge diagnosis of acute colonic
diverticulitis. The study took place at two urban U.S. academic medical centers over a
ten-year study period (1998 –2007). Patients 40 years of age and younger were
compared to a group of older patients (age 41– 65 years old) with acute diverticulitis
who presented to the ED during the same time period. The diagnosis was confirmed
by at least one of the following: computerized tomography (CT), contrast enema
study, colonoscopy, or surgical findings. Patient demographics, clinical findings, and
imaging studies were recorded using a standardized classification system. Treatment
modalities, length of hospital stay, and outcome were assessed as well. Comparative
data were analyzed using chi-square, t-tests, and relative risk. One investigator
performed a blinded critical review of a random sample of 10% of the charts to
determine reliability (Kappa statistic).
Results: A total of 2,407 cases of acute colonic diverticulitis were identified
during the study period that met the inclusion criteria. Overall, 9% (208/2609) of
the patients were 40 years of age and younger; mean age was 33.9 ⫹ 5.9 years. In
comparison, 60% (1454/2407) of patients were between 41– 65 years old; mean age
51.4 ⫹ 7.8 years. The older age group were more likely to be female (64% vs. 33%,
p⬍.001), Caucasian (88% vs. 71%, p⬍.001), and have “text-book” signs and
symptoms (73% vs. 43%, p⬍.001). There were no differences between the two
groups with respect to duration of symptoms or leukocyte count .As expected, the
associated co-morbidities were far more common in the older age group, though only
hypertension and ischemic heart disease reached statistical significance. Younger
patients were more likely to be misdiagnosed in the ED (RR⫽5.0 [95% CI: 4.3–
5.7]). Analysis of hospital admission rates, complication rates, type of surgical
procedures and length of hospital stay, showed no significant differences between the
two age groups. The consistency of the recording of data was excellent, with a median
kappa statistic of 0.89.
Volume , .  : September 
Research Forum Abstracts
Conclusions: Nine percent of patients presenting to the ED with acute
diverticulitis were under 41 years of age. Although the disease does not appear to take
a more aggressive course in younger patients, the epidemiology and clinical features in
this group are unique and pose special challenges to emergency health care providers.
100
Fecal Occult Blood Testing Does Not Predict Major
Gastrointestinal Bleeding in Heparinized Patients
Bennett CJ, Moskovitz J, Mayo DD, Witting MD/University of Maryland,
Baltimore, MD
Study Objectives: It is a generally accepted practice to perform a digital rectal
examination and a fecal occult blood test (FOBT) prior to administering intravenous
heparin. However, the ability of a positive FOBT result to predict gastrointestinal
(GI) bleeding after administration of heparin has not been documented. The goal of
this study was to estimate the likelihood of GI bleeding associated with a positive
FOBT result in patients receiving intravenous heparin.
Methods: This was a retrospective, double-cohort study. Inclusion criteria were
the following: age ⬎18 years, admission during the 6-year study period, treatment
with continuous heparin infusion, completion of a FOBT in the 48 hours prior to
initiation of heparin, and at least two sequential high partial thromboplastin time
(PTT) measurements. Patients receiving anticoagulation as outpatients were
excluded. The main outcome was major GI bleed, as defined by physical exam
evidence of GI bleed plus a drop in hematocrit of ⬎5 points, need for transfusion, or
death within 1 hour after detection of the bleed. Data were collected using standard
chart review methodology. We categorized patients with bleeding into those with
major GI bleed, minor GI bleed, and major bleed of questionable source.
Results: A total of 624 patients were included in the analysis, of which 61 had
positive FOBT results and 563 had negative results. Eleven patients had GI bleeds: 3
major GI bleeds, 1 minor GI bleed, and 7 major bleeds of questionable source. One
of the 61 (1.6%) patients with a positive FOBT result had a major GI bleed,
compared with 2 of the 563 (0.4%) with a negative FOBT result, for a risk difference
of 1.2% [(⫺)2% - (⫹)5%, 95% CI, p⫽0.3]. If major bleeds of questionable source
were categorized as a major GI bleed, then 2 of the 61 (3.3%) patients with positive
FOBT results had a GI bleed, compared with 8 of the 563 (1.4%) patients with
negative FOBT results, for a risk difference of 1.9% [(⫺)3% - (⫹)6%, 95% CI,
p⫽0.3].
Conclusion: We found no significant difference in the incidence of major GI
bleeding between patients with positive FOBT results and those with negative FOBT
results prior to heparinization. This observation was consistent whether or not we
included major bleeds of questionable source in the major GI bleed category. We
estimate the risk difference of major GI bleeding associated with a positive FOBT
result at 1.2% in patients receiving heparin.
101
The Utility of Routine Reticulocyte Count in
Uncomplicated Vaso-Occlusive Crisis Due to Sickle
Cell Disease
diagnosed. Data was recorded on a standardized data sheet and 20% of the charts
were reviewed by both reviewers to assure consistent data collection.
Results: Over an 8-year period, 346 SC patients presented to the ED. Limiting
the patient population to those presenting with pain who were patients of the
institution’s SC clinic yielded 192 patients with 1885 ED visits. This correlates to an
average of 9.8 ED visits over the study period per patient. There were 7 (0.4 %) cases
of aplastic crisis diagnosed in the ED using the initial reticulocyte count. However, all
of these patients met at least one of the study’s exclusion criterion. Two additional
patients were diagnosed with aplastic crisis after during their hospital admission. Each
had an elevated reticulocyte count during the ED evaluation. One presented with a
hemoglobin of 8.3 mg/dl (baseline 14 mg/dl) and a reticulocyte count of 8.3%. The
other presented with a hemoglobin of 3.9 mg/dl (baseline 8.3 mg/dl) and a
reticulocyte count of 4.7%.
Conclusion: In patients presenting to the ED with otherwise uncomplicated
sickle cell VOC, routine utilization of the reticulocyte count to diagnose aplastic crisis
is of little utility.
102
Does Correlation of Faculty Assessment of
Emergency Medicine Residents’ Medical
Knowledge Competency With Performance on the
In-Training Examination Improve With
Advancement Through the Program?
Barlas D, Ryan JG/New York Hospital Queens, Flushing, NY
Study Objectives: Faculty assessment of emergency medicine (EM) residents on
the medical knowledge (MK) core competency may or may not be predictive of
performance on the annual in-training examination. We sought to determine if a
greater degree of faculty exposure and experience with EM residents, as determined
by PGY level, improved the correlation of the faculty’s assessment of MK on
quarterly summative evaluations with the score received on the EM in-training
examination taken during the same time period.
Methods: Data was obtained from the records of residents from an urban,
established PGY 1–3 EM residency program in this observational, cohort study.
Fixed, 9-point (1⫽ Level of a medical student, 9⫽Level of an attending) MK core
competency summative assessments by 25 board prepared/certified EM faculty during
the 3rd academic quarter (Jan–Mar) were compared with the score received on the
EM in-training exam for individual residents grouped by PGY year. Degree of
correlation was determined using Pearson Correlation Coefficients.
Results: Data from 73 quarters for 37 EM residents over 4 years was analyzed.
Correlation between faculty assessment of medical knowledge and performance on
the in-training exam was poor across all PGY years, but improved with each year. For
PGY1 residents r⫽⫺0.08, for PGY2, r⫽0.03, and for PGY3 residents, r⫽0.43.
Conclusions: Assessment of medical knowledge by EM faculty does not correlate
well with residents’ performance on the in-training exam given during the same
evaluation period, but improves somewhat as residents advance through their
training. Alternative MK evaluation tools that better correlate with exam performance
should be sought, especially for residents early in their training.
Garman A, Lyon M, Kutlar A/Medical College of Georgia, Augusta, GA
Study Objectives: A common component of emergency department (ED) care of
sickle cell (SC) patients presenting with vaso-occlusive crisis is measurement of the
reticulocyte count. The reticulocyte count is a measure of immature red blood cells
(RBC) and should be elevated with acute RBC destruction that occurs during a vasoocclusive crisis (VOC). When the bone marrow fails to respond to the acute anemia
due to RBC destruction, an aplastic crisis may be present. However, aplastic crises are
quite rare. Our objective is to evaluate the utility of routine reticulocyte count
measurement in uncomplicated VOC due to SC disease.
Methods: This was a retrospective chart review of all patients with SC disease and
pain suggestive of VOC presenting to an academic ED with an average annual census
of 78,000 patients. Inclusion criteria included any SC patient older than 18 years
presenting to the ED with pain and had a reticulocyte measurement as part of their
ED evaluation. Exclusion criteria included fever (⬎38.5 oC), hypotension (BP ⬍90/
60), hypoxia (oxygen saturation 100) was not regarded as an exclusion criterion.
Patients who did not receive routine care at the institution’s SC clinic were excluded.
Reticulocyte count along with presenting hemoglobin and baseline hemoglobin were
the variables used to determine the presence of aplastic crisis on presentation to the
ED. Charts of SC patients admitted to the hospital were reviewed for development of
aplastic crisis. All discharged patients were evaluated for a return visit within 10 days
to the ED or the SC clinic in which symptomatic anemia or aplastic crisis was
Volume , .  : September 
103
Is There a Doctor in the House? The Experience of
Medical Students as Responders to Out-of-Hospital
Emergency Medical Situations
Greene T, Cho E, Shearer P/Mount Sinai School of Medicine, New York, NY
Study Objectives: Outside of a hospital anyone can be called upon to deliver
emergency care, but medical students exist on a spectrum between a lay person and a
credentialed provider. Most medical schools teach only BLS and few have a course at
the beginning of the first year to teach an approach to basic medical situations. There
is no past research on this topic so how often medical students are called upon to
provide such care remains unclear. We hypothesized that medical students encounter
a wide variety of medical and trauma situations outside of the hospital during their
medical school years.
Methods: An anonymous Web-based survey was distributed to all medical
students of the Mount Sinai School of Medicine, an urban institution, to assess their
experience with medical situations outside of the hospital setting during their years as
medical students. Multiple choice questions asked respondents to describe the type of
event encountered (eg, seizure, trauma, choking) and how they responded (eg, called
911, administered CPR). When respondents entered free text the information was
kept confidential and later stripped of identifiers.
Annals of Emergency Medicine S33
Research Forum Abstracts
Results: 139 of 520 possible Mount Sinai medical students completed the survey
for a response rate of 27%; 46 first years, 30 second years, 18 third years, and 45
fourth years. 40 students (28.8% ⫹/⫺ 7.4%, 95% CI) reported 50 medical events
encountered outside of the hospital since beginning school. Only 32% of those who
encountered emergent situations had any medical training before medical school.
Location of these incidents was most commonly on the street (40%), at home (22%),
or on the subway (16%). Trauma of varying degree (40%), seizure activity (14%),
and syncopal episodes (14%) were most commonly encountered. Student
interventions included: calling 911 (42%); providing medical advice (46%); checking
vitals (36%); wound dressing (10%); performing CPR (4%). One student delivered a
baby in the back of a taxicab.
Conclusion: Medical students in an urban area are potential first responders to
emergency situations outside of their schools and hospitals. In our student body over
one quarter of those responding had encountered such situations while in medical
school. The variety of encounters reflects the types of clinical scenarios typical to
emergency medicine and supports providing medical students with basic clinical
training for emergency situations early in medical school.
104
Performance of an Ultrasound-Guided
Thoracentesis Teaching Model
Nomura JT, Goodgame BR, Bauman MJ, Schofer JM, Bollinger M, Reed III JF,
Sierzenski PR/Christiana Care Health System, New Castle, DE
Study Objectives: Ultrasound (US) use for thoracentesis guidance is becoming
more common. US-guided procedural skills must be practiced prior to patient care
situations, most commonly with ultrasound procedure phantoms. Commercial
phantoms are available, but are costly. Our goal was to construct a low cost
thoracentesis phantom and report its performance by physicians skilled in ultrasound.
Methods: A fluid bladder to simulate fluid-filled pleura was embedded in an
opacified gelled mineral oil tissue analog with interspersed solid echo-dense rib
analogs. Models were presented to physicians skilled at both ultrasound procedures
and thoracentesis for use and evaluation. The model was rated on a 10-point scale
regarding realism, usefulness, and likelihood of use.
Results: Ten physicians skilled in US and thoracentesis evaluated the model on a
10-point rating scale. The model had an average score of 8.2 ⫹ 0.9 (95% CI 7.6 –
8.8) for realistic appearance. The realism of the procedure was rated at 8.4 ⫹ 1.2
(95% CI 7.7–9.1) and the usefulness of the model was 8.9 ⫹ 0.9 (95% CI 8.3–9.5).
The physicians rated their likelihood to use this model as a teaching aid at 8.8 ⫹ 1.5
(95% CI 8.0 –9.6).
Conclusion: This low cost and easily constructed ultrasound-guided thoracentesis
model performed well and is a reasonable alternative to expensive commercial
phantoms. This model provides affordable access to a procedural education model.
105
Results: The maximum obtainable score on the critical actions checklist was 50
points. In addition to improper technique, residents lost points if they breached
sterile precautions or if it took more than 3 attempts to puncture the target vessel. Of
the forty residents, three received all 50 points (one R1, one R2, and one R3). The
minimum score obtained was 27 and the average score was 43 for all three levels of
training. R1’s averaged 42 points (SD⫾6.7), R2’s averaged 43.5 points (SD⫾4.8),
and R3’s averaged 43.9 points (SD⫾3.4). One R1 had performed ⬍5 central lines
but scored a perfect 50. Two R3’s reported they had completed ⬎15 central lines and
still scored one standard deviation below the mean. Three R2’s reported they had
completed ⬎10 central lines, but still scored more than one standard deviation below
the mean. There was no statistically significant association between level of training,
number of central lines completed, and the total score obtained.
Conclusions: Quantitative competency assessments for procedure credentialing
are needed to ensure appropriate mastery of skills. The number of procedures
completed or logged may not be an adequate predictor of competency and
proficiency. Current credentialing standards can be improved via the development of
valid metrics and benchmarks, in conjunction with expert assessment and feedback in
both simulated and live settings.
Evaluation of Quantity-Based Credentialing: The
Need for Competency Metrics
Wu TS, Rosenberg M, Simpson C/Orlando Health, Orlando, FL
Study Objective: Institutions nationwide have demonstrated interest in utilizing
simulation-based training (SBT) modules and standardized metrics for procedure
credentialing. Currently, most credentialing departments require residents to log and
report the number of procedures they have performed. Once a sufficient number of
supervised procedures have been performed, the resident is deemed competent to
perform those specific procedures in an unsupervised setting. In this study, we
obtained a quantitative assessment of resident performance during ultrasound-guided
central venous access training and sought to evaluate the difference between the scores
obtained, the residents’ level of training, and the reported number of central lines
logged.
Methods: This was a prospective study conducted in a simulation-based training
center at an academic institution with an annual census of 90,000 patients. Forty
residents participated in a simulation session where they were asked to place a central
line under ultrasound guidance on a central venous access trainer. Each resident was
given two separate attempts to complete the procedure. A rigorous checklist of critical
actions was devised by a panel of experts and utilized to score each resident’s
performance. Video recordings of each procedure were independently reviewed and
scored by three members of the research team. Scores from the critical action checklist
were analyzed against the resident’s level of training (R1, R2, R3) and the reported
number of central lines completed prior to the training session. The critical actions
checklist was used to provide both formative and summative feedback during
individual debriefing sessions.
S34 Annals of Emergency Medicine
106
Improved Resident Knowledge and Adherence to
Care Guidelines Using an Algorithm for Ectopic
Pregnancy Evaluation
Nelson BP, Noble VE, Choi J, Truong T, Levine AC/Mount Sinai School of
Medicine, New York, NY; Harvard Medical School, Boston, MA; Walnut Creek
Medical Center, Walnut Creek, CA; Santa Clara Valley Medical Center, Santa
Clara, CA
Study Objectives: Bedside pelvic ultrasound has gained widespread use in
emergency medicine (EM) residency programs. In an effort to improve residents’
knowledge and increase awareness of a new interdepartmental protocol, a poster
demonstrating pelvic ultrasound images and an ectopic pregnancy evaluation
algorithm was created. This study assessed whether this simple intervention could
improve resident knowledge and impact the care of patients being evaluated for
ectopic pregnancy.
Methods: There were 2 phases: 1. Prospective, controlled study of resident
knowledge performed at two urban academic EM programs, and 2. Before-after study
assessing adherence to inderdepartmental ectopic pregnancy evaluation guidelines.
EM residents completed a 22-question test on the evaluation of ectopic pregnancy.
Half of the questions were image-based. In the study program, a poster containing
pelvic ultrasound images and the ectopic pregnancy evaluation algorithm was
installed in each obstetric evaluation room. There was no intervention in the control
program. The study group completed a post-test after a four-week block in the
emergency department where the posters were exhibited. The control group took the
post-test about one month after the pre-test. To assess impact on patient care, patient
charts before and after the posters were installed were reviewed. A score was given to
each chart, marking adherence to key components of the algorithm (maximum score
7 points). Length of stay (LOS) and other demographic information was recorded as
well.
Results: Phase 1: Pre-test scores for the control group (median, 72.7%;
interquartile range [IQR], 65.9% to 84.1%) and study group (median, 72.7%; IQR
68.2% to 81.8%) did not differ significantly (p⬍0.984). For the control group, there
was no significant change between the pre-test and post-test scores (post-test median,
72.7%; IQR 65.9% to 86.4%; p⬍0.205). The study group demonstrated a
significant improvement from its pre-test to post-test scores (post-test median,
86.4%; IQR 75.0% to 90.9%; p⬍0.001). The study group achieved significant
increases in both image recognition questions (median 75.0% to 83.3%; p⬍0.001)
and non-image recognition questions (median 80.0% to 90%; p⬍0.004).
Phase 2: 89 patients charts were reviewed before poster installation and 85 charts
after. The mean score for adherence to the departmental guidelines improved from
5.7 to 6.1 (out of 7) after installation of the posters (p⬍0.05). There was no
difference in LOS before and after the posters were installed.
Conclusion: In this study, a novel educational intervention improved emergency
medicine residents’ fund of knowledge on ectopic pregnancy evaluation compared to
controls. In addition, adherence to departmental guidelines improved without specific
in-servicing, lectures, or other cumbersome interventions. This poster, targeted in a
high-yield area of the emergency department for ectopic pregnancy evaluation, may
be a low-cost and simple tool to educate residents and improve patient care.
Volume , .  : September 
Research Forum Abstracts
107
Assessing Reaction Time Among Emergency
Medicine Residents Working Different Shift Hours
Berios I, Surani S, Simmons M/Christus Spohn Memorial Hospital, Texas A&M
University, Corpus Christi, TX
Study Objectives: To assess reaction time and sleepiness among emergency
medicine residents after 9-hour and 12-hour shifts.
Background: Fatigue and sleepiness leading to increased medical error is a
paramount factor in the implementation of the resident work hours mandated in
2003 by the ACGME. There are a variety of ways that emergency medicine programs
comply with these rules. Most commonly, EM residents work either 9 or 12-hour
shifts.
Methods: We conducted a prospective study of emergency medicine residents
using psychomotor vigilance testing (PVT) using a validated PVT 192 tool, Stanford
sleepiness scales and Epworth sleepiness scales. Six emergency medicine residents
completed Stanford sleepiness scales and PVT before and after working 12 and 9hour shifts, as well as an Epworth sleepiness scale after one week of 12-hour shifts and
one week of 9-hour shifts.
Results: Our results showed an increasing trend in mean reaction time (rt),
minimum rt, and maximum rt. There was a significant increase in sleepiness towards
the end of shift as manifested by Stanford sleepiness score. The mean rt increased
from 275 milliseconds pre shift, 300ms post 9-hour shift and 327ms post 12-hour
shift, as well as increasing pre minimum rt (171ms), post 9-hour shift minimum rt
(185ms) and post 12-hour shift minimum rt (197ms). The Stanford sleepiness scale
scores increased significantly from a score of 1.66 pre shift, to 2 post 9-hour shift (p
value ⫽ 0.027), and 4.16 post 12-hour shift (p value ⫽ 0.002). There were no
differences between the pre shift and post shift PVT in false starts or errors, such as
lapses, or differences in Epworth sleepiness scales (7.67 for 12-hour shifts and 8.33
for 9-hour shifts). One interesting side note is that residents consumed more caffeine
while working 12-hour shifts (50%) than they did on 9-hour shifts (33%).
Limitation: This is a single center study with a small sample size.
Conclusion: Excessive sleepiness was seen at the end of both shifts among EM
residents. In addition, even with a small sample size, there seems to be an increasing
trend in slower reaction times as length of shift increases.
108
The Effect of Video Demonstration to Improve the
Quality of Dispatcher-Assisted Chest CompressionOnly Cardiopulmonary Resuscitation Amongst
Middle-Age Persons
109
Airway Management by Critical Care Teams Is Not
Associated With Physiologic Decompensation
Starr GA, Stewart CE, Thomas SH, CCT CORE Research Group/University of
Oklahoma School of Community Medicine Department of Emergency Medicine,
Tulsa, OK
Study Objectives: This study was performed to: 1) assess the incidence of critical
care transport (CCT) crews’ airway management-associated physiologic derangement,
and 2) assess for predictors of new physiologic derangement, that could be used to
identify future foci for education and practice improvement.
Methods: Over 2008, 603 airway management attempts (nearly all oral
endotracheal intubation {ETI}) were performed by 11 CCT services (all but one,
helicopter EMS). Data included patient demographics, diagnoses, indications for
airway management, airway management setting, and peri-airway management
physiology including pulse rate, systolic blood pressure, pulse oximetry (SpO2), and
end-tidal CO2. This abstract focuses on “new SpO2 abnormality,” defined as
SpO2 ⬍ 90% during or after airway management by the CCT crew, in a patient who
had pre-airway management SpO2 exceeding 90%. The study aimed to provide
descriptive assessment of SpO2 derangement. Additionally, in order to ascertain foci
for future education and research efforts, we performed analytic testing to assess
associations between new SpO2 drop and patient/airway management factors.
Results: Of 603 patients, 163 were in-hospital, 162 attempts in-transport, and
314 in the field; 2/3rds were scene missions. Casemix included 70% trauma, 11%
neurologic, 9% cardiac, 8% general medical/surgical, and 2% neonatal. The difficulty
of airways is exemplified by the fact that 182 (30%) had at least 1 failed attempt by a
practitioner prior to arrival of the CCT team.
CCT crew ETI was successful in 582 patients (96.5%). In 130 cases (22%)
multiple attempts at ETI were performed. The final airways in the study included: 2
BVM (0.3%), 3 Cricothyroidotomy (0.5%), 4 Combitube (0.7%), 12 Laryngeal
Mask Airway (LMA, 2%), 16 Nasal Endotracheal Intubation (2.7%), 566 Oral
Endotracheal Intubation (93.9%). Physiologic deterioration in the study was unusual,
with new hypoxemia occurring in 6 cases (1.6% of the 365 cases with ongoing SpO2
monitoring; 95% binomial exact confidence interval .61–3.5%). There were no
associations other than pre-existing hypotension (p ⬍ .001), with development of
new hypoxemia. Requirement for multiple ETI attempts by CCT crews was not
associated with new hypoxemia (Fisher’s exact p ⫽ 0.13).
Conclusions: CCT crews’ ETI success rates were very high, and even when ETI
required multiple attempts, airway management was rarely associated with SpO2
derangement.
110
The Impact of Unit Hour Utilization on Out-ofHospital Interventions
You Jr Y, Ji sook Sr L/Ajou University, Suwon, Republic of Korea
Myers LA, Russi CS/Mayo Clinic Medical Transport, Rochester, MN; Mayo Clinic,
Rochester, MN
Study Objectives: Bystander cardiopulmonary resuscitation (CPR) significantly
improves survival of cardiac arrest victims. Dispatcher assistance increases bystander
to do CPR but the quality of CPR remains unsatisfactory. This study was conducted
to assess the effect of video demonstration performing CPR by non-trained middleage person compared with traditional voice instructions in simulated cardiac arrest.
Methods: The subjects of middle age were randomized to receive voice dispatcher
assistance instruction (voice group⫽39), and the other to voice and demonstrated
video instruction (video group⫽39) via a cell phone on chest compression to
scenario-based simulated cardiac arrest situation. Performance of chest compressiononly CPR throughout the scenario was video recorded. The quality of CPR was
evaluated by reviewing videos and mannequin reports (skill reporting systemTM,
Laerdal).
Results: In video group, chest compressions per minutes were more adequate
(99.5/min vs 77.4/min, p⬍0.01) and shorter period from initial phone call to first
compressions (184sec vs 211sec, p⬍0.01). Depth of compression were deeper in
voice group (31.3mm vs 27.5mm, p⫽.21) but not matched to recommended levels
in both groups. Hand positions of compression were more appropriate in video group
(62.2% vs 37.8%, p⫽0.012). 71.8% of video group performed no “hands off”
compressions ( vs 46.15%, p⫽0.21).
Conclusion: Dispatching with video demonstration to do CPR improved time to
initiate compression, compressions per minute, correct hand positioning and also
reduced “hands-off” events. But more emphasized instruction to improve depth of
compression is needed through video demonstration.
Study Objectives: To evaluate differences in out-of-hospital interventions and
care provided to patients based on the activity or unit hour utilization (UHU) of an
ambulance service.
Methods: This was a retrospective analysis of out-of-hospital electronic records
from January 2007 through February 2008. All non-interfacility ground transports in
which the patient was taken to a hospital were included for analysis. Patient records
were examined for interventions; defined as any treatment or diagnostic tool (ie,
ECG, blood glucose monitor). Advanced life support (ALS) intervention is defined as
any advanced procedure, assessment or treatment such as IV medication
administration or ECG monitoring.
UHU is a measurement of the productivity of an ambulance system calculated by
dividing the number of transports by the number of unit hours over a given time
period. In this study, 4 of the 12 sites had a UHU number greater than .25 (⬎25%
productivity). The remaining 8 sites had UHU of less than .25 (⬍25% productivity).
Data abstraction and statistical analysis was completed using JMP v6.0 software. This
study was approved by Mayo Clinic IRB.
Results: There were 33,067 patients included for analysis. The ⬎25% group had
22,954 (69.4%) in which 15,703 (68.4%) patients received at least one intervention.
In those that received an intervention, 8,175 (35.6%) received an ALS intervention.
The remaining 10,113 (30.6%) patients from the entire sample were designated as
the ⬍25% group. An intervention was performed on 8,056 (79.7%) of these
patients. This is a difference of 11.3%. An ALS intervention was performed on 4,265
(42.2%) patients which is a difference of 6.6%. The median transport times for the
two groups; ⬎25% ⫽ 8 minutes, ⬍25% ⫽ 9 minutes.
Volume , .  : September 
Annals of Emergency Medicine S35
Research Forum Abstracts
Morphine administration for pain occurred in 537 (2.3%) of the ⬎.25% group
while it was administered to 487 (4.8%) of the ⬍.25% group. This is a difference of
2.5%.
Conclusion: Ambulance services with UHU of ⬍25% have a higher rate of
delivering at least one intervention to a patient, providing an ALS intervention and
treating pain with morphine sulfate. Further study is necessary to determine what
these differences have on patient outcomes.
111
Insurance Status as a Predictor of Mode of Arrival
for Patients Who Present to the Emergency
Department With Chest Pain
Wu JT, Bhatti P, Goetz JD, Weiner SG/Tufts University School of Medicine,
Boston, MA; Tufts Medical Center, Boston, MA
Study Objectives: Previous studies have evaluated patient-specific factors for
patients who choose to take an ambulance to the ED. We wished to determine if
insurance status was a predictor for EMS arrival for the common, but potentially lifethreatening, complaint of chest pain.
Methods: All adult patients ages 18 –99 who presented to an urban academic ED
between 1/06 and 7/06 with a chief complaint that included “chest pain” were
eligible for retrospective analysis. For patients with multiple visits, only the first visit
for this complaint during the study period was included. Patients who were
transferred, incarcerated or who left without being seen or against medical advice
were excluded. Insurance status was documented by registration personnel on a
computerized record.
Results: There were 690 visits for chest pain during the study period, representing
4% of total ED census. A total of 42 visits met exclusion criteria, and 37 patients had
52 repeat visits, leaving 596 visits included for analysis. 22% (56/250) of patients
with private insurance arrived via EMS. Using private insurance as a reference, 36%
(46/129) of Medicare patients (OR 1.92, 95% CI 1.20 –3.06), 24% (36/152) of
Medicaid patients (OR 1.08, 95% CI 0.67–1.73) and 25% (16/65) of Self Pay
patients (OR 1.13, 95% CI 0.60 –2.14) arrived by ambulance. Only Medicare
patients had a statistically significant increased likelihood of EMS transport (OR
1.84, 95% CI 1.21–2.80) when compared with private, Medicaid and Self Pay
patients (p⫽0.005). Patients who arrived via ambulance were more likely to be
admitted to the hospital (OR 1.75, 95% CI 1.21–2.55) but there was no difference
in final diagnosis of “myocardial infarction” among the different insurance types
(p⫽0.40).
Conclusion: Of the four major types of insurance, only Medicare patients with a
chief complaint of chest pain were more likely to utilize EMS. There was no
significant difference among patients with private insurance, Medicaid or self-pay
status.
112
Knowledge of Self-Injectable Epinephrine Technique
Among Emergency Medical Services Providers
Davis JE, Churosh N, Borloz M, Howell J/Georgetown University Hospital &
Washington Hospital Center, Washington, DC; Inova Fairfax Hospital, Fairfax, VA
Study Objectives: Emergency medical services (EMS) personnel may be the first
to encounter a patient with an allergic emergency. Several studies have revealed that
health care provider (physician, nurse) knowledge of the technique of self-injectable
epinephrine (such as EpiPen® or EpiPen® Jr) administration is deficient in general.
Studies focusing specifically on EMS personnel are lacking. We therefore sought to
assess emergency medical technician (EMT) knowledge of self-injectable epinephrine
use, and evaluate the efficacy of a brief, directed educational intervention.
Methods: We assessed baseline knowledge of self-injectable epinephrine
technique among EMT providers, then provided an educational intervention (we
created an online training module lasting less than 5 minutes). Study subjects were
retested immediately following training module completion, and again at 3-months.
Proper technique was defined in 5 steps, per self-injectable epinephrine medication
package insert instructions: (1) grasp device, (2) remove safety cap, (3) inject into
lateral thigh, (4) hold in place for 10 seconds, and (5) rub injection site for 10
seconds following device removal. This study was approved by our institutional
review board. Nominal data were analyzed using chi square and Fisher’s Exact tests.
Alpha was set at 0.05 for all comparisons. Data were analyzed using GraphPad Prism
version 5.00 for Macintosh, GraphPad Software, San Diego, California, USA,
www.graphpad.com.
Results: All participants were EMT basic certified providers from a single
collegiate EMS system, with a mean of 1.8 years of experience (range: ⬍1 year to 3.5
S36 Annals of Emergency Medicine
years). At baseline, 4.6% of 22 participants correctly demonstrated all 5 steps
compared with 73% (95% confidence interval: 50 – 89%) immediately post
intervention, and 72% (95% confidence interval: 49 – 88%) at 3-month follow-up.
Four participants were lost to 3-month follow-up. Baseline measurements were
significantly different than immediate and 3-month post-intervention measurements.
Conclusion: Similar to studies of other health care providers, EMT basic
providers demonstrated poor baseline knowledge of proper self-injectable epinephrine
technique. Knowledge improved significantly following a brief educational
intervention, and was well retained at 3-month follow-up. Brief, focused educational
interventions may assist health care providers in learning and retaining knowledge
regarding the proper technique for self-injectable epinephrine administration.
113
The Treatment of Motion Sickness in the Out-ofHospital Setting: A Comparison of Metoclopramide
and Diphenhydramine to Placebo
Weichenthal LA, Andrews J, Rubio S/UCSF-Fresno, Fresno, CA
Study Objectives: To determine the incidence of motion sickness in patients
being transported via ambulance in a mountainous setting while comparing
metoclopramide and diphenhydramine to placebo in the treatment of these patients.
Methods: This was a prospective, randomized, double-blinded, placebo
controlled study of patients transported by ambulance in the mountainous regions of
Fresno County. Patients who met inclusion criteria and who agreed to participate in
the study were asked to rate their motion sickness every 5 minutes on a visual analog
scale (VAS) during transport. If they developed motion sickness, they were
randomized to recieve metoclopramide (20 mg IV), diphenhydramine (50 mg IV), or
placebo (saline). Symptoms then continued to be recorded every 5 minutes on a VAS.
If subjects continued to have signs and symptoms of motion sickness after 15
minutes, a rescue dose of metoclopramide was offered.
Results: Twenty six subjects were enrolled in the study. Twenty two (84.6 %)
developed motion sickness during transport. These patients were randomized to the
three different treatment arms: Eight receive metoclopramide, seven received
diphenhydramine, and seven recieved placebo. The metoclopramide group showed a
significant decrease in mean VAS score at 15 minutes compared to the
dihenydramine and placebo groups (p⫽0.0226). Twelve of the twenty two patients
required a rescue dose of metoclpramide after 15 minues. Eleven of these patients
were from the diphenhydramine and placebo groups. At twenty five minutes, there
was no difference in the VAS score between the three groups.
Conclusion: There is a significant incidence of motion sickness in patients being
transported by anbulance in a mountainous setting. Metoclopramide is superior to
diphenhydramine and placebo in the treatment of motion sickness in this
environment.
114
A Comparison of Out-of-Hospital Rapid Sequence
Intubation Success to Non-Paralyzed Patients
Felderman H, Walsh B, Yasbin P/Morristown Memorial Hospital, Morristown, NJ;
Atlantic Ambulance, Morristown, NJ
Study Objectives: Out-of-hospital intubation, and especially out-of-hospital rapid
sequence intubation (RSI), is a controversial procedure that is frequently debated in
the literature. Our paramedics intubate frequently, have regular educational updates,
and are evaluated routinely in cadaver labs. In order to fine-tune our educational
process, we sought to determine our paramedics’ baseline intubation skills and the
impact of RSI on success rates.
Methods: We retrospectively analyzed all patients in which intubation was
attempted by our ground and air units over a 23-month period. In order to determine
baseline procedural competence and the impact of RSI, we subdivided patients in to
three groups: those in cardiac arrest (CA), those with a pulse who underwent RSI
(RSI), and those with a pulse who did not receive RSI (I). We compared the group in
terms of “successful” intubation (⬍⫽ 2 attempts) and “overall” intubation (⬍⫽4
attempts) using a Chi-Square test with a Marasciullo correction for multiple
comparisons.
Results: Of the 751 patients with intubation attempts, 330 were in cardiac arrest,
196 received RSI, 225 did not receive RSI. In terms of “successful” intubations: 88%
of CA patients were intubated within 2 attempts, 90% of RSI patients were intubated
within 2 attempts, and 82% of I patients were intubated within 2 attempts. The
differences in “successful” intubation rates between these groups did not reach
statistical significance. In terms of “overall” intubation rates, there were a total of 687
Volume , .  : September 
Research Forum Abstracts
patients (91.5%) who were intubated out-of-hospitally: 94% of the CA group, 94%
of the RSI group and 85% of the I group. Patients in the CA and RSI groups were
significantly more likely to be intubated than those in the I group (p⬍0.05 for both
comparisons).
Conclusion: Although rates approached significance, we found no difference in
rates of “successful” intubation in the three groups. In terms of “overall” intubation
rates, paramedics have higher intubation rates in patients with a pulse when utilizing
RSI, and the success rate of RSI approaches that of patients in CA. This suggests that
RSI is an effective adjunct to intubation for patients with a pulse. Prospective,
outcome-based studies are needed to determine the true impact of RSI in our group
of paramedics.
115
The Predictive Value of Arrival With EMS
Felderman H, Walsh B, Shih S, Luk J, Sturm D/Morristown Memorial Hospital,
Morristown, NJ
Study Objectives: Estimating the severity of illness is a crucial part of the initial
triage in an emergency department. arrival with emergency medical services (EMS) is
considered to be associated with increased severity, although it is unproven to date.
We sought to determine the significance of mode of arrival in patients who present to
the emergency department.
Methods: A retrospective analysis of all patients seen in four emergency
departments between 11/1/04 and 10/31/06 was conducted. Patients were evaluated
with the following chief complaints: 1) All Diagnoses (AD), 2) Dyspnea (SOB), 3)
Abdominal Pain (AP), 4) Mood Disorders (MD), 5) Palpitations (HR), 6) Syncope
(S), and 7) Alcohol Abuse (AA). These patients were then subdivided into 20-year age
groups (0 –20, 21– 40, 41– 60, 61– 80, ⬎80). We used admission to the hospital as a
marker for severity of illness. We calculated the odds ratio (OR) and 95% confidence
intervals for admission to the hospital for those who arrived with EMS compared
with those who did not.
Results: Of the 231,219 patients in our database, 222,619 patients had delineated
modes of arrival; 50,700 arrived via EMS, 171,919 patients did not. Arrival by EMS
was associated with an increased rate of admission for AD: OR 4.9[4.8 –5.0], SOB:
OR 7.2[6.9 –7.7], AP: OR 2.4[2.1–2.6], and MD: OR 1.23[1.1–1.4]. These positive
associations were significant in all age groups. For HR, positive associations were
found in all age groups except 0 –20: OR 1.8[0.3–11.6], and ⬎80: OR 1.4[0.9 –2.2].
For S there were no significant associations when corrected for age. Interestingly, for
patient arriving with AA, arrival by EMS is a negative predictor of admission: OR
0.4[0.3– 0.5].
Conclusion: While arrival by EMS, in general, is associated with an increased rate
of admission, there are many important exceptions to this rule. This study suggests
that arrival by EMS should not be used alone to make triage decisions.
116
Postural Hypotension in the Elderly: Predictors for
Intervention
Chan W, Foo C/Tan Tock Seng Hospital, Singapore, Singapore, Singapore
Background: Postural hypotension in an elderly patient usually demands a search
for, and management of, reversible causes. To date, however, there are no studies
examining postural hypotension in elderly patients who present to the emergency
department (ED). This study aims to identify predictors for intervention in patients
with postural hypotension.
Study Objectives:
This study examines:
1. The characteristics of postural hypotension
2. The possible causes of postural hypotension
3. The factors that may predict the need for intervention
Methods: This is a retrospective study evaluating elderly patients aged 65-andabove who were found to have postural hypotension prior to discharge from a 24hour ED short stay ward (Emergency Diagnostic and Treatment Centre; EDTC)
from 1st April 2007 to 31st December 2008. Nursing home residents, patients with
severe cognitive or functional impairment, patients already on follow-up with a
geriatrician, and patients who refused geriatric assessment were excluded.
Patient demographics, characteristics of postural hypotension and the likely
causes were examined.
Through review of case records by an independent reviewer, patients who required
and benefited from intervention were identified and compared against those who did not,
to determine if there were any variables that predicted the need for intervention.
Volume , .  : September 
Results: Of the 869 patients aged 65 years and above who were admitted to
EDTC during the study period and received geriatric screening, 157 (18.1%) had
postural hypotension, of which 92 (58.6%) were female and 140 (89.2%) required
intervention. The mean age in the intervention group was 79.4, compared to 73.7 in
the non-intervention group (p⫽0.01). The intervention group had a lower mean
abbreviated mental test (AMT) score (7.4) when compared to the non-intervention
group (8.7; p⫽0.02).
With regards to the characteristics of postural hypotension, 145 (92.4%) had a
systolic blood pressure (SBP) drop of 20mmHg, 149 (94.9%) were detected in the
first minute of standing, 91 (63.6%) were reproducible, 75 (47.8%) were
symptomatic and 64 (40.8%) had a history of falls or near falls.
In 46.5% of cases, medications were found to be a contributor to postural
hypotension. Dehydration (28.0%), sepsis (26.1%) and diabetic autonomic
neuropathy (22.3%) were other common causes. 74 (47.1%) of postural hypotension
cases were multifactorial. An etiology was not found in 29 (18.5%) of cases.
We also found that postural hypotensive patients who were symptomatic (OR
3.3; 95% CI 1.0 to 10.8) and on 3 or more medications (OR 3.3; 95% CI 1.1 to 9.4)
were more likely to have received intervention.
Conclusions: Postural hypotension was found in 18.1% of elderly patients in the
EDTC. Medications, dehydration, sepsis and diabetes were common causes. The
majority required treatment and follow-up. Increased age, lower AMT score,
polypharmacy and being symptomatic were predictors for need for intervention.
117
Do HIV-Positive Patients With Severe Sepsis
Receive Adequate Initial Antibiotics in the
Emergency Department When Compared With HIVNegative Patients?
McGrath ME, Bullock HN, Whitney D/Boston Medical Center, Boston, MA
Study Objectives: To determine if HIV-positive (HIV⫹) patients with severe
sepsis received adequate initial antibiotics (abx) in the emergency department (ED)
compared to HIV-negative (HIV⫺) patients.
Methods: Retrospective observational study of HIV⫹ and HIV⫺ patients with
severe sepsis (2⫹ SIRS criteria) admitted to the ICU from an urban academic ED
over 18 months. HIV status was determined by review of ED and hospital records 6
months prior to presentation for CD4 counts and viral load. Patient characteristics,
mortality, and length of stay was compared between groups using Chi-square, Fisher’s
exact, and Wilcoxon rank sum tests. Cochran-Mantzel-Haenszel(CMH) test
calculated relative risk (RR) of infection. Adequacy of coverage was determined by
comparing initial abx ordered in the ED with sensitivities of pathogens cultured.
Results: 325 patients were included: 39 HIV⫹ and 286 HIV⫺. HIV⫹ patients
more often were younger (mean 47 yrs vs 62 yrs, p⬍0.001), black (59% vs 38%,
p⫽0.02), used drugs (28% vs 7%, p⫽0.001) and smoked (41% vs 11%, p⬍0.001).
No difference was found in length of hospital/ICU stay, MEDS score or mortality;
13% HIV⫹ patients died in hospital vs 18% HIV⫺ patients (p⫽0.41). Abx-resistant
pathogens were common overall (20% MRSA, 7% VRE). In HIV⫹ patients, 21/
24(88%) pathogens cultured were gram pos, 3/24(12%) gram neg. In HIV⫺ patients
122/208(59%) pathogens cultured were gram pos, 83/208(40%) gram neg, and 3/
208(1%) fungal (p⬍0.001). HIV⫺ patients had 3.2 times RR of infection by gram
neg pathogen than HIV⫹ patients (95%CI, 1.1–9.5). In HIV⫹ patients,
19/24(79%) pathogens were adequately covered by initial ED abx and 5/24(21%)
were not. In HIV⫺ patients, 148/208(71%) pathogens were adequately covered and
60/208(29%) were not. No difference was found in adequacy of abx coverage
between the groups (p⫽0.41).
Conclusion: We found no difference in adequacy of initial ED abx coverage,
length of stay, or hospital mortality of HIV⫹ patients with severe sepsis compared to
HIV⫺ patients. HIV⫹ patients had more gram pos infections and there was a high
prevalence of abx resistant pathogens overall.
118
External Site Testing of an Instrument to Predict
Endocarditis in Injection Drug Users With Fever
Romero K, Rodriguez R, Chiang W, Fortman J, Colucci A/University of California,
San Francisco, San Francisco, CA; Bellevue Hospital, New York City, NY
Study Objective: To externally test a previously derived decision instrument
(100% sensitivity and 44% specificity in prior study) for endocarditis prediction in
injection drug users (IDUs) admitted from the ED with fever.
Methods: Blinded to the prior instrument, an investigator used the same chart
Annals of Emergency Medicine S37
Research Forum Abstracts
abstraction tool to review ED and inpatient charts of all IDUs admitted to rule out
endocarditis at another hospital in 2006 – 07. Individual criteria screening
performance was determined. Classification tree analysis was used to derive optimal
combinations of predictive criteria and test the prior instrument.
Results: Of 75 IDUs admitted with fever, 6 (8%) were diagnosed with
endocarditis. Consistent with the previous study, criteria with the highest diagnostic
odds ratios (95% CIs) were prior endocarditis 6.5 (1.3, 33.9), pneumonia on chest
x-ray 5.3 (0.9, 31.1), lack of skin infection 4.9 (0.7, 32.6), hyponatremia 2.7 (0.4,
22.3), and murmur 2.6 (0.4, 14.8); WBC count and degree of fever again showed no
diagnostic utility, with diagnostic odds ratios of .2 (0.0, 1.5) and 0.7 (.1, 5.1).
Thrombocytopenia showed no diagnostic utility as well, with a diagnostic odds ratio
of 0.0 (.0, 0.2). The most sensitive combinations of criteria were pneumonia on chest
x-ray ⫹ lack of skin infection (100% sensitivity and 47% specificity) and lack of skin
infection ⫹ murmur (100% sensitivity and 39% specificity). The previously derived
instrument of thrombocytopenia ⫹ pneumonia on chest x-ray ⫹ absence of skin
infection predicted endocarditis with 100% sensitivity (63–100%) and 36%
specificity (33–36%).
Conclusions: The previously derived instrument for the prediction of
endocarditis in IDUs with fever retained high sensitivity and moderate specificity at
another site.
119
Diagnostic Testing and Site-of-Care Assigned to
608 Pneumonia Patients Admitted to the Hospital
After Evaluation at the Emergency Department
Ferre C, Llopis F, Jacob J, Juan A, Alonso G, Corbella X, Salazar A/Bellvitge
Universitary Hospital, L’Hospitalet de Llobregat, Spain; Sant Joan de Deu
Hospital, Sant Boi de Llobregat, Spain
Study Objectives: To review diagnostic testing procedures and site-of-care
assigned to community-acquired pneumonia (CAP) patients admitted to the hospital
after evaluation at the emergency department (ED).
Methods: Design: Descriptive and retrospective study. Setting: ED of a 960-bed
tertiary care teaching hospital in the metropolitan area of Barcelona, Spain. Period: a
total of 18 months from October 2005 to April 2007. Patients: All patients with CAP
according to clinical and radiological findings admitted to the hospital after
evaluation at the ED with exclusion of those admitted to the Intensive Care Unit and
patients with empyema, immunosuppression, renal failure requiring dialysis and HIV
infection. Data were collected for demographic variables, Fine and CURB-65 scores,
blood cultures (BC), urinary antigen tests (UAT), sputum culture (SC) and site-ofcare assigned either the ED Short-Stay Unit (EDSSU) or a general ward (pneumology
or infectious diseases unit).
Results: During the study period, 608 patients with CAP were admitted to the
hospital (general ward or EDSSU) after evaluation at the ED. Mean age was
70.7⫾SD 15, 391 male /217 female. Globally, 581 patients (95.5%) had at least one
diagnostic test performed and 140 (23%) had 3 of them (blood culture, UAT and
sputum culture). From 202 sputum samples, 112 (55.4%) yielded a positive result,
blood cultures were positive in 65 cases (13.4%) out of 484 and 517 UAT gave a
positive result in 262 cases (50.7%). A presumed or confirmed microbiological
diagnosis was achieved in 335 cases (55.1%). Regarding Fine score, 121 patients
(19.9%) were I–II, 188 (30.9%) III, 255 (41.9%) IV and 40 (6.5%) V. When
considered CURB-65, 96 patients (15.8%) scored 0, 225 (37%) 1, 211 (34.7%) 2,
65 (10.2%) 3 and 7 (1.1%) 4 –5. In total 419 (69%) of patients were admitted to a
general ward and 189 (31%) to the EDSSU. Patients assigned to the EDSSU were
older (mean age 77 vs 67.9), around 3⁄4 of cases with lower scores (Fine I–II and
CURB 0 –1) were admitted to a general ward and one third of patients scored Fine
III–IV or CURB 2–3 were admitted to the EDSSU.
Conclusion:
1. In our experience, there is a great variability in diagnostic testing in
community-acquired pneumonia.
2. Implementation of local guidelines considering cost-benefit ratio for diagnostic
strategy may be needed.
3. A significant number of patients, although suposed to be eligible for treatment
in an outpatient basis according to Fine and CURB-65 scores, were admitted to the
hospital.
4. The proportion of patients admitted to the ED Short-Stay Unit increased with
higher Fine or CURB-65 scores.
S38 Annals of Emergency Medicine
120
How Many Methicillin-Resistant Staphylococeus
Aureus Infections Are Missed Upon Admission to
the Emergency Department?
Akpunonu P, Ruggiero L, Pearce A, Snow J, Brickman K/University of Toledo
College of Medicine, Toledo, OH
Study Objective: The objective of the study was to assess the carriage rates of
methicillin-resistant Staphylococcus aureus (MRSA) at different body sites.
Background: MRSA is a significant cause of morbidity and mortality. Knowledge
of frequently colonized sites may prevent nosocomial and post-procedural MRSA
infection. Current practice focuses on the internal nares as the primary source. This
study suggests that addition sites should be screened.
Methods: This prospective case cohort study was conducted at a university
medical center. The internal nares, axilla and groin of eligble emergency department
patients and visitors were cultured bilaterally. Eligible participants were adults with
decisional capacity and minors who assented with parental or guardian consent.
Swabs were plated on BBL CHROMagar MRSA plates. Agar plates were observed at
24 and 48 hours for growth. Suspected MRSA colonies were biochemically tested to
confirm their identity.
Results: Among 93 participants, 82% cultured negative for MRSA, 16% had
MRSA colonization at one site, while 2% cultured were positive at two sites. Of the
positive cultures the nares(48%), groin (47%) and axilla (5%) were the most
common sites of colonization. Approximately 53% of patients who cultured positive
at least one site were positive in the groin, while the remaining 47% cultured positive
from the internal nares. No participants cultured positive from all three sites.
Conclusion: The greatest proportions of ED patients were positive at the internal
nares and groin respectively (48%, 47%). The internal nares and groin are likely sites
of MRSA colonization but with minimal overlap. Based on this study nasal swabs
alone do not provide a clear picture of MRSA prevalence in our patient population.
Axillary swabbing is not an effective means of detecting MRSA carriage in our
population.
121
Prognosis of Urosepsis Patients Who Are Treated
by Inappropriate Initial Antimicrobial Therapy in the
Emergency Department
Imamura T, Ohta B, Tanaka E, Branch J/Shonan Kamakura General Hospital,
Kamakura, Japan
Study Objectives: Urosepsis is known to have a better prognosis than other types
of sepsis. However, it is not clear whether there is an increase in adverse outcome if
there is erroneous initial antimicrobial therapy administration followed later, by a
change to appropriate therapy after cultures results become available. We categorized
patients with urosepsis into two groups with regard to appropriate and inappropriate
initial antibiotic choice and measured the outcome, which included the difference of
mortality rate and cost of hospitalization.
Methods: We retrospectively analyzed all patients diagnosed with urinary tract
infection and bacteremia in our community general hospital from January 2008 to
December 2008 inclusive. Patients were included if they met the criteria for systemic
inflammatory response syndrome and positive blood cultures. Urinary tract infection
with bacteremia was defined by the identification of the identical organism in both
the blood and urine cultures. Bacterial isolation and subsequent antibiotic
susceptibilities were determined using an automatic system (VITEK®2). Mortality
rate and cost of hospitalization were compared using Wilcoxon test.
Results: A total of 105 patients met the criteria for urinary tract infection and
bacteremia. The mean age was 76.09 ⫾ 2.44 years old and 69% of the study sample
were female. Thirty patients (28.6%) were both bedridden and fecally incontinent.
Isolated pathogens included 94 (89.5%) gram negative bacilli, 11 (10.5%) gram
positive cocci. Thirty-eight patients had a history of recent hospitalization, 29 came
from a nursing home and 31 had a history of antibiotics use within the previous 3
months.
Of the 105 patients, Group A composed 85 (81%) appropriately treated patients
and Group B composed 20 (19%) patients who received inappropriate initial therapy.
A total of 91 antibiotics were initially administered to Group A patients, (37.6%
ceftriaxone, 34.1% cefotiam, 10.5% carbapenem, 7.1% cefmetazole, 3.5%
vancomycin 3.5%, ampicillin, 2.4% ampicillin/sulbactam) and a total of 23
antibiotics were initially administered to Group B patients (35% ceftriaxone, 20%
cefotiam, 15% cefmetazole, 10% ampicillin/sulbactam, 5% ampicillin, 5%
vancomycin, 0% carbapenem). All of the Group B patients had their antimicrobial
therapy changed after culture results were obtained (43.4 ⫾ 6.7 hours later).
Volume , .  : September 
Research Forum Abstracts
The 12-week mortality rate of Group A was 13 of 85 (15%) and Group B was 2
of 20 (10%) respectively, (P⫽0.56). The median total cost of hospitalization for
Group A was $ 3916 and for Group B was $ 7151 (1$⫽100 JPY) respectively
(P⫽0.006).
Conclusion: Patients with urosepsis who were given inappropriate initial
antimicrobial therapy in the emergency department had a similar 12-week mortality
rate compared to those patients receiving correct therapy. However, the cost of
hospitalization for inappropriate treatment increased significantly. The difference in
cost is explained by the fact that patients who were administered inappropriate
antibiotics had more severe medical problems and were bedridden, which are risks for
developing multi-resistant organism infection. The increased cost was positively
correlated to longer inpatient admission.
122
Vancomycin Minimum Inhibitory Concentration
Values >1.0 ␮g/mL Do Not Predict a Worse
Clinical Outcome in Non-ICU, Adult, MethicillinResistant Staphylococus Aureus-Positive Patients
Virk PS, Berkeley RP, King J, Saripella S, Abrahamian FM, Slattery DE/University
of Nevada School of Medicine, Las Vegas, NV; University Medical Center of
Southern Nevada, Las Vegas, NV; University of Nevada, Las Vegas, NV; Olive
View-UCLA Medical Center, Sylmar, CA
Background: Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for
an increasing number of infections worldwide. Heightened vancomycin resistance of
MRSA may predict a more virulent infection.
Study Objective: To determine whether vancomycin minimum inhibitory
concentration (MIC values) ⬎1.0 ␮g/mL (MIC⬎1) in non-ICU, adult, MRSApositive patients predict a worse clinical outcome as compared with MRSA-positive
isolates with vancomycin MIC values ⱕ1.0 ␮g/mL (MICⱕ1).
Methods: IRB-approved, structured chart review over a 12-month period (7/1/
07–7/1/08). Setting: Academic, urban, emergency department (ED) with 70,000
annual visits. Inclusion criteria: Adult patients who received vancomycin in the ED,
admitted, and had a MRSA-positive source identified from ED-collected cultures.
ICU admissions were excluded. Trained abstractors, who underwent periodic
monitoring, utilized a standardized data collection tool to extract elements from an
electronic records system. 25% of the data were adjudicated by the lead investigator.
Baseline patient demographics, co-morbidities, laboratory values, in-hospital
antibiotic profiles, and clinical outcomes were captured. The primary outcome
measure was a composite triple-endpoint: development of severe sepsis/septic shock
after admission; upgrade to ICU; or death. Our secondary measure was hospital
length of stay (LOS). Data were analyzed as appropriate using NCSS statistical
software. We utilized Chi-square and calculated 95% confidence intervals for
differences and set statistical significance at p⬍0.05.
Results: Sixty-five of 115 identified MRSA-positive patients met inclusion criteria and
comprised our study cohort. 36/65 (55%) had MIC values ⱕ1, and 29/65 (45%) had
MIC values ⬎1. The mean (⫾SEM) age was 51.3 (1.8) years, and 21/65 (32%) were
female. MRSA-positive culture sources were wound 42 (65%), blood 16 (25%), urine 4
(6%), and sputum 3 (5%). There were no statistical differences between baseline
demographics, prevalence of comorbidities, or lab values (lactate, peak WBC, peak
creatinine, and vancomycin trough levels) between the two groups. The MICⱕ1 group
had a higher prevalence of wounds as the source, 27/36 (75%) than the MIC⬎1 group,
15/29 (65%); difference ⫽ 0.41 (0.19,0.63). Primary outcome: We found no difference
in the prevalence of the triple-endpoint between the two groups: MICⱕ1 ⫽ 24/36
(66.7%) vs. MIC⬎1.0 ⫽ 22/29 (75.9%); difference (95% CI) ⫽ ⫺0.092 (⫺0.09,0.16);
⫼2 ⫽ 0.66, p ⫽ 0.58. The mean (95% CI) hospital LOS was not different between the
two groups: MICⱕ1 ⫽ 12.2 (8.5,16.0) days vs. MIC⬎1 ⫽ 12.3 (5.7,18.8) days, p ⫽
0.99. Limitations: Our study is limited by the small size, the inherent limitations of
retrospective data collection, and by the fact that the abstractors were not blinded to the
study hypothesis.
Conclusion: In our cohort, vancomycin MIC values ⬎1 did not predict a worse
clinical outcome.
123
The Significance of Lactate Clearance Rate as a
Predictor of Organ Failure
Cho YD, Hong Y, Choi S, Lee S, Moon S, Lee S, Kim J/Korea University Medical
Center, Seoul, Republic of Korea
Study Objectives: Serum lactate level is one of many variables with prognostic
values in sepsis and septic shock. Its correlation to mortality rate and the duration of
Volume , .  : September 
admission in patients with sepsis had been acknowledged to a certain extent, but its
value as a predictor of organ failure - the main cause of death, had not yet been
examined in detail.
With increasing emphasis of role of lactate in sepsis, a “lactate clearance rate” is
recently being proposed by many as an effective predictor of organ failure. We thus
attempted to estimate the role of lactate clearance rate (in contrast to classical serum
lactate level measurements), in predicting the mortality rate, duration of admission,
and organ failure in patients with sepsis.
Methods: Fifty-nine patients over the age of 18, who presented to the emergency
department of Korea University Medical Center during January 2005 to June 2006,
and were consequently diagnosed with sepsis and septic shock, were the major
candidiates in this study. Serum lactate level was measured initially upon presentation
and once more 4hours later. Lactate clearance rate, defined as [(initial lactate-lactate
level 4hrs later)/initial lactate*100] was further determined, and patients were sorted
into 2 groups, either low or high lactate group, based on initial serum lactate level and
lactate clearance rate (4mmol/L and 10% as the cutoff value, respectively). Organ
failure as described by the sepsis-related organ failure assessment score, duration of
ICU stay, duration of admission, and mortality rates were compared for both groups.
The data was processed with Student t-test and kai-square test using SPSS 12.0.
Results: In relevance to the initial serum lactate level, whereas a mortality rate of
38% and shorter duration of ICU stay was observed in the low lactate group, a
mortality rate of 66% and longer duration of ICU stay was observed in the high
lactate group, revealing a statistically significant difference in the 2 groups.
Also, in the case of initial lactate clearance, a mortality rate of 71%, and ICU stay
of 14 days was observed in the low lactate clearance group, which was significantly
higher than 29% and 7 days respectively observed in the high lactate clearance group,
thus suggesting a worse prognosis.
Furthermore, concerning organ failure, SOFA scores calculated at 24, 48, 72hrs
after admission revealed correlation of initial lactate level and lactate clearance rate,
suggesting significant potency in predicting the severity of multiple organ failure
(p⬍0.05).
In comparing the relevance to various organ failures, total number of organ
failure was summed up 24, 48, 72hrs after admission, and lactate clearance rate was
found to be statistically significantly related to renal failure (p⬍0.05), hepatic failure
(p⬍0.05), and failure of other organs (p⬍0.05). Initial serum lactate levels alone
failed to demonstate any significant relation to each organ failure.
Conclusion: Initial serum lactate level may have some implication in predicting
the overall development of multiple organ failure and its prognosis, but was found to
be limited in predicting the likelihood or outcome of each specific organ failure.
Lactate clearance rate, however, may have a role not only in predicting the mortality
rate and duration of ICU stay, but also in predicting the likelihood or outcome of
each specified organ failure.
124
Rapid HIV Testing in a Large Urban Emergency
Department
Lowman E, Harper JB, Livak M, Jain S, Rush A, Kessler A, Purin-Shem-Tov Y,
Rumoro DP, Kessler HA/Rush University, Chicago, IL
Background: In 2006 the CDC recommended universal HIV testing for patients
13– 64 in all health care settings where the seroprevalence is greater than 0.1%. They
noted several advantages of using rapid HIV testing; however, recent studies have
raised concerns of false positives using rapid HIV tests in populations with a low
seroprevalence.
Methods: A serosurvey using a convenience sample of 1348 patients seen in our
emergency department (ED) were offered rapid HIV 1/2 testing (OraQuick
ADVANCE, Bethlehem, PA) using an oral mucosal swab beginning August 13,
2008. Subjects with a preliminary positive result were told of their preliminary results
and blood was obtained for a confirmatory Western blot. Subjects declining
participation were asked to complete an opt-out survey.
Results: 1000 patients were tested. 12 had positive results, all but 1 were
previously known to have serologically confirmed HIV infection. 988 patients tested
negative. Of these 335 (33.3%) had never been tested (640 had a prior history of a
negative HIV test). No false positives results occurred. 98.7% received the results of
their preliminary HIV test, including 100% of those who tested positive. All 348
subjects who declined testing completed the opt-out survey. Most cited either a recent
negative HIV test (160/348) or a belief they were at low risk for HIV (65/348) as
their reason for declining testing. A minority cited a concern regarding their privacy
(11/348) or that the test might delay their treatment (7/348). The remainder (93/
348) declined to give a reason for not accepting the test.
Annals of Emergency Medicine S39
Research Forum Abstracts
Conclusions: There were no false positive rapid HIV results using oral mucosa
swabs. The seroprevalence rate suggests we should adopt routine universal testing in
this setting. The acceptance rate of rapid HIV testing in our patient population was
high, as was the percentage of patients who received their results. In our setting the
rapid HIV test has performed well. Reasons for the better performance in our study
compared to other recent reports requires further investigation.
125
Trauma Care Access for Road Traffic Injuries in
Hanoi City
Nagata T, Kimura A/Himeno Hospital, Hirokawa-city, Japan; International
Medical Center of Japan, Tokyo, Japan
Background: Road traffic injury (RTI) is the leading cause of death in Vietnam
now. The economic growth of Vietnam has recently accelerated in the last ten years;
however, reducing the number of RTIs is difficult despite the varieties of effort for
injury prevention in Vietnam. The aim of this research is to understand
epidemiological characteristics of RTIs in Hanoi City and evaluate the trauma care
access by applying a geographical analysis.
Methods: A cross-sectional study by using Hanoi City police reports in 2006. In
addition to descriptive epidemiology of RTIs that occurred in Hanoi City, geographic
patterns will be investigated by applying geographical information system (GIS)
software. The association of RTIs distribution in Hanoi City and location of ten
major hospitals with capability for trauma care is analyzed by geographical
information system.
Results: 1271 cases were mapped in Hanoi City. About 40% of RTIs occur
among people aged 20 –29 years old. 78% of RTIs were associated with motorcycles.
RTIs in males occurred significantly more than in females in all age groups (pvalue⬍0.05). There were two high peaks of occurrence time of RTIs (14:00 –15:59
and 20:00 –23:59) In Kernel density estimation, “hot spots” for road traffic injuries/
fatalities in the city area and main highways were found. Two major trauma hospitals
(Viet Doc hospital and Saint Paul Municipal hospital) are located in the city area, and
about 50% of RTIs occurred within 5 km from these two trauma hospitals. RTIs
occurring along the two south-north highways are not in the range of easy access to
the hospitals.
Conclusions: The difference of geographical patterns of RTIs in Hanoi City by
sex, time, and injury mechanism will be a clue for injury prevention. To provide the
trauma care for the RTIs occurring in the two south-north highways, a new hospital
should be built or an emergency medical service system should be established.
126
Road Traffic Injury Hot Spots in Yerevan, Armenia
Lynch CA, Crape B, Tadevosyan M, Lyman T, Chekijian S/
Yale School of Medicine, New Haven, CT; American University of Armenia,
Yerevan, Armenia; Erebouni Medical Center, Yerevan, Armenia
Study Objectives: To identify locations and characteristics of road traffic injuries
within the city of Yerevan, Armenia.
Methods: A retrospective review of out-of-hospital records from the city of
Yerevan identified incident location, injury type and severity, out-of-hospital
treatment, and transport information. Locations for ambulance substations, hospitals
and road traffic injuries were then visited; global positioning (GPS) data, car and
pedestrian densities were collected between 12 noon and 6 PM on regular business
days. Data was entered into ARCGIS 9.2 software/ Global Information System (GIS)
for spatial analysis. Road traffic injury characteristics were analyzed for frequencies.
Results: To date, 63 patient records from 52 accidents had 66% male patients
with the average age of 39. They showed a death on scene rate of 3%, refusal of
hospital transfer rate of 20% and refusal of out-of-hospital care of 3%. Total call
time, or time from dispatcher receiving a call to the ambulance becoming available,
ranged from 14 minutes to 3 hours 13 minutes with an average of 46 minutes. Time
to locate the scene averaged 2 minutes while time to gain access to the patient
averaged 8 minutes. Total treatment and transport time averaged 22 minutes.
Localization of road traffic injuries reveled a significant hot spot of road traffic injuries
with 7 of 63 injured patients at the same location.
Conclusion: Preliminary data has revealed a road traffic injury hotspot where a
local park entrance is around a bend from a heavily trafficked, high-speed road.
Although a recent underground pedestrian walkway has been built pedestrians fail to
use the walkway. Based on this localization of road traffic injury hotspot,
interventions to protect pedestrians and drivers are planned. Continued localization
of road traffic can be used to monitor success of planned interventions.
S40 Annals of Emergency Medicine
127
Comparison of Acidosis Markers Associated With
Law Enforcement Applications of Force
Ho JD, Dawes DM, Lundin EJ, Miner JR/Hennepin County Medical Center,
Minneapolis, MN; University of Louisville, Louisville, KY
Study Objective: Force applied by Law Enforcement Authorities (LEA) has
inherent risk for injury and sometimes death. Occasionally, unexpected sudden death
(SD) occurs. A hypothesized cause of SD is a worsening acidosis leading to a
cardiopulmonary arrest. It is not clear if this acidosis is due to volitional suspect
behaviors or to LEA tools/tactics. Our objective is to compare volitional suspect
behaviors and commonly used LEA tools/tactics to determine which, if any, cause the
highest levels of acidosis.
Methods: This was a prospective evaluation of human volunteers in a LEA
training class. Randomization to 1 of 5 study arms occurred: 1. Maximal “heavy bag”
exertion x 45 sec (simulating suspect resistance) 2. 10 sec TASER® X26 application
3. Full face exposure to Oleoresin Capsicum (OC) spray 4. 150 meter sprint ⫹
scaling a 4 foot wall (simulating suspect fleeing) 5. 40 yard flee ⫹ 20 sec fight with a
police K9.
Volunteers had venous sampling before and after their events. Sampling
continued at 2-minute intervals until 12-minutes post event. Values for pH and
Lactate were determined and compared between study arms using k-sample equality
of medians tests.
Results: Sixty-two volunteers enrolled. The median age was 35 (range 19 to 67),
85.5% male, median BMI 27.8 (range 19.1 to 44.1). There was no difference
between age, sex, or BMI between the groups.
The median baseline pH was 7.36 (range 7.28 to 7.44) with no difference
between the groups (p⫽0.23). The median post exposure pH for group 1 was 7.01
(range 6.94 to 7.18, IQR 6.99 to 7.05), for group 2 was 7.29 (range 7.24 to 7.35,
IQR 7.26 to 7.33), for group 3 was 7.37 (range 7.33 to 7.40, IQR 7.38 to 7.39) for
group 4 was 7.16 (range 7.05 to 7.31, IQR 7.13 to 7.31) and for group 5 was 7.26
(range 7.30 to 7.40, IQR 7.22 to 7.31)(p⬍0.001). These differences persisted over
the subsequent 6 measured time points.
The median baseline lactate was 1.15 (range 0.61 to 3.55, IQR 0.75 to 2.35)
with no difference between the groups (p⫽0.07). Median post exposure lactate for
group 1 was 14.71 (range 8.9 to 18.7, IQR 13.7 to 17.40, for group 2 was 5.49
(range 1.3 to 7.2, IQR 4.3 to 5.9), for group 3 was 1.39 (range 0.6 to 2.4, IQR 1.3 to
1.7), for group 4 was 10.98 (range 3.3 to 14.6, IQR 7.4 to 13.2) and for group 5 was
5.01 (range 1.5 to 9.6, IQR 3.5 to 7.0)(p⬍0.001). These differences persisted over
the subsequent 6 measured time points.
Conclusion: The exertional groups of heavy bag and sprint had a lower pH and
higher lactate after the exposure than the other groups. The painful exposures of the
TASER and the OC spray had higher pH and lower lactate than the other groups.
Volitional behaviors of resistance and fleeing induced the most profound levels of
acidosis. Measured LEA tools/tactics did not induce acidosis to the same levels as
volitional subject behavior. This work represents the first known study to evaluate
acidosis that may be associated with LEA applications of force.
128
Radiation Exposure in Emergency Physicians
Working in an Urban Emergency Department: A
Prospective Cohort Study
Gottesman B, Gutman A, Lindsell CJ, Larrabee H/University of Cincinnati
College of Medicine, Cincinnati, OH; Unviersity of Cincinnati College of Medicine,
Cincinnati, OH
Study Objectives: The National Council on Radiation Protection (NCRP) has
established limits on health care associated occupational exposures to radiation of
5000 mrem/year. While prior studies suggest that emergency physicians were not
exposed over this limit, their relevance to contemporary practice is unknown. Due to
increased radiographic imaging in the emergency department (ED), we hypothesized
that resident and attending emergency physicians are currently exposed to radiation
levels above the acceptable limits for health care workers.
Methods: This prospective cohort study was conducted at an urban, academic,
level 1 trauma center ED; annual census of ⬃85,000 patients. Thermoluminescent
dosimeter (TLD) radiation badges were placed on the torso and ring finger of all
resident and attending physicians staffing the ED during May 2008; investigators
were present at every shift change to ensure placement of badges and rings. In
addition, TLD badges were affixed to each of eight portable phones that are carried
by physicians 24 hours a day. At the end of the study period, torso and extremity
TLD badges were analyzed to obtain mrem exposure doses for each subject.
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Research Forum Abstracts
Results: There were 41 resident and 34 attending physicians enrolled. Residents
worked a median of 94 hours (range 24 –186) and attendings worked a median of 54
hours (range 12–162) during the study period. Compliance for physician badge
wearing was 99%, for physician ring wearing was 98%, and for phone wearing was
100%. Two subjects had detectable levels of radiation on their torso TLDs of four
and one mrem respectively. One phone TLD badge had a detectable level of radiation
of one mrem. No other TLD indicated any detectable radiation exposure. The annual
extrapolated exposure for the subject with the highest radiation level would have been
48mrem, well below the 5000 mrem exposure limit for health care workers.
Conclusion: Emergency physicians working in an urban, academic, level 1
trauma center ED do not appear to be at risk of exceeding the NCRP dose limits for
ionizing radiation exposure to their torso or extremities.
129
Industrial Accidents: An Epidemiological Profile of
866 Emergency Admissions in a Tertiary Care
Teaching Hospital, S. India
Banala SR, Cattamanchi S, Trichur RV/Sri Ramchandra Medical College &
Research Institute, Chennai, India
Study Objectives:
● To study epidemiological profile of industrial accidents registered in emergency
department.
● To find the annual overall rate of ED visits following industrial accidents.
● To identify population at risk & enumerate preventable aetiological factors
from industrial accidents.
Methods: A prospective, descriptive analytical study done in the emergency
department of a tertiary care university hospital in Chennai, India, from 1st
September 2007 to 31st August 2008. A pre-formatted questionnaire used as
instrument. Consecutive sampling technique employed. Data on demographics,
clinical and disability-adjusted life years were collected and analyzed using done using
SPSS ver. 15.
Inclusion criteria: All injured patients attending ED with accidental industrial
injuries.
Exclusion criteria: Old injuries, and injuries sustained while not at work or in the
workplace.
Results: There were 866 patients, 3.61% of ED visits after an industrial accident
in the study period. Majority of these patients (49%) were young adults of the age
group 20 –29 (Mean age ⫽ 29.2 years; SD⫽11.1). Male predominance (92%) was
observed. Of these, 31% were injured at large scale industries, 29% at small scale
industries, and 21% at construction site. Among them 19% were permanent workers,
31% contractual workers, and 39% daily laborers. Crush injury (33%) is main
mechanism, injury due to fall 21%, and 4% due to explosion. About 19% sustained
complete amputation of a limb and 25% sustained partial amputation.
Trauma team activated for 16 patients (1.84%). Incidences of mass casualty
activated 2 times in ED with a total of 23 patients (2.6%). Mean duration of stay in
ED was 5.31 ⫾ 3.67 hours. Only 19% wore protective gear during injury. A total of
19,386 DALYs lost. A total of 155 patients were discharged AMA, 346 admitted to
wards, and 285 discharged from ED. Death rate of 1.1% recorded.
Conclusion: The studies gave us a quantitative insight into burden on ED and on
society and necessitate development of a good quality out-of-hospital care and
implement prevention measures like strict use of helmets, gloves and restrain belts
while at work. It also gives us scope for societal education on first aid and injury
prevention directed at industrial workers. It also highlights need for proper, effective
rehabilitation program to decrease burden on the society.
130
131
Abstract Withdrawn
Impact of Rapid Streptococcal Test on Antibiotic
Use in a Pediatric Emergency Department
streptococcal tests for streptococcal pharyngitis have made diagnosis simpler and
reduced the use of antibiotics. Overuse of antibiotics leads to drug-resistant bacterial
strains. Reducing the number of antibiotic prescriptions provided for upper
respiratory infections has been recommended as a way to limit bacterial resistance.
Study Objective: To assess the impact of rapid streptococcal tests (RST) on the
antibiotic prescriptions in children with pharyngitis in the emergency department.
Methods: A retrospective study from September 2005–September 2007 of all
children (3 to 18 years) presenting to the pediatric emergency department with sore
throat as the chief complaint, or suspected clinically to have acute pharyngitis, and
had rapid streptococcal test performed. Patients with negative rapid strep test have
culture performed. The information in patients with the diagnosis of pharyngitis was
also collected in a two-year control period prior to the availability of the test. Patients
with negative rapid strep test had culture performed. In addition, the antibiotic
prescription for these patients was also recorded.
Results: A total of 8280 patients were included in the study. Throat culture
results of 1723 patients were reviewed in the pre-rapid phase. During the post rapid
phase, 6,557 children underwent rapid strep testing. The RST results were positive
for 1474 children (22.5 %), and negative in 5,083 patients (77.5%). Rapid strep
testing was associated with a lower antibiotic prescription rate for children with
pharyngitis (41.38% treated in pre-rapid phase vs. 22.45% in post-rapid phase; P
⬍.001).
Conclusions: The availability of RST could substantially reduce the unnecessary
prescription of antibiotics. This study supports screening of all children with
pharyngitis by performing an RST to guide decisionmaking for antibiotic
administration. This strategy has a significant impact in reducing the antibiotic
prescription rate to almost 50%.
132
Obesity in Children
Chohan JK, Singer AJ/Stony Brook University, Stony Brook, NY
Study Objectives: Compare the characteristics of pediatric patients by weight
categories to see if obesity is associated with outcome.
Methods: Study Design: Observational retrospective chart review. Setting:
Academic, suburban emergency department, annual census 70,000. Subjects: ED
pediatric patients 2–17 years of age with recorded height and weight in 2007.
Measures: Height and weight were used to calculate body mass index (BMI); age-sex
specific BMI percentile charts were used to classify patients into 4 weight categories;
outcomes were admission and hospital length of stay (LOS). Analysis: Univariate
comparisons, logistic/linear regression for multivariate analysis.
Results: 6,304 pediatric visits during the study period. Mean age was 10.2 (sd
4.9), 53% male, 76% white. 12% were admitted. 6.9% were underweight, 16.8%
were at risk of overweight and 18.4% were overweight. Fewer males were in the
healthy weight range than females (54% vs 63%, diff⫽9%, CI 6 –11). Underweight
patients were younger (6.9 CI 5.9 – 6.7) compared to other weight categories (mean
ages 10.5, 11.4, 9.7 by increasing weight, p ⬍.001). Patients outside of the healthy
range (both under and over) were more likely to be admitted (47% vs 41%,
diff⫽6%, CI 2–10). In multivariate analysis sex, age and obesity class were all
associated with admission: Males more likely to be admitted than females (OR 1.2,
CI 1.02–1.40), younger more likely than older (OR 0.98 per year, CI 0.96 – 0.99),
and healthy weight range less likely than overweight class (OR 0.80, CI 0.65– 0.96).
Mean LOS for admitted patients was 5.1 (sd 17.2); underweight patients had the
shortest mean LOS (2.0 vs 4.1, 8.3, 6.1 for the other weight classes, p⫽.04). Males
had a higher LOS (6.0 vs 3.7, diff⫽2.3, CI 0.1– 4.5), and there was no association of
age with LOS. In multiple regression, only obesity class remained statistically
associated with LOS.
Conclusion: Admission and hospital length of stay are associated with unhealthy
weight in pediatric patients, even after adjusting for demographic factors.
133
Emergency Department Blood Cultures Have
Limited Usefulness in the Management of Children
Hospitalized for Community-Acquired Pneumonia
Waseem M, Ayanruoh S, Humphrey A, Reynolds T/Lincoln Hospital, Bronx, NY;
Lincoln Medical & Mental Health Center, Bronx, NY
Davis V, Gupta P, Monroe K/University of Alabama at Birmingham, Birmingham,
AL
Background: Acute pharyngitis is commonly seen in children. Group A beta
hemolytic Streptococcus (GABHS) is the most common bacterial cause of acute
pharyngitis, but accounts for approximately 15% to 30% of cases in children. Rapid
Study Objectives: Community-acquired pneumonia (CAP) is a frequent cause of
hospitalization in children. The Joint Commission mandates obtaining two sets of
blood cultures before treating hospitalized adult CAP patients in effort to identify the
Volume , .  : September 
Annals of Emergency Medicine S41
Research Forum Abstracts
pathogens and narrow the spectrum of antibiotic coverage. Many practitioners
routinely obtain blood cultures in children hospitalized for CAP. However, since the
introduction of Prevnar, limited data exists on the clinical value of blood cultures and
pneumonia. The purpose of this study was to investigate the utility of blood cultures
obtained at admission in the management of pediatric CAP.
Methods: We conducted a retrospective chart review of patients aged 3 months to 18
years with a discharge diagnosis of pneumonia who were admitted to an urban tertiary
care children’s hospital from 2004 to 2007. Study protocol was approved by the IRB.
Cases were excluded for sickle cell (55); immunodeficiency including cancer and
transplant (77); central venous access (7); tracheostomy (32); hospitalized in the last 2
weeks (44); in-patient transfer (80); or incorrect diagnosis or incomplete chart (30).
Results: 988 cases were identified. After exclusions, 663 cases were included in
the study. 473 (71%) of these children had a blood culture obtained at admission. Of
these cultures, 442 (93.5%) were negative. Contaminates grew in 17 patients (3.6%)
while pathogens grew in 14 (3.0%). Streptococcus pneumoniae (n⫽10, 71%) was the
most common pathogen. There was no difference in the 3 groups with respect to age,
race, length of stay, or initial temperature. The presence of an effusion on admission
was likely to predict a positive culture (p⫽0.02). Of the 473 blood cultures obtained,
culture results influenced antibiotic selection in only 2 cases (⬍0.5%).
Conclusion: Our data indicate that bacteremic pneumonia is rare in children.
The presence of effusion at the time of admission increases the likelihood of
bacteremia. Cultures were unlikely to influence therapy and appear to have limited
utility in the management of children admitted to the hospital for CAP. Routinely
obtaining blood cultures for pediatric patients cannot be recommended.
134
Does a Novel Abscess Drainage Technique Differ in
Procedural Times and Times to Discharge From
Traditional Incision and Drainage at a Level I
Pediatric Trauma Center?
Ladde J, Wan M, Baker S, Rodgers N, Carballo N, Papa L/Orlando Regional
Medical Center, Orlando, FL
Study Objective: The LOOP is a novel incision and drainage (I&D) technique
for pediatric skin abscesses that uses 2 polar incisions and a LOOP drain through the
abscess pocket that has lower failure rates than standard I&D. This study compared
length of procedure and time to discharge between the LOOP and standard I&D in
pediatric patients requiring sedation.
Methods: This retrospective cohort of pediatric patients age birth to 18 years was
conducted at a Level I pediatric trauma emergency department (ED). Patients with
ICD-9 codes for skin abscesses from January to December 2007 were identified. Over
900 charts were reviewed by three different emergency physicians using a standard
data extraction form. Inter-rater reliability of extraction was assessed in 100% of
charts. Inclusion criteria were patients presenting to the ED with chief complaint of
skin abscess who had their I&D in the ED under sedation. Exclusion criteria
included surgical debridement and facial, hand, and foot abscesses. The main
outcomes were length of procedure (minutes) and ED length of stay (hours).
Results: Over a 1-year period there were 233 pediatric abscesses identified. Of the
79 who received sedation; 50 (63%) were treated with LOOP technique and 29
(37%) with standard I&D. The overall mean age of patients was 3.3 yrs (range 5mo18yrs), with 3.1 yrs in the LOOP group and 3.7 yrs in the standard group (P⫽0.50).
Females comprised 56% of the LOOP group and 62% of the standard group
(P⫽0.64). Mean procedure time in the LOOP versus standard I&D group was 12.4
min (SD6.1) and 14.4 min (SD6.8) respectively (P⫹0.15). Mean ED length of stay
in the LOOP versus standard I&D group was 4.5 hrs (SD 2.25) versus 4.25 hrs
(SD2.2) respectively (P⫹0.61).
Conclusion: There were no significant differences in procedure time or length of
stay in the LOOP and the standard I&D groups. This novel procedure shows
promise as an alternative technique in the management of skin abscesses in pediatric
ED patients.
135
Provider Compliance With the Food and Drug
Administration Recommendation to Avoid the Use
of Over the Counter (Nonprescription) Cough and
Cold Medications in Children Under Two Years Old
Goo R, Miller M, Coon TP/Tripler Army Medical Center, Honolulu, HI
Study Objectives: On January 17, 2007 the Food and Drug Administration
(FDA) issued a public health advisory recommending that the use of over-the-counter
S42 Annals of Emergency Medicine
(OTC) cough and cold medications be avoided in children under the age of two years
old. We performed a system-wide quality assurance project to evaluate the
compliance of prescribing health care providers with this public health advisory. Our
primary focus was upon ensuring compliance within our hosting department, the
department of emergency medicine (ED).
Methods: Outpatient prescription information for prescriptions written and
dispensed to patients under the age of 2 years old between 01Feb2007 to
31July2007 and 01Feb2008 and 31July2008 were collected and compiled from
the Department of Defense (DoD) order processing database. Following provider
visits within our system, a majority of typically OTC medications are dispensed
via prescription through local pharmacies. Data collected included patient’s date
of birth (DOB), medication prescribed, American Hospital Formulary Service
(AHFS) therapeutic classification and the originating location of prescriber. All
provider and patient identification information was excluded from the data
collection. The percentage of prescriptions written by various departments for
“excluded” OTC cough and cold medications in children under two years old was
examined relative to the total percentage of prescriptions written for children
under two. Feedback was given to each prescribing group to guide further
education efforts if needed. Clearance of this quality assurance project was gained
through our department chief and the Department of Clinical Investigations
prior to conducting this project.
Results: Before the release of the FDA public health advisory recommending that
the use of OTC cough and cold medications be avoided in children under the age of
two years old, prescription data from 01Feb2007 to 31Jul2007 revealed that 1.5% of
all prescriptions generated by ED providers and issued to children under the age of
two years old were written for OTC cough and cold medications. This percentage of
prescriptions was slightly lower then the average for all departments which was
2.35%. Following the FDA’s advisory statement the percentage of ED prescriptions
written for OTC cough and cold medications in the same patient population fell to
0.2%, which was below the clinic average of 1.07%.
Conclusion: Prior to the release of the FDA advisory statement regarding the
use of OTC cough and cold medications in children under the age of two years
old, providers in this network seldom prescribed these classes of medications to
young children. Following the FDA’s advisory statement the ED use of these
medications in this particular patient population fell even further to 0.2% of all
prescriptions written. Furthermore, on average ED-dedicated providers appeared
to use these medications less frequently then the average across all providers. This
data supports the compliance of ED-based providers with current standards and
recommendations issued by the FDA regarding the use of OTC cough and cold
medications in young children. This data also demonstrates widespread
compliance across our local providers prescribing medications to children less
than two years of age.
136
Fever in Children Less Than 60 Days Old: What Are
Current Cerebrospinal Fluid, Blood, and Urine
Culture Positive Rates in the Vaccination Era?
Morley EJ, Lapoint JM, Wittick L, Wojcik SM, Cantor R, Grant WD/SUNY Upstate
Medical University, Syracuse, NY
Study Objectives: Newborn children (⬍ 60-days-old) who present to the
emergency department with fever are subjected to several invasive procedures as part
of their workup including blood cultures, bladder catheterization, and often lumbar
puncture. The practice of performing these tests stems from historically high rates of
occult serious bacterial infection (SBI) in children less than 2-months-old, who have
fever over 100.4°F and do not appear clinically ill. The advent and widespread use of
the H. influenza and S. pneumoniae vaccines has dramatically decreased the incidence
of SBI in older children. The primary objective of this study is to determine the
current rate of positive cerebrospinal fluid (CSF), blood, and urine cultures in febrile
children less than 2 months old.
Methods: This study is a retrospective chart review performed from December 2006
– June 2008. The study was performed in an academic tertiary care center which sees
approximately 14,000 children per year. A structured data extraction form was used. The
electronic medical record was queried for all children less than 60 days old who had urine,
blood, or CSF culture performed. Emergency department notes were read for all children.
Inclusion criteria were age ⬍ 60 days-old, recorded temperature of 100.4° F in the
emergency department or by history, and the workup had to be done for fever or sepsis.
Exclusion criteria included a workup done outside the emergency department, the
presence of a ventriculoperitoneal shunt, multiple visits to the emergency department in
the past week, and antibiotics prior to the ED visit.
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Results: 112 subjects met our eligibility criteria. Blood cultures were sent on
all 112, urine cultures were sent on 110, and CSF cultures were sent on 68
subjects. Blood cultures were positive in 4.6% of subjects (5/112). Medical
records indicated that four of these cases were likely due to skin contaminants.
Urine cultures were positive in 8.2% of subjects (9/110). All 68 CSF cultures
were negative.
Conclusion: Positive blood and CSF cultures are extremely rare in the vaccination
era and a large prospective study should be performed to determine there utility these
test in the febrile child who is less than 60 days old.
137
Frequency of Preschoolers Positive for Drugs or
Alcohol After Suffering Traumatic Injuries
Irvin CB, Eadeh H, Ma M/St. John Hospital and Medical Center, Detroit, MI
Background: Although alcohol-related traumatic injuries in young adults are
common, there is little discussed in the literature regarding alcohol or drug
involvement in preschool children suffering traumatic injuries. Children in this age
group may ingest alcohol or drugs accidentally; however, the presence of alcohol or
drugs in this age group may also raise concerns regarding the supervisory status for
the child, or even the possibility of child abuse.
Study Objective: To estimate the frequency of alcohol or drug presence in
preschool children suffering traumatic injuries using the National Trauma Data Bank
(NTDB).
Methods: Data extracted from the NTDB (v6.2) included: age (1–5 years), race,
sex, presence of alcohol, presence of drugs, Injury Severity Score (ISS), emergency
department disposition, and discharge status (alive or dead).
Results: Of the 53140 children, 18% (9605/53140) had alcohol tests performed,
and 13% (6783/53140) had drug testing done. Although only 1.9% (187/9605)
tested positive for alcohol the mortality rate was 6.4%, compared to those negative for
alcohol with a mortality rate of only 2.0% (p⬍.01), with no significant difference in
ISS score in those testing positive or negative for alcohol. Of children who were tested
for drugs, 54% (3658/6783) were positive with a mortality rate of 2.0%, compared to
those testing negative for drugs with a mortality rate of 3.0% (p⬍.01), with no
difference between mean ISS scores in the two groups. Black children were more
likely to be tested for both alcohol (20% tested compared to white 17% tested)
p⬍.01, and for drugs (17% blacks tested compared to 13% whites tested) p⬍.01.
Black children were also more likely to test positive for alcohol (4.8% tested positive
for alcohol compared to 0.3% for whites) p⬍.01, and drugs (66% tested positive for
drugs compared to 60% for whites) p⬍.05.
Conclusions: Although drug and alcohol testing in preschool trauma victims is
uncommon (less than 20% overall tested), numerous preschoolers may actually test
positive. Additionally, those preschoolers testing positive for alcohol had substantially
increased mortality. Reasons for children testing positive for alcohol or drugs is
unknown, but this study suggests there may be value in more liberal testing for
alcohol or drugs in these preschool children and further research in this area is
needed.
138
ondansetron (85%). The mean volume of NS administration was 1400 ⫾ 700ml. All
groups improved significantly over the course of the study period (p⬍0.001);
however, the mean VAS at 120 minutes was higher for the AE alone group (P⫽0.02).
There was no significant difference in the change in VAS among the groups over time
when controlling for the volume of NS administration or physical evidence of
dehydration. There was no significant difference in admission rates between the
groups (total admission rate 26%).
Conclusion: Nausea and vomiting improved regardless of treatment with AE
and/or NS. Patients treated with AE alone, although improved, had a higher nausea
VAS after 120 minutes.
Nausea and Vomiting: Are We Treating the
Patients or Ourselves?
Garra G, Singer AJ, Chohan JK, Thode Jr HC/Stony Brook University, Stony
Brook, NY
Study Objectives: A number of studies have compared the relative efficacy of
anti-emetics (AE) and intravenous hydration with normal saline (NS) for the
treatment of nausea and vomiting (N/V). No study has examined the natural
course without any treatment. We hypothesized that patients with any treatment
(NS or AE) would have greater improvement in nausea severity compared to no
treatment.
Methods: Study Design: Prospective observational. Setting: University emergency
department. Subjects: Convenience sample of patients presenting with N/V.
Measures: Standardized collection of demographic and clinical measures, severity of
nausea on a 100mm Visual Analog Scale (VAS) and qualitative rating scale at 0, 30,
60 and 120 minutes. Outcomes: Change in nausea VAS over time. Analysis: t-test,
chi square and repeated measures analysis for VAS.
Results: We enrolled 103 patients, mean age 39 ⫾ 16 years, 63% female, 44 had
physical evidence of dehydration. Complete VAS data was available on 97. AE alone
were administered to 12 patients, AE and NS to 47 patients, NS alone to 13 patients
and no treatment was given in 25 patients. Groups were similar in age, sex, presence
of vomiting and baseline nausea VAS. The most frequently prescribed AE was
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139
Comparison in the Management of Inhalational
Injuries Presenting to a Tertiary Hospital
Emergency Department
Ngo AS, Wong E, Ponampalam R/Singapore General Hospital, Singapore,
Singapore
Study Objectives: To compare the management and outcome in patients with
inhalational injuries presenting to the emergency department before and after the
implementation of the emergency observation ward (EOW) toxic inhalation protocol
in a tertiary hospital setting. The protocol was developed to be evidence-based and
reduce variation in clinical practice.
Methods: We conducted a retrospective chart review of all patients presenting to
an urban tertiary hospital, Singapore General hospital emergency department
between 2006 –2008 via the hospital’s EMERGE Version 4.9.1 system with a
diagnosis of inhalational injuries, smoke inhalation, gas inhalation, carbon monoxide
poisoning, toxic gas inhalation, poisoning by gas and burn injury to airway. Included
patients had no or mild symptoms at presentation. Patients were excluded if they had
potential for deterioration, needed inpatient care, had abnormal physical findings
such as stridor and abnormal initial investigations including chest x-ray, arterial blood
gas, carboxyhaemoglobin levels and electrocardiography with evidence of cardiac
arrythmias or ischaemia.
Data collected included signs and symptoms, physical examination, laboratory
determinations, treatment, and outcomes.
Patients admitted under the EOW protocol were observed for a duration of
between 8 to 23 hours.
Results: There were 48 patients in 2007 and 49 patients in 2008. In 2007, 30
patients (62.5%) had smoke inhalation and 8 patients (16.7%) had eloxatin exposure
from a single Hazmat exposure. In 2008, 31 patients (63.2%) had smoke inhalation
and 11 patients (22.4%) had tear gas exposures from a single Hazmat exposure.
Respiratory symptoms were the main complaint (43.8% in 2007, 59.2% in
2008). Other symptoms were neurological (16.7% in 2007, 32.7% in 2008) and
chest pain (19.4% in 2007 and 22.4% in 2008). There were 45.8% asymptomatic
patients in 2007 and 30.6% in 2008.
Investigations done included electrocardiography (18.8% in 2007, 42.7% in
2008), blood gas (47.9% in 2007, 44.9% in 2008), carboxyhaemoglobin level
(47.9% in 2007, 59.2% in 2008), chest x-ray (58.3% in 2007, 67.3% in 2008) and
endonasoscopy (29.2% in 2007, 34.7% in 2008).
In 2007, 88.3% of patients were discharged from the emergency department after
an average observation period of 3.1 hours. 12.5% of patients were admitted for an
average of 1.5 days. They were given an average of 9 days of medical leave if
discharged from the inpatient and 2.6 days if discharged from the emergency
department.
In 2008, 20.4% of patients were discharged from the emergency department after
observing an average of 3.8 hours. 45.2% of patients were admitted for an average of
1.4 days. 30.6 % of patients were admitted to the EOW. They were given an average
of 5.1 days of medical leave if discharged from the inpatient and 2.8 days if
discharged from the emergency department.
There was less variation in patient management after the implemention of the
EOW protocol with better documentation observed. There was 1 reattendance in
2008 in a patient who was discharged after inpatient admission for persistent chest
pain. There was no bad outcomes due to observing the patient in EOW.
Conclusion: There were more patients admitted and more investigations
ordered following the implementation of the EOW inhalation protocol.
However, there was improvement in the documentation and less variation in the
management of patients.
Annals of Emergency Medicine S43
Research Forum Abstracts
140
A Prospective Observational Study of Medication
Errors in a Tertiary Care Academic Emergency
Department
Patanwala A, Warholak-Jackson T, Sanders A, Erstad B/University of Arizona,
Tucson, AZ
Study Objectives: The objective of this study was to evaluate the rate of
medication errors identified in the emergency department (ED) using a continuous
observation technique and to categorize these errors based on severity and stage of
occurrence. Factors that are associated with a higher risk for medication errors were
determined.
Methods: An observer was present in the ED for a total of 14 days (28 12– hour
shifts) during a nine-month timeframe. All information regarding the medication use
process, including the occurrence of errors, was recorded. The observer intervened
only if it was determined that a medication error had the potential to cause patient
harm. The errors were categorized by two independent investigators (an emergency
physician and a clinical pharmacist) into categories defined by the National
Coordinating Council for Medication Error Reporting and Prevention
(NCCMERP). Factors that affected the occurrence of a medication error were
analyzed by logistic regression analysis.
Results: The observer identified 178 medication errors in 192 patients during the
observation period. Overall, 59.4% of patients had one or more errors. Only one
medication error resulted in patient harm, but interventions by the observer to
prevent possible harm did occur. Medication errors were categorized according to
NCCMERP as follows: circumstances or events that have the capacity to cause error
(category A ⫽ 19.1%); an error occurred but the error did not reach the patient
(category B ⫽ 11.8%); an error occurred that reached the patient but did not cause
patient harm (category C ⫽ 39.9%); an error occurred that reached the patient and
required monitoring to confirm that it resulted in no harm to the patient and/or
required intervention to preclude harm (category D ⫽ 28.7%); One error occurred
that may have contributed to or resulted in temporary harm to the patient and
required intervention (category E ⫽ 0.5%). There were no errors that exceeded the
severity of the latter category. Errors categorized according to stage of occurrence were
as follows: administering (34.8%), dispensing (0.6%), prescribing (53.9%) and
transcribing (10.7%). In the logistic regression analysis, variables that were predictive
of medication errors were: number of medication orders (OR 1.25, p⬍0.001);
boarded patient status (OR 2.15, p⫽0.043); nursing employment status (less error if
full-time) (OR 0.37, p⫽0.021). Variables that were not significant were patient age,
patient sex, years of nursing experience and shift type (day or night).
Conclusion: Medication errors in the ED are common when identified by a
direct observational approach, particularly those that occur during the prescribing and
administration stages of the medication use process. Number of medication orders,
boarded patient status and part-time nursing status are associated with a significantly
increased risk of medication errors.
141
Patient Satisfaction of Emergency Department
Boarders With Inpatient Hallway Admission
Zito JA, Viccellio P, Sayage V, Chohan JK, Singer AJ/Stony Brook University,
Stony Brook, NY
Study Objectives: Boarding of admitted patients in the emergency department is
a major cause of crowding. Objections to admitting boarders to in-patient hallway
beds include the concern for decreased patient satisfaction. The current study
examined patient satisfaction with admission to in-patient hallways due to crowding.
We hypothesized that most patients would prefer to board on in-patient hallways
than the ED.
Methods: Study Design-Telephone survey. Setting: Suburban academic ED with
an annual census of 80,000. Subjects: Admitted ED patients transferred to in-patient
hallways during the year of 2008. Measures and Outcomes: Demographic and clinical
characteristics as well as patient preferences based on a structured telephone survey
including items related to patient comfort and safety using a 5-point Likert scale.
Analysis: Descriptive statistics.
Results: There were a total of 445 patients boarded in the ED with in-patient
hallway admission in 2008. Of the 445 patients boarded, 358 were contacted and of
that 347 (78%) consented to participate. Mean age was 57 ⫹/⫺ 16; 52% were
female. All patients were initially boarded in the ED prior to their transfer to an inpatient hallway bed. 100% of respondents agreed with the following statements: it
was alright to move another person into an in-patient hall so that they could be seen
quicker and it was alright to move themselves into an in-patient hall so that another
S44 Annals of Emergency Medicine
ED patient could be seen quicker. In comparing ED vs. in-patient hallway boarding,
the following % of respondents preferred in-patient boarding with regards to: rest
(87%), safety (82%), confidentiality (85%), treatment (77%), comfort (77%), quiet
(86%), staff availability (85%), and privacy (84%). The overall preferred location
after admission was the in-patient hallway in 87% (95% CI 75–90) of respondents.
There were no differences by age or sex.
Conclusion: Patients overwhelmingly preferred the in-patient hallway rather than the
ED hallway when admitted to the hospital. Patients are very willing to be moved out of
their ED rooms after being seen so that another patient can be seen and vice versa.
142
Medication Errors Recovered by Emergency
Department Pharmacists
Rothschild JM, Churchill W, Erickson A, Munz K, Schuur JD, Salzberg CA,
Shane R, Patka J, Steffenhegan A, Bates DW/Brigham and Women’s Hospital,
Boston, MA; Cedars-Sinai Medical Center, Los Angelos, CA; Grady Medical
Health System, Atlanta, GA; University of Wisconsin Hospital and Clinics,
Madison, WI
Study Objectives: Medication errors (MEs) in emergency departments (EDs) are
an important patient safety concern. This is not surprising since over 3⁄4 of ED visits
are associated with medication administration or prescribing. EDs are considered a
high risk environment due to many factors including multitasking, frequent
interruptions, potent drugs, the fast pace of care and incomplete medical histories.
Previous studies have demonstrated that inpatient clinical pharmacists improve
medication safety. We sought to study the impact of dedicated clinical ED
pharmacists on reducing MEs during the ordering, administration and monitoring
phases of the ED medication use system.
Methods: This direct observational study was conducted in 2008 in four academic
EDs in CA, WI, GA and MA. The ED volumes ranged from 37,000 to 104,000 annual
visits. Experienced ED pharmacists consented to be observed during 3 to 5 hour periods
during daytime and evening shifts. Pharmacy resident researchers were trained in the
technique of direct observation. The primary outcome was MEs recovered by ED
pharmacists. Following recovery of a ME, observers identified if the pharmacist
recommendations, for example reducing a dangerous medication dose, were accepted by
the clinician. Recovered MEs are: MEs with no potential for harm; potentially harmful
MEs intercepted by the pharmacist before reaching the patient (potential adverse drug
event or potential ADE); MEs caught after reaching the patient but before causing harm
(mitigated ADE); and MEs caught after causing some harm but before additional harm
(ameliorated ADE). Paired physician and pharmacist reviewers confirmed the presence of
recovered MEs and assessed their potential for harm.
Results: We conducted 227 observation periods over 791 hours at the 4 EDs. We
observed pharmacists reviewing a total of 17320 medications ordered or administered to
6471 patients, a mean of 76.6 medications and 28.6 patients during the average 3.5 hour
observation period. We identified 505 recovered MEs or a mean of 7.8 MEs (range 6.2 –
9.6) per 100 patients and 29.2 MEs (range 21.6 – 42.9) per 1000 medications. Most
recovered potentially harmful MEs were intercepted potential ADEs (90.3%), with fewer
mitigated (3.9%) and ameliorated (0.2%) ADEs. The potential severities of the recovered
MEs were most often serious (47.9%) and significant (36.2%); additionally 4.4% were
life-threatening. Almost all pharmacist recommendations were accepted by the physician
or nurse (96.8%). The most common type of recovered MEs were underdose (16.4%),
overdose (14.7%), drug omission (11.7%) and wrong strength (9.5%). The most
common medication classifications associated with recovered MEs were antimicrobial
agents (32.3%), central nervous system agents (16.3%) and anticoagulant and
thrombolytic agents (14.1%).
Conclusion: Emergency department pharmacists commonly recover potentially
harmful MEs. The effects of other responsibilities of ED pharmacists including
toxicological consultations, formulary substitution, assisting guideline compliance, therapy
optimization including dose and route adjustments, and staff and patient education were
not included in this study. Controlled trials are necessary to determine the net cost-benefit
effects of ED pharmacist staffing on safety, quality and costs, which are especially
important considerations for smaller EDs and pharmacy departments.
143
Materials Management of a Busy Emergency
Department
Richardson D, Rupp V, Fredericks K, Talmage C, Reed J/Lehigh Valley Hospital,
Allentown, PA
Study Objectives: Proper materials management in an emergency department
(ED) is crucial in order to efficiently and effectively take care of patients. Studies
Volume , .  : September 
Research Forum Abstracts
suggest that stocking should be done routinely to ensure that at least 95% of the time
patient rooms do not run out of stock during a shift. However, one study proposed
that at a minimum 8% of a shift, almost one full hour of a 12-hour shift, is lost
retrieving supplies that are not available in the room. The study objectives were to
determine the amount of time ED nurses spend outside of a patient room obtaining
supplies to care for the patient, and what supplies are most commonly retrieved.
Methods: This was a prospective, observation study of nurses in a 43-bed ED of a
tertiary, suburban hospital. Nurses were observed for an entire shift each time they
left a patient’s room to obtain patient care items that were not found in the room.
The amount of time spent outside of the patient room obtaining supplies, and what
supplies the nurses obtained was recorded. Observations occurred when the nurse
began searching for supplies related to procedural tasks associated with patient care
and did not include items such as medications or stationary supplies.
Results: The total number of observations was 610, of these, 75 were excluded;
20 due to discrepancies noted with an observer, and the remaining 55 due to
observation of searching for exclusionary supplies. The average time nurses spent
away from the bedside each time they left to look for stock, was 1.4 minutes. Nurses
working either eight or 12- hour shifts left the bedside an average of nine times per
shift to look for stock. Therefore, with an average of 15 nurses working in any given
12-hour time period, the overall amount of time spent away from the bedside looking
for stock was 282 minutes (4 hours and 42 minutes). In a 24-hour time period with
an average of 15 nurses working, the overall amount of time spent away from the
bedside looking for stock was approximately 564 minutes (9 hours and 24 minutes).
Nurses were sidetracked during their search for supplies 113 times out of a total of
535 observations (21%). The most commonly searched for supplies were: IV
supplies/tubing, thermometer, phlebotomy supplies, blankets, saline flushes, syringes,
personal hygiene products, gown/clothing, catheter/urine kit, linens, and needles.
Conclusion: Nurses spend a substantial amount of time leaving patient rooms to
search for patient care items during eight and 12- hour shifts. The most common
items searched for were items that would be found in the patient room if properly
stocked. Materials management is a strategy that, when implemented efficiently,
could help to reduce time wasted searching for patient care items as a result of understocked rooms in the ED.
144
Evaluating Predictors of Door-to-EKG Times
Borquez EA, Susim SS, Garcia UJ, Desai S, Challoner K,
McClung CD/Los Angeles County/University of Southern California, Los Angeles,
CA
Study Objectives: To review qualitative descriptors of chest pain and
impediments to timely EKGs within the American Heart Association Guidelines.
Methods: Retrospective chart review of patients presenting to the emergency
department (ED) with a chief complaint of chest pain. Charts were abstracted from a
single calendar month. This occurred in a large academic, county-based hospital with
an annual ED census of 160,000 visits. Patients arriving by ambulance were stratified
from walk-in patients. Statistical analyses was performed using STATA 10.0,
differences between groups were compared using one-way analysis of variance and
logistic regression.
Results: There were 244 patients who met inclusion criteria. The median time to
receive an EKG from arrival was 19 minutes (IQR 11–52 minutes). The median
difference for men was significantly better than women (16 min vs. 21 min,
p⬍0.001). Patients with complaints of severe chest pain 8 –10/10 were significantly
associated with timely EKG (EKG ⬍ 10min) (OR⫽2.2; 95%CI 1.16,3.99). The
quality, radiation, and location of the chest pain, and age were not predictive of
receiving a timely EKG.
Conclusion: The majority of patients presenting to a high-volume emergency
department do not receive screening EKG’s within the AHA recommended
timeframe. Sex and severity of pain are significant predictors of timely EKG. These
results support prior evidence that women continue to suffer health disparities with
potential coronary heart disease.
145
Content Validity Testing for the Agitation Severity
Scale: Development of a Measure for Use With
Acute Presentation Behavioral Management
Patients
Strout TD, Baumann MR/Maine Medical Center, Portland, ME
Study Objective: Agitation is a condition frequently observed in behavior
management patients presenting to the emergency department (ED). The Joint
Volume , .  : September 
Commission on standards for the assessment and monitoring of behavioral health
patients would be easier implemented with a reliable, valid agitation rating scale
appropriate for use in the emergency setting. The purpose of this research was to
conduct primary content validity testing for an initial version of an observation-based,
ED-focused, agitation rating tool.
Methods: This project used a methodological design and was approved by both
university and hospital institutional review boards. A panel of eight experts from the
fields of emergency medicine, emergency nursing, acute psychiatry, and psychiatry
was used to examine the representativeness and clarity of twenty-six items for
potential inclusion on the agitation rating scale. The twenty-six items considered for
inclusion were previously developed utilizing focus groups of direct patient care
providers and a survey of emergency department and acute psychiatry clinicians.
Measures of interrater agreement, the content validity index, and factorial validity
index were calculated for both representativeness and clarity on a by-item and acrossthe-scale basis.
Results: Initial evaluation of the potential scale items yielded an average content
validity index of 0.725 for the representativeness of the items and of 0.725 for the
clarity of the items. Eliminating four items with item-level content validity indexes of
0.142 – 0.375 improved scale-level content validity to 0.80 for both
representativeness and clarity. Experts had difficulty consistently identifying domains
for the scale items, with a factorial validity index of 0.50. Interrater agreement was
good to very good for the majority of the individual items, and with k ⫽ 0.80 for the
scale as a whole.
Conclusions: Utilizing a panel of experts to develop and evaluate content validity,
an initial version of the Agitation Severity Scale has been constructed. Additional
psychometric evaluation is necessary to evaluate the reliability and validity of the
newly developed instrument, as well as to refine domains for the individual items.
146
Punch Injuries and Psychiatric Comorbidity in Men
and Women
Damewood S, Perry C, Powers M, Jeanmonod D, Jeanmonod R/Albany Medical
College, Albany, NY; St. Luke’s Hospital, Bethlehem, PA
Study Objective: To determine what differences exist between men and women
in regards to injuries sustained after intentionally striking an object with a closed fist.
Methods: This is a retrospective study of patients who presented to an academic
tertiary care emergency department (ED), with an annual volume of 72,000 patients, who
underwent a radiographic study of their hand from July 1st 2007 to June 30th 2008.
Research associates queried the electronic Patient Archiving and Communication System
for patients who had hand films performed and then identified the mechanism of injury
through the electronic medical record for that visit only. For patients receiving
radiographs for punch injuries, the electronic medical record was queried for details
regarding that ED visit, including presence of fracture, patient age and sex, and psychiatric
history defined as diagnoses corresponding to the DSM IV classification system
mentioned in the past medical history or history of present illness for the visit. Previous
hand radiographs for punch injury in the Patient Archiving and Communication System
was also recorded. All data points were recorded into a standard spreadsheet. Children
under the age of 13 were excluded. 8% of the collected data was confirmed by a second
investigator with a kappa value of 1.0 for agreement of punch mechanism. Descriptive
statistics were used to analyze the data. The study protocol was reviewed and approved by
the institutional review board.
Results: During the 12-month study period, 1292 patients underwent hand
radiographs from the ED. Four patients had no dictated ED chart, and were therefore
excluded. 172 patients sought medical attention after intentionally striking an object.
Only 35 (20%) of those patients were women. Of those patients, four (11%) patients
sustained a fracture, and 17 (49%) had underlying psychiatric disease. On the other
hand, of the 137 patients in the male group, 65(48%) patients sustained fractures,
and 36 (26%) had underlying psychiatric disease. 29% of women and 23% of men
had had prior radiographs for intentional punch injuries.
Conclusion: Women are far less likely to punch objects or sustain a fracture after a
punch compared to men. The lack of serious injury in most women after punching an
object appears to be in line with past data regarding differences between the sexes in selfdestructive behavior, such as suicide attempts. This may be due to last minute hesitation
or that women typically have less upper body strength than men. Nearly half of the
women in this study who did intentionally strike an object had underlying psychiatric
disease, compared to less than 1⁄4 of the men. This is much higher than the incidence of
psychiatric disease in the general population, which is estimated to be about 16%. Since
these injuries can be disabling and occur in a young group of patients with a high rate of
recidivism, these patients might benefit from psychiatric referral.
Annals of Emergency Medicine S45
Research Forum Abstracts
147
Psychiatric Clearance in the Pediatric Emergency
Department
Waseem M/Lincoln Hospital, Bronx, NY
Study Objectives: Do emergency physicians obtain psychiatric consult in all
children with psychiatric complaints or do they feel comfortable to clear some of
these patients without psychiatric consultation and which patients they clear without
psychiatric referral?
Methods: This is a simple observation study. 100 questionnaires were sent by
mail to physicians working in pediatric emergency department.
1. Do you refer all children with psychiatric complaints to a psychiatrist?
2. Do you give psychiatric clearance yourself without psychiatric consultation if
the patients are
Not suicidal
Not homicidal
Not hallucinating
3. Did your training prepare you to evaluate patients with psychiatric complaints
and teach you when to or not to obtain psychiatric consultation?
Results: Out of 73, twenty eight were emergency medicine trained (EM)
physicians (38%), thirty seven were pediatric emergency medicine trained (PEM)
physicians (51%), six were pediatricians (8%) and two (3%) respondents did not
mark their specialty.
42 (56%) physicians obtained psychiatric consultation on all pediatric patients
with psychiatric complaints and behavioral issues. 30 physicians (41%) still obtained
psychiatric consultation, even if they felt the patients were not suicidal, homicidal or
actively hallucinating. 80% emergency physicians thought that their previous training
adequately prepared them to evaluate pediatric patients with psychiatric conditions,
but 19% felt that they were not fully trained.
Emergency physicians were less likely to obtain psychiatric consultation on all
pediatric psychiatric patients (50%), followed by PEM trained physicians (59%) and
pediatricians (83%). Emergency physicians (82%) were more willing to
psychiatrically clear pediatric patients than PEM (38%) or pediatric trained
physicians if the patients were not obviously suicidal, homicidal or actively
hallucinating. Emergency physicians (93%) felt better prepared by their training to
evaluate pediatric patients with psychiatric complaints than PEM or pediatric trained
physicians.
Conclusion:
1. The majority of physicians working in the ED obtained psychiatric
consultations on all children who presented to the ED with psychiatric complaints.
2. Almost half of these physicians obtained psychiatric consultation on these
patients and would not discharge the patient without it even if the patient was felt by
them not to be suicidal, homicidal or hallucinating.
3. EM-trained physicians felt better prepared to evaluate and clear psychiatric
patients.
148
Factors Predicting Return Visits Among Emergency
Department Patients With Psychiatric Complaints
Groke S, Zink A, Bennett A, Knapp S, Phanthavady T, Madsen T/University of
Utah School of Medicine, N Salt Lake, UT
Study Objectives: We have previously reported that psychiatric patients return to
the emergency department (ED) within 30 days at significantly higher rates than nonpsychiatric patients. In this study, we attempted to determine which factors among
psychiatric patients may predict return ED visits within 30 days.
Methods: We reviewed the charts of all ED patients evaluated by licensed clinical
social workers between January–February 2007. Prior history of a psychiatric-related
admission or a suicide attempt, current suicide attempt or parasuicidal gestures, drug
or alcohol use, feelings of hopelessness/depression, violent behavior, length of
symptoms, presence of stressors or the availability of a caregiver were recorded. We
then reviewed subsequent hospital records to determine if the patient returned to the
ED within 30 days. Multivariate analysis was used to identify factors predicting a
return visit.
Results: 92 patients presented during the study period expressing suicidal
ideations or having attempted suicide vs. 142 patients with non-suicidal psychiatric
complaints. 31.5% of suicidal patients vs. 20.4% of non-suicidal patients were
admitted to an inpatient psychiatric facility at the time of their initial presentation to
the ED. Of the patients who were discharged, 17.5% (11/63) of the suicidal patients
and 23% (26/113) of the non-suicidal patients returned to the ED within 30 days
with psychiatric complaints (p⫽0.386). Predictors of return ED visit among
S46 Annals of Emergency Medicine
psychiatric patients included not having a caregiver available at the time of discharge
and a history of a previous suicide attempt. There were no completed suicides among
study patients.
Conclusion: Among psychiatric patients discharged from the ED, significant
predictors of return ED visits within 30 days include lack of a caregiver at the time of
discharge and a history of a previous suicide attempt. This study identified factors
which may allow for interventions to reduce return visits among emergency
department psychiatric patients.
149
Psychiatric Transfers From the Emergency
Department: Factors Associated With Length of
Stay
Klope JL, Jordan MT, French SC, Burkard W/Resurrection Medical Center,
Chicago, IL; St. Francis Hospital, Evanston, IL
Study Objectives: Psychiatric complaints remain a common emergency
department (ED) problem. Transfer of these patients from EDs without inpatient
psychiatric capability continues to occupy significant resources. In this study, we
sought to investigate factors associated with ED length of stay (LOS) of psychiatric
transfers.
Methods: We performed a retrospective review of all psychiatric transfers from
two urban academic ED’s over a four-month period. Such data as age, sex, insurance
type, lab studies, vital signs, and prior medical history was examined. A univariate and
multivariate analysis of mean LOS concerning these factors was performed. Statistical
significance was set at 0.05.
Results: Ninety-two patients were reviewed. The mean LOS for all patients was
562 minutes. The mean number of labs performed was 5.0, with only 1.1 being
abnormal. 37% had an ancillary study (EKG/CT/x-ray) performed. Only two
ancillary studies had abnormalities, and neither was clinically relevant. The
performance of any ancillary study added an additional 63 minutes to LOS. 43%
were provided an ED medication for their condition. On univariate and multivariate
analysis, such factors as insurance status (p⬍.001), day of the week (p⫽.012),
abnormal lab values (p⫽.044), and ancillary studies performed (.043), all affected
LOS.
Conclusion: Numerous factors appear to affect ED LOS for psychiatric transfers.
In particular, insurance status, the day of the week, abnormal lab data, and ancillary
studies performed all affected mean LOS. This study demonstrated that for each
ancillary test performed an additional 63 minutes was added to the LOS.
150
The Effect of Access to Health Care and SocioEconomic Status on the Availability and
Effectiveness of Medical Treatment for Asthma and
Hypertension Among Patients Presenting to the
Emergency Department
Miner JR, Olives T, Westgaard BC, Patel R, Patel S, Biros MH/Hennepin County
Medical Center, Minneapolis, MN
Study Objectives: To estimate the availability and effectiveness of treatment for
asthma or hypertension among patients presenting to the emergency department
based on various socio-economic factors and access to health care.
Methods: This was a cross-sectional study at an urban, Level 1 trauma center
with 98,000 annual visits. We prospectively screened all patients presenting to the
ED during a randomized distribution of 8-hour periods between June 1 and August
31, 2008. Consenting patients completed a survey on living situation, employment,
family income, education, access to primary care, how often they experienced hunger,
whether or not they ever had to chose between buying food and buying medicine and
the frequency at which this occurred, whether or not they had hypertension or
asthma, what medications they took, their blood pressure and the peak flow. Effective
treatment was defined as a systolic blood pressure ⬍140 in a patient with a history of
hypertension or a peak flow ⬎50% of predicted in a patient with asthma. Data was
analyzed using descriptive statistics and ordinal logistic regression using a generalized
log linear model.
Results: 8340 patients presented during the study. 2654 were eligible, 2336
(88.0%) were enrolled. 6.1% were homeless, 3.6% lived in a halfway house, 17.3%
were living with friends (non-renters), 54.8% were renting, 16.2% were property
owners, 1.4% lived in nursing homes. Hunger from food scarcity was reported in:
3.8% daily, 4.4% 2–3 times/week, 3.0% weekly, 4.4% monthly, 4.6% yearly, and
78.7% never. 59.4% claimed access to primary care medical facilities. 42.8% of
Volume , .  : September 
Research Forum Abstracts
patients were unemployed, 42.8% reported having a chronic illness. 33.8% of
patients did not have insurance health insurance, 40.7% had Medicaid or Medicare.
23.9% had private health insurance. Having to choose between buying food and
buying medicine was reported in: 4.5% weekly, 5.4% monthly, 7.5% yearly, and
76.8% never. 20.4% of patients reported having asthma, 46.7% of whom were on an
asthma medication, 58.1% of whom had a peak flow ⬍50% of predicted (median
260, range 60 –700). 33.7% of patients reported having hypertension, 13.5% of
whom were on a medication for hypertension, 44.5% of whom had a blood pressure
⬎140 while in the ED. A blood pressure ⬎140 in a patient with HTN or a peak flow
⬍50% of predicted in a patient with asthma was associated with (coefficient and 95%
CI included): being on a hypertension or asthma medication (⫺0.42, ⫺0.83 to
0.02), and choosing between food and medicine (0.32, 0.07 to 0.63), being on a
medication for hypertension or asthma in patients with the disease was associated
with; access to a primary care provider (0.61, 0.41 to 0.81).
Conclusions: Being treated for asthma or hypertension was associated with access
to a primary care provider, but not insurance, employment, housing, or hunger
status. Not having effective control of asthma or hypertension was associated with not
being on a medication for the problem and having to choose between buying
medication and buying food.
151
Emergency Department Patient Acceptance of
Rapid HIV Testing Practices, Revisited: The 2006
CDC Recommendations for Non-Targeted, Opt-Out
HIV Screening
Prekker ME, Olives T, Hanley O, Miner JR/Hennepin County Medical Center,
Minneapolis, MN
Study Objective: Patient acceptance of non-targeted, opt-out HIV screening in
the emergency department (ED) is variable based on published reports. We sought to
evaluate patient approval of Centers for Disease Control and Prevention (CDC)recommended HIV testing practices in an urban ED without rapid HIV testing
currently available, apart from occupational exposures.
Methods: Cross-sectional survey conducted in an urban, county hospital with
98,000 annual visits. The estimated prevalence of known HIV infection in the ED
population is 1.8%. Trained research assistants administered a previously developed,
standardized survey to all adult, non-critically ill, English-speaking patients who
presented to the ED during randomized shifts over a three-month period.
Results: Of the 2197 enrolled patients, 53% were men, 41% were black, 37%
were white, 7% were Native American, 6% were Hispanic, 9% were another
ethnicity, and the median age was 39 years (interquartile range 27–50 years). A larger
proportion of patients would accept testing if an opt-out methodology were used
(78%, 95% confidence interval [CI] 76% to 80%) versus an opt-in methodology
(73%, 95% CI 72% to 75%) (absolute difference 5%, 95% CI 4 to 6%). If their
physician recommended an HIV test during the ED visit, 87% (95% CI 86 – 89%)
would accept testing. A minority of patients believed that consent for HIV testing
needed to be separate from general consent for medical care (37%, 95% CI 35% to
39%). Regarding counseling, 65% (95% CI 63% to 67%) of patients did not feel
pretest counseling was necessary, while 60% (95% CI 58% to 62%) of patients did
not feel post-test counseling was necessary after a negative result.
Conclusion: The majority of ED patients in an institution naı̈ve to HIV
screening would accept an HIV test regardless of selection strategy or criteria. This
finding supports continued efforts to expand non-targeted, opt-out HIV screening in
the ED, in accordance with current CDC recommendations.
152
Epidemiology of Advance Directives in Extended
Care Facility Patients Presenting to the Emergency
Department
Wall JJ, Hiestand BC/The Ohio State University, Columbus, OH
Study Objectives: In the emergency department (ED), the documented existence
of an advance directive (AD) or Do-Not-Resuscitate (DNR) order may affect initial
treatment decisions, even in non-life threatening situations. We performed an
epidemiologic evaluation of AD and DNR prevalence among residents of extended
care facilities (ECF) presenting to the ED of a large university hospital.
Methods: We retrospectively identified patients originating from an ECF from
the ED medical record. Data was collected from the hospital electronic medical
record on age, sex, race (white vs. non-white), triage acuity, ED disposition, and AD
status. In Ohio, AD consist of DNR-CC (comfort measures only), DNRCC-Arrest
Volume , .  : September 
(complete care up to arrest), living wills (LW) and health care power of attorney
(POA). Descriptive statistics were generated, Fisher’s exact test was used to compare
categorical variables, and multiple variable logistic regression was used to evaluate
predictors of DNR status.
Results: A total of 238 patients were identified over 4 months. 170 (71%) were
white, 107 (45%) were male, and the mean age was 64 ⫹/⫺ 16.3 years, with 163
(68%) admitted. Of the 238 patients, 44 (18.5%, CI95 13.5–23.4%) had DNR
orders, of which 15 were DNR-CC. In addition, 94 (39.5%, CI95 33.2– 45.8%) had
a POA, and 60 (25.2%, CI95 19.7–30.8%) had LW. There was a significant
difference in AD by race (51% whites with AD vs. 37% non-whites, p⫽0.046) and
DNR by race (24% of whites with DNR vs. 6% of non-whites, p⬍0.001). Using
multiple variable logistic regression, the variables significant in predicting DNR status
(both CC and CC-Arrest) were LW (OR 11.54, CI95 5.03–26.46, p⬍0.0005), age
(OR 1.061 per year increase in age, CI95 1.03–1.10, p⬍0.0005) and white race (OR
3.83, CI95 1.16 –12.65, p⬍0.028). Sex was not found to be a significant predictor
(p⫽0.18) of DNR use. There were no interaction terms that affected the model.
Patients with DNR orders were more likely to be transported by EMS than private
ambulance (p⫽0.032), although though there was no relationship between DNR
status and initial triage acuity (p⫽0.527) or admission rate (34/44 [77%, CI95 64 –
90%] DNR vs. 129/194 [66%, CI95 60 –73%] p⫽0.21). We also found that DNR
status was not a significant predictor of death in the hospital (3/44 DNR [6.8%, CI95
0 –15%] vs. 41/194 non-DNR [4.1%, CI95 1.3– 6.9%] p⫽0.43).
Conclusion: Age and LW use are strong predictors of ECF patient DNR use.
Non-white race greatly decreases the odds of DNR use; whether this represents a
preference or a lack access to full patient education cannot be determined from this
retrospective study. AD provide the ability to decide care prior to incapacitation and
are an invaluable tool in respecting patient decisions. ED clinicians should be alert for
opportunities to discuss end-of-life care preferences in appropriate patients.
153
Do Attitudes About Homosexuality Affect
Emergency Medicine Practice? Results of a Survey
Shearer P/Mount Sinai School of Medicine, New York, NY
Study Objectives: The diversity of patients in the emergency department
provides unexpected rewards and challenges. There are no studies in the
emergency medicine literature that address emergency physicians attitudes
towards homosexuals. The purpose of this study was to evaluate emergency physicians
beliefs about homosexuality and whether such beliefs impact patient care.
Methods: An anonymous, self-administered survey was competed by emergency
physicians, physicians assistants (PAs) and nurse practitioners (NPs) attending the
2003 ACEP Scientific Assembly. Data were analyzed using a chi-square analysis; a pvalue ⱕ 0.05 indicated statistical significance.
Results: 608 surveys were completed; 379 (63%) attending physicians; 169
(28%) residents/fellows; 54 (9%) PA or NP; 44 (73%) were male; respondents came
from all regions of the United States. 15.5% of emergency physicians agreed with the
statement “homosexuality is immoral.” More respondents from the Southeast agreed
with that statement (p⫽.02) than from other areas of the country. 76.7% of the
respondents reported having co-workers who are gay, lesbian, bisexual or transgender
(GLBT). Significantly more emergency physicians with a known GLBT co-worker
disagreed that “homosexuality is immoral” (73.9%) compared to those without a
GLBT co-worker (57.3%) (absolute difference 16.6; 95%CI [4.9, 28.3]). Emergency
physicians who believe that homosexuality is immoral were more likely to be
uncomfortable giving post-exposure prophylaxis to males after unprotected same-sex
intercourse (26.9%) than emergency physicians who do not believe that
homosexuality is immoral (14.2%) (absolute difference 12.6; 95%CI [2.4, 22.9]).
Conclusion: Emergency physicians attitudes and acceptance of homosexuality
differ geographically. Positive attitudes towards homosexuality are reported by
emergency physicians with GLBT co-workers. Negative attitudes towards
homosexuality affect some aspects of the care received by GLBT patients in the ED.
154
Impact of Care Management on the Highest
Utilizers of Camden NJ’s Emergency Departments
Sciorra D, Brenner J, Gill J, Linden A, Mazzarelli A/University of Medicine and
Dentistry of New Jersey, Camden, NJ; Cooper University Hospital, Camden, NJ;
Delaware Valley Outcomes Research, Newark, DE; Linden Consulting Group,
Hillsboro, OR
Study Objectives: The highest utilizers of emergency department (ED) services
typically have complex medical conditions compounded by an array of social issues.
Annals of Emergency Medicine S47
Research Forum Abstracts
Programs that improve the outpatient management of these complicated patients are
likely to reduce ED utilization. The objective of this study was to examine the effect
of a citywide care management (CM) project on the subsequent ED utilization of
enrolled high utilizers.
Methods: We conducted a retrospective cohort study of 33 patients who met the
CM project enrollment criteria of Camden City residency with five or more ED visits
during a one-year period of time. Enrolled high-utilizing patients were provided with
targeted care management to help them towards stabilizing their social environment
and finding an appropriate medical home. CM patients were recruited from 11/1/
2007– 4/30/2008 and followed until 6/30/2008. These patients were then
retrospectively matched into a citywide database of all Camden City hospital visits to
determine both utilization rates before and after project enrollment. Based on each
individual CM patient’s age, sex, and baseline utilization, three matched control
patients were selected from the database to form a comparison group of 99 patients.
Time to event analysis was performed using multivariable Cox regression. Insurance
status, a history of substance abuse, and homelessness were explored as potential
confounders. The event of interest was defined as a subsequent ED visit and
censoring took place in the event of death, loss to follow-up, and at study completion
on 6/30/2008.
Results: Fourteen patients in the CM group (42.4%) and 60 patients in the
matched control group (60.6%) experienced a subsequent ED visit. Through
multivariable Cox regression, having a history of substance abuse was associated with
a 60% increased risk of a returning ED visit (hazard ratio 1.60 [CI, 1.01 to 2.55]).
After adjustment for a history of substance abuse, CM project enrollment was
associated with a 69% reduced risk of subsequent ED utilization (hazard ratio 0.31
[CI, 0.15 to 0.62]).
Conclusion: In the early evaluation of this intervention, participation in the CM
project was associated with a significantly lower risk of experiencing a subsequent ED
visit. This suggests that providing primary medical care and social support, over a
relatively short period of time, is effective in decreasing ED visits for high utilizers.
155
Preliminary Results of the Survivors of Torture
Presenting to an Urban Emergency Department
Prevalence Study
Hexom B, Beattie L/Mount Sinai School of Medicine, New York, NY
Study Objectives: It has been reported that 8 –11% of patients presenting to
urban primary care clinics have experienced torture. Given potential barriers to health
care access, we hypothesize that emergency departments (EDs) may see higher rates of
survivors of torture. As our medical center is located in the most ethnically diverse
county in the United States, with the highest portion of foreign-born New York City
residents, we sought to determine the prevalence of survivors of torture presenting to
our urban ED.
Methods: A previously validated survey instrument regarding exposure to torture
- the Detection of Torture Survivors Survey - was administered by convenience
sample to patients presenting to a New York City ED. Additional questions were
asked to determine whether individuals’ experiences met internationally accepted
definitions of torture. Surveys were verbally administered to patients regardless of
ethnicity or complaint and language interpretation was provided if needed. Prisoners,
children under 18 years, critically ill, demented, or disoriented patients were
excluded.
Results: Preliminary results of the first 185 surveys are presented here and
enrollment is ongoing. Mean age was 49.21, 48.6% were female, and 79.5% foreign
born. 41 countries of origin were represented; most frequently the United States
(n⫽38), Columbia (23), Dominican Republic (18), Mexico (12), Bangladesh (11),
and Ecuador (11). Mean duration of residence in the United States for foreign-born
patients was 19 years. 9.2% of respondents (17) stated that they had been harmed by
groups such as the government, police, military, or rebel soldiers. 10.8% (20) stated
they or their family had experienced torture (10 self, 5 family, 5 both). 23 were
further asked about their experiences including torture by military (7), police (6),
family (5), rebel soldiers (3), individuals (1), or groups of individuals (1). 73.9% (17)
of these suffered physical harm, 47.8% (11) emotional harm, 8.7% (2) sexual harm,
and 21.7% (5) other. Countries of origin for those reporting torture include the U.S.
(7), Columbia (5), Dominican Republic (4), and 1 each for Bangladesh, El Salvador,
Honduras, Morocco, Nepal, and Tanzania. Reasons for torture included ethnicity/
tribal affiliation (4), political affiliation (3), religion (2), local customs (2), sexual
orientation (1), no reason (4), and other (9). 13 of 22 (59%) left home or country as
a result of their torture. 5 of 22 (22.7%) have physical disabilities, 6 of 22 (27.3%)
S48 Annals of Emergency Medicine
have recurrent intrusive or distressing memories, 6 of 22 (27.3%) have ever had a
physician ask them about their torture and 3 have requested political asylum.
Conclusion: Survivors of torture are a distinct cohort of patients presenting to
our urban ED and are of diverse background. We found prevalence rates similar to
previously reported studies. Patients self-report torture by many groups including
abuse by family, governments, military, and police and for varied reasons including
no reason at all. Further data collection will help determine significance and whether
self-identification of torture is a significant predictor of torture as defined by
international standards. Practitioners should consider asking patients about torture.
156
Large Increase in Emergency Department Visits for
Head Trauma After Natasha Richardson’s Death
Campo C, Walsh B, Cochrane D, Allegra J/Morristown Memorial Hospital,
Morristown, NJ
Study Objective: Actress Natasha Richardson died from a head injury on March
18, 2009. According to some reports, she initially appeared well after sustaining the
injury. We hypothesize that the publicity surrounding this tragic event would be
associated with an increase in emergency department (ED) visits for evaluation of
head trauma.
Methods: Design: Retrospective cohort. Setting: Consecutive patients seen by ED
physicians in 19 urban, suburban and rural EDs in New Jersey and New York during
March 2009. Protocol: We classified patients as having head injury based on ICD9
codes. A priori, we chose to compare the daily visits for head injury for the ten days
before and after March 18. We used the Student’s t-test for statistical significance
with alpha set at 0.05.
Results: Of the 86,791 total ED visits in March, 2009, 2567 (3%) were for head
trauma. Of these, females comprised 46%. The median age was 21 years
(interquartile range: 7 years to 51 years). There was a 73% (95% confidence interval,
53% to 94%, p ⬍ 0.0001) increase in daily ED visits for head trauma for the 10 days
following March 18, 2009 compared to the 10 days before. There was little difference
in median age, interquartile age range and sex before and after March 18 for patients
presenting to the ED with head injuries. The number of visits for head trauma
returned to the pre-March 18 range by March 31.
Conclusion: There was a large increase in ED visits for head trauma for a brief
period following the death of Natasha Richardson. Media coverage can have a
profound influence on ED visits.
157
Patient Perceived Alcohol and Substance Abuse
Treatment Needs: An Urban Emergency
Department Pilot Study
Scott S, Kassem JN, Nagurka R, Velasco W, Valenzuela R, Grant WD, Lamba S/
The University of Medicine and Dentistry of New Jersey, Newark, NJ; State
University of New York Upstate Medical University-University Hospital, Syracuse,
NY
Background: Substance abuse (SA) increases the risk of disease, injury, and
disability, and this vulnerable population often seeks the emergency department (ED)
for their routine health care needs. The ED may represent the only opportunity to
connect these patients with adequate referrals to SA rehabilitation facilities.
Study Objective: This study is a needs assessment to identify alcohol and SA
treatment needs among our ED population with our purpose to further address the
patient-perceived barriers.
Methods: This pilot study is a convenience sample using a cross-sectional
descriptive design to explore the prevalence of alcohol and SA. We used the selfreport survey methodology to assess demographics and patient-perceived barriers.
Our study population consisted of consenting adult patients presenting to our urban
hospital ED from September ‘08 –February ‘09. Data were analyzed using Microsoft
SPSS.
Results: We enrolled: 102 patients; 51 male and 51 female; 58% of the
respondents were in the age range 30 –53; 57% (58/102) African-Americans; 20%
(20/102) Hispanic; 58% (59/101) were high school educated; 72% (72/100) were
health insured; 44% (45/101) did not have a primary care provider; 92% (94/102)
sought treatment in the ED within the past 1 year; 31% (32/101) identified the ED
as their sole health care provider. Sixty-three percent (64/102) of respondents
reported depression and 66% (67/102) reported anxiety within the past month.
Forty-seven percent (41/88) of respondents reported using drugs for non-medical
reasons with 38% (9/24) perceiving a need for drug rehabilitation now. Half (12/24)
of those perceiving a need for rehabilitation, used cocaine; 38% (9/24) used heroin;
Volume , .  : September 
Research Forum Abstracts
10% (10/101) used intravenous drugs. Seventy-six percent (74/97) of respondents
stated they would be willing to speak with someone while in the ED, if available.
Twenty-two percent (14/65) of respondents considered themselves to be
moderate or heavy drinkers and 39% (25/65) of all alcohol consumers felt they
should cut down on their drinking. Of these, 6% (4/65) felt they needed to be in an
alcohol treatment program now. Furthermore, of these, 100% (4/4) patients are
willing to speak to someone while in the ED, if available.
Seventy-two percent of respondents said the ED is a good place to get
information about drug and alcohol treatment.
Conclusions: One-third of our respondents reported using the ED as their sole health
care provider and more than 90% visited the ED in the past 1 year, providing an
opportunity for lifestyle interventions. Nearly half of our respondents reported SA. Threequarters of the patients in need of these services are willing to talk about rehabilitation
while in the ED. This pilot study serves as an initial needs assessment to identify the
prevalence and barriers preventing access to community resources for SA treatment.
158
Interobserver Reliability of a Novel Scar Evaluation
Scale
Singer AJ, Taira BR, Dagum AB, Hollander JE/Stony Brook University, Stony
Brook, NY; University of Pennsylvania, Philadelphia, PA
Study Objectives: We have recently described a novel scale to measure the
appearance of healed wounds based on photographs of scars. The current study
evaluated the interobserver reliability of the scar appearance scale (SES) on emergency
department patients with repaired lacerations.
Methods: Study Design-Prospective, observational. Setting-Academic suburban
emergency department with emergency medicine residency. Subjects-Convenience
sample of ED patients participating in multi-center randomized trial of new topical
skin adhesive. Measures-Demographic and clinical information were collected using
standardized data collection forms. Two emergency physicians (masked to each other)
evaluated all patients one month after wound repair and determined the cosmetic
appearance of the scars on a scar evaluation scale (SES). Scars were assigned 0 or 1
point each for the presence or absence of the following: width ⬎ 2mm, elevation or
depression, suture or staple marks, discoloration, and overall poor appearance. A total
cosmetic score was then calculated by adding the individual scores on each of the 5
categories ranging from 0 (worst) to 5 (best). Scars were also scored on a validated
100-mm VAS marked “worst scar” and “best scar” at the low and high ends. Data
Analysis-Interobserver agreement was calculated using Pearson’s, Spearman’s and
Kappa coefficients.
Results: The wounds of 33 patients were evaluated. Interobserver agreements for
the total SES and VAS scores were 0.83 and 0.60 (P⬍0.001 and P⬍0.01),
respectively. Interobserver agreement on the individual elements of the SES ranged
from 0.47 to 0.86. The agreement between the total SES and VAS scores for the 2
observers were 0.91 and 0.77 (P⬍0.001 for both).
Conclusion: The new scar evaluation scale was highly reliable and correlated with
the VAS in ED patients with repaired lacerations supporting its construct validity.
159
Use of the Descriptive Term “Experiment” Does
Not Significantly Influence a Potential Subject’s
Decision to Participate in Research
Schroeder JW, Carter MA, Jerusik B, Verma M, Heard K, O’Malley GF/
Philadelphia College of Osteopathic Medicine, Philadelphia, PA; Albert Einstein
Medical Center, Philadelphia, PA; University of Colorado, Denver, CO
Background: In an informal survey at our institution, 85% of emergency
department attending and resident physicians thought the word “experiment” is
inflammatory when used to describe a research study and would negatively impact a
patient’s decision to enroll.
Study Objective: Compare the willingness to participate among potential research
subjects when a hypothetical research proposal is described as an “experiment” versus
a “research project.” We hypothesize that potential subjects will be less likely to agree
to participate if the word “experiment” is employed. Methods: Survey of patients
presenting to an urban level 1 trauma center. Two hypothetical scenarios were
described to 200 subjects; one study described a relatively noxious minor procedure,
the other study described taking a pain medication. The descriptions were randomly
alternated so that one was described as an “experiment” and the other was described
as a “research project.” Subjects were then asked which study they would prefer to
participate in.
Results: There were no baseline (age, sex, race) differences between groups. 176
Volume , .  : September 
subjects expressed a preference for one study, 7 had no preference and 17 refused to
participate in either study. Of those who selected a specific study, 91/176 (51% [CI:
44 –59]) chose the study described as a “research project.” 99/176 (56% [CI:49 – 64])
chose the medication study, over the intervention. Older patents were less likely to
choose the study described as an “experiment” (Odds Ratio 0.97 per year); sex and
ethnicity were not associated with preference.
Conclusion: In general, describing a study as either an “experiment” or “research
project” did not affect subject preference or willingness to participate. Older subjects
were less likely to prefer studies described as experiments compared to younger
subjects.
160
Survey of Medical Decisionmaking: Ability of the
Public to Self-Triage and Recognize Symptoms of
Emergency Conditions
Plonk T, Gough JE, Brewer KL/East Carolina University, Greenville, NC;
Department of EM, East Carolina University, Greenville, NC
Study Objectives: Emergency department (ED) utilization continues to be a
major concern. The decision as to where to receive care is based on many factors such
as ability to pay, availability of alternatives, and ability to self-triage. The authors
sought to survey how individuals make decisions about medical care.
Methods: An anonymous online survey was sent to North Carolina residents. In
addition to collecting demographic information, participants were asked to indicate
where they would seek care based on 10 common complaints. Respondents were able
to choose from the following options: go to an ED; go to a primary care physician
(PCP); go to urgent care; go to pharmacy for over the counter medications, do
nothing - it will get better; or other. Participation in the survey was voluntary and
without compensation. The survey was approved by the institution’s institutional
review board under an exempt category.
Results: 506 responses were obtained. Of respondents, 73% were female and the
mean age was 49.9 years (SD ⫹ 14.9), Race was predominantly Caucasian (77.1%)
with 13% African American and ⬍1% Hispanic. Educationally, the majority (58%)
had completed all or some college. Older age, higher income, and higher education
were associated with having a PCP while younger age, lower income and less
education were associated with obtaining usual care from an ED, urgent care, or no
care at all. The majority (74%) indicated they receive most of their health care
through a PCP, while only 4% identified EDs as their primary source. For minor
complaints such as sore throat, fever, sprained ankles, cough and congestion, and
abdominal pain the majority indicated they would present to a PCP rather than an
ED. When respondents were asked if they thought they were having a heart attack
90% noted they would present to an ED and only 1% said they would do nothing.
However, when asked what they would do if they were having chest pain, trouble
breathing and sweating, only 69% stated they would go to an ED and 6% said they
would do nothing. Similarly, when asked if they thought they were having a stroke,
88% stated they would go to an ED and 1% would do nothing. However, when
asked if they had the sudden onset of the worst headache of their life, 30% said they
would go to an ED and 8% would do nothing. When asked if they experienced
abrupt onset of slurred speech 65% would seek care in an ED and 5% would do
nothing.
Conclusion: These data indicate that the majority of respondents would present
to an ED for major complaints and utilize alternative resources for less acute
complaints. Further studies should examine if this population is a representative
sample of ED patients and if these responses reflect actual behavior. Of note,
participants appeared to recognize the need for ED presentation for complaints such
as heart attack and stroke; however, they did not appear to recognize common
presenting symptoms of such diagnoses which may be an area for future study and
patient education.
161
Do Prolonged Emergency Department Waiting
Times Reduce Emergency Research Consent
Rates?
Limkakeng Jr AT, Glickman SW, Freeman D, Drake W, Mani G, Chandra A,
Cairns CB/Duke University, Durham, NC; University of North Carolina, Chapel
Hill, Chapel Hill, NC
Study Objectives: Emergency department (ED) crowding has resulted in
increased waiting times for patients, with deleterious effects on patient care and
resident education. There are unique challenges to enrolling patients in emergency
department clinical research studies, including the time-sensitive nature of emergency
Annals of Emergency Medicine S49
Research Forum Abstracts
conditions, the acute care environment, and the lack of an established relationship
with patients. The objective of this study was to assess the impact of emergency
department wait times on patient participation in clinical research in the emergency
department. We hypothesized increased ED waiting times will be associated with
reduced research consent rates.
Methods: Prospective study of all patients eligible for 2 diagnostic clinical
research studies from 01/01/08 to 12/31/08 in an academic emergency department.
The times to registration and to see a physician (MD) were obtained from
administrative databases, and sex, age, race, study eligibility and consent were
recorded by trained, dedicated study personnel. An analysis of association between
consent rate and patient waiting times was performed using an adjusted logistic
regression model (dependent variable consent yes/no) with independent variables
being time to registration, time to physician and other patient demographic factors
previously described to predict enrollment (age, race, sex).
Results: 877 patients were eligible for enrollment and consent requested. 572 of
877 eligible patients (65%) gave consent and were enrolled. The median time to
registration did not differ between those consenting to enrollment (9 minutes (min);
interquartile range (IQR) 15,36 min) versus those that did not consent (10 min; IQR
15,39 min) [p⫽0.80, OR 1.00 (0.99, 1.01)]. Similarly, there was no difference in the
median time to MD between those consenting (15 min; IQR 25, 55 min) versus
those that did not consent (15 min; IQR 25,56 min) [p⫽ 0.70, OR 1.00 (0.99,
1.01)]. Furthermore, consent rates did not change when stratified for the highest and
lowest quartile wait times to registration (68%, 65%) or MD (65%, 66%).
Conclusion: Regardless of waiting times to registration and to see a physician,
two-thirds of eligible patients were willing to consent to diagnostic research studies in
the emergency department. These findings suggest that effective enrollment in clinical
research is possible despite challenges with crowding and prolonged waits in the
emergency department.
162
Trends and Disparities in Emergency Department
Asthma Care, 1992–2006
Heins A, Rask K, Houry D/University of South Alabama College of Medicine,
Loxley, AL; Emory University, Atlanta, GA
Study Objectives: To describe temporal trends and racial and sex disparities in
asthma morbidity, as measured by emergency department visits and episodes of
hospitalization, from 1992–2006, testing the hypotheses that asthma morbidity is
decreasing and that disparities in asthma morbidity are narrowing across all
demographic categories of the U.S. population.
Methods: We conducted a secondary analysis of the National Hospital and
Ambulatory Care Surveys from 1992–2006. Data on all patients with a primary
diagnosis of asthma, ICD-9 493.xx, were collected including demographics,
characteristics of the ED visit, and disposition. Descriptive and regression methods
were used to examine the temporal trends and disparities in ED asthma visits and
admissions.
Results: Approximately 27 million visits for asthma occurred during the study
period, representing about 2.0% of ED visits and 0.3% of admissions, from 1992–
1999, but only about 1.5% of visits and 0.2% of admissions for 2000 –2006.
Emergency department visits and hospital admissions for asthma declined for most of
the population over the study period; however, children 0 –5 years of age, with a
consistent 15 visits per 1,000 population through the study period, had about double
the rates of ED visits compared to 6 –11 (8 per 1,000 in 2006) and 12–17 (6 per
1,000 in 2006) years and 5 times the rate for the 65⫹ group (⬍3 per 1,000). In
addition, rates of admissions for age group 0 –5 (2.7 per 1,000 in the early 1990s and
1.8 in 2006) were more than twice that for the 6 –11 age group (1.3 in early 1990s
and about 0.5 in 2006). Males had higher sex-standardized rates of asthma visits (3.8
per 1,000 average in 1990s, down to about 3 in 2006) and admissions compared to
females (about 3 in the 1990s, down under 2.5 in 2006), but the gap between the
sexes appeared to be narrowing. Blacks, in 2006, had about 4 times the ED visits and
admissions for asthma compared to whites (17 visits per 1,000 versus about 4 for
whites, and 2 admissions versus ⬍0.5), up from about 2 1⁄2 times the visits and
admissions in 2000 (14 visits versus 6 and 1.6 admissions versus 0.7).
Conclusions: Persistent disparities in the burden of asthma continue to affect
children and males, but the disparities are increasing for blacks. Research priority
should focus on determining the causes of the worsening burden of asthma among
Blacks and developing effective interventions to reduce the burden among all
demographic groups at highest risk.
S50 Annals of Emergency Medicine
163
Educational Intervention in Adult Asthma: A
Randomized Clinical Trial to Determine If Adult
Patients With Asthma Can Learn How to Use a
Metered Dose Inhaler
Acosta JF, Eckardt P, Negron D, Rubin D/Yakima Regional Medical & Cardiac
Center, Yakima, WA; Adelphi University, Garden City, NY; St. Barnabas Hospital,
Bronx, NY
Background: Asthma patients have difficulty using the metered dose inhaler
(MDI) correctly. Prior studies have shown that adequate training helps in the correct
usage of this method of drug administration. The aim of this study is to determine if
patients can be taught the use of the MDI with a video intervention. We will examine
retention of this information as well.
Methods: Patients were randomized into an experimental group (MDI training
video) and a control group (asthma information video). Demographic information
was obtained as well as the initial peak flow (PF). Every patient had a pre, post and
one month follow-up evaluation by the same examiner to avoid examiner bias. The
examiner was blinded to the intervention. This study was approved by the hospital
institutional review board.
Results: There were 133 patients enrolled in the study; 116 completed the study.
On average, the experimental group (MDI training video) had a 15.92% increase in
correct usage after intervention, whereas the control group (asthma information
video) had a 1.16% increase in correct usage (t ⫽ ⫺ 6.682 (95%CI for a mean diff of
⫺14.77, ⫺19.149, ⫺10.391 p⬍ 001). Comparing percent correct change from pre
video to one-month later post-video, the experimental group (MDI training video)
had a 15% increase in percent correct after intervention, whereas the control group
(asthma information video) had an increase in percent correct of 1.62% (t ⫽ ⫺5.772
(95CI for mean diff of ⫺13.298 was: ⫺17.862, ⫺8.735) p⬍ 001).
Conclusion: The MDI video training was demonstrated to improve subjects’ use
of the MDI. Study subjects with the MDI training video were also shown to retain
this information after one month.
164
Percutaneous Vagal Electrical Stimulation for
Severe Asthma
Lewis L, Theodoro D, Purim-Shem-Tov Y, Mosnaim G, Sepulveda P, Staats P,
Hoffman T/Washington University, St. Louis, MO; Rush University Medical
Center, Chicago, IL; Alamo Clinical Research Center, San Antonio, TX; Johns
Hopkins Medical Institutions, Baltimore, MD; ElectroCore LLC, Morris Plains, NJ
Study Objectives:
1) Determine if percutaneous electrical stimulation of the vagus nerve in patients
with acute asthma causes any adverse events.
2) Determine if percutaneous electrical stimulation of the vagus nerve improves
airflow in patients with acute asthma, who have failed to respond to inhaled ␤
adrenergic agonist therapy.
Methods: Study Design: Prospective within-group, non-randomized, noncontrolled interventional study. Setting: Multi-center emergency department (ED)
trial. Participants: Adult patients, seen in the ED for moderately severe asthma (FEV1
40%–70%), who failed to respond to 60 minutes of conventional pharmacologic
therapy (inhaled bronchodilators ⫾ steroids) were eligible for the study. Response
failure was defined as a post-treatment FEV1⬍ 70%.
Four patients met criteria and consented to the procedure. Following consent,
patients were prepped and draped, and an electrode lead was placed percutaneously
using ultrasound guidance in the vicinity of the vagus nerve, posterior to the carotid
sheath. The procedure was conducted in fully conscious and responsive patients using
local anesthesia at the insertion site. Treatment consisted of up to 180 minutes of
continuous electrical stimulation at 25Hz and 200ms pulse width at amplitude
ranging between 1–12 volts. End points for voltage increase were symptomatic
improvement, muscle twitching, or discomfort. FEV1 measurements were obtained
pre-stimulation, at 30min intervals during stimulation, and post stimulation. Pre/post
results were compared using paired t-tests.
Results: All patients were unresponsive to standard pharmacologic therapy,
including ␤2-adrenergic receptor agonists (4/4) and (3/4) steroid treatment.
Following 30 minutes of continuous electrical stimulation therapy (mean 7.6v; range
6.5 – 8.9v), the mean % predicted FEV1 increased from 59.5⫾4.7 to 68.3⫾ 5.2
(p⫽0.014). FEV1 continued to improve during the 180 minutes of treatment and
achieved a mean peak % predicted FEV1 of 75.2 ⫾ 5.5 (p⫽0.004). Additionally, the
FEV1 remained significantly improved at 30 minutes (p⫽0.035) after treatment was
completed. No patients required discontinuation of the device, and there were no
Volume , .  : September 
Research Forum Abstracts
episodes of worsening bronchoconstriction, hypotension, bradycardia, diaphoresis, or
increased tachycardia.
Conclusion: Electrical stimulation may be safely used to reduce
bronchoconstriction in certain patients with acute asthma. This presents a novel,
non-pharmacologic, and non-airflow dependent therapy for the treatment of asthma
in critical care settings.
165
Initial Out-of-Hospital End-Tidal Carbon Dioxide
Measurements in Adult Asthmatic Patients
Lamba S, Gluckman W, Nagurka R, Rosania A, Bechmann S, Langley DJ,
Scott S, Compton S/The University of Medicine and Dentistry of New Jersey,
Newark, NJ; St. Joseph’s Regional Medical Center, Paterson, NJ
Background: Early recognition of asthma severity is dependent upon the health
care provider’s physical assessment of the patient and is not usually aided by the
additional use of pulse-oximeter or peak-flow measurements. End-tidal carbon
dioxide (EtCO2) monitoring may provide out-of-hospital personnel supplemental
information on a patient’s ventilatory status and assist in the early recognition of
severe asthma exacerbations.
Study Objectives: To describe the distribution of initial out-of-hospital EtCO2
measurements in adult, non-chronic obstructive pulmonary diseases (COPD),
asthmatic patients, in relation to patient outcomes.
Methods: This observational study is a review of EtCO2 assessment data in a
convenience sample of adult, asthmatic patients transported via advanced life support
units (ALS) to a large, urban, Northeastern teaching hospital between October, 2005
and January 2008. Initial EtCO2 measurements were obtained routinely on all
respiratory distress patients in the field and emergency physicians were not aware of
the results. Data were analyzed using descriptive statistics, including percentages,
means, and 95% confidence intervals (CI). In addition, comparisons between patients
with and without markers of poor outcome were performed using chi-square analyses
and Fisher’s exact tests, with an aim toward hypothesis generation for future
prospective studies of the potential added value of initial EtCO2 measurements to aid
in the recognition of severe asthma.
Results: We reviewed data for out-of-hospital initial EtCO2 measurements on
299 unique asthma patients. Mean (SD) age was 43.1 years (12.5) and 142 (47.5%)
were male. Overall, the mean EtCO2 measurement was 38.8 mmHg (CI: 37.7 –
39.9; range: 14 to 82). Examination of initial EtCO2 measurements by deciles
revealed that extreme values, in the lowest (14 to 28mmHg) and highest (50 to
82mmHg) deciles, experienced more markers of poor outcome than less extreme
measurements. Patients were thus dichotomized by extreme (n⫽59) or non-extreme
(n⫽240) EtCO2 measurements. More extreme patients were ultimately intubated
(30.5% vs. 5.8%; p⬍0.001), and/or admitted to the intensive care unit (28.8% vs.
6.7%; p⬍0.001), and/or expired [5.1% vs. 0%; p⫽0.007 (Fisher’s Exact test)], than
non-extreme patients, respectively.
Conclusion: The results of this study suggest that extreme (both low and high)
out-of-hospital initial EtCO2 measurements may be associated with markers of poor
patient outcomes. Future work will prospectively determine whether the addition of
this information improves early recognition of severe asthma episodes beyond clinical
assessment.
166
Emergency Department Operational Improvements’
Impact on Volume, Quality Core Measures, Patient
Stay and Satisfaction
Sayah A, Lobon L, Rivard L, Skura S/Cambridge Health Alliance, Cambridge, MA
Study Objectives: Emergency department (ED) crowding and the resulting
ambulance diversion, long patient waits, and many patients leaving without being
evaluated have been major issues that have affected the satisfaction of patients with
their emergency visits. This is an observational, descriptive, retrospective study in a
community teaching hospital that looks at the impact of a series of ED changes on
volume, quality core measures, patient flow and satisfaction.
Methods: Between August 2006 and July 2008, multiple ED changes were
implemented in the areas of personnel and leadership, culture, technologies,
communication, policies and procedures, and flow. The ED leadership team in
collaboration with many hospital services reengineered the patient ED experience
from arrival to departure. Implemented changes included rapid assessment protocol
with bedside registration, electronic triage and patient tracking. Various ED metrics
were followed including diversion rates, ED volume, ED patient length of stay, ED
Volume , .  : September 
patient left before treatment complete (LWOT) rates, Press Ganey patient satisfaction
scores, and ED-specific quality core measures.
Results: Ambulance diversion decreased from a historical 3.6% of time in FY05
and FY 06 to zero since September 2006. ED length of stay decreased from a mean of
187 minutes in August 2006 to 150 minutes during Q2 FY09. Patient satisfaction
Press Ganey scores rose from 76.1 (5th percentile) in Q4 FY06 to 85.6 (64th
percentile) in Q2FY09. ED patient volume is growing by a projected 7.2% between
FY06 and FY09 (28,481 to 30,500) resulting in a 30% increase in inpatient
admissions from the ED for the same period (2,905 to 3,781). ED-specific quality
core measures increased from 82% in Q4 FY06 to 98% in Q4FY08. The rate of ED
patients who left before treatment was completed dropped from 3.7% in FY06 to
0.80% during Q2 FY09.
Conclusion: The ED operational changes have had a significant positive impact
on all measured metrics. While the volume of ED visits and resulting inpatient
admissions have increased, ambulance diversion was eliminated, patient length of stay
was reduced, the rate of patients who left without evaluation was reduced, and patient
satisfaction and quality measures increased to a record high. Improving ED
operational efficiency has provided our department with the ability to accommodate
increasing volume and acuity and improve the quality of care and the experience of
patients who visit our ED.
167
Implementation of Crowding Solutions From the
American College of Emergency Physicians Task
Force Report on Boarding
Handel DA, Boehland A, Ginde AA, Raja AS, Rogers J, Sullivan AF, Camargo CA/
Oregon Health & Science University, Portland, OR; University of Colorado,
Denver, CO; Brigham and Women’s Hospital, Boston, MA; Monroe County
Hospital, Forsyth, GA; Massachusetts General Hospital, Boston, MA
Study Objectives: In 2008, the Task Force Report on Boarding proposed highimpact crowding solutions such as hospital discharge coordination, inpatient full
capacity protocols, and the coordination of elective surgeries. To date, there are no
data on the implementation of these crowding solutions. The purpose of this study is
to crowding and solutions in EDs of different annual visit volumes in a single state.
Methods: We mailed surveys to all physician and nursing emergency department
(ED) directors in Oregon. Federal and military hospitals were excluded. Survey
questions related to crowding were drafted based on the ACEP Task Force’s
recommended solutions, and responders were asked to provide data pertaining to
2008. Initial non-responders received two subsequent mailings of the survey.
Respondents were contacted via telephone and e-mail to obtain missing data. EDs
were classified according to their average visit volume: ⬍ 1 patient per hour (ie,
⬍8760 ED visits/year), 1–1.9 patients per hour, 2–2.9 patients per hour, and 3 or
more patients per hour.
Results: 51 of 59 EDs responded (86% response rate). 14% (7/49) EDs stated
that they cared for patients in the hallway, a practice most prevalent amongst EDs
seeing 3 or more patients per hour (29%). 61% (30/49) of all EDs, except for those
that saw ⬍1 patient per hour (14% in this group), stated that they boarded patients
for ⬎2 hours on a typical day at 6 pm until an inpatient bed became available. The
ED attending was the physician of record for boarded patients in 73% (30/41) across
all volume categories. The median elopement rate was 1.5% (range 0 –9%) with no
significant difference between ED groups. Overall, 45% (22/49) of EDs stated they
went on ambulance diversion in 2008. Diversion was most prevalent in EDs with 3
or more patients per hour (71%, 12/17). The median number of hours on diversion
per month was 24. In EDs that saw 3 or more patients per hour, the median number
of diversion hours per month was 55 hours vs. 6 or less for the other three groups
(p⫽0.03). Of the hospital-wide crowding solutions, 10% (5/48) had inpatient full
capacity protocols, 54% (26/48) had inpatient discharge coordination, 34% (15/44)
had surgical schedule smoothing, and 26% (12/47) cancelled elective surgeries if
needed. In terms of ED solutions, 47% (23/49) had bedside registration, 25% (12/
48) had a fast track unit, 12% (6/49) had an observation unit, 4% (2/49) had a
physician at triage, and 37% (18/49) had expanded the number of ED beds in the
past 3 years.
Conclusion: While many of the ACEP strategies have been employed, there
remains room for increased implementation. Diversion is more prevalent in larger
EDs but is seen EDs of all sizes in Oregon.
Annals of Emergency Medicine S51
Research Forum Abstracts
168
Utilization of the Situation-BackgroundAssessment-Request, Companion Phones, and Cell
Phones Improves Communication With Consultants
in the Emergency Department
Farley H, Choy H, Ellicott A, Mascioli S, Reed III J, Weintraub W, Reese IV CL/
Christiana Care Health System, Newark, DE
Study Objective: Timely and effective interdepartmental communication is a vital
component of ED patient care. Objective: To determine if emergency physicians and
cardiologists perceive an improvement in interdepartmental communication after
implementation of situation-background-assessment-request (SBAR) guidelines and
the use of companion and cell phones.
Methods: A 4-question survey assessing the timeliness and effectiveness of
interdepartmental communications was distributed to all emergency medicine
attendings, EM residents, and cardiologists in 1 hospital in 9/07. Responses were
recorded on a 5-point Likert scale from 1(poor)–5(excellent). The SBAR guidelines
were then introduced to the EM residents and incoming consultant calls were routed
directly to EM resident companion phones and EM attending cell phones.The survey
was repeated in 9/08 and the results compared using Pearson’s chi-square. A p-value
of ⬍0.05 was significant.
Results: 76 physicians (56.3%) responsed to the 1st survey, 55 (40.7%) to the
2nd. Analysis of EM responses revealed an improvement in perceived responsiveness
of the cardiologist (3.44⫾0.80vs.2.83⫾1.06,p⬍0.01), ability to anticipate
information requests (4.43⫾0.70vs.3.72⫾0.98,p⬍0.01), and overall
interdepartmental communications (3.41⫾0.80vs.2.91⫾1.05,p⫽0.01). There was
no change in the perceived ability of the emergency physician to reach the
cardiologist on the first call (3.14⫾1.21vs.2.83⫾1.15,p⫽0.21). Analysis of
cardiologist responses revealed no improvement in perceived responsiveness of the
emergency physician (2.83⫾1.47vs.2.32⫾1.09,p⫽0.25), ability to contact the
emergency physician on the first attempt (2.17⫾1.19vs.2.14⫾1.13,p⫽0.94),
emergency physician communication of necessary information
(3.42⫾0.9vs.2.68⫾1.32,p⫽0.96), or overall interdepartmental communications
(2.17⫾1.12vs.2.14⫾1.08,p⫽0.94).
Conclusion: By implementing SBAR guidelines and direct routing of consultant
calls to emergency physician companion and cell phones, emergency physicians
perceived an improvement in interdepartmental communications.
169
A Protocol to Improve Door-to-EKG Times in the
Emergency Department
Mostofi M, Tivnan E, Barnewolt B, Penzias A, Weiner S/Tufts Medical Center,
Boston, MA
Study Objectives: Time is of the essence in the treatment of acute myocardial
infarction. As part of a multi-disciplinary process to improve our hospital’s door-toballoon times in these patients, we instituted various techniques focusing on
improving the door-to-electrocardiogram (EKG) times in all eligible emergency
department (ED) patients.
Methods: In 2007, our department instituted a protocol in which all patients
over age 35 with chest pain or possible angina equivalent (including epigastric pain,
shortness of breath, dizziness, upper back pain, palpitations and others) receive an
EKG within 10 minutes of arrival to the ED. For walk-in patients, we provided a
chair and additional EKG machine at triage to rapidly perform the EKG by an ED
technician who received specific training. For emergency medical service (EMS)
patients, nurses were instructed to immediately obtain the EKG in a designated area
and then move the patient if necessary. EKGs were handed to any attending
physician in the ED for quick review. We measured the time from arrival to EKG in
all such patients during an 18-day period after the intervention and a similar control
time period prior to the intervention. Chief complaints, modes of arrival, time to
EKG and rates of performance of EKGs in eligible patients were recorded.
Results: 145 patients met inclusion criteria (by chief complaint and age) in the
control cohort, and 105 (72.4%) had an EKG. 163 patients were included in the
study cohort, of which 126 (77.3%) had an EKG. The average time to EKG before
the intervention was 71.3 minutes (95% CI 55.8 – 86.8), median 36 minutes (IQR
19.0 –92.5), and 9/105 (8.6%) were performed in 10 minutes or less. The average
time to EKG after initiation of our protocol was 30.3 minutes (95% CI 23.4 –37.3),
median 16 minutes (IQR 10 –29), and 35/126 (27.8%) were performed in 10
minutes or less. The difference in time to EKG was statistically significant (p⬍0.001),
as was the percentage of EKG performance ⬍10 minutes (p⫽0.004).
Conclusion: A multi-focal process to improve door-to-EKG times, including
S52 Annals of Emergency Medicine
institution of a formal protocol, EKGs from triage and a designated area for obtaining
EKGs for EMS patients is useful to decrease door-to-EKG times in patients with
chest pain or angina equivalents.
170
Managing Patient Expectations at Emergency
Department Triage
Rumoro D, Shah S, Patel A, Hohmann S, Fullam F/Rush University Medical
Center, Chicago, IL; University HealthSystem Consortium and Rush University
Medical Center, Chicago, IL
Study Objectives: Crowding, closure of emergency departments (ED), long waits
coupled with reductions in resources (eg, limited staff), lower reimbursement rates,
and uncomfortable waiting room conditions may contribute to lowering the
perceived quality of the patient experience and patient satisfaction. This study
investigates the relationship between patient satisfaction and communication of
expected wait times (ie, managing expectations), at the point of triage.
Methods: A pre-post non-equivalent group study design with convenience sample
of all discharge to home adult ED patients was utilized for this study. Patients
returning within 72 hours were removed from the analysis. A static expected wait
time model (ie, average wait time plus one standard deviation calculated with twelve
months of data) based on time of the day, day of the week and triage levels was
employed (ie, communicating expected wait time) at the triage while an in-house
survey with five-point Likert-scale patient satisfaction questions (satisfied with wait
time in triage, informed about delays, and overall ED rating) was administrated at the
discharge desk. The pre- and post- implementation time periods were November 4,
2008 – January 3, 2009 (n⫽887) and January 4, 2009 – February 5, 2009 (n⫽322),
respectively.
Results: Though the actual communication of delays intervention wasn’t
significant for patient satisfaction questions (ie, wait time in triage and being
informed of delays except for the overall ED rating), the communication status (yes/
no) and other known factors of ED crowding (eg, time of day, day of week, ED
length of stay, and acuity) were significantly associated with patient satisfaction. The
patients who did not receive communication about delays, whether before or after the
intervention, were between 1.5 to 5.0 times more likely to rate the three satisfaction
questions lower than very good. Patients during the pre- and post-implementation
who did not receive communication about expected wait times were 2.6 and 2.83
times more likely to rate the item on satisfaction with wait time as fair compared to a
rating of very good. The percentage of patients responding very good and very poor
for the item on satisfaction with wait time were 15% higher and 6% lower,
respectively, with the communication status as yes.
Conclusion: Although communication of delays was not significant in the initial
analysis, the patients who received information about wait times were significantly
more satisfied. This indicates that patients are more likely to accept longer wait times
provided their expectations are managed (ie, delays were communicated). The limited
sample size of post-implementation justifies future studies which will incorporate
longer post-implementation sample, more rigorous implementation (communication
of delays to patients) and adherence of the intervention.
171
Characteristics of an Emergency Medicine-Led
Rapid Response Team at an Academic Tertiary
Care Hospital in the United States
Mace SE, Buller L, Thallner E, Tallman T/Cleveland Clinic, Cleveland, OH
Study Objectives: Rapid response teams (RRTs) have been developed to respond
to changes in a patient’s condition. Intensivists often lead RRT in large academic
teaching hospitals. The Cleveland Clinic, a 1000 bed, academic, tertiary care hospital
began an Adult Medical Emergency Response Team (AMET) in January 2008.
Methods: AMET is staffed by a 3 member emergency medicine (EM) team:
nurse, respiratory therapist, and physician. Each AMET team member has AMET as
their primary assignment and responds to the patient’s bedside within 10 minutes of
being paged. Hospital employees activate AMET by dialing 122. AMET carries 2
bags containing emergency medications, respiratory supplies including intubation
equipment, and point-of-care testing via a portable rolling luggage cart. Criteria for
calling AMET include acute respiratory, cardiac, neurologic or BP change defined as
any of the following: RR⬍8 or ⬎32, pulse oxygen saturation ⬍90%, HR ⬍40 or
⬎140 with symptoms, HR ⬎160, BP ⬎220 with symptoms, BP⬍80, chest pain
(CP) with ECG changes or unresponsive to NTG, mental status change, loss of
consciousness, lethargy, new focal weakness or loss of movement, sudden collapse.
AMET calls for the first year of operation were evaluated.
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Results: 1284 in first 15 months of operation. Calls gradually increased with a
spike in July, then leveled off averaging 90/month. Demographics: age (mean) 61.4
years (range 15–99), 51% male, 49% female, 68% Caucasian, 28% African
American, 4% other.
Reasons for call were any acute change in: respiratory 42%, cardiac 21%,
neurologic 20%, BP 16%, other 1%. Respiratory calls (42%) were abnormal RR
27%, decreased oxygen saturation 15%. Neurologic calls (20%) were loss of
consciousness 11%, lethargy 5%, sudden collapse 3%, new focal weakness 1%.
Cardiac calls (21%) were bradycardia or tachycardia 17%, CP 4%.
Conclusion: Demographic data indicates over 3⁄4 of the patients were ⬎50 years
old (78.2%) and, by decade of age 1⁄4 (26.4%) of the patients were between 60 and
70. Sex and race reflected our patient population. The majority of calls were
respiratory (42%) followed by cardiac (21%) then neurologic (20%). Call analysis
reveals that there were no inappropriate calls, as reflected by the call criteria. To our
knowledge, this is the first emergency medicine led RRT. There are many benefits to
an emergency medicine-led team including: increased throughput for emergency
department patients due to additional ED staffing when team members are not on an
AMET call, maintenance of technical skills by emergency medicine staff and
increased teaching for medical/surgical residents by emergency medicine attending
staff.
172
An Analysis of Patients Treated by a Rapid
Response Team: A High Acuity, Critically Ill
Patient Population Requiring Multiple Procedures
and Transfer to a Higher Level of Care
Mace SE, Buller L, Thallner E, Tallman T/Cleveland Clinic, Cleveland, OH
Study Objectives: Rapid response teams (RRTs) were developed to improve
patient outcomes. An Adult Medical Emergency Team (AMET) was initiated January
2008 to respond to acute changes in patient status. Emergency medicine (EM)
personnel: nurse/respiratory therapist/physician respond to AMET calls within 10
minutes of being paged. The team brings emergency supplies including: respiratory/
intubation equipment, intravenous line setup, point of care testing, medications.
Methods: 2008 AMET calls were analyzed re interventions, patient dispositions,
outcomes (mortality). Follow-up of AMET patients as of March 31, 2009 regarding
mortality was done.
Results: 1284 AMET calls in the first 15 months of operation; 87.9% to nonintensive care unit (ICU) inpatient medical/surgical floor, 12.1% for
visitors/outpatients.
Interventions on all AMET calls:
Airway interventions: pulse oximetry 76%, supplemental oxygen 75%, oral/nasal
airway 21%, suctioning 10%, nebulizer treatment 8%, BiPAP 6.5%, intubated 23%.
Intravenous (IV) interventions: bolus IV fluids 50%, second peripheral IV line
34%, central IV line 5%.
Diagnostic testing: ECG 57%, chest x-ray 22%, point-of-care testing (POCT):
blood gas 50%, electrolytes/BUN/creatinine 42%, hemoglobin/hematocrit 34%,
lactate 33%.
Cardiopulmonary resuscitation was needed in 8%.
AMET Call Disposition:
Only 27% (347/1284) of all patients remained on their medical/surgical floor,
while 73% (937/1284) were emergently transferred to a higher level of care or expired
during the AMET call. “Immediate” transfers during AMET call were ICU 50%,
emergency department (ED) 12%, telemetry 5%, operating room (OR) 1%, cardiac
catheterization lab 1%, expired 5%.
Of the 27% (n⫽347) remaining on their original floor, 85% were transferred or
expired within hours when they failed to improve despite initial AMET therapy.
“Delayed” transfers in these 347 patients included: 29% ICU, 6% ED, 10% OR, 4%
telemetry, 1% cardiac catheterization lab, 35% expired.
Overall analysis reveals that 4% (52/1284) of AMET patients remained on the
same floor during their hospital stay, with 96% eventually transferred to a higher level
of care or expired (includes visitors/outpatients).
Patient status as of March 25, 2009: 30% of AMET patients (n⫽385) have since
expired.
Conclusion: AMET patients are critically ill, need numerous diagnostic
interventions, multiple therapeutic interventions, especially airway and venous access
procedures. They require transfer to a higher level of care and have a high eventual
mortality. Only 4% of the patients remained at their initial inpatient floor.
Volume , .  : September 
173
Effect of an Attending Physician Float Shift to Care
for Boarding Patients in a Crowded Emergency
Department
Holt S, Hardy L, Mistry C, Kulstad E/Advocate Christ Medical Center, Chicago, IL
Study Objectives: Despite the increasing problem of emergency department (ED)
crowding, few solutions that can be readily implemented in the ED have been
examined. Patients backlogged in the ED waiting for an inpatient bed (boarders)
continue to require the attention of emergency physicians, further exacerbating
crowded conditions. To address this problem, our department added a ”float shift” to
our winter schedule solely to provide care to boarders. We sought to quantify the
effect of this float shift, hypothesizing greater physician productivity when this shift
was utilized.
Methods: We performed a retrospective observational study in our community
hospital ED, measuring the number of new patients seen in each 10-hour shift in the
presence or absence of a float shift physician. By querying our ED electronic tracking
board, we extracted the number of new patients seen for each of 7 daily shifts during
the months of February (when the float shift was present) and May (when the float
shift was absent) of 2008. We then compared the mean number of patients seen per
shift in February with the mean number seen per shift in May.
Results: Total monthly patient volume was 6656 for February and 6775 for May,
with the mean daily census being 230 and 219 patients, respectively. Mean door-todisposition time (256 minutes versus 222 minutes) and total time on diversion (83
hours versus 43 hours) was greater in February than in May. However, the number of
new patients seen during each shift in February was greater than in May (mean
increase of 1.1 patients per shift), with 2 daily shifts having significantly greater mean
new patient volume (19 versus 17 patients, P⫽.049, and 22 versus 19 patients,
P⫽.012).
Conclusion: The presence of a “float shift” physician caring only for boarding
patients allows other physicians to maintain and even increase their productivity in
our ED, despite the presence of longer throughput times and increased time on
diversion.
174
Emergency Severity Index Triage System
Correlation With Emergency Department Evaluation
and Management Billing Codes
Hendry D, Wiler J, Poirier RF, Griffey RT, Farley HL, Zirkin W/Washington
University St. Louis, St. Louis, MO; Washington University, St. Louis, MO;
Christiana Care Health System, Newark, DE; Greater Baltimore Medical Center,
Baltimore, MD
Study Objectives: Estimating financial data from patient information is valuable
for operations management. Emergency Severity Index (ESI) triage acuity levels
predict facility resource utilization, but correlation to physician billing as a forecast
surrogate for revenue has not been studied. We investigate and describe the
correlation between Emergency Severity Index levels and (i) emergency department
evaluation and management billing codes 99281-99285 and 99291, and (ii) total
provider service charges (procedure and E&M charges).
Methods: Multi-centered retrospective study of 192,147 adult patients at 3
institutions. Using Spearman rank correlation coefficient, we determined the
correlation of ESI levels with evaluation and management billing codes and total
provider charges. Analysis of ESI and evaluation and management code associations
were broken down by center type. Demographics were analyzed using regression
analysis.
Results: ESI level and emergency department evaluation and management billing
codes were moderately correlated, Spearman r⫽ 0.51. ESI high acuity levels 1, 2 and
3 were most frequently associated with evaluation and management level 5 code
(99285) at 50, 63, and 44% of the time respectively. ESI less-acute levels 4 and 5
were most frequently associated with an evaluation and management level 3 code
(99283) at 56 and 67%, respectively. ESI acuity level was correlated with emergency
physician billing charges at r⫽0.33. This relationship was preserved across settings.
Average total provider charges for ESI 1 was $604 and ESI 5 $265.
Conclusion: We found a consistent relationship between ESI triage level and (i)
emergency department evaluation and management billing codes and (ii) total
physician billing charges which was preserved across practice settings. ESI levels 1 and
2 corresponding to evaluation and management level 5 code (99285) and ESI levels 4
and 5 corresponding to evaluation and management level 3 code (99283). This
correlation can be used for forecasting financial outcome data which may be helpful
for operations management.
Annals of Emergency Medicine S53
Research Forum Abstracts
175
Emergency Department Inpatient Bed Management
Inventory System
Shah S, Silva J, Ward E, Rumoro D/Rush University Medical Center, Chicago, IL
Study Objective: Emergency department (ED) crowding is an important issue
affecting patient care, quality, and safety as well as increasing health care costs. To
improve these factors, streamlining ED operations and reducing waste (ie, delays) are
essential. One of the areas to improve ED throughput is to reduce disposition delays,
which are divided into time-to-bed-ready and bed-ready-to-patient-out delays. Thus,
the objective of the project is to develop a quantitative methodology to reduce ED
crowding and increase ED capacity by eliminating process (time to bed ready) delays
at ED disposition.
Methods: Theoretical inventory bed management policy (IBMP) was developed
and applied (current and proposed strategies) to a large academic medical center
(AMC) with a 34-bed ED to reduce delays associated with ED patient disposition to
inpatient general medicine beds. The goal of IBMP is to optimally balance between
additional charges/revenue opportunities for ED and maximum utilization of
requested inpatient beds. The data elements utilized for this study included the time
to bed ready delays, type of bed, day of week, hour of the day, distribution of bed
request, and financial charges (ie, ED charges per hour per patient and general
medicine bed charges per day).
Results: Based on the policy, the recommended general medicine bed requests,
for the AMC with 34 ED beds, was 14, 12, 10, and 8 general medicine beds for
Monday-Thursday, Friday, Saturday, and Sunday, respectively. The anticipated
additional charges (revenue) in the first year and each subsequent year were estimated
at $1.47 million (revenue ⫽ $513,000) and $160,000 (revenue ⫽ $50,000),
respectively with the time to bed ready substantially (⬃ 0 minute) reduced.
Conclusion: Apart from improving the direct outcomes such as time to bed ready
delays and financial profitability, IBMP will also improve patient and staff
satisfaction, length of stay, and left without been seen statistics. The first steps in
implementing the IBMP intervention were to place the bed request demands per day
of the week on the capacity management dashboard, which allows bed controllers to
plan for anticipated ED to inpatient bed requests. Full implementation will result in
additional ED capacity and further streamlining of ED operations.
176
D-ECG times between PRE and month 1 (p⬍0.0001), month 2 (p⬍0.0001), month
3 (p⬍0.0001), month 4 (p⬍0.0001), and month 5 (p⫽0.0001). See tables below.
In the POST cohort, patients with final diagnosis of ACS had significantly
shorter D-ECG times when compared to NC-CP, with a median D-ECG time 10
min for ACS (IQR 5 to 20), versus 20 min (IQR 10 to 41) for NC-CP (p⬍0.0001).
In patients with final diagnosis of ACS and with final diagnosis of NC-CP, there
was a significant difference in D-ECG times between PRE and each following month,
except for month 5 in de ACS group that was not significant (p⫽0.53).
Conclusions: The educational intervention significantly reduced overall door to
ECG times during the study period. This intervention effectively maintained D-ECG
times within current national recommendations. However, there is a trend in the
ACS group to returning to baseline times, suggesting that a new intervention is
needed after this period.
Further work should be done to explore additional strategies that focus on
standardized process improvement to benefit patients presenting to the ED with CP
and possible ACS.
Evolution of Door to Electrocardiogram Times After
an Educational Strategy in Patients Presenting
With Chest Pain to the Emergency Department in
a Chilean Academic Center
Aguilera P, Altamirano R, Bellolio M, Pineda N, Morales JF, Alcayaga A,
Gabrielli L, Castro P, Mardónez JM/Pontificia Universidad Católica de Chile,
Santiago, Chile; Mayo Clinic, Rochester, MN
Study Objective: To evaluate the effect over time of an educational strategy for
reduction on door to ECG times (D-ECG) among patients presenting with chest
pain (CP).
Methods: This was a prospective cohort study of door to first ECG times for
patients presenting to an urban, academic emergency department (ED) in Santiago,
Chile, with non traumatic CP. All patients with CP who had an ECG recorded
during the ED evaluation were included. Our previous study showed a significant
reduction in D-ECG times one month after intervention. The intervention consisted
on education to all the ED staff about the importance of providing prompt care of
CP patients, as well as letting the staff know that the D-ECG time and final ED
diagnosis will be recorded.
Times were collected for 5 consecutive months and were compared with the
times before the intervention. D-ECG times did not follow a normal distribution,
Wilcoxon rank sum test was used, and median with interquartile ranges (IQR) were
reported.
Results: 711 patients presenting with CP to the ED were included in this study;
there were 163 patients in the pre-intervention (PRE) period, and 548 in the postintervention (POST) period (months 1–5).
The ED diagnosis for the PRE cohort was: 20.3% acute coronary syndrome
(ACS), defined as myocardial infarction or unstable angina, and 79.8% non-coronary
CP (NC-CP), including any other non traumatic chest pain etiologies. In the POST
cohort, the diagnosis was 23.7% ACS and 76.3% NC-CP. The difference in
diagnosis PRE vs POST was not significant (p⫽0.35).
The median D-ECG time PRE was 29 minutes (min) (IQR 15 to 52), and
POST was 15 min (IQR 8 to 33), (p⬍0.0001). There was a significant difference in
S54 Annals of Emergency Medicine
177
A Comparative Analysis of Screening Hypertensive
Patients for Left Ventricular Abnormality With
Electrocardiograph and NT-proBNP
Chandra A, Freeman D, Mani G, Drake W, Limkakeng A/Duke University Medical
Center, Durham, NC
Study Objective: A new heart failure (HF) classification system recommends
therapeutic interventions performed on hypertensive patients before the appearance
of left ventricular dysfunction symptoms in order to reduce the morbidity and
mortality of HF. We evaluated the effectiveness of electrocardiograph (ECG), NTproBNP, and ECG with NT-proBNP in identifying left ventricular abnormality.
Methods: This was an interventional, prospective trial performed at an urban,
tertiary care hospital. Convenience sampling was used to identify and enroll patients
with two emergency department blood pressure (BP) measurements in the JNC-7
Stage 2 category. Patients were excluded if they exhibited moderate or severe renal
dysfunction, acute coronary syndrome, pulmonary embolism, or a history of
congestive heart failure as they may influence NT-proBNP values. Blood was
obtained and NT-proBNP determined using the Response Biomedical RAMP
platform technology. A NT-proBNP of 250 ng/L was used as a cutoff. Left
ventricular dysfunction was defined as the presence of any hypertrophy. Descriptive
statistics are used to report diagnostic performance. Area under the curve (AUC)
analysis is performed to identify ideal NT-proBNP value.
Results: Forty-nine patients were enrolled with a mean age of 58 yo. Twenty-four
percent of these patients were not being treated for hypertension. The AUC was 0.67
(CI 95 0.52– 0.80). The best diagnostic performance occurred when NT-proBNP
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Research Forum Abstracts
and ECG were combined to screen for left ventricular hypertrophy, sensitivity 65%
(CI 95 43– 83%) and specificity 83% (CI 95 51–97%).
Conclusion: NT-proBNP combined with an ECG is effective at screening for left
ventricular abnormality in patients with hypertension. These findings may be initially
used to screen for end-organ changes of the heart when echocardiography is not easily
available.
178
The Percent of Total Emergency Department Visits
for Congestive Heart Failure Declined From 1996
to 2008
Wreschner BM, Allegra JR, Eskin B/Morristown Memorial Hospital, Morristown,
NJ
Study Objectives: Many advances have been made over the last decade in the
treatment of congestive heart failure (CHF) patients, including the use of beta
blockers and a focus on patient education. We hypothesized that this should result in
a decrease in patients presenting to the emergency department (ED) with CHF. Our
objective was to test this hypothesis in a large database of ED visits.
Methods: Design: Retrospective cohort. Setting: Consecutive patients seen by
emergency physicians in 28 urban, suburban and rural hospitals in New Jersey and
New York between 1/1/1996 and 12/31/08. Protocol: We classified patients as
having CHF if the first ED diagnosis was congestive heart failure, heart failure or
pulmonary edema or if one of these was listed as the second diagnosis and the first
diagnosis was a respiratory diagnosis (shortness of breath, dyspnea, respiratory failure
or wheezing). Data Analysis: We compared the annual CHF visits to total annual ED
visits using the Student t test and performed a regression analysis. Alpha was set at
0.05.
Results: Of the 7,567,002 ED visits in the database, there were 104,489 visits (1.4%)
with an ED diagnosis of CHF. The mean age of the patients with CHF was 73 ⫹/⫺ 18
years; 54% were female. There was a 49% (95% CI: 46% to 51%, p⬍0.001) decline in
the percent of total ED patients that had CHF, from 1.6% in 1996 to 0.8% in 2008. The
correlation coefficient for this downward trend was R2 ⫽ 0.75 (p⬍0.0001).
Conclusion: We found a 49% decline in the percent of total ED visits for CHF
from 1996 to 2008. We speculate the cause for this decline is likely due to advances
in treatment for CHF.
179
Disposition and Final Diagnosis of Patients
Presenting with Chest Pain to an Academic
Emergency Department in Chile
Aguilera P, Altamirano R, Pineda N, Bellolio M, Alvizú S, Mardónez JM/Pontificia
Universidad Católica de Chile, Santiago, Chile; Mayo Clinic, Rochester, MN
Study Objectives: To describe and evaluate the hospital admission rate and final
diagnosis of a cohort of patients presenting to the emergency department (ED) with
non-traumatic chest pain (CP).
Methods: This was a prospective cohort study of a consecutive cohort of patients
presenting with CP to an academic ED during a 4 month period. Information was
collected on demographics, signs and symptoms at presentation, comorbidities,
medication use, final ED diagnosis, troponin values, disposition, and final
hospitalization diagnosis. Patients discharged from the ED were followed through a
telephone call at 30 days. As per our protocol, all patients presenting with CP in
whom an acute coronary syndrome (ACS) was suspected, were assessed by a
cardiologist in the ED. Results were analyzed with T test, Chi-square and nonparametric test according to the type and distribution of the data.
Results: A total of 541 patients with CP were included. The mean age was
Volume , .  : September 
48.3 ⫾ 18.2 years, 58% were men. A total of 489 (90.7%) had an ECG recorded in
the ED, with a median door to ECG time of 16 minutes, 293 (54.2%) had Troponin
measured, and 195 (36%) were evaluated by a cardiologist in the ED.
There were 114 patients with suspected ACS (21.1%), and 3 of these were
transferred to a different hospital. A total of 154 (28.5%) patients were admitted with
the following ED diagnoses: 111(72.1% of admissions and 20.5% of the study
cohort) ACS, including 23 patients with ST elevation MI; 17 (11%) respiratory
causes, 9 (5.8%) non differentiated CP, 6 (3.9%) supraventricular arrhythmias, 9
(5.8%) other causes.
Comparison of the clinical characteristics of the ACS vs non-coronary CP (NCCP) are displayed in Table 1.
Among patients admitted as an ACS to our hospital (n⫽111), 16 of the 23
STEMI (70%) went to cardiac catheterization. When comparing ED diagnosis of
ACS vs hospital diagnosis, we found overall agreement of 71%.
There was 86.3% follow up at 30 days. We found that 26 of 333 (7.8%) patients
discharged directly from the ED, 11 of the 130 (8.5%) admitted to the hospital, and
1 of the 4 (25%) transferred patients had an unscheduled return ED visit. There was
no difference in return to ED between ACS and NC-CP (RR 1.23, 95%CI 0.6 –2.5,
p⫽0.57). There were no fatal outcomes in this cohort.
Conclusions: There was good overall agreement between the diagnosis of ACS by
the emergency physician and cardiologist, this might be related to the high rate of
consulting to cardiologist, and however, 29% of the patients admitted for ACS were
discharged after hospitalization with non-coronary CP as the principal diagnosis,
increasing costs and hospitalization days. The implementation of a chest pain unit
with a standardized protocol could be an alternative for this problem. There was an
8% of unscheduled ED visits, and there were no adverse outcomes in this cohort.
180
Epidemiology of Elevated Blood Pressure in
Emergency Department
Adhikari S, Shostrom V, Carson R/University of Nebraska Medical Center,
Omaha, NE
Study Objectives: Knowledge of distribution of elevated blood pressure (BP) in
emergency department (ED) patients is useful for developing ED-based interventions
for hypertension. No prior studies reported the prevalence of elevated blood pressure
in different age groups, ethnic categories, different shifts, and severity of elevated BP
in ED patients. The objective of this study is to determine the prevalence and
demographics of elevated BP in ED patients.
Methods: Retrospective, cross-sectional review of a tertiary care center ED
electronic medical records. Patients with any systolic blood pressure (SBP) ⬎140 mm
Hg or diastolic blood pressure (DBP) ⬎90 mm Hg over a one-year period were
included. Two reviewers extracted data using a standardized data extraction form.
Descriptive statistics are used to summarize the data. Data are presented as
percentages with 95% confidence intervals. A Chi-Square test was used for
comparisons.
Results: A total of 44,435 charts were accessed. Overall, 47.6% (CI 47.2– 48.1%)
of patients had elevated BP, 53% (CI 52–54%) were women. Patients ⬎ 45 years
were more likely to have elevated BP. The difference in age-specific prevalence of
elevated BP among different age groups ⬍ 44 years (33%), 45– 64 years (67%),
and ⬎ 64 years (77%) was statistically significant (p⬍0.01). The prevalence of
isolated SBP elevation increased by age. But isolated DBP elevation was more
prevalent among younger age groups. 59% of patients with isolated DBP elevation
were ⬍ 45 years old. No significant differences were noted in the prevalence of
elevated BP between whites (52% CI 51.6%–52.8%) and blacks (45% CI
Annals of Emergency Medicine S55
Research Forum Abstracts
44%– 46%). White women (48.8% CI 48 – 49.6%) were slightly more likely to have
elevated BP than all other groups. Blacks (45%) were more likely to have elevated BP
compared to Hispanics (31%) (p⬍0.01). Across all ethnic groups BP increased with
age. 8.6% (CI 8.3– 8.9%) had severe BP elevation (SBP ⬎180 or DBP ⬎120), 61%
(CI 59 – 62%) were women. 12% (CI 11–13%) of patients ⬎ 45 years and 30% (CI
28 –31%) of patients ⬎75 years had severe BP elevation. Blacks (9%) were more
likely to have severe BP elevation compared to Hispanics (4%) (p⬍0.01). 64.3% (CI
63.6 – 64.9%) of patients with elevated BP were discharged from ED. 44% (CI 42–
45%) of patients with severe BP elevation were also discharged from ED. No
statistically significant differences were noted in between different shifts and days of a
week.
Conclusions: This study provides knowledge of distribution of elevated BP
among different age, sex and ethnic groups in ED which can be used to develop
specific interventions to improve prevention, detection, and treatment of
hypertension.
181
Describing Global and Tissue Level Perfusion in
Congestive Heart Failure Patients Presenting to an
Urban Emergency Department: A Pilot Study
Sherwin R, Mango L, Medado P, Levy P/Wayne State University, Detroit, MI
Study Objective: The primary objective of this study was to describe the initial
(⬍ 2 hours from arrival) hemodynamic and perfusion state in a prospective cohort of
congestive heart failure (CHF) patients presenting to an urban emergency department
(ED).
Methods (Design, Setting, Type of Participants): This was an observational study
at a Level I tertiary care center with an annual volume of ⬎96,000 patients. All
patients presenting to the ED with a chief complaint of dyspnea in whom CHF was a
diagnostic consideration by the treating physician were consented and enrolled.
Perfusion status was assessed in each patient using capillary lactate measurement
(systemic perfusion), near infrared spectroscopy (tissue level perfusion) and
impedance cardiography (cardic output). Furthermore, each patient underwent a
vascular occlusion test (VOT) during which tissue oxygenation (StO2) response was
monitoring during and following a three-minute period of arterial occlusion. Only
patients whose final ED or hospital discharge diagnosis was CHF were included in
the final analysis for this study.
Results: Twenty-three patients were enrolled who had a final diagnosis of acute
decompensated CHF. The mean age was 58.9 ⫾ 13.6 years, 15/23 (70%) were male
and 100% were black. All the patients were admitted to the hospital and the inhospital mortality was zero. The media BNP was 753 (IQR 463, 1410). Twelve
patients (52%) had baseline capillary lactate levels ⬎ 2.0 mmoL suggesting systemic
hypoperfusion. The mean capillary lactate, cardiac index and StO2 (tissue level
oxygenation) was 2.6 ⫾ 2.1 mmol/dL, 2.1 ⫾ 1.1 L/min/m2, 74.3 ⫾ 9.3%
respectively. The mean measured minimum StO2 following the VOT was 52.9 ⫾
14.2%. In univariate analysis only BNP (p ⫽ 0.043), the minimum StO2 value
(p⫽0.028) and time to peak StO2 Recovery (p⫽ 0.031) were significantly associated
with a hospital length of stay ⬎ 48 hours.
Conclusions: In this pilot study, we found evidence of baseline hypoperfusion in
patients with acute decompesated CHF which may be associated hospital outcome.
Further defining these variables in this cohort may be useful in the initial assessment
of these patients.
182
Performance of a Novel Spanish-Language Chest
Pain Tool for Evaluation, Risk-Stratification, and
Dissection/Fibrinolysis Screening in SpanishSpeaking Emergency Department Patients
Slattery DE, Munassi D, Khine L, McCoy G, Forred W/University of Nevada
School of Medicine, Las Vegas, NV; University of Nevada at Las Vegas, Las
Vegas, NV; Kern Medical Center/UCLA, Bakersfield, CA; University Medical
Center of Southern Nevada, Las Vegas, NV
Background: Assessing Spanish (SP) speaking chest pain (CP) patients represents
a unique, time-sensitive challenge for emergency physicians. It is critical to have the
ability to quickly gather the necessary information to recognize and act on lifethreatening causes of CP; however, immediately available (in the emergency
department) language translators are scarce.
Study Objective: We sought to assess the performance of a novel CP tool that
helps obtain pivotal history elements to: 1) Characterize the chest pain presentation;
S56 Annals of Emergency Medicine
2) Obtain history for appropriate risk stratification; 3) Screen for factors suggestive of
aortic dissection; and 4) Screen for absolute contraindications to fibrolinoysis.
Design: Institutional review board-approved, prospective observational trial.
Inclusion criteria: Adult (⬎18), solely SP-speaking patients, presenting to an
academic, urban, ED via triage with non-traumatic CP. Exclusion criteria: patients
with acute myocardial infarction, clinical instability, illiteracy. After initial
electrocardiograms (EKG), subjects completed a 72-item SP questionnaire which was
time stamped and collected prior to emergency physician assessment. Emergency
physicians blinded to tool answers, utilized in-person certified SP translators to
conduct their usual patient evaluation. Emergency physicians records were reviewed
retrospectively by trained/monitored abstractors utilizing a standardized data
collection tool. Our primary performance measure was the proportion of the history
elements captured. (⬎ 75% capture proportion was considered useful). We also
compared capture proportions using the CP tool to those obtained during the usual
ED evaluation. Data were analyzed as appropriate using NCSS statistical software.
Results: We enrolled 54 patients, 8 were excluded, leaving 46 that comprised our
cohort. The mean (SEM) age was 45.6(1.9) years and 67% were female. 7(15%) were
diagnosed with ACS. The mean (SEM) 95%CI time to complete the tool was 13.9
(0.97); (11.9,15.8) minutes. The CP tool performed in the useful range for the
following: determination of the quality ⫽39(84%), pain intensity ⫽38(82%),
radiation 41(89%). Compared to the usual history, the CP Tool performed better
for: determining quality of CP, time of onset, radiation, Framingham risk factors,
TIMI score, and screening for fibrinolysis contraindications. The tool’s performance
was equivalent to usual history taking for all other elements. (See table.) Limitations:
Small sample size, high illiteracy rates.
Conclusion: Our Spanish CP tool, in isolation, allowed proper characterization of
CP but did not perform well enough for excluding dissection or fibrinolytic
contraindications. Compared to the usual history taking, the tool performed better
for some, and was at least equivalent on all other, pivotal historical elements.
183
Effects of Body Mass Index and B-type Natriuretic
Peptide Level in Chronic Heart Failure Patients
Phelan T, Chan W, Ewing J, Mahler S, Wang H/LSUHSC-Shreveport, Shreveport,
LA
Study Objectives: Obesity is known to be one of the risk factors for the
development of chronic heart failure (CHF). The incidence and prevalence of both
obesity and CHF are increasing rapidly in the United States and these 2 conditions
are likely to be co-existed in 1 patient. The aim of this study is to investigate the
relationship between obesity and the severity of CHF patient in the emergency
department (ED).
Methods: Clinical data and lab results were obtained from 125 CHF patients
seen in ED from Jan. 2006 till Dec. 2007. These patients were all admitted to
hospital. Patients were divided into 4 groups according to their body mass index
(BMI). (Group 1 was morbid obese patients with BMI ⱖ40kg/m2, group 2 was obese
patients with BMI 30 – 40kg/m2, group 3 was overweight patients with BMI 24 –30
kg/m2, and group 4 was normal/ underweight patients with BMI ⱕ24 kg/m2.) Btype natriuretic peptide level (BNP) was compared in obese (group 1 and 2) and nonobese (group 3 and 4) groups. Multivariate regression analyses were performed to
measure the severity of CHF and level of BNP in obese and non-obese groups.
Results: BNP level was 832⫾1259 pg/ml in group 1, 1349⫾1425 pg/ml in
group 2, 2064⫾1548pg/ml in group 3, and 2772⫾2466 pg/ml in group 4. The
average BNP level in group1 and 2 was 1163⫾1381pg/ml compared with
2451⫾2115pg/ml in group 3 and 4 (p⬍0.001). When analyzed using multivariate
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Research Forum Abstracts
regression model, there is no statistically significant difference between the level of
BNP and the severity of CHF in non-obese patient group (p⬎0.05). However, in
obese CHF patients, when divided into 3 subgroups according to the level of BNP
(higher BNP group with level ⱖ1000pg/ml, mid-level group with level between 500
to 1000pg/ml and lower BNP group with level ⱕ500pg/ml), BUN in higher BNP
group was 42.2⫾26.7mg/dl and low BNP group was 21.0⫾13.5mg/dl (p⬍0.03),
Creatinine level in higher BNP group was 2.54⫾1.69mg/dl and 1.25⫾0.51mg/dl in
lower BNP group (P⬍0.03), The length of hospitalization in higher BNP group was
5.2⫾2.3 days and lower BNP group was 3.9⫾1.6 days (p⫽0.045).
Conclusion: Higher BMI is associated with relatively lower level of BNP and the
level of BNP is also reversely proportional to the severity of obesity in CHF patients.
However, only in obese CHF patients, higher BNP is associated with worsening renal
function and longer hospitalization stay.
184
Quantitative Meaning of Common Terms Like “Very
Low Risk” and “Low Risk” for Chest Pain Patients
Menchine M, Wiechmann W/University of California, Irvine, Irvine, CA
Study Objectives: Although emergency physicians often use the terms low risk or
high risk to describe chest pain patients, little is known about their quantitative
meaning. We sought to assign a quantitative meaning for these common qualitative
terms with respect to acute coronary syndrome and serious outcomes in chest pain
patients. We also sought to identify the risk threshold at which emergency physicians
admit or discharge these patients.
Methods: We conducted a web-based survey of emergency medicine residents at
11 academic medical centers. Participants were given 5 case scenarios of common ED
presentations for chest pain. The scenarios were designed to encompass a broad range
of risk, although none had frank ST-elevation myocardial infarction. All participants
received the same clinical scenarios - half were asked to qualitatively assess the risk of
ACS and half were asked to assess the risk of serious complications (death,
dysrhythmia, or congestive heart failure). For each scenario, participants were asked
to evaluate the patients’ risk as Very Low, Low, Moderate, High, or Very High. Once
this determination was made, subjects were asked to quantify the exact risk the
patient had and choose an appropriate disposition for the patient. Responses were
grouped according to the qualitative risk categorization and the mean quantitative
response was tabulated for each of the 5 categories. The admission rate for each risk
category was also evaluated. Descriptive statistics are presented.
Results: 217 physicians (90.6% residents) completed the questionnaire. For cases
that were categorically coded as Very Low Risk of ACS, the median quantitative risk
was 0.088% [IQR 0.009 – 0.20%] with an associated admission rate of 7.14% [CI
0 –15.2%]. Those coded as Low, Moderate, High, and Very High Risk had values of
0.45% [IQR 0.1–1.0%], 1.05% [IQR 1.0 –2.29%], 3.33% [IQR 1.6 –10%], and
10% [IQR 2.94 –20%], respectively, with admission rates of 31.6% [CI
23.1– 40.1%], 93.8% [CI 90.1–97.3%], 100% [CI 97.1–100%], and 100% [CI
93.7–100%] respectively. Cases coded as Very Low Risk for serious complications
had a median quantitative risk of 0.015% [IQR 0.009 – 0.1%] with an associated
admission rate of 1.89% [CI 0 –5.7%]. Those coded as Low, Moderate, High, and
Very High Risk had values of 0.25% [IQR 0.09 –1.0%], 1% [IQR 0.49 –2%], 1.68%
[IQR 1– 4%], and 5%[IQR 1.0 –10%] respectively, with admission rates of 42.3 [CI
33.7–50.9%], 92.4% [CI 88.4 –96.4%], 99.3% [CI 98.1–100%], and 100% [CI
92.1–100%] respectively.
Conclusion: This is the first study to determine the quantitative meaning of the
common terms Very Low, Low, Moderate, High, and Very High Risk with respect to
chest pain scenarios. High rates of admission are seen for patients assessed as
Moderate, High, and Very High risk. Quantitative risk assessments were similar when
physicians were asked to assess the risk of ACS or assess the risk of serious
complications despite epidemiologic evidence that these should markedly differ. This
finding merits further study.
185
Asymptomatic Bacteriuria: Is the Presence of
Microscopic Bacteriuria Without Pyuria in
Asymptomatic Pregnant Females Associated With
Positive Urine Culture? A Retrospective CrossSectional Study
Hile D, Cashin B, Crouch R, Strode C/Madigan Army Medical Center, Tacoma, WA
Study Objectives: Urine samples are frequently collected from pregnant females
in the acute care setting during triage, or as part of initial workup, regardless of the
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presence of symptoms consistent with urinary tract infection. Asymptomatic cultureproven bacteriuria in pregnant females is typically treated with antibiotics due to
concern for risks to the pregnancy and the development of pyelonephritis. In the
acute care setting, it is common practice to treat patients with abnormal urinalysis
results, as patient follow-up for culture results may be problematic. While the
sensitivity and specificity of the various components of microscopic urinalysis have
been well described, there is a paucity of literature comparing culture results of
abnormal urinalyses to normal urinalyses in asymptomatic pregnant females. Our
objective was to determine if there is a significant difference in positive culture results
in pregnant patients whose urinalysis is positive only for microscopic bacteria, as
compared to those with normal urinalysis.
Methods: A retrospective cross-sectional study was performed on pregnant
females who presented as outpatients to a military treatment facility (MTF), and
had both a urinalysis and urine culture performed. Pregnant females aged 18 –50
were included who denied symptoms of urinary tract infection. Exclusion criteria
included symptoms of urinary tract infection, urinalysis positive for markers
other than bacteria, or incomplete information regarding symptoms, urinalysis or
culture results. The study variables included positive or negative microscopic
bacteria on urinalysis, and positive or negative urine culture. The data was
summarized by comparing proportions with 95% confidence interval for positive
culture results in both groups.
Results: All pregnant females who presented to an MTF in 2008 – February
2009, and had a urinalysis and urine culture performed, were identified via
computer data extraction. A total of 3547 charts were reviewed. 2552 charts were
excluded due to incomplete data or exclusion criteria. 995 patients were included;
473 with urinalysis abnormal only for presence of bacteria, and 522 with normal
urinalysis. Nine patients with bacteria noted on urinalysis had positive urine
cultures; 1.9% (95% confidence interval, .95% to 3.6%). Twelve patients with
normal urinalysis had positive urine cultures, 2.2% (95 % confidence interval,
1.3% to 4.0%).
Conclusion: There was no significant difference between proportions of positive
culture results in the groups evaluated in our study. In this study population,
pregnant patients without symptoms of urinary tract infection whose urinalysis is
positive only for bacteria do not have a significantly greater incidence of bacteriuria as
defined by culture results, compared to those with completely negative urinalyses. It
may be reasonable to withhold antibiotics from asymptomatic pregnant females
whose microscopic urinalysis demonstrates presence of bacteria without other
indicators of infection.
186
Tamsulosin Does Not Increase One-Week Rate of
Passage of Ureteral Stones in Emergency
Department Patients
Lipe KM, Ziadeh J, Bui D, Swor R, Jackson R, Ross M/William Beaumont
Hospital, Royal Oak, MI
Study Objective: Our objective was to determine if tamsulosin monotherapy
improves rates of ureteral stone passage at one week or time to pain resolution,
compared to placebo.
Methods: We conducted a prospective, double-blind, randomized, trial of
Tamsulosin compared to placebo in the treatment of ureterolithiasis, with a primary
outcome of proportion of stones passed at 7 days. Emergency department (ED)
patients who presented with documented kidney stone by Helical CT between April
2007 and February 2009 were considered for inclusion. Patients received standard
analgesia and either tamsulosin or placebo for a total of 10 days. A structured
telephone survey was conducted at days 2, 3, 5, 7, and 10 to assess for stone passage
and pain scores. Exclusion criteria included stone ⬎ 8mm, patients who required
immediate surgical intervention, concurrent infection, and presence of ureteral stent.
Our power analysis, based on previous reports, assumed a one-week passage rate with
tamsulosin of 85% and placebo of 60%. Based on an alpha error of 0.05 and power
of 80%, we needed 57 subjects per group. Chi square and Fisher’s exact test were
used for analysis.
Results: 127 patients were enrolled over a 22-month period; 15 were lost to
follow-up and 12 required a surgical intervention before 7 days, leaving 100 patients
for analysis. Of these, 47 received placebo and 53 received tamsulosin. Groups were
similar for age, sex, initial serum creatinine, initial pain score on ED presentation,
location of stone, proportion of stone ⬍ 6 mm, history of prior stone or stent, and
degree of hydronephrosis. There was no difference in pain medication usage between
the two groups at days 2, 3, and 7. The percentage of patients who had stone passage
Annals of Emergency Medicine S57
Research Forum Abstracts
within seven days was 42.2% in the placebo group and 44.2% in the tamsulosin
group, with Fisher’s exact ⫽ 1.00.
Conclusion and Discussion: In this study, there was no statistical difference in the
proportion of stone passage at 7 days between tamsulosin and placebo. We observed a
lower one-week pass rate than previous reports. We also did not find a difference in
pain medication requirements between patients in the two groups. Limitations of this
study include non-consecutive enrollment and small sample size. Further
investigation should be performed with a larger sample size and should include
combination therapy.
187
Value of Head CT in Syncope Patients in the
Emergency Department
Vélez I, Bellolio MF, González JA, Decker W, Stead L, Serrano LA/University of
Puerto Rico School of Medicine, Carolina, PR; Mayo Clinic, Rochester, MN;
University of Rochester, Rochester, NY
Background: Patients with syncope often undergo extensive and expensive workup in order to rule out serious causes for the event. Current guidelines do not
recommend the routine screening of syncope with advance imaging, such as head
computed tomography (head CT) in the absence of focal neurologic findings, but it is
still a common practice among physicians.
Study Objectives: Our goal was to determine the usefulness of head CT scan
aiding in diagnosing the cause of syncope in patients presenting to an academic
emergency department (ED) in Puerto Rico.
Methods: Retrospective cohort study of consecutive patients who presented
to a single academic ED in Puerto Rico during a 12-month period with
documented syncope. We evaluated how many patients had a head CT ordered
and among them, how many had abnormal results. The primary outcome was an
abnormal head CT with relevant findings to the cause of syncope defined as:
epidural or subdural hematoma, intracerebral hemorrhage, ischemic stroke or
brain mass. Non-parametric test were used accordingly to the skewed distribution
of the data.
Results: A total of 210 patients presented to the ED with a diagnosis of syncope
between January and December 2007, 47 patients were excluded because have
neurological deficit, seizures, hypoglycemia, near syncope or were younger than 18
years old. A total of 163 patients were included in the study. The mean age was
63.2 ⫹ 19.9 years and 56% were females. A total of 141 (87%) patients had a head
CT ordered, and among them only 2 (1%) had an abnormal head CT. Those with a
head CT ordered were older (72 vs. 46 years, p⫽0.0001), had a first-time syncope
(69% vs. 31%, p⫽0.0001) and had history of hypertension (92% vs. 8%) when
compared to those without head CT performed.
Conclusions: Head CT is frequently used in syncope patients. This study
supports the evidence that head CT for syncope in the absence of focal neurologic
findings or significant head trauma may not be indicated and does not aid in the
clinical management. By limiting its use we will decrease the overall cost of syncope
evaluations.
188
Evaluation of a Non-Contact Infrared Thermometer
in an Adult Emergency Department
Patyrak S, Luber S/UT Southwestern, Dallas, TX
Study Objectives: Temperature measurement is an essential component of patient
vital signs. While the pulmonary artery catheter thermistor is the gold standard for
core temperature measurement, this method is invasive and impractical in emergency
department (ED) patients. ED providers need a rapid, accurate and non-invasive
method to measure patient temperatures. The ThermoFocus™ non-contact infrared
thermometer is a novel device that meets these needs while also eliminating the need
for probe covers. Therefore, we set out to evaluate this thermometer and compare its
agreement with the currently used non-invasive methods of oral and tympanic
thermometry.
Methods: A convenience sample of adult patients presenting to an urban,
teaching hospital ED with a census of 87,000 patients was evaluated June thru
August 2008. Patients were screened prior to enrollment for oral and/or facial
trauma. In addition, patients were equilibrated to ambient temperature for a period of
5 minutes and any residual moisture was wiped from face. Temperatures were taken
three times at each of four locations: Left sublingual fossa using the Filac™ 3000 AD
(Kendall, Mansfield, MA), left tympanic membrane using Genius 2™ (Kendall,
Mansfield, MA), center of forehead and left temple using the Thermofocus™
Infrared Thermometer (Technimed, Italy).
S58 Annals of Emergency Medicine
Results: 298 patients aged 18 – 88 years (mean 44.1 years, SD 13.9) were
evaluated. Oral temperatures ranged from 92.3°F ⫺102.2°F (mean 97.7°F, SD
0.95). Tympanic temperatures ranged from 93.4°F ⫺101.5°F (mean 97.0°F, SD
0.96). Center of forehead temperatures ranged from 94.2°F ⫺100.0°F (mean
97.2°F, SD 0.89). Temple temperatures ranged 95.7°F ⫺101.4°F (mean 97.7°F,
SD 0.88). Bland-Altman analysis was used to evaluate agreement between
temperatures at the different locations. Center of forehead to tympanic
measurements demonstrated a bias of 0.26°F (SD 0.90) with 95% limits of
agreement (LOA) of ⫺1.51 to 2.02°F. Center of forehead to oral comparison
demonstrated bias of ⫺0.51°F (SD 1.03) with 95% LOA of ⫺2.52 and 1.51.
Center of forehead to temple demonstrated bias of ⫺0.49 (SD 0.63) with 95%
LOA of ⫺1.72 and 0.75°F. Oral to tympanic comparison demonstrated bias of
0.76 (SD 0.74) with 95% LOA of 0.69 to 2.22°F. Temple to tympanic
comparison demonstrated bias of 0.74 (SD 0.95) with 95% LOA of ⫺1.11 to
2.56°F. Temple to oral comparison demonstrated bias of ⫺0.02 (SD 0.99) with
95% LOA of 1.96 to 1.92°F.
Conclusion: While the bias between the Thermofocus™ and oral/tympanic
thermometers was less than 1°F, the disagreement between thermometers was as large
as 2.5°F. This disagreement would be unacceptable in many clinical circumstances.
Of note, the tympanic and oral thermometers demonstrated poor agreement with
each other. Ultimately, we cannot recommend the use of the Thermofocus™
thermometer in adult ED patients at this time and recommend further investigation
into the accuracy of oral and tympanic thermometers.
189
Accuracy of Point-of-Care Finger Stick Hemoglobin
Compared to Laboratory Value
Morris DF, Guluma K/UCSD, San Diego, CA
Study Objective: Point-of-care finger-stick hemoglobin (FS Hgb) measurement is
frequently used in the emergency department (ED) to obtain a rapid estimate of a
patient’s Hgb concentration. In many cases the value obtained influences patient care
by leading the emergency physician to conclude that either clinically significant or
insignificant bleeding is occurring. The device used to determine FS Hgb in our ED
uses azide-methethemoglobin spectrophotometry to measure capillary Hgb
concentration. Prior studies have only evaluated the accuracy of such a device in a
stable outpatient population. There is no published data on the accuracy of the this
type of FS Hgb measurement compared to a Hgb from a hematology laboratory
complete blood count (Lab Hgb) as performed in an ED setting, where it might be
used to screen patients suspected of having acute or critical blood loss.
Methods: We examined all patients evaluated in the ED over a six-year span (Jan2003–Dec-2008) who had both a FS Hgb and a Lab Hgb. At our institution, we use
electronic records into which point-of-care and laboratory results are incorporated.
Records are retrieved utilizing searchable criteria, and using this system, 8585 records were
retrieved. Since patient clinical status may change or bleeding may be ongoing between
the two types of measures, we used a maximum of two hours between the FS Hg and
correlating Lab Hgb in order to minimize this effect. 1884 records were excluded due to a
time difference of greater than two hours leaving 6701 total records.
Results: The Lab Hgb had a median of 12.2 g/dl with an interquartile range (IQR) of
10.1 to 13.8. The FS Hgb had a median of 12.0 g/dl with an IQR of 9.8 to 13.8. The
average difference between the two values was 0.77 g/dl (6.8%) with a standard deviation
of 0.96 g/dl. The difference between the FS Hgb and Lab Hgb values was statistically
significant with a P-value ⬍0.05. The correlation coefficient was 0.91. 74.8% of the FS
Hgb values were within 1g/dl of the Lab Hgb value; however, 7.5% were more than 2g/dl
apart, with a maximum difference of 11.2 g/dl. There was a normal distribution to the
difference between the FS Hgb and Lab Hgb (47.1% of FS Hgb’s were less and, 46.6%
were greater than their counterpart Lab Hgbs).
Conclusion: For a large majority of patients the FS Hgb is moderately accurate
and represents a value within 1 g/dl of the patient’s Lab Hgb. However, in almost 8%
of patients the discrepancy between the FS Hgb and the Lab Hgb was ⫾ 2 g/dl
(approaching 10 to 11 g/dl in some patients), which we consider to be clinically
significant, given the distinct possibility that such a difference in the two might lead
to different clinical decisions with regards to transfusion, disposition, and evaluation
in certain clinical scenarios. Based upon this it seems that it would be risky to base
clinical decisions upon only the value of the FS Hgb.
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190
Fear of Brain Herniation From Lumbar Puncture: Do
History and Physical Exam Indicate Abnormalities
on Head Computed Tomography?
O’Laughlin KN, Go S, Gabayan GZ, Iqbal E, Merchant G, Lopez-Freeman R,
Zucker MI, Hoffman J, Mower W/Harvard Medical School, Boston, MA; University
of Kentucky Medical Center, Lexington, KY; Greater Los Angeles Veterans’ Affairs,
Los Angeles, CA; UCLA School of Medicine, Los Angeles, CA; UCLA Medical Center,
Los Angeles, CA; University Hospital in Cincinnati, Cincinnati, OH
Study Objectives: There is a fear that performing a lumbar puncture (LP) on a patient
with increased intracranial pressure (ICP) may lead to tonsillar herniation. Because of this,
many physicians first check a screening head computed tomography (CT) looking for
abnormalities suggestive of elevated ICP. Checking a head CT on every patient prior to
LP is time consuming, costly, and exposes patients to significant radiation. Our goal was
to define clinically significant head CT abnormalities and then to analyze the ability of
certain history and physical exam findings to predict those radiographic findings.
Methods: This was a secondary analysis of a prospectively maintained head CT
database of patients presenting to the UCLA Medical Center Emergency Department
between April 2006 and February 2007. We used the Delphi method to define
clinically significant radiographic head CT abnormalities. We then analyzed the test
characteristics for history and physical exam findings in predicting clinically
significant head CT abnormalities.
Results: When analyzed individually, the history and physical exam findings did not
predict significant head CT abnormalities well. The most sensitive individual findings
were: the presence of a neurological deficit, sensitivity 68.9% (CI 53.4, 81.8) and NPV
93.4% (CI 89.1, 96.3); altered level of consciousness, sensitivity 67.39% (CI 52.0, 80.5)
and NPV 91.8% (CI 86.8, 95.3); and lack of proper orientation, sensitivity 65.1% (CI
49.1, 79.0) and NPV 92.1 (CI 87.3, 95.5). Using the combined criteria of all of the
history and physical exam findings together, the sensitivity for predicting clinically
significant head CT abnormalities was good but not perfect. The sensitivity for the
combined criteria was 95.7% (CI 85.5, 99.5) and the NPV was 96.1% (86.5, 99.5).
Conclusions: Our data suggests that history and physical exam alone may be
inadequate to detect the subtle head CT changes that could indicate potential for
brain herniation as defined by the Delphi criteria. Despite that finding, we
acknowledge the major limitation that our outcome measure was radiographic
abnormalities rather than actual brain herniation, which makes it difficult to
extrapolate concrete conclusions regarding the clinical relevance of this information.
We think that the likelihood of herniation is much lower than the Delphi criteria
caution and that because of this the head CT criteria we used are too sensitive.
191
Disease and Non-Battle Traumatic Injuries
Evaluated by Emergency Physicians in a U.S.
Tertiary Combat Hospital
Bebarta VS, Mason PE, Ferre RM, Eadie JS, Muck AE, Joseph J, Pitotti RL/
Wilford Hall Medical Center, San Antonio, TX; University of Pittsburgh,
Pittsburgh, PA
Study Objectives: Emergency physicians have played a central role in medical care
delivery in Operation Iraqi Freedom. Medical war planning has focused on combatrelated injuries; however, since 2004 nearly half of the patients treated in a tertiary
U.S. combat hospital in Iraq are not combat related. In order to plan for future wars
and properly train emergency physicians, the common emergent and urgent noncombat diagnoses and complex procedures performed should be identified. These
data have not been previously collected or studied to determine the types of noncombat injuries and illnesses seen at a tertiary combat hospital and the types of
procedures performed to manage these patients.
Methods: In our institutional review board-approved study, we enrolled all noncombat injured patients over one year who were evaluated in the emergency
department (ED) of a US military tertiary hospital in Iraq. The treating emergency
physician used a standard data collection form to enroll all patients who arrived to the
ED whose injury or illness was unrelated to combat. Data collected included age,
time of visit, ED diagnoses, emergency procedures, disposition, and consultations.
The diagnosis and procedure lists were defined before study start.
Results: Data were gathered on 1745 patients with a mean age of 30.2 years (range 6
months – 72 years). 1460 (83%) patients were male and 1316 (75.4%) were U.S. military
personnel, with Iraqis, foreign military members and third country nationals making up
the remaining. The most common diagnoses evaluated in the ED were abdominal
disorders (302 cases, 17.3%), orthopedic injuries (209, 12%), headache (108, 6.2%),
ophthalmologic injuries (106, 6.1%), lacerations or abrasions (99, 5.7%), soft tissue
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infections (94, 5.4%), and renal colic (88, 4.7%). Emergent medical diagnoses consisted
of 10.2% (179) of cases (aortic dissection, meningitis, altered mental status, overdose,
pulmonary embolism, intestinal bleeding, acute myocardial infarction, chest pain, atrial
fibrillation). Urgent medical diagnoses consisted of 4.4% (78) of cases (pneumonia,
diverticulitis, deep venous thrombosis, seizure, syncope). Emergent surgical diagnoses
consisted of 10.7% (186) of cases (appendicitis, cholecystitis, bowel obstruction,
peritonsillar abscess, fracture, dislocation, gunshot wound, eye trauma, brain injury). 52%
(909 cases) required IV access, 45% (793) received laboratory testing, 31% (537) received
radiographs, and 28% (488) received CT scans. Complex procedures include ECG
interpretation (9%, 160 cases), lumbar puncture (1.1%, 20), procedural sedation (0.8%,
14), endotracheal intubation (10), and central line (4). 4.5% of cases were admitted to the
operating room, 6.5% to the ICU, and 21.6% to the ward. 12.6% of patients were
evacuated out of Iraq.
Conclusion: Life-threatening diseases and non-battle traumatic injuries are
common in a tertiary-combat hospital emergency department. Providers working in
similar settings should have diagnostic and procedural skills to evaluate and treat a
range of emergently ill patients.
192
The Utility of HbA1C Screening in Low Risk Chest
Pain Patients in the Emergency Department
Observation Unit
Wiederhold H, Swor R, Robinson D, Clark CL/William Beaumont Hospital, Royal
Oak, MI
Background: The American Heart Association and The American Diabetes
Association recommend early identification of pre-diabetic and undiagnosed diabetic
populations. HbA1C has been shown to be an independent predictor of Type 2
diabetes. Previous studies have shown low yield for the use of HbA1C as a screening
tool in the general emergency department population.
Study Objective: To identify the proportion of non-diabetic patients with
abnormal HbA1C within an Emergency Department Observation Unit (EDOU)
population of low risk chest pain patients.
Methods: We performed a retrospective review of patients admitted to the EDOU at
a large academic community hospital for low risk chest pain evaluation from August 1,
2008 through September 18, 2008. Patient data was extracted for patient demographics,
known history of diabetes, current treatment for hyperglycemia, random glucose and
HbA1C levels. We dichotomized values of random glucose levels ⬎ 110 mg/dl and
HbA1C levels greater than 5.9%, per recommended screening levels, and calculated the
proportion of possibly undiagnosed diabetic patients. We assessed whether abnormal
random glucose levels might identify a similar proportion of non-diabetic patients as
found by abnormal HbA1C levels.
Results: During the study period, 457 low risk chest pain patients were admitted
to the EDOU. Of these, 342 received HbA1C and random glucose testing. These
patients were 60.8% male, their mean age was 57.9 ⫹/⫺ 15.38 years and 279
patients had no known history of diabetes. Of patients with no known history of
diabetes, 66 (23.7%) were found to have elevated HbA1C and 85 (30.5%) were
found to have elevated random glucose. 36 (54.5 %) patients with elevated HbA1C
had random glucose levels within the normal range.
Conclusion: Screening evaluation by HbA1C of EDOU low risk chest pain patients
appears to identify patients with impaired glucose metabolism not found by random
glucose screening alone. Prospective studies of low risk chest pain patients should be done
to validate and assess the value of using elevation of HbA1C as a screening tool.
193
A New Study of Intraosseous Blood for CBC and
Chemistry Profile
Miller L, Philbeck T, Montez D, Spadaccini C/Vidacare Corporation, San Antonio,
TX; Ameripath, Inc., San Antonio, TX
Study Objectives: Recent studies have indicated a resurgence in using the intraosseous
(IO) route for vascular access because of improved devices that enable providers to deliver
critically needed drugs systemically as quickly as central lines, and faster than peripheral
lines. Increased awareness of IO vascular access has led to questions about other uses of the
IO space, including the viability of IO blood for routine laboratory analysis. Despite
earlier studies, some laboratory personnel have voiced concern over the adequacy of the
data supporting the use of IO-derived blood for routine laboratory tests. This study was
designed to validate earlier studies and address these concerns.
Methods: The study was approved by IntegReview Institutional Review Board and 10
healthy adult volunteers were recruited. After written consent, standard phlebotomy blood
samples were obtained. Following phlebotomy, an IO catheter (EZ-IO®, Vidacare
Annals of Emergency Medicine S59
Research Forum Abstracts
Corporation, San Antonio, TX, USA) was placed in the proximal humerus and two sets
of IO blood samples were obtained; one following 2ml of marrow/blood waste, and one
following 6ml of waste. All three samples sets were sent to a reference laboratory for
chemistry profile and complete blood count (CBC) analysis. Means for each value for the
three blood draws (designated IV, IO-1, and IO-2) were calculated and compared with
the intravascular (IV) blood serving as a control for the IO draws.
Results: For IO-1, mean red blood cells (RBC), hemoglobin (Hgb), hematocrit,
glucose, blood urea nitrogen (BUN), sodium, chloride, total protein and albumin levels
were within 5% of mean values from IV blood. For IO-2, mean Hgb, glucose, BUN,
sodium, chloride, total protein and albumin levels were within 5% of mean values from
IV blood. For both IO samples, most other values were within 10% of IV blood.
Conclusion: In the first study of its kind in 15 years, we have found that the
intraosseous space is a reliable source for blood used for laboratory analysis commonly
performed in emergency medicine, including CBC and chemistry profile. Results may
be moderately reliable for carbon dioxide, but unreliable for WBC counts that appear
to be elevated and platelets counts that appear lower.
194
The Use of a Subcutaneous Insulin Aspart Protocol
for the Treatment of Hyperglycemia in the Emergency
Department: A Randomized Clinical Trial
Harper JB, Barnard J, Munoz C, Baldwin D/Rush University, Chicago, IL
Study Objective: Emergency physicians have a unique and challenging
interaction with patients who have diabetes. Such patients commonly present with
significant hyperglycemia. Patients presenting with a specific diabetes-associated
illness routinely have the complaint directly addressed and treated. However, when
patients present with a non-diabetic chief complaint, there are no established
protocols for how best to address the common issue of hyperglycemia. We
prospectively evaluated a SQ insulin protocol for use in the emergency department
(ED) in patients with known Type 2 diabetes mellitus (DM) and hyperglycemia.
Methods: Patients with Type 2 diabetes had a point-of-care blood glucose (BG)
measured soon after ED presentation; those with BG ⬎200mg/dL were randomized
to an intervention group (INT) vs. usual care (UC). All INT subjects (n⫽66)
received subcutaneous insulin aspart (0.05 U/kg for BG 200 –299mg/dL, 0.1 U/kg
for BG 300 –399mg/dL, 0.15 U/kg for BG ⱖ 400mg/dL) every 2 hours until BG
⬍200 mg/dL. Insulin aspart was chosen for this protocol because its onset of action is
30 minutes and it can be redosed every 2 hours, thus making it easy for
implementation in a busy ED. Emergency physicians treated UC subjects (n⫽72) at
their discretion, and 49% did not receive insulin. Subsequent blood glucose was
measured every 2 hours in the ED until discharge home or hospital admission.
Results: Mean initial ED BG for all subjects enrolled in the study was 299 ⫾78 mg/
dL. At ED discharge either to home or the hospital, the mean BG decreased by 76 ⫾67
mg/dL with INT, and by 82 ⫾77 mg/dL with UC (ns). 47 UC subjects were admitted to
the hospital, and 43% of those had received SQ insulin aspart in the ED, while 40% of
INT subjects were admitted. When the first BG after admission to the hospital was
assessed, however, the mean decreases from the first ED BG were greater: UC subjects
who received insulin decreased 131 ⫾104 mg/dL, while UC subjects who did not receive
insulin only decreased 33 ⫾67 mg/dL (p⫽ 0.04). INT subjects decreased 104 ⫾80 mg/
dL. Only 1 subject had a BG reading less than 100 mg/dL (76 mg/dL). Mean ED length
of stay was similar, INT 5.4 ⫾1.8 hours, UC 4.8 ⫾1.8 hours (ns).
Conclusion: A weight-based protocol for dosing SQ insulin aspart every 2 hours
in the ED for the treatment of hyperglycemia in patients with Type 2 diabetes was
safe and effective. This protocol was easy for physicians to determine insulin dosing
and nursing to administer without significantly increasing ED length of stay. The
insulin treatment of ED patients with hyperglycemia achieves rapid and significant
lowering of BG. A higher unit per kg insulin dosing algorithm can achieve greater
decreases in BG; however, our previous pilot study found an excess of hypoglycemia.
Thus these doses seem optimal. Further study is required to delineate possible benefits
to patients who are subsequently admitted to the hospital.
195
Refusals of Medical Aid in the Out-of-Hospital
Setting
Waldron R, Finalle C, Mogelof D/New York Hospital Queens, Flushing, NY
Study Objective: Our research examined the characteristics of both patients and
EMTs who are involved in the Refusal of Medical Aid (RMAs.) As well, we studied
the timing of RMAs both by shift and within an individual shift.
Methods: The study was carried out using data from the New York Hospital
S60 Annals of Emergency Medicine
Queens (NYHQ) ambulance service, which is a large urban ambulance service
providing 9-1-1 basic life support and advanced life support care. This was a
retrospective chart review of all patient charts in which the patient RMA’d for the
time period 8/1/05 through 7/31/06, a one-year period. These patients were then
compared to a control set of patients that was created by reviewing every chart in a
24-hour period for ten randomly selected days within the same one-year period. The
data was obtained from the patient care reports that are scanned by NYHQ EMTs
into HealthEMS database. Data analysis was performed using SAS 9.1 for Windows.
For continuous variables, the Student’s t test was used to test for differences between
the control and research groups. For categorical variables, the Chi-Square test was
used and the Fisher’s Exact test was used if cell counts were less than 5.
Results: The RMA data set had a total of 238 patients, 58% female and 42% male,
with a mean age of 56. The control data set had a total of 303 patients, 53% female and
47% male, with a mean age of 53. There was no difference in the sex distribution between
the RMA and control groups (P ⬍⫽ 0.2965.) There was also no difference in average age
of the RMA and control patients on the day and evening shifts (P ⫽ 0.1764 & 0.0711).
However, on the night shift the patients in the RMA group were significantly younger mean age of 47 in the research group versus 55 in the control group (P ⫽ 0.0160).
The EMS team consists of two EMTs. The presence of a male on the team increased
the likelihood of an RMA. The EMT teams in the RMA set were 0.42% female/female,
7.1% male/female, and 92.4% male/male. The EMT teams in the control set were 4.6%
female/female, 34.7% male/female, and 60.7% male/male. The higher percentage of male
EMTs in the RMA set achieved statistical significance (P ⬍ 0.0001). The sex of the EMT
team versus the sex of the patient had no effect on increasing RMAs (P ⫽ 0.9936).
The patient’s chief complaint was significantly different in the RMA versus
control groups. The RMA group had more neurological, psychiatric, and social chief
complaints. (P ⬍ 0.0001) This difference holds true for both day and evening shifts
(P ⫽ 0.0003, 0.0001); however, on night shifts there is no significant difference in
chief complaints (P ⫽ 0.0812).
In the RMA group, the shifts were 35.7% day, 41.6% evening, and 22.7% night.
In the control group, the shifts were 51% day, 30% evening, and 18.5% night.
RMAs were more common on the evening and night shifts (P ⫽ 0.0011).
The calls were also broken down as to whether occurring in the first two hours of
the shift, the middle four, or the last two hours. There was no difference in the
frequency of RMAs based on the timing within the shift. (P ⫽ 0.5488).
Conclusions: The call most likely to generate an RMA contains the following set
of characteristics: a younger patient with a chief complaint falling out of the usual
medical categories like trauma or cardiac, two male EMTs on the team, and an
evening or night shift. The commonly held perception that RMAs are more common
at the end of a shift (to avoid working late) was proven to be untrue.
196
Intubation Success Rates in Helicopter Emergency
Medical Services: A Prospective Multicenter
Analysis
Patel P, Melissa S, Brunko M, Domeier R, Funk D, Greenberg R, Judge T,
Lowell M, MacDonald R, Madden J, Thomas S, Howard Z/Harvard Affiliated
Emergency Medicine Residency, Boston, MA; Massachusetts General Hospital,
Boston, MA; Flight for Life Colorado, Denver, CO; Midwest MedFlight, St. Joseph’s
Mercy Hospital, Ypsilanti, MI; LifeNet of New York, Albany Medical College, Albany,
NY; PHI Air Medical StatAir, Texas A&M University, Temple, TX; LifeFlight of Maine,
Bangor, ME; Survival Flight, University of Michigan Health Sciences Center, Ann
Arbor, MI; ORNGE Transport Medicine, University of Toronto, Toronto, Ontario,
Canada; Christiana Care, Wilmington, DE; University of Oklahoma School of
Community Medicine, Tulsa, OK; Brigham and Women’s Hospital, Boston, MA
Study Objectives: The Critical Care Transport Collaborative Outcome Research
Effort (CCT-CORE) Airway Study is a multicenter analysis of air medical programs’
performance on airway management variables defined by the National Association of
Emergency Medical Services Physicians (NAEMSP). This study examines the success rate
of endotracheal intubation (ETI) in air transport programs across a variety of settings. It
also examines whether there are lower success rates for air medical crews attempting ETI
in patients in whom ETI by non-air medical providers has already failed.
Methods: This was a prospective consecutive-case series of patients undergoing
air medical transport in whom advanced airway management was attempted. There
were 11 participating sites, and all crews had access to RSI drugs. Eligible subjects
included all patients in whom air transport crews attempted advanced airway
management. Prospectively defined data points were collected and entered into a
secure Web-based data entry system. The primary analysis for this report was
descriptive, focusing on ETI success rates (reported with exact binomial 95%
Volume , .  : September 
Research Forum Abstracts
confidence intervals); for analysis of categorical variables Fisher’s exact and Pearson
chi-square was used (p ⬍ .05 for all tests).
Results: There were 603 total attempts at airway management, and 582 (96.5%,
95% CI 94.7–97.8%) were successful with either oral or nasal ETI. Of 603 total
attempts, 182 cases (30.2%, 95% CI 26.5–34.0%) had failed ETI attempts prior to
the arrival of flight crews. Air medical crews successfully intubated 175 of the 182
patients (96.2%, 95% CI 92.2–98.4%) in whom pre-air medical airway management
failed; pre-CCT crew airway management failure was not associated (p ⫽ .81) with
likelihood of CCT crews’ ability to successfully perform ETI. Success of intubation
was not associated with age, weight, or presence of cervical spine immobilization. It
was, however, associated with need for multiple attempts (Pearson chi-square
p⬍0.001) and a more limited Cormack-Lehane grade view (Fisher’s exact p⫽0.001).
Conclusion: ETI success rates remain high in air medical programs. It is not
necessarily unsafe for air medical crews to proceed with ETI attempts, even if
previous attempts at airway management have failed.
197
Endotracheal Tube and Laryngeal Mask Airway Cuff
Pressures Can Exceed Critical Values During Air
Transport
Miyashiro R, Yamamoto L/University of Hawaii John A. Burns School of
Medicine, Honolulu, HI
Study Objectives: Aeromedical transport planes keep cabin pressure between 1700 to
2500 meters of equivalent altitude. Unpressurized helicopter transports fly at about 1700
meters. During ascent, ambient pressure decreases and any fixed volume of gas will
expand, therefore increasing the relative pressure in the container. It has been shown that
tracheal mucosa perfusion is compromised at an endotracheal tube (ETT) cuff pressure of
30 cmH2O, and blood flow is obstructed at pressure of 50 cmH2O.
Methods: We measured the change in pressure of the inflated cuffs of 6.0 and 7.5
ETTs and a size 4 laryngeal mask airway (LMA) from sea level to 2400 meters. The
ETTs and cuff measurements were done with the devices uncontained, and an
additional 6.0 ETT was placed in a 10 mL syringe barrel to mimic placement in a
trachea. This latter model restricted cuff expansion simulating what would occur
when it is placed within the trachea.
Results: By linear regression, the pressure within the ETT cuffs increased with
elevation by 3.0 cmH2O (6.5 ETT), 2.1 cmH2O (7.5 ETT), 7.4 cmH2O (LMA), and
6.4 cmH2O (6.5 ETT contained within trachea) per 100 meters of increasing elevation.
Note that pressure increases faster when the ETT cuff is contained within the rigid syringe
barrel because cuff size expansion is restricted. The trachea is not as rigid as the syringe
barrel, thus, the ETT cuff pressure within the trachea should increase at a rate of
somewhere between 3.0 and 6.4 cmH2O per 100 meters. Starting at an ETT cuff
pressure of 20 cmH2O would result in a pressure of 50 cmH2O (the critical value)
somewhere between 468 and 1000 meters elevation. At a typical flight altitude of 2000
meters, the ETT cuff pressure would increase to a pressure of somewhere between 80 and
148 cmH2O. LMA cuff pressures increase more rapidly despite being unrestricted because
of the greater thickness and lower compliance of the plastic comprising the cuff.
Conclusion: This model indicates that ETT cuffs inflated prior to air transport
are likely to exceed critical pressure levels rapidly during flight. Additionally, there
will be loss of ETT cuff pressure (with loss of a good seal) during descent if a cuff is
inflated at peak higher altitudes. ETT cuff pressures should be monitored and
adjusted continuously during ascent and decent.
198
Injury Incidence and Predictors on a Mass Bicycle
Ride
Boeke P, House H/University of Iowa, Iowa City, IA
Study Objectives: The “Register’s Annual Great Bike Ride Across Iowa”
(RAGBRAI) is a 7-day recreational bicycle ride with over 10,000 participants
covering 500 miles. The heat and humidity of late July in Iowa, the prevalence of
amateur riders, and the abundant consumption of alcohol can combine creating the
potential for a significant number of injuries. The purpose of this study is to
determine the type, quantity and severity of injuries on RAGBRAI and gather data on
the factors related to these incidents.
Methods: This retrospective chart review examined paramedic run sheets for
patients requiring transport to the hospital from the bike route between 2004 and
2008. The age, sex, date of incident, weather, chief complaint, mechanism, injury
location, and care administered from each patient was recorded.. Chi-square tests,
Volume , .  : September 
Pearson’s correlation tests, and t-tests were applied to determine significant statistical
outcomes.
Results: From 2004 –2008, 419 RAGBRAI participants were attended to by
paramedics. 190 of these participants required transport. Female patients were more
likely to require transport; 53.7% of transports were male and 46.3% were females
yet 65% of RAGBRAI riders are male (p ⫽ 0.0011). Accidents were caused by riderto-rider contact (46.6%), rider error (30.4%), road conditions (19.6%), and bike
malfunctions (3.4%). Age was a significant predictor of transport for injury in older
males (p ⫽ 0.0277). Of participants asked, 90.1% had not imbibed any alcohol prior
to their injury and 85.1% had completed at least minimal training prior to
RAGBRAI. Higher temperatures were correlated with an increased number of
dehydration/heat stroke cases (r ⫽ 0.953, p ⫽ 0.046). Abrasions and lacerations were
located on the head (20.0%), upper extremity (43.0 %) and lower extremity (37.0%).
Fractures occurred to the clavicle (44.4%), shoulder (22.2%), wrist (13.3%) and
ankle (8.8%).
Conclusion: This study suggests that females and older males are more likely to
require transport for injuries sustained on RAGBRAI, that the majority of injuries
occur around the head and upper extremities, dehydration/heat stroke is correlated
with temperature, and that incidents are usually caused by rider-to-rider contact or
rider error. This research could be used by multiday recreational bicycle tour
organizers to continue educating riders on riding carelessness and etiquette and
prepare medical services for certain quantities and types of injuries.
199
Does “Off-Hour” Presentation Contribute to Out-ofHospital Process Delays Among Patients With STElevation Myocardial Infarction?
Agarwal A, Koneru S, Griffen D, Pfeiffer AM, Brennan J, Gilmore J, Markwell SJ,
Aguirre FV/Southern Illinois University, Springfield, IL; Prairie Education &
Research Cooperative, Springfield, IL; Memorial Medical Center, Springfield, IL;
St. Johns Hospital, Springfield, IL; Prairie Cardiovascular Consultants, Ltd.,
Springfield, IL
Study Objectives: Increasing emphasis is being placed on refining out-of-hospital
processes of care among ST-elevation myocardial infarction (STEMI) patients
transported via ambulance (EMS) with the goal of reducing delays initiating
reperfusion therapy. Prior studies have shown that “off-hour” (OFF) presentation (ie,
weekdays: 5:00 PM–7:00 AM and weekends) contributes to greater in-hospital
treatment delays compared to “on-hour” (ON) presentation (ie, weekday: 7:00 AM–
5:00 PM) among STEMI patients undergoing mechanical reperfusion (PCI). The
objective of this study was to determine the impact of time-of-day on out-of-hospital
STEMI times.
Methods: Between 1/2005–12/2008 we retrospectively evaluated both pre- and
in-hospital time interval components of care among a consecutive group of STEMI
patients brought by EMS during ON vs OFF to 2 tertiary hospitals in rural, Central
Illinois with 24-hour, 7 day/week primary PCI capabilities. Out-of-hospital process
components evaluated among EMS-transported patients included: a.) EMS dispatchscene arrival, b.) Scene arrival-scene departure (on-scene time), c.) Scene departureemergency department (ED) arrival (transport time), d.) EMS Dispatch-ED arrival.
In-hospital process components included: a.) ED arrival (door)-ECG acquisition, b.)
ED door-cardiac cath lab (triage time), d.) Cardiac cath lab-balloon (procedure time),
d.) ED door-balloon (D2B time). Our EMS system consisted of 10 independent
transport services. There was no utilization of out-of-hospital ECG in this EMS
system.
Results: Of the 358 consecutive STEMI patients, 158 (44%) were EMS
transported. The median (25th, 75th percentile) distance traveled from scene to ED
was 6 (3, 16) miles. EMS utilization increased from 2005 (38/114; 33%) to 2008
(43/80; 54%; p⫽0.01). Among the EMS-transported group, 10 (6%) did not receive
PCI, and 14 (9%) had incomplete analyzable data. Of the remaining 134 patients, 85
(63%) presented OFF and 49 (37%) presented ON. There were no differences in
baseline demographics among the STEMI patients presenting ON vs OFF. Table 1
lists the differences between out-of- and in-hospital process of care components
among the EMS-transported patients presenting ON vs OFF.
Conclusions: Despite longer in-hospital delays among STEMI patients presenting
OFF vs ON, there was no difference in proportion of patients achieving D2B ⱕ 90
minutes between these two groups. Importantly, there is no significant difference
among any out-of-hospital component, including: a.) EMS dispatch-to-scene arrival,
b.) on-scene, and c.) transport times, demonstrating a consistency of EMS-associated
out-of-hospital STEMI care, regardless of time of day.
Annals of Emergency Medicine S61
Research Forum Abstracts
200
The Impact of 24-Hour Shifts on Paramedics
Providing Out-of-Hospital Analgesia in PatientReported Pain Scales
Myers LA, Russi CS/Mayo Clinic Medical Transport, Rochester, MN; Mayo Clinic,
Rochester, MN
Study Objectives: To evaluate out-of-hospital pain management by timeframe in
ambulance crews working twenty-four hour shifts. These lengthy clinical shifts are a
unique characteristic of EMS with little research evaluating pain management to the time
of day.
Methods: A retrospective data review from January 2007 through May 2008 in a
large multi-site EMS system, examined the administration of morphine sulfate (MS)
in patients categorizing their pain between a “1” and “10” on a 1-10 pain scale during
24-hour paramedic clinical shifts. Patients with cardiac-related chest pain,
hemorrhagic injuries, altered mental status and an allergy to MS were excluded. Data
abstraction and statistical analysis was completed using JMP v6.0 software. This study
was approved by Mayo Clinic institutional review board.
Results: There were 16,450 patients identified to have reported pain in EMS
documentation. There were 2,236 cases where pain scales were reported by paramedics.
There were 214 instances of a “0” score leaving 2,022 cases with a score of 1–10.
The proportion of treatment by timeframe in scores of 1–5: 0700 –1259 n⫽16/
252 (6.0%); 1300 –1859 n⫽22/269 (7.4%); 1900 – 0059 n⫽10/199 (5.3%); 0100 –
0659 n⫽7/139 (5.0%).
The proportion of treatment by timeframe in scores of 6 –10: 0700 –1259
n⫽83/373 (22.3%); 1300 –1859 n⫽106/354 (29.9%); 1900 – 0059 n⫽80/282
(28.4%); 0100 – 0659 n⫽22/153 (14.4%).
The total proportions of treatment and pain scales: “1” n⫽ 2/120 (1.7%), “2”
n⫽ 35/148 (3.4%), “3” n⫽ 14/187 (7.5%), “4” n⫽11/201 (5.5%), “5” n⫽23/203
(11.3%), “6” n⫽18/162 (11.1%), “7” n⫽37/217 (17.1%); “8” n⫽ 59/245 (24.1%);
“9” n⫽41/155 (26.5%), “10” n⫽136/383 (35.5%).
Conclusion: The percentage of pain scales that were documented (12.6%) is low.
Treatment of patients with moderate to severe pain (scales 6 –10), declines after 1:00
AM in ambulance crews working 24-hour shifts. Further investigation is needed to
determine the reasons for this decrease, including crew workload.
201
Safety and Efficacy of a Novel Abdominal Aortic
Tourniquet Device for the Control of Pelvic and
Lower Extremity Hemorrhage
Greenfield EM, McManus J, Cooke WH, Pittman D, Shiver SA, Beatty J,
Croushorn J, Schwartz R/Medical College of Georgia, Augusta, GA; US Army
Medical Department Center and School, Fort Sam Houston, TX; The University of
Texas at San Antonio, San Antonio, TX
Study Objectives: Hemorrhage from the pelvis and lower extremities is a leading
cause of potentially preventable death and morbidity in both the military and civilian
setting. Current commonly employed out-of-hospital strategies to achieve hemostasis
in these areas have limited to no efficacy. This study examines the safety and efficacy
S62 Annals of Emergency Medicine
of a novel externally applied pneumatic abdominal aortic tourniquet device to
significantly decrease or halt blood flow from the abdominal aorta.
Methods: Eight anesthetized (n⫽8) swine were instrumented with catheters inserted
in the carotid and femoral arteries and internal jugular vein. A urinary bladder catheter
with a pressure transducer was placed as a marker of intra-abdominal pressure. The
tourniquet was applied to the animal, inflated, and left in place for 60 minutes. Pressures
were recorded in 5-minute intervals. Serum potassium and lactate levels were obtained at
0 minutes, 55 minutes, and 65 minutes. Doppler ultrasound was utilized at 5-minute
intervals to measure blood flow through the femoral artery. After release of the device, an
open laparotomy was performed and tissue samples from the large and small intestine
were collected. End points were mean arterial pressure, central venous pressure, intraabdominal pressure, potassium levels, lactate levels, and tissue histology.
Results: Flow was essentially undetectable in the femoral catheter during the
tourniquet application. For hemodynamic variables, there were no significant differences
in mean arterial pressure or central venous pressure measurements among animals.
However, using one way repeated measures analysis of variance, there was a significant
difference in mean arterial pressure (P ⫽ 0.008) between 0 and 55 minutes for each
subject. Serum potassium and lactate did not reach clinically significant numbers.
However, serum lactate was significantly different between times 55 minutes (3.6 mmol/L
⫹/⫺ .95) and after tourniquet release 65 minutes 5.9 mmol/L ⫹/⫺ .87) (p ⬍0.001).
Gross and histological examination revealed no signs of significant ischemia or necrosis of
the small and large intestine.
Conclusion: The abdominal aortic tourniquet appears safe and efficacious in
decreasing or eliminating blood flow to the pelvis and lower extremities when deployed
for sixty minutes.
202
Improvement in Bag-Mask Ventilation Performance
After Training With a Novel Terminal Feedback
Manikin System
Salvucci Jr AA, Squire BT, Kaji AH, Niemann JT, Chase DG/Ventura County
Medical Center, Ventura, CA; Harbor-UCLA Medical Center, Torrance, CA
Study Objectives: Bag-mask ventilation (BMV) is commonly used in emergency and
out-of-hospital care. With the de-emphasis of endotracheal intubation, BMV has become
increasingly important in cardiac arrest and traumatic brain injury. It is considered a basic
skill, often taught only by demonstration and brief practice. However, poorly performed
BMV is common, resulting in brief, high-volume inspirations delivered at a rapid rate.
Consequences include gastric inflation, an increase in intrathoracic pressure with resultant
hypotension, and hypocarbia reducing cerebral blood flow. Despite known complications,
training methods have remained largely unchanged. A well-known and effective method
to learn motor skills is terminal feedback - performance assessment provided after task
completion. We investigated the effect of a novel terminal feedback system to train out-ofhospital personnel in BMV.
Methods: Prospective pre-post interventional study design using 28 volunteer
on-duty EMTs and paramedics who had completed an American Heart Association
basic life support course within the previous 2 years. All subjects were tested by
performing one minute of BMV on a SmartMan© manikin (Ambu, Inc.) per local
protocols which conformed to the AHA CPR/ECC Guidelines 2005. Subjects then
practiced for 1 minute using the SmartMan continuous terminal feedback
(bandwidth knowledge of results) training system, utilizing a color bar display to
indicate specified ranges for “acceptable,” “too high” and “too low” on each of three
parameters: duration of inspiration, volume of inspiration, and duration of breath-tobreath interval. After training, subjects repeated the 1-minute BMV test. Descriptive
statistics were calculated, and when appropriate, pre-post results of the ventilation
tests were compared using the non-parametric Wilcoxon rank sum test and are
reported as medians with interquartile ranges. To account for potential correlations
among ventilations for each paramedic, a cluster analysis was performed using
generalized estimating equations and an exchangeable covariance matrix; proportional
odds ratios (OR) with 95% confidence intervals were calculated.
Results: Twenty-eight subjects performed a total of 672 total breaths, 336 per
trial. Individual measurements were considered correct if performed to within 20% of
the AHA Guidelines for inspiration (500 – 600 mL over 1 second) and breath-tobreath interval (5– 6 seconds). Correctly performed duration of inspiration increased
from 34% of ventilations to 80%, and the proportion that were delivered too rapidly
decreased from 50% to 15%. Correct volume of inspiration increased from 63% to
96%. Correct breath-to-breath interval increased from 63% to 93%. All differences
were significant (P⬍0.0001). When adjusted for subject and clustering of breaths,
OR for the intervention remained statistically significant.
Conclusion: Initial BMV was performed inconsistently over a wide range of durations
Volume , .  : September 
Research Forum Abstracts
and volumes. Too-rapid inspiration was the most common error, occurring in nearly 50%
of breaths. A brief visual terminal feedback training session substantially improved
performance, with a large majority of breaths delivered within acceptable ranges. Correct
rate and volume with bag-mask ventilation appears to be a learnable skill. Terminal
feedback methods of training can optimize motor skills learning and performance.
203
Hospital Processes, Not EMS Transport Times, Are
Crucial Predictors of Rapid Reperfusion for ST
Segment Myocardial Infarction Patients
Swor R, Robinson D, Clark C, Berman A, Roe E/William Beaumont Hospital,
Royal Oak, MI
Background: Regional EMS networks to treat ST segment myocardial infarction
(STEMI) are being developed to provide rapid mechanical reperfusion (PCI). Key
elements debated in this process include transport times to PCI hospitals.
Study Objective: To assess whether EMS scene and transport intervals or internal
hospital process intervals are associated with rapid reperfusion after EMS contact and
hospital arrival in STEMI patients.
Methods: Secondary analysis of a prospectively collected database of STEMI
patients transported to a large single academic community hospital from 2004- 4/
2009. Population: EMS patients transported with 12-lead EKG to hospital with
STEMI. The hospital utilizes a single page acute myocardial infarction team, which is
activated by emergency physicians based on out-of-hospital data (telemetry or voice)
from paramedics or after hospital arrival. Patients transferred from another hospital,
Do-Not-Resuscitate patients, or patients whose care was delayed because of refusal of
care were excluded. All cases were reviewed by two physicians to confirm STEMI
diagnosis. EMS and hospital data intervals including EMS scene, EMS transport,
arrival to myocardial infarction team activation (D2page), and arrival to lab (D2lab).
Our outcomes are proportion with arrival to reperfusion (D2b)⬍90 minutes, and
EMS EKG to reperfusion (E2b)⬍ 90 minutes. Means and proportions are reported,
T-test and Fisher’s exact used for analysis.
Results: We included 267 STEMI patients, 246 (92.1%) MI team activations, 240
(90.0%)to lab, 208 (77.9%) had PCI. EMS intervals were; scene 20 min (5–50);
transport 15.5 min (1–46). Of PCI patients, 48.8% had pre-arrival activation, 81.8% had
D2b⬍ 90 min and 54.9% with E2B⬍ 90 min.. Mean intervals were: D2page 2.7 min;
D2lab 35.1 min; D2B 70.6 min. Comparison of key intervals are listed in table:
Conclusion: Hospital process intervals (time to page and time to lab), but not
EMS process intervals (scene and transport) were associated with short D2b and E2B
times. Hospital processes, rather than EMS scene and transport times, are crucial
factors in producing rapid reperfusion for STEMI patients.
204
Endotracheal Intubation Success in an Ambulance
by Emergency Medical Out-of-Hospital Personnel
Using Direct and Glidescope® Laryngoscopes
Toofan M, Bhakta N, Greenberg R, Rush C, Kjar D, Drigalla D/Scott & White
Memorial Hospital, Temple, TX
Study Objectives: Previous studies have reported increased success in
endotracheal intubation among individuals with limited airway management
experience when using the GlideScope® video laryngoscope (GS) as compared to
direct laryngoscopy (DL). Out-of-hospital providers are trained in endotracheal
intubation and frequently face the added challenge of implementing this skill in
various environments. Our study investigated intubation success of out-of-hospital
providers using GS vs. DL in an ambulance setting.
Methods: Design: Institutional review board-approved, randomized, crossover
study. Setting: Volunteer subjects were recruited during a statewide emergency
medical services (EMS) professional conference. Participants: 49 conference attendees
enrolled. Interventions: Following a brief demonstration of the use of the
GlideScope® and orientation to the Cormack & Lehane (CL) airway grading scale,
subjects were randomized to initially use the GS or a DL to intubate a Laerdal®
Volume , .  : September 
Difficult Airway Manikin. The manikin was positioned on a stretcher in an
ambulance to simulate an EMS environment. Each subject then intubated both the
normal and difficult (severe glossitis) airway using both GS and DL. Level of training
certification, prior intubation experience, time and number of attempts to intubation,
failed airways, glottic view using the CL scale, and ease of use (by numerical scale)
were recorded. Numerical means and CL grades were compared using paired t-tests.
Results: There were 49 out-of-hospital providers (still in-training to 25 years
experience, EMT-basic to EMT-paramedic) with average monthly intubations ranging
from 0 to 6. Ten of the 49 (20.4%) volunteers had previous experience with the GS.
Normal Airway Scenario: Time to intubate was faster for GS [35.4 sec] vs. DL
[53.1 sec], but not statistically significant (p⫽0.8429). GS required fewer attempts on
average for successful intubation (GS 1.1 vs. DL 1.4, p⫽0.0205). CL glottic view was
significantly better with GS (1.2⫾0.5 vs. 2.2⫾0.9, p⬍0.0001). 2 (4.1%) airway
failures occurred with DL, zero with GS.
Difficult Airway Scenario: Time to intubate was faster for GS [34.8 sec] vs. DL
[100.0 sec] and was statistically significant (p⬍0.0001). GS required fewer attempts
on average for successful intubation (GS 1.1 vs. DL 2.0, p⬍0.0001). CL glottic view
was again significantly better with GS (1.6⫾0.8 vs. 3.1⫾1.0, p⬍0.0001). GS had
fewer airway failures (1 vs. 14, 2.0% vs. 28.6%).
Ease of use: Subjects found the GS overall easier to perform an intubation (1.5 vs.
2.9, p⬍0.0001).
Conclusion: In the hands of out-of-hospital providers in both airway scenarios,
the GS required fewer intubation attempts, provided a better glottic view, and
resulted in more successful intubations. GS was also significantly faster than DL in
the difficult airway. This study attempts to replicate the unique intubation
environment of an ambulance. The GlideScope® appears to be a useful tool in both
normal and difficult airways in the out-of-hospital setting.
205
Accountability, Transparency, and Interoperability:
Developing a Database of Federal Efforts in
Emergency Medical Care
Johnson KA, Handrigan MT/Dept. of Health and Human Services, Washington, DC
Study Objectives: The Emergency Care Coordination Center (ECCC) has been
established within the Dept. of Health and Human Services (HHS). Through
collaboration with the Council on Emergency Medical Care (CEMC), a coordinating
body consisting of Federal partners from the Departments of Transportation (DOT),
Defense (DoD), Homeland Security (DHS), and Veterans’ Affairs (VA), the ECCC
aims to inform the development of joint strategies and cohesive policies to collaborate
and coordinate ongoing Federal efforts to improve emergency medical care (EMC)
systems nationwide. The first step in achieving this goal is developing situational
awareness, gaining an understanding of existing efforts addressing EMC within each
of the relevant departments and agencies. The purpose of the present research project
is to demonstrate the feasibility and potential of a searchable online database
dedicated to identifying and organizing the myriad Federal EMC initiatives in a
systematic, logical, and accessible fashion.
Methods: A survey device was distributed for input from CEMC members
representing relevant agencies within DoD, DOT, DHS, HHS, and the VA.
Responders were asked to provide information on their agencies’ existing EMC
programs, describing each initiative with respect to the following categories: program
name, responsible agency subcomponent, program description and goals,
classification as a grant or research program, total funding and mechanism, start and
end dates, legal authority/authorizing legislation, and contact information. Results
were compiled in a master database with an eye toward gaining perspective on the
breadth, scope, and focus of current Federal EMC efforts.
Results: A total of 20 survey responses were received from representatives of 19
Federal agencies, with each of the 5 targeted Federal departments well represented.
Responses were typically detailed and thorough, demonstrating Federal partners’
willingness to share related EMC activities and participate in a process designed to
promote collaboration and interoperability throughout the US Government. The
resulting database represents 110 individual Federal EMC programs, organized by
department, agency, focus area, and specified characteristics.
Conclusion: Having demonstrated the feasibility of collecting and systematically
organizing data on existing Federal EMC efforts, this project’s template spreadsheet
should be further developed into a functional online database operating in
conjunction with the ECCC Web site. With both an external component open to the
public — allowing interested parties to search for specific programs, research, or grant
opportunities — and an internal face allowing CEMC members to update and edit
their agencies’ entries, this database would serve to open the lines of communication
Annals of Emergency Medicine S63
Research Forum Abstracts
amongst EMC stakeholders. Ultimately, this tool could help identify both areas of
overlap and opportunities for collaboration, reducing duplication of effort and
promoting continuity and synergy throughout the EMC community.
206
Poor and Sick: Do Low-Income Areas Have Fewer
Emergency Departments?
Ravikumar D, Hsia R/University of California, San Francisco, San Francisco, CA
Study Objectives: No previous study has attempted to describe access to emergency
care based on socioeconomic status. This study attempts to characterize one aspect of
health disparities by attempting to find out whether low socioeconomic areas have less
access to emergency care. The objective of this study is to examine the relationship
between number of emergency departments per capita and median household income in
California FIPS (Federal Information Processing Standard) county codes.
Methods: This study is a retrospective analysis using cross-sectional data from the
American Hospital Association (AHA) Annual Survey of Hospitals from 2005. FIPS
county codes for the state of California were used to delineate socioeconomic areas.
The outcome variable we examined was the number of emergency departments per
capita (100,000) for FIPS county codes in California. The main independent variable
we used was median household income. We included two other measures of
socioeconomic status as independent variables: percent uninsured and percent of
people of age 25 or more with less than nine years of education. Outcomes were
transformed for normality and correlations were performed using STATA IC10.
Results: We analyzed 58 FIPS county codes in California. The correlation
between number of EDs per capita in California to median household income
showed a small negative relationship, where poorer areas actually had a larger number
of EDs (Pearson correlation ⫺0.322, 95% CI [⫺0.544 to ⫺0.081]). The number of
of EDs per capita was neither correlated with percentage of the population without
insurance nor those with low education.
Conclusion: Our findings show that, contrary to our hypothesis, the number of
EDs per capita is inversely related to median household income in a particular area.
In other words, there are a greater number of EDs per 100,000 people in lower
socioeconomic areas. This study has important policy implications for emergency
department patients as well as the delivery of emergency services in California. If
there is indeed a negative relationship between number of emergency departments per
capita and income, more research needs to be conducted to determine the factors
leading to crowding in low socioeconomic areas.
207
Penetration of Board Certified Emergency Physicians
Into Rural Emergency Departments in Iowa
House H, Young R, DeRoo E/University of Iowa, Iowa City, IA
Study Objectives: The American College of Emergency Physicians (ACEP) endorses
emergency medicine (EM) residency training as the only legitimate pathway to an EM
career, yet the economic reality of Iowa’s rural population will continue to support the
hiring of non-board certified physicians. Rural communities struggle to support
emergency physicians because of their smaller populations and inadequate patient
volumes. This survey will determine the minimum population needed to support an
emergency physician and examine the market forces that contribute to emergency
department (ED) staffing with emergency physicians versus family physicians in Iowa.
This project was supported by an ACEP Chapter Development Grant.
Methods: The research team identified a member of the ED administration at all
119 Iowa hospitals and asked the following:
1. What are the qualifications of your emergency staff?
a. Do you hire emergency physicians only?
b. Do you hire family physicians only?
c. Do you hire a combination of family and emergency physicians
2. What area of the state do you provide emergency medical care to?
3. What are your reasons for hiring your choice of ED staff in question 1?
The population of the catch area of each hospital was calculated to determine the
minimum population that supports the ED categories listed in question 1.
Results: 119 of 119 hospitals responded to this survey (100% response rate). It
was found that only 14 (11.8%) of Iowa emergency departments exclusively utilize
emergency physicians in order to staff their ED. 76 (63.9%) utilize a combination of
emergency physicians and family physicians, while 27 (22.7%) of Iowa hospitals
solely use family physicians in their ED. It was also found that 46 (38.7%) of Iowa
emergency departments utilize physician’s assistants or NP’s in solo coverage. It was
determined that the minimum population in the state of Iowa to support exclusive
BCEP coverage is 25,136, with a mean population of 88,143. Also, the minimum
population to support a combination (emergency physicians and family physicians) is
S64 Annals of Emergency Medicine
1465, with a mean population of 18,244. The most common reasons cited by
emergency departments hiring only family physicians included recruiting difficulties
of emergency physicians, the low patient census did not require emergency physician
specialty training, and the hospital was satisfied with the quality of care provided by
family physicians. Emergency departments that hired a combination of family
physicians and emergency physicians cited factors that included the ability to increase
recruiting of family physicians for local clinic with the incentive of no required ED
coverage, less ED call increases time off for local physicians, and the care of patients
in clinic increases with family physicians not being called away from clinic. Finally,
emergency departments that hired only emergency physicians cited factors that
included the quality of care provided by emergency physicians, high patient acuity
best supported by emergency physicians, and a high patient census best supported by
emergency physicians.
Conclusion: Many emergency departments in Iowa, a predominantly rural state,
remain staffed by family physicians. In fact, without the contribution of family
physicians, large areas of the state would be unable to provide adequate emergency
care. Emergency physicians remain concentrated in urban areas of the state, where
patient volumes and acuity support their hiring.
208
Does Having and Using a Usual Source of Care
Decrease Emergency Department Use?
Gabayan GZ, Asch SM, Starks SL, Sun BC/VA Greater Los Angeles Health
System, Los Angeles, CA; UCLA, Los Angeles, CA
Background: One of the most widely prescribed solutions to emergency department
(ED) crowding is increased access to a regular source of care. However, previous studies
have found conflicting associations between regular source of care and ED use.
Study Objectives: To evaluate the relationship between having and using a usual
source of care and emergency department use.
Methods: Data from the 2005 California Health Interview Survey (CHIS) were
used. The study was conducted as a two-stage cross-sectional population-based
random-digit dial survey of California households between 07/05 and 04/06. ED use
was assessed based on a respondents reporting of having an ED visit over the past 12
months. The relationship between usual source of care, visits to primary medical
doctor (PMD) and ED use was evaluated using multivariate logistic regression
accounting for potential confounders and comorbidities.
Results: Of 44,500 households contacted, there were 43, 020 adults interviewed.
Over ninety percent (n ⫽ 39, 094) of subjects reported having a usual source of care.
Visits to primary medical doctors (PMDs) were made by 19,774 (46%) 1–3 times per
year and by 14,178 (33%) 4 – 8 times a year. Having a usual source of care was not
significantly associated with visiting the emergency department. Compared to
subjects with no visits, subjects with 1–3 PMD visits per year had 2.4 times the odds
of visiting an ED (OR 2.4, 95%CI 2.1–2.7), subjects with 4 – 8 PMD visits per year
had 5.4 times the odds of visiting an ED (OR 5.4, 95%CI 4.8 – 6.0), and subjects
with greater than 8 visits per year had 10.4 times the odds of visiting an ED (OR
10.4, 95%CI 9.1–11.9). Additional associations of emergency department use included
household annual income below $10,000 (OR 1.3, 95%CI 1.1–1.4), public fee-forservice insurance (OR 1.3, 95%CI 1.1–1.4), having an emotional or physical disability
(OR 1.3, 95%CI 1.3–4.3), and suffering from one of number of chronic diseases:
cerebrovascular disease (OR 1.3, 95%CI 1.2–1.5), epilepsy (OR 1.5, 95%CI 1.3–1.8),
lung disease (OR 1.3, 95%CI 1.1–1.4), and diabetes (OR 1.1, 95%CI 1.0–1.2).
Conclusion: CHIS is the largest state-level health survey in the nation and is
descriptive of a state in which emergency services are in crisis. Controlling for
potential covariates, we found that having a usual source of care was not associated
with reduced ED use. Greater use of PMDs was associated with a greater likelihood
of visiting an ED, though this could be confounded by unmeasured disease severity.
As expected, poor, sick and disabled patients, as well as those with public fee for
service insurance were most likely to visit the ED. This suggests that providing access
to PMDs may not be sufficient for improving ED crowding and further work is
needed to help understand this complex problem.
209
Determinants of Health Care Access on the U.S.Mexico Border
Watts S, Tarwater P/Texas Tech University Health Sciences Center, El Paso, TX
Study Objectives: Emergency departments (EDs) are the health care safety nets in
many communities and are being flooded with increasing numbers of patients who
lack any other source of primary care. This study was conducted to identify the
determinants associated with health care access in a U.S.-Mexico border community.
Volume , .  : September 
Research Forum Abstracts
Methods: Using multiple variable logistic modeling, cross-sectional data from the
2005 Behavioral Risk Factor Surveillance System (BRFSS) for El Paso County, TX was
analyzed to identify factors associated with 2 different health care access measures: 1)
having insurance and 2) having a primary care provider (PCP). Exposure variables
considered for the multivariable model and which were univariately associated with either
outcome were age, sex, ethnicity, income, employment status, education, and history of
chronic disease (diabetes, hypertension, or asthma). Final model selection was based on
backwards elimination using a p-value ⬎0.10 as exclusion criteria.
Results: The age-adjusted model of having insurance found income level and
employment status to be significantly associated. Specifically, those with income
greater than $50,000 had eight times greater odds of having insurance (p⬍0.001)
than those with income less than $25,000. Those with income between $25,000 and
$50,000 had almost 6 times greater odds of having insurance (p⬍0.001). Also,
unemployed persons had a 73% decrease in odds of having insurance compared to
employed persons (p⫽0.008). Ethnicity and education level were retained in the final
model, whereby non-Hispanics were twice as likely to have insurance along with
those who had attained at least some college education. Similarly, in the age-adjusted
multivariable model of having a PCP, education level had a significant positive
association, whereby college graduates had 3 times greater odds of having a PCP than
those who did not finish high school (p⬍0.0001). In addition, diabetics had 2 1⁄2
times greater odds than non-diabetics (p⫽0.018) of having a PCP.
Conclusion: In this large U.S.-Mexico border community where emergency
departments are the health care safety nets for those who lack access to primary care,
we found age, income, and education to be significant determinants of health care
access. In addition, ethnicity and employment were associated with having insurance
while being diabetic was associated with having a primary care provider. Therefore,
intervention programs addressing determinants of access may require separate or
tailored implementation strategies, at least along the U.S.-Mexico border.
210
Severity of Illness Does Not Differ Based on
Insurance Status in Two Urban Emergency
Departments
Shukla KT, Eilbert W, Sloan E/University of Illinois, Chicago, IL
Study Objectives: It is the opinion of many emergency department (ED) health
care providers that patients with no insurance or Medicaid present to the ED for nonurgent care causing ED crowding. We seek to determine if the type of insurance, or
lack thereof, is correlated with the severity of illness for which patients present to the
ED.
Methods: Data was collected from two urban EDs that treat a total of 75,000
patients per year, one a university tertiary medical center and the other a community
teaching hospital with an emergency medicine residency. Billing level of service
(LOS) and admission rates were used as indicators of overall illness severity. This
injury severity data was compared among patients with Medicare, Medicaid, private
insurance and those with no health insurance. The time period of the study was from
January 2005 to April 2008.
Results: The total number of patients treated was 264,849, with 52% treated in
the community ED and 48% treated in the university hospital ED. The distribution
was 13% Medicare, 42% Medicaid, 27% private insurance, 13% no insurance, and
7% other. The most common LOS was level 3 (45% of patients). The LOS
distributions did not differ between the two hospitals. Admission information was
available for the 136,658 patients treated in the community hospital, 22% of these
patients were admitted. Medicare patients had a higher LOS distribution (71% in the
top 3 levels) when compared to all other groups together (46%) (p⬍0.05). Medicare
patients also had a 3-fold higher admission rate compared with the other groups, 51%
vs.15% (p⬍.05). There was no significant difference in the LOS and admission rates
when comparing those patients with Medicaid, private insurance, and no insurance.
Conclusion: Medicare patients, who presumably are older and have more medical
illnesses, are treated with a higher ED LOS and have a higher hospital admission rate
than patients with other insurance types. This finding suggests that LOS and
admission rate are a reasonable proxy for illness severity. The absence of a difference
in ED LOS and admission rates among Medicaid, privately insured and uninsured
patients refutes a widely held assumption that patients with Medicaid or no insurance
are more likely to use the ED as a source of primary care and non-urgent care.
Instead, all patients, regardless of insurance type, access the ED because of the need
for both emergency and unscheduled care. ED crowding is a complex issue that
involves all economic groups.
Volume , .  : September 
211
Does Pay for Performance Lead to Potential
Misuse of Antibiotics Among Patients With
Congestive Heart Failure?
Duseja R, Nsa W, Belk K, Schwartz S, Bratzler D/Wharton School, University of
Pennsylvania, Philadelphia, PA; Oklahoma Quality Improvement Organization,
Oklahoma City, OK; Premier, Inc, Charlotte, NC
Background: Pay for performance is intended to accelerate improvements in hospital
care, yet little is known about whether such incentives lead to worsening performance on
unmeasured quality metrics or if it decreases the variation of care delivered.
Study Objective: To determine whether the performance incentive measures,
antibiotic timing in pneumonia patients (receiving antibiotics within four hours) and
blood cultures drawn prior to antibiotic administration is associated with an
unintended increase in antibiotic administration and blood cultures drawn among
patients with congestive heart failure.
Design and Setting: An observational study of all hospitals (N⫽266) in the payfor-performance demonstration project ran by Premier, Inc. and the Centers for
Medicare and Medicare Services, from the fourth quarter of 2003 through the third
quarter of 2006. We retrospectively look at hospital billing data, and perform a time
series analysis of antibiotic use in and blood cultures drawn on heart failure and
pneumonia patients. We then examine correlations between changes in antibiotic
timing and blood cultures drawn in pneumonia patients and antibiotic
administration and blood cultures in heart failure patients.
Results: We find that with the incentivized quality measures, time to antibiotic within
four hours for pneumonia patients and blood cultures drawn prior to antibiotic
administration, there is no significant correlation with antibiotics administered to patients
admitted in day one for patients with congestive heart failure (p⫽.19), as well as blood
cultures drawn before antibiotic administration (p⫽.13). Over time, there is improvement
and decrease in variation in the incentivized measures across hospitals.
Conclusion: Hospitals engaged in the pay-for-performance project show little
evidence that incentivizing performance on hospital antibiotic timing scores lead to
adverse consequences with inappropriate antibiotic administration, and inappropriate
drawing of blood cultures. Additional research is required to determine whether other
financial or payment models can minimize or exacerbate unintended consequences within
the health system.
212
Resident Alertness, Stress, and Self-Reported
Medical Errors in an Urban Teaching Hospital
Emergency Department
Hansen KN, Marshall AJ, Heitmann A, Santiago MJ/University of Maryland
School of Medicine, Baltimore, MD; Awake Institute, LLC., Arlington, MA
Background: Overnight shift work causes fatigue due to circadian rhythm
disruption and sleep loss. Fatigue has been shown to be a significant factor
contributing to the occurrence of medical error.
Study Objectives: We sought to investigate the frequency of medical errors reported
by residents, and to determine whether the occurrence of errors varied by shift type or
other parameters. We also sought to identify factors related to resident stress and fatigue.
Methods: We conducted a prospective observational study of emergency
medicine residents working in an urban academic emergency department between
6/08 and 11/08. Subjects worked at least 10 consecutive shifts, including a minimum
of 2 night shifts. Subjects performed computerized visual analog score (VAS) tests of
alertness before, during, and after each shift. At the end of each shift subjects filled
out confidential questionnaires to collect information including an estimate of hours
slept in the preceding 24 hours, number of patients seen, stressfulness of the shift, and
subjective measures of fatigue. Subjects were asked to report the occurrence and
number of any errors they recalled making during the shift. Errors were categorized
into medication, charting, diagnostic, or other types of error, and included minor
problems such as forgetting to place an order or check an Xray.
Results: Twenty residents (PGY 1–5) completed VAS tests and questionnaires for
206 total shifts. Of these, 59 were day shifts (7A–7P), 28 evening (1P–1A), and 119
night (7P–7A). A total of 302 errors were reported, occurring during 123 (60%) of all
shifts. Of these, 91 (30.1%) were medication errors, 71 (23.5%) charting errors, 62
(20.5%) non-medication-related ordering errors, 42 (13.9%) diagnostic errors, 16
(5.3%) communication errors, and 20 (6.6%) “other.” Forgetting to place a
medication order was the most common specific type of error, occurring 24 times
(7.9%). Errors occurred with similar frequency during day, evening, and night shifts.
The occurrence or number of errors did not vary significantly in relation to VAS
score, hours slept, subjective busyness or stressfulness of shift, or number of patients
Annals of Emergency Medicine S65
Research Forum Abstracts
seen. Average stressfulness was higher when residents saw ⱖ 20 patients per shift (p ⫽
.03), or if acting in a supervisory role (p ⫽ .03). Stressfulness correlated with
subjective busyness of the department (r2 ⫽ 0.57, p⬍.001). Average VAS scores were
lower for all overnight measurements compared with day and evening (p ⬍ .001),
and were consistently lowest at the end of the night shift.
Conclusion: Errors were reported often in this setting, and most commonly
involved medication, charting, or ordering mistakes. Number of errors did not vary
by shift type, or other measured parameters. Residents reported more stress when
acting in a supervisory role or when caring for 20 or more patients per shift.
213
Major Barriers to Follow-Up of Emergency
Department Patients at Federally Funded Clinics:
Metropolitan-Wide Survey Pilot Data
Lewis L, Dziuba D/Washington University, St. Louis, MO
Background: Previous research has shown follow-up (F/U) rates of 11–30% for
patients referred to a federally qualified health center following an emergency
department visit. This research was conducted to identify major barriers to F/U.
Study Objectives: Identify major barriers to follow-up at federally qualified health
centers (FQHC) for uninsured or underinsured patients seen and discharged from an
urban-based ED.
Methods: Study Design: Prospective cohort, descriptive, observational Study
Setting: A large urban ED with annual volume of 80,000. Participants: All uninsured
or underinsured patients seen and discharged from an urban, adult ED during study
hours, with no self-identified usual source for outpatient medical care, were English
speaking, and had a telephone for F/U, were eligible. Patients were given information
regarding the FQHC closest to them for F/U and were asked for a number where
they could be reached by phone to answer questions about their clinic appointment.
Phone F/U was attempted within a few weeks, with multiple attempts made for up to
2 months. Research assistants used a standardized questionnaire to determine patient
demographics and: 1) If the patient followed-up; and 2) If not, what was the major
barrier to F/U. We asked all patients who successfully followed up if they had to pay a
co-pay. Patients were asked for the single, most important factor to improve access to
FQHCs. Descriptive statistics include proportions with 95% confidence intervals.
Results: 213 patients were screened and consented to be in the study. Fifteen
patients were excluded because they had an alternate source of care. Of 198
remaining subjects, 100 were women (50.5%) and 151 African-Americans (76.3%).
Mean age was 35.2 years. We have complete F/U data on 114 patients (49.1%). 57
patients (50%; 95%CI 40.8 –59.1) followed up to an FQHC. Of the 57 that did not
keep their F/U appointment; 54 completed the survey. Transportation was the major
identified barrier N⫽ 17 (31.5%; 95%CI 19.1– 43.9); followed by feeling better
N⫽10 (18.5%; 95% CI 8.2–28.9). Other reasons included cost N⫽8; and lost
appointment information N⫽6. Of the patients who kept their appointment, only
18 (31.6%; 95%CI 19.5– 43.7) had a co-pay, and only 8 (14%: 95%CI 5.0 –23.1)
paid more than $15. The most important factor identified to improve access by the
59 respondents to this question was transportation N⫽20 (33.9%; 95% CI 21.8 –
46.0). Cost was an important factor in 10 respondents (17.0%; 95% CI 7.4 –26.5).
Conclusion: F/U rate for patients in this study was higher than in previous reports
and may reflect a selection bias in patients able to be followed up by phone, or an effect of
knowing they would be contacted about their appointment. Transportation was the major
barrier to F/U to an FQHC, followed by cost. Offering transportation and lower cost
alternatives would likely increase F/U at FQHCs in this population.
214
Emergency Department Boarding Is Associated
With Higher Medication-Related Errors but Fewer
Laboratory Errors During the Early Admission
Period
Liu SW, Chang Y, Weissman J, Griffey R, Hamedani A, Thomas J, Nergui S,
Singer S/Massachusetts General Hospital, Boston, MA; University of
Massachusetts, Boston, MA; Washington University School of Medicine, St.
Louis, MO; Wisconsin University, Madison, WI; Good Samaritan Medical Center,
Brockton, MA; Harvard School of Public Health, Boston, MA
Study Objectives: As hospitals have become increasingly crowded, more patients
have ended up “boarding” in the emergency department (ED) while awaiting their
inpatient beds. Prior studies have not compared the quality of care of boarders and
nonboarders. We hypothesized that patients who board or have longer boarding times
are more likely to have errors and adverse events during an early admission period
than non-boarders or those with shorter boarding times.
S66 Annals of Emergency Medicine
Methods: This retrospective study utilized data from chart review and
administrative databases and employed an explicit/implicit review methodology.
Setting: The study took place at two academic, urban hospitals. Participants: All
patients with the admitting diagnosis of chest pain, pneumonia and cellulitis between
August 2004 and January 2005 were eligible. We excluded patients ⬍ 18 years of age,
those admitted directly to the catheterization lab, ⬍ 36 hours, to nonfloors, to
precaution rooms and those transferred from other hospitals. The dependent variables
were: 1. Adverse events/near misses over the early admission period (24 hours) 2.
Errors: Medication errors and process measure errors such as delayed repeat cardiac
enzyme labs, late prothrombin time (PTT) level checks, late antibiotic doses, missed
home medications over the early admission period. Independent variables were:
dichotomous and continous definitions of “boarding” status as defined respectively by
1) time from bed request to ED departure ⬎ two hours and 2) time between bed
request and ED departure. We defined the first 24 hours after this two-hour time
point as the early admission period. Biostatistical Analysis: We tested our hypothesis
by utilizing individual-level, cross-sectional, multiple logistic regression models,
controlling for potential confounders.
Results: 2234 patients were initially eligible. After exclusions, our analysis was
based on 1668 charts. 450 were nonboarders and 1218 were boarders. There were no
significant differences between boarders and nonboarders in terms of sex, age,
ethnicity, or adjusted Charlson score, nor differences in adverse events and near
misses. Boarding time was associated with higher odds of missing at least 50% of
home medications (AOR 1.086 95% CI (1.057–1.115)) and having a medication
error (AOR 1.056 95% CI (1.028 –1.084)) controlling for age, sex, ethnicity, means
of arrival, ESI, shift of arrival, hospital capacity, hospital site, and comorbidities.
There was no relationship between boarder status or boarding time with late PTT
checks, antibiotic administration and adverse events. Longer boarding times decreased
the odds of having a late cardiac enzyme check [AOR 0.927 95% CI (0.887– 0.970)].
Conclusion: Longer boarding times are associated with a higher likelihood of
medication related errors but a lower likelihood of some lab related errors. Patient
who spend more time boarding in the ED may miss home medications more often
because EDs are not designed to provide inpatient level of care. However, the finding
that patients who board longer do better or no worse in terms of lab checks indicates
that not all care provided to patients boarding in the ED is inferior to inpatient
management. This may be secondary to resources inherent to each setting. Future
studies should examine which processes allow optimal care for boarded patients.
215
A Comparison of Inferior Vena Cava Measurements
in Emergency Department Patients With Acute
Systolic Versus Diastolic Heart Failure
Sen A, Hegg AJ, Strote S, Miller JB/Henry Ford Hospital, Detroit, MI
Study Objectives: Measurement of inferior vena cava (IVC) diameter and
collapsibility index has been reported to estimate volume status in different cohorts of
patients. Our objective was to assess whether IVC diameters and collapsibility index
differ among patients presenting to the emergency department (ED) with
decompensated diastolic heart failure versus systolic failure.
Methods: We analyzed a convenience sample of 70 patients prospectively
enrolled in the ED of an inner-city teaching hospital between July 2008 and April
2009. Inclusion criteria were age ⬎ 50 years and the chief complaint of acute
dyspnea. Exclusion criteria were mechanical ventilation, trauma, portal hypertension,
and recent abdominal surgery. After informed consent was obtained, all patients were
assessed with routine clinical evaluation and bedside sonography of the IVC and aorta
(Ao) by emergency physicians. Echocardiographic measurements and outcomes were
compiled following admission to the hospital. Diastolic dysfunction was defined as
symptomatic heart failure with preserved systolic function (ejection fraction ⬎ 50%).
The maximum antero-posterior diameter of the IVC was measured sonographically
both in inspiration (i) and expiration (e) by M-mode in the subxiphoid area. The
difference between the diameters of IVCe and IVCi was regarded as collapsibility, and
the collapsibility index was defined as (IVCe – IVCi)/IVCe ⫻ 100%. The diameter
of the aorta proximal to the celiac trunk was also measured in M-mode, and the
IVCe/Ao index was calculated for each patient. Statistical analysis included student’s
t-test and correlation analysis with test of significance set at p⬍0.05. Figures are
expressed as mean values with standard deviations unless otherwise stated.
Results: Of the 70 patients enrolled, we evaluated 31 patients who were
diagnosed with decompensated heart failure. One of these patients was excluded from
analysis because no estimate of the ejection fraction was present. The mean age of the
study cohort was 72 ⫹ 10 years. 71% were males and 90% were African-American.
50% of these patients had echocardiographic evidence of systolic dysfunction and the
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Research Forum Abstracts
remaining had diastolic failure. There was a significant difference between the
maximum IVC diameter (IVCe) of patients with systolic dysfunction versus patients
with diastolic dysfunction (2.35 ⫹ 0.66 cm vs. 1.89 ⫹ 0.47 cm, p⫽0.04). There was
no difference in the collapsibility index between systolic failure and diastolic failure
(20.86 ⫹ 15.3% vs. 26.45 ⫹ 20.3%, p⫽0.4). Differences were also observed in the
IVCe/Ao ratios (1.21 ⫹ 0.28 cm vs. 0.99 ⫹ 0.21 cm, p⫽0.02) between the systolic
and diastolic failure cohorts.
Conclusion: Among patients diagnosed with decompensated heart failure, IVC
diameter is greater in patients with systolic dysfunction than diastolic dysfunction.
IVC collapsibility index did not differ between the two groups.
216
Comparison of Bedside Ultrasound and Panorex
Radiography in the Diagnosis of a Dental Abscess
in the Emergency Department
Adhikari S, Blaivas M/University of Nebraska Medical Center, Omaha, NE;
Northside Hospital Forsyth, Cuming, GA
Study Objectives: Panorex x-rays are often obtained to evaluate patients with
suspected dental abscess in the emergency department (ED) to determine if
someone needs incision and drainage. But it requires the patient leaving the ED
and time to interpret the x-rays which adds a delay to the patient care and
disposition in ED. To our knowledge, the utility of bedside ultrasound (US) in
diagnosing a dental abscess has never been investigated before. The objective of
this study is to compare bedside ultrasound and Panorex radiography in the
diagnosis of a dental abscess in ED.
Methods: This is a retrospective review of patients presenting to an academic
ED with facial pain, swelling and toothache who received a bedside US and a
Panorex x-ray for suspected dental abscess. ED US logs were reviewed for the
diagnosis of dental abscess. Emergency physician investigators performed bedside
US prior to Panorex x-rays. The bedside US examinations were performed using
either a Phillips Envisor system or a SonoSite M-Turbo system with a broadband
linear array transducer. Both x-rays and US were independently reported. The
medical records of these patients were reviewed for history, physical examination
findings, additional diagnostic testing, and disposition plan. The US images
obtained in ED were subsequently reviewed by another sonologist who is blinded
to the study hypothesis, and ED US interpretations. Data are summarized using
descriptive statistics. Continuous data are presented as means with standard
deviations and dichotomous data are presented as percent frequency of
occurrence with 95% confidence intervals.
Results: A total of 19 patients (mean age, 40 years ⫹/⫺ 13.6 [standard
deviation]) were identified over a two-year period. All patients had facial pain,
swelling, and tenderness of teeth. No periapical abscess was reported in 6/19 (31% CI
10 –52%) patients, with which US showed 100% concordance. A radiological
diagnosis of periapical abscess was made in 13/19 (68% CI 47– 89%) patients. US
agreed with Panorex x-ray in 10/13 (76% CI 54 –99%) cases. In the 3 cases where US
disagreed with X-rays, radiographic abnormalities were reported on the opposite side
where patient didn’t have any symptoms. 10 patients were evaluated by dentistry or
ENT service in ED and incision and drainage was performed in 9 cases. There is
100% agreement between emergency physician investigator and blinded sonologist
US interpretations.
Conclusion: Bedside US is non-ionizing, can provide an alternative to Panorex
x-rays in the evaluation of dental abscess and improve throughput in the ED.
217
INSPIRED: Instruction of Sonographic Placement of
IVs by RNs in the Emergency Department
Liteplo AS, Patel P, Huang C, Dipre M, Kimberly H, Noble VE/Massachusetts
General Hospital, Boston, MA
Study Objectives: Vascular access is a critical aspect of patient care for all
hospitalized patients. When standard palpation techniques of peripheral IV
placement fail, patients often require alternative methods of vascular access, but
these alternatives pose risks to patient safety, can be costly, and utilize valuable
resources.
Ultrasound has been shown to be a valuable tool in successful placement of
peripheral IVs. We hypothesize that emergency nurses can easily learn this
technique and successfully and safely use ultrasound to assist them with
peripheral IVs after a brief training course taught by emergency physicians
experienced in ultrasound. We also seek to identify vein characteristics predictive
of failure of IV placement and patient satisfaction with the procedure.
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Methods: Emergency physicians with prior experience with ultrasound designed a
two-hour training course. Twelve nurses participated in the project. All twelve nurses
completed a pre- and post-course survey of their comfort level with ultrasound. Once
certified, nurses were able to use the ultrasound to guide IV insertion, after obtaining
verbal consent. For each patient enrolled, a datasheet was filled out describing the
number of prior blind sticks, the perceived difficulty of the IV placement, vein
characteristics (visibility, palpability), and the results of each attempt. Patients were
asked if they would prefer an ultrasound-guided IV to a standard IV in the future.
Data were entered into a Microsoft Excel spreadsheet and tabulated. This study was
institutional review board-approved.
Results: Prior to the training, 16% (2/12) of nurses reported they were
comfortable with general use of an ultrasound machine, 40% (5/12) were
comfortable identifying a vein on ultrasound, and 8% (1/12) were comfortable
placing an IV with ultrasound guidance. After the training, 100% (12/12) of
nurses were comfortable with all three of these measures. This comfort level
persisted at a 1-month follow-up survey. After the course, 100% (12/12) of
nurses felt likely to attempt an ultrasound-guided IV when they have a difficult
stick patient, and 92% (11/12) felt likely to help a colleague. At one month,
these values were both 100%.
120 patients were enrolled. There was an average of 2.6 blind attempts per
patient prior to an attempt with ultrasound. The average perceived difficulty of IV
before ultrasound guidance was 4.5 on a scale of 1–5, 5 being most difficult.
Nurses successfully punctured a vein in 93% of patients (111/120). An IV was
successful 74% of the time (89/120), on the first try in 63% (76/120). Arterial
puncture occurred in 2.5% (3/120) of patients. There was no difference between the
successful and unsuccessful attempts in vein depth (5.0 vs 5.1 mm) or diameter (3.9
vs 3.8 mm).
Of the patients surveyed, 78% (79/101) of patients would prefer an ultrasoundguided IV in the future, 3% (3/101) would not, and 19% (19/101) had no
preference.
Conclusion: A 2-hour training module taught by physicians is an effective
modality for teaching nurses how to use ultrasound for guidance of peripheral IV
placement. Nurses are able to achieve IV access in the majority of patients in whom
blind sticks have failed, and can do so safely, accurately, and usually on the first
attempt. The rate of arterial puncture is very low. Vein depth and diameter do not
correlate with likelihood of success. Patients overwhelmingly would prefer
ultrasound-guided IVs in the future.
218
Bedside Ultrasound Evaluation of Tendon Injuries
Wu TS, Rosenberg M, VanDillen C, Flach F, Simpson C/
Orlando Regional Medical Center, Orlando, FL
Study Objectives: For years, subspecialists have utilized musculoskeletal
ultrasound during the assessment and diagnosis of potential extremity tendon
lacerations. Ultrasound can diagnose full and partial tendon disruptions in a quick
and non-invasive manner with sensitivities and specificities approaching 100%. Goaldirected, focused ultrasonography is becoming a mainstay of practice in multiple
emergency departments (ED) nationwide, and emergency physicians are learning how
to perform basic musculoskeletal scans. We sought to determine if bedside
ultrasonography can be used to expedite diagnosis and discharge planning in patients
with suspected tendon injuries in the ED.
Methods: This was a prospective study conducted at an academic Level 1 trauma
center with an annual ED census of approximately 90,000 patients. Patients were
eligible for study enrollment if they were at least 16 years of age, and had sustained a
closed or open extremity injury that put them at risk for potential tendon injury.
Prior to initiation of the study, resident and attending physicians were given a twohour course on how to perform tendon ultrasonography. Enrolled patients underwent
a bedside ultrasound evaluation prior to wound irrigation and exploration. For each
study participant, the following data were noted: injury location, suspected degree of
tendon injury based on physical exam, degree of tendon injury visualized on
ultrasound, degree of tendon injury visualized on exploration, time of initial patient
encounter, time to diagnosis via ultrasound, and time to disposition based on
exploration findings. Ultrasound results were verified against findings seen on wound
exploration or MRI.
Results: Twenty-one adult patients were prospectively enrolled in the study.
There were five finger injuries, seven hand injuries, three forearm injuries, four
arm injuries, and two leg injuries. Of the 21 total patients, three patients had
partial tendon injuries, four suffered from 100% tendon laceration or rupture,
and fourteen had no tendon injury noted on exploration or MRI. Bedside
Annals of Emergency Medicine S67
Research Forum Abstracts
ultrasound was accurate in estimating the degree of tendon injury in 20 of the 21
cases (sensitivity 100%; specificity 92.9%). In contrast, predictions of suspected
tendon injury by physical exam were correct in 16 of the 21 patients (sensitivity
100%; specificity 65%). It took an average of 27 minutes to evaluate the
suspected tendon injury using bedside ultrasound. In contrast, tendon evaluation
following local anesthesia, irrigation, and open wound exploration took on
average 92 minutes to complete.
Conclusion: Emergency physicians trained in basic tendon ultrasonography can
utilize ultrasound at the bedside to rapidly and accurately evaluate potential tendon
lacerations. Bedside ultrasound is more specific than physical exam for detecting
tendon lacerations, and takes less time to perform than traditional wound exploration
techniques.
standardized phantoms (Blue Phantom™, Bothell, WA) in one of 5 randomized
positions. Emergency medicine residents and attendings were instructed to
evaluate NT location simulating a right internal jugular vein approach. Subjects
sequentially scanned the phantoms in randomized order, with each phantom
randomized to either SA or LA. An expert observer verified NT location at the
time of study. The outcome measure was correct NT position identification. All
studies were recorded on SVHS video. Videos were reviewed by investigators.
Time was calculated using the SVHS on-screen clock. Time ”began” at the first
transducer contact with the phantom. Time ”ended” when the transducer was
finally removed from the phantom. Analysis using Pearson’s Chi-square and
Agresti-Coull binomial confidence intervals was performed, with significance
defined as p ⬍ 0.05.
Results: 416 (90%) of 462 times were included. Due to video corruption 46
scans were not included. See Table.
Conclusion: The time required to identify the needle tip location was
independent of the US transducer orientation and level of training. With increased
accuracy in needle tip identification in the long axis, our study further supports using
the long axis as a primary technique for ultrasound guided central venous
cannulation.
220
How Accurate Is the Last Menstrual Period in
Dating a First Trimester Pregnancy?
Saul T, Lewiss RE, Del Rios M/St. Luke’s Roosevelt Hospital, New York, NY
219
Time to Identify Needle Tip Location Is
Independent of Ultrasound Transducer Orientation
and Physician Level of Training
Sierzenski P, Kochert E, Mink JT, Cook D, Nichols WL, Reed III J, Nomura J/
Christiana Care Health Services, Newark, DE
Study Objective: To determine the accuracy of last menstrual period (LMP) in
determining gestational age and to determine the accuracy of emergency physician performed crown-rump length (CRL) measurement as an estimation of gestational
age (GA).
Methods: We prospectively enrolled a convenience sample of patients
presenting to the emergency department (ED) and thought to be in the first
trimester of pregnancy. Study physicians underwent a didactic lecture and hands
on focused training in 1st trimester gestational age determination by emergency
department ultrasound (EDUS). Ultrasound scans were compared to those
performed in the department of radiology as the gold standard. Paired sample
t-test was used to determine the correlation between GA by LMP and by EDUS
compared to GA as determined by radiology US. Descriptive statistics were used
to determine the frequency by which gestational age by LMP and by EDUS had a
discrepancy of greater than 7 days and the average discrepancy compared to
radiology US.
Results: 72 patients have been enrolled. Of these patients 4 did not consent. 68
patients with suspected 1st trimester pregnancy underwent EDUS. Table 1
summarizes our results.
Conclusion: An accurate determination of gestational age is important in
prioritizing the differential diagnosis and triage of patients as conditions such as
ectopic pregnancy present at certain times in gestation. Our data suggests that
determining LMP is an inaccurate method of estimating GA when compared
with radiology-performed ultrasonography. Bedside ultrasound is more accurate
and should be used by emergency physicians to determine GA in patients
presenting with suspected 1st trimester pregnancy.
Background: Ultrasound (US)-guided central venous access is recommended by
national organizations and medical societies. Increased accuracy for ”needle tip” (NT)
identification in a long axis orientation has been demonstrated.
Study Objective: To determine if NT identification with US requires
more time (seconds) in a long-axis (LA) or a short-axis transducer orientation
(SA).
Methods: Standard central access introducer needles were placed in 6
S68 Annals of Emergency Medicine
Volume , .  : September 
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221
Evaluation of Ectopic Pregnancy With Bedside
Ultrasound by Emergency Physicians: A MetaAnalysis
Stein JC, Wang R, Adler N, Goldstein R, McAlpine I, Won G, Jacoby V, Kohn M/
University of California, San Francisco, CA
Study Objectives: Early and accurate recognition of ectopic pregnancy (EP) is
essential to avoid morbidity and mortality. Research and clinical practice have
demonstrated a clear role for pelvic ultrasound examination in patients at risk for EP.
Such evaluations have typically been performed by radiologist or OB/GYN consultants.
Several studies have investigated the accuracy of pelvic ultrasound by emergency
physicians. These studies have generally shown both high sensitivity and negative
predictive value for ruling out EP. It has been demonstrated that this approach is cost
effective, and decreases the time patients spend in the ED. However, these accuracy
studies have been relatively small with wide confidence intervals around the performance
estimates, perpetuating uncertainty regarding the appropriate role of this technology. In
order to better assess overall test characteristics of the use of pelvic ultrasound by
emergency physicians in the evaluation of EP, we conducted a systematic review and
meta-analysis.
Methods: A structured search was performed of both MEDLINE and EMBASE
from 1966 through August 2008. The search string utilized the following subject
terms and text words: “ectopic pregnancy,” “ultrasound or ultrasonography or
sonography,” and “emergency.” The search was limited to human subjects, and
included all languages. We conducted online bibliographic searches of abstract
submissions to Annals of Emergency Medicine and Academic Emergency Medicine from
1990 through August 2008. Additionally, we searched through the bibliographies of
studies that met relevance criteria for further articles on the subject.
Two independent reviewers screened all abstracts and subsequent manuscripts for
inclusion using the following criteria: 1) original research of female emergency
department patients at risk for EP, 2) emergency physician performed and interpreted
the initial pelvic ultrasound, 3) a gold standard follow-up criterion (formal radiology
or clinical) was used for all patients. Two independent reviewers then extracted data
from the included studies, and standardized the testing vocabulary such that a
negative study for emergency physician was a definite intrauterine pregnancy
(gestational sac plus yolk sac and/or fetal pole). Study quality was assessed utilizing a
validated tool for quality assessment of diagnostic accuracy studies (QUADAS).
Pooled data was analyzed with a random effects model.
Results: The initial search yielded 576 publications. Abstract review yielded 57 with
potential relevance. After full manuscript review, final inclusion yielded eight articles and
one abstract for a total of 1987 patients (99% agreement, kappa 0.95). Our random
effects model of the sensitivity demonstrated homogeneity and showed a pooled estimate
of 99.3% (95% CI: 96.5 to 100). The model also demonstrated homogeneity for negative
predictive value, with overall estimate of 99.96% (95% CI: 99.6 to 100). For both
specificity and positive predictive value, there was significant heterogeneity. Overall,
emergency physicians were able to rule out emergency physician in 63% of patients.
Conclusions: This systematic review demonstrates that studies of the use of
bedside ultrasound performed by emergency physicians consistently demonstrate
excellent sensitivity and negative predictive value for ruling out ectopic pregnancy in a
wide variety of clinical settings.
222
Nurse Utilization of Ultrasound Guidance for
Peripheral IV Placement in the Emergency
Department: Does It Change Over Time?
Lyon M, Sinex JE, Shiver SA, Bloch A, Flake M/Medical College of Georgia,
Augusta, GA
Study Objectives: Nurse utilization of ultrasound (US) for peripheral intravenous
(PIV) access has been increasing, particularly in academic medical centers. However,
little is known about how the frequency of use of this technique changes over time
following initial adoption within an institution. Our objective is to describe the
utilization of US for PIV access over time in a well-developed nursing based program.
Methods: This was a prospective observational trial performed in a Level I
academic ED. Nurses, both RN and LPN, trained in US-guided PIV access recorded
their use of and indications for the procedure for quality assurance purposes. A 5month sample period in 2008 was compared to a similar 5-month sample period in
2003. The data were evaluated using descriptive techniques.
Results: ED volume was comparable between the two study periods (75,000 vs.
78,000, respectively), as was nurse staffing (105.6 vs. 120.4 FTE). During the 2003 time
period, 10 nurses were trained (6.4%), and during the 2008 time period 30 nurses had
Volume , .  : September 
attended training (25%). The 2003 time period yielded 321 US-guided PIV access
procedures by 7 nurses (70% of the trained staff ), and the 2008 time period yielded 217
US-guided PIV access procedures by 18 nurses (60% of the trained staff). In the most
recent study period, 48.8% of US-guided PIV access procedures were performed by 2
nurses and 89.8% of procedures were performed by 7 nurses. During the 2003 time
period, procedures were equally divided among the 7 users. The most common reasons
given for using US during either time period were prior failed access (60.4%), need for
large bore PIV access for IV contrast or resuscitation (24.4%), or a physical examination
consistent with poor venous access (22.6%).
Conclusion: US-guided PIV placement by nurses can be described as being
performed by a relatively small core cadre of users who employ US relatively
frequently, and a larger group who use it rarely. It was further observed that the
overall number of procedures did not increase over time, though the number of
nurses employing this technique did increase. Further research is needed to define the
barriers to implementation of the technique after training.
223
Emergency Department Bedside Ultrasound
Measurement of Caval Index as Non-Invasive
Determination of Low Central Venous Pressure: A
Multi-Center Validation of an Emergency
Department Protocol
Hansen AV, Medak AJ, Campbell C, Nagdev A, Castillo EM/University of
California - San Diego, San Diego, CA; Highland General Hospital, Oakland, CA
Study Objectives: An initial study has shown that among critically ill adult emergency
department (ED) patients undergoing central venous catheterization, a greater than 50%
decrease in the inferior vena cava (IVC) diameter measured by experienced emergency
physician sonographers is a good predictor of low central venous pressure (CVP). This is
preliminary data from a study that seeks to validate this protocol at an additional center
among emergency physician sonographers of varying experience.
Methods: Critically ill adult ED patients undergoing central venous catherization
were enrolled in a prospective, observational study. Their maximal inspiratory (IVCi) and
expiratory (IVCe) IVC diameters were measured by two-dimensional bedside ultrasound
completed by emergency medicine residents and attendings of varying ED ultrasound
experience. Prior to measurement of a transduced CVP, emergency physician
sonographers were also asked to estimate the CVP as ⬎ or ⬍ 8mm Hg by visually
estimating respiratory variation of the IVC diameter. The caval index (CI) was calculated
as the relative decrease in IVC diameter over one respiratory cycle (IVCe–IVCi/IVCe).
Linear regression was used to assess the association of CVP and CI. The sensitivity,
specificity, positive (PPV) and negative (NPV) predictive values and 95% confidence
intervals of a CI ⱖ 50% to predict a CVP ⬍ 8 mm Hg were estimated. These
characteristics were also estimated for the emergency physician sonographer’s ability to
predict a CVP ⬍ 8 mm Hg based on visual estimation of inspiratory collapse of the IVC.
Results: 25 patients have been enrolled; however, 1 patient was excluded as the
operator was unable to locate the IVC. 12.5% of operators were second year
residents, 41.7% were third year residents, 16.7% were fourth year residents and
29.2% were attending emergency physicians.
Of 24 patients, the median age was 56 and 58% were female. Mean time and
fluid administered from ultrasound measurement to CVP determination was 18
minutes and 10 mL, respectively. 50% of the patients had had a measured CVP less
than 8 mm Hg. The relationship between CI and CVP in an unadjusted linear
regression model was ␤: ⫺.12 (95% CI: ⫺0.23, ⫺.010). The sensitivity of a CI ⱖ
50% to predict a CVP ⬍ 8 mm Hg was 60% (24.7– 86.3%), specificity was 85.7%
(56.2–97.5%), PPV was 75% (35.6 –95.5%), NPV was 75% (47.4 –91.7%). The
sensitivity of emergency physician sonographer estimated CVP ⬍ 8 mm Hg to
predict an actual CVP ⬍ 8 mm Hg was 90% (54.1–99.5%), specificity was 78.6%
(48.8 –94.3%), PPV was 75% (42.8 ⫺93.3%), NPV was 91.6% (59.8 –99.6%).
Conclusions: These preliminary data suggest that a protocol in which emergency
physician bedside ultrasound measurement of CI ⱖ 50% has shown to be a good
noninvasive predictor of low CVP may be validated when performed by emergency
physician ultrasonographers of varying experience. In particular, clinician estimated
CVP ⬍ 8 mm Hg based on bedside ultrasound appears to be a good predictor of a
low CVP. Rapid, bedside measurements of CI could be a useful guide in the
resuscitative management of critically ill patients.
Annals of Emergency Medicine S69
Research Forum Abstracts
224
Teaching the Focused Assessment With
Sonography in Trauma Exam: Is an Ultrasound
Mannequin Simulator as Good as or Better Than
Using Live Models for Practical Training?
Damewood S, Cadigan B, Jeanmonod D/Albany Medical Center, Albany, NY; St.
Luke’s Hospital, Bethlehem, PA
Study Objective: This study was designed to evaluate the effectiveness of two
different “hands-on” Focused Assessment With Sonography in Trauma (FAST)
curricula, a mannequin model with ultrasound simulator and a human model with
ultrasound machine, in teaching the skills of both image acquisition and image
interpretation of the exam.
Methods: This study is a prospective randomized controlled study conducted on
a consecutive sample of fourth year medical students enrolled during their required
emergency medicine rotation. Fourth year medicals students were chosen as an
ultrasound naı̈ve population, and were screened to ensure a lack of prior ultrasound
training. All study participants received a standardized didactic presentation on the
FAST exam, which illustrated both normal and abnormal findings. The students were
randomized into two groups for the hands-on intervention. The first group practiced
the FAST exam on the Ultrasim (MedSim Ft. Lauderdale, FL), an ultrasound
mannequin simulator, set to simulate both positive and negative findings. The second
group practiced on normal human subjects.
The students were then tested on whether images of pre-recorded FAST exams
were positive or negative. After the interpretive test, both groups performed the FAST
exam on a standardized normal patient. The students recorded still images
representing each of the four views of the traditional FAST exam that they deemed
were adequate images. The time required for each participant to complete the FAST
exam was recorded. After finishing image acquisition, the students recorded their
perceived level of confidence in the quality of images that they acquired. Two blinded
investigators with expertise in EM ultrasound scored the acquired images according to
a pre-established set of scoring criteria. A third blinded investigator reviewed images if
there was a discrepancy in scores.
The adequacy of the obtained images, time to acquisition of the images, the
students’ levels of confidence in image acquisition, and scores of the interpretive test
between the two groups were compared.
Results: To date, 56 participants have been enrolled in this study. The adequacy
of the obtained images scored out of a possible 24 points was similar between the
simulator and human subject groups, with means of 14.8 (95% CI 12.7–17.0) and
15.2 (95% CI 13.6 –16.9) (p⫽0.68) respectively. The median time for the simulator
group to record the FAST exam was 223 seconds (IQR 155–298.5) while the human
subjects group’s median time was 270 seconds (IQR 202–310) (p⫽0.059). The
participants’ perceived confidence was also similar. The simulator group’s median
confidence score on a scale of 0 –10 was 5 (IQR 4.2– 6.7) while the human subject
group’s median score was 4 (IQR 3.7–5.2) (p⫽0.213). In regards to the interpretive
test, the median score of the simulator group was 84% (IQR 75– 89), compared to
78% (IQR 68.5– 87.5) (p⫽0.134) in human subject group.
Conclusions: According to our preliminary data set, there was no significant
difference between the groups for the measured outcomes of perceived confidence of
image adequacy, time to image acquisition, image interpretation, or acquired image
adequacy. This data set suggests there is no difference between ultrasound simulators and
human subjects in teaching students how to perform and interpret the FAST exam.
225
Should This Stroke Patient Be Transferred?
Computed Tomographic Angiography Predicts Use
of Tertiary Interventional Services
Thomas LE, Goldstein JN, Hakimelahi R, Gonzalez RG/Massachusetts General
Hospital, Boston, MA
Study Objectives: Many organizations have recommended that primary and
comprehensive stroke centers be established to organize stroke care. However, there
are no formal guidelines for determining which patients should be transferred to
comprehensive stroke centers. A rapidly available prediction tool for advanced
interventional services would help community hospitals determine which patients
might benefit from transfer. Multislice computed tomographic scanners are widely
available in U.S. emergency departments; we hypothesized that the finding of an
occlusive thrombus in a proximal cerebral artery on computed tomographic
angiography (CTA) would predict use of advanced neurointerventional services.
Methods: Consecutive ischemic stroke patients presenting within 24 hours of
symptom onset to a single academic emergency department in 2006, and who
S70 Annals of Emergency Medicine
underwent emergent CTA, were retrospectively reviewed. Proximal cerebral artery
occlusions on CTA were defined as distal/terminal (intracranial) internal carotid
artery, proximal (M1 or M2) middle cerebral artery, and/or basilar artery. Tertiary
care interventions including intra-arterial (IA) thrombolysis, mechanical clot retrieval
or removal, and any neurosurgical procedure were captured.
Results: During the study period, 283 patients presented within 24 hours of
symptom onset, and 207 (73%) received a CTA. 25% of patients received
intravenous tissue plasminogen activator, 2.4% received IA thrombolytics, 6.8%
received a mechanical intervention, 3.3% underwent surgery, and 52% were admitted
to the neuroscience intensive care unit. 72 (35%) showed evidence of a proximal
cerebral artery occlusion on CTA, and 22 (11%) received a tertiary
neurointervention. Patients with proximal thrombi had higher National Institutes of
Health stroke scale scores than those without this finding (17 (IQR 9 –21) vs. 4 (IQR
2–9), p⬍0.0001). In addition, those with proximal thrombi were more likely to
receive an intervention (25% vs. 3%, p⬍0.001). They were more likely to undergo
IA thrombolysis (8% vs. 1%, p⫽0.008), a mechanical intervention (19% vs. 0%,
p⬍0.0001), or admission to the neuroscience ICU (85% vs. 35%, p⬍0.0001). They
were also more likely to suffer in-hospital mortality (30% vs. 6%), and less likely to
be discharged home (10% vs. 48%) (p⬍0.001). Evidence of proximal occlusion on
CTA predicts use of IA thrombolysis with sensitivity 86%, specificity 67%, PPV 8%
(5–9%), and NPV 99% (97–99%). It predicts use of mechanical intervention with
sensitivity 100%, specificity 70%, PPV 19%, and NPV 100%. In multivariable
logistic regression controlling for age, sex, initial National Institutes of Health Stroke
Scale score, and time to presentation, the only independent predictors of
interventional services were increasing NIHSS (OR 1.1, 95%CI 1.01–1.2) and
proximal clot on CTA (OR 5.8, 95%CI 1.7–20).
Conclusion: Proximal cerebral artery occlusion on CTA is a sensitive, but not
specific, independent predictor of use of advanced neurointerventional services. While
not all centers can perform a comprehensive CTA, almost all emergency departments
in the US can perform multislice CT scanning with contrast, and have the ability to
determine presence of a thrombus in a proximal cerebral artery. CTA may be a
valuable tool in determining which stroke patients would benefit from transfer to a
center with comprehensive neurointerventional services.
226
Nonaneurysmal Subarachnoid Hemorrhage: Clinical
Course and Outcome in Two Distinct Hemorrhage
Patterns
Gilmer M, Wiliams A, Ray D, Jones JS/Michigan State University College of
Human Medicine, Grand Rapids, MI; MERC/Michigan State University Program
in Emergency Medicine, Grand Rapids, MI; MERC/ Michigan State University,
Grand Rapids, MI
Background: Fifteen percent of spontaneous SAH have a normal cerebral
angiogram, which indicates non-aneurysmal SAH (NASAH). In contrast to
aneurysmal SAH, patients who have a NASAH have a better prognosis and fewer
neurological complications. Two distinct hemorrhage patterns in NASAH have been
identified on initial computed tomography (CT): perimesencephalic and diffuse
subtypes. The diffuse hemorrhage pattern involves more than the prepontine cisterns
and mimics aneurysmal rupture. The perimesencephalic hemorrhage pattern has
blood confined to the midbrain cisterns with no evidence of intraventricular and
intracerebellar hemorrhage.
Study Objectives: To compare the predisposing factors, treatment, and
subsequent complications in patients with two different patterns of NASAH.
Methods: This retrospective cohort analysis evaluated consecutive adult patients
presenting to the emergency department with an admitting diagnosis of SAH. The
study took place at two urban U.S. academic medical centers over a six-year study
period (2003–2008). The patients were stratified based on grade at presentation,
severity, and pattern of SAH on initial CT of the head into perimesencephalic and
diffuse subtypes. The patients were further differentiated based on the development
of vasospasm, hydrocephalus and required treatments, and clinical outcomes. Patients
were excluded if a causative lesion was discovered subsequently. Chi-square and
ANOVA tests were used to compare clinical features among the cohorts examined.
Results: A total of 436 patients with subarachnoid hemorrhage were evaluated
during the study period; 89 (20%) had no identified source of bleeding (NASAH)
and fulfilled the inclusion criteria. Twenty-nine patients were considered to have the
perimesencephalic (p-SAH) subtype, while 60 patients fit criteria for the diffuse (dSAH) subtype. There were no significant differences between the two hemorrhage
subtypes in age, sex, ethnicity, hypertension, tobacco or alcohol use, or use of
anticoagulants. Patients with perimesencephalic hemorrhage had a milder, gradual
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onset headache and significantly less altered level of consciousness. Patients with dSAH subtype had a higher risk for complications related to SAH with an increased
incidence of hydrocephalus (33% vs. 3%, p⬍.01), symptomatic vasospasm (28% vs.
7%, p⫽.04) and secondary stroke (15% vs. 0%, p⫽.07). Ultimately, only 67% of
d-SAH patients achieved complete recovery and independent living, compared to
90% of p-SAH patients.
Conclusions: Patterns of hemorrhage on the initial CT scan are important
prognostic factors for NASAH. The patients that fit strict criteria for
perimesencephalic hemorrhage demonstrated a relatively benign course. Patients with
a diffuse hemorrhage pattern are at increased risk for hydrocephalus and secondary
stroke; they are also less likely to achieve complete recovery and should therefore be
cared for with a higher level of surveillance.
227
Examination of Adherence to Evidence-Based
Practices and 30-Day Outcomes for Emergency
Department Patients Treated for Transient
Ischemic Attack
Baumann MR, Halberg MJ/Maine Medical Center, Portland, ME
Study Objectives: Little evidence regarding outcomes in transient ischemic attack
(TIA) patients discharged from the emergency department (ED) or on local adherence to
identified best practices in TIA care was available. The purposes of this study were to: 1)
evaluate health outcomes in patients treated in the ED for TIA at 48 hours, 7 days, and
30 days, 2) to evaluate compliance with identified best practices in TIA care, and 3) to
examine the relationship between ABCD2 score and disposition in TIA patients.
Methods: This retrospective health records survey was exempted by the hospital
institutional review board. A sample of 50 health records for patients seen in a single
academic tertiary care ED with a diagnosis of TIA was randomly selected for review
and study inclusion. Demographic characteristics, ABCD2 score, treatment regime,
imaging results, and disposition were collected from all records. Examination of the
electronic health record for a 30-day period following the initial visit was conducted
to determine repeat visits for TIA or stroke at 48 hours, 7 days, and 30 days.
Results: In our randomly selected cohort, 28 (56%) patients were admitted to the
hospital and 22 (44%) were discharged to home. Eight percent of the study
population had a repeat visit for TIA or stroke during the 30-day period following
their initial ED visit. Patients admitted on their initial visit returned for TIA or stroke
more frequently than their discharged counterparts (10.7% vs. 4.5%, respectively,
␹2 ⫽ 36.255, p ⫽ 0.000) and had higher ABCD2 scores (22 vs. 8 with moderate to
high risk scores, respectively, ␹2 ⫽ 26.8, p ⫽ 0.000). ED workups for TIA compared
favorably with identified evidence-based practices: 100% of patients received an
electrocardiogram, 98% received brain computed tomography or magnetic resonance
imaging, and 86% received carotid imaging. Carotid imaging was performed 100%
of the time in admitted patients. Echocardiograms were obtained in 79% of admitted
patients versus 0% of discharged patients. The majority of patients (94%) were
discharged on anti-platelet medications. Those patients with high and moderate risk
ABCD2 scores were admitted to the hospital in 80% and 72% of cases, respectively.
This relationship was noted to be statistically significant, r ⫽ 0.512, p ⫽ 0.000.
Conclusions: In this cohort of emergency department patients, 8% of the study
population was treated for repeat TIA or stroke within 30 days of the index ED visit.
Care for the majority of patients followed identified evidence-based practices. We
found ABCD2 scores to be correlated with admission to the hospital and return visits
for TIA or stroke. Additional research on the use of the ABCD2 score as a predictor
of risk for repeat TIA or stroke is warranted.
228
Cephalgia in Emergency Department Responds to
Oxygen Decreasing Time to Relief, Length of Stay,
Computed Tomography Utilization, and Need for
Pharmacotherapy
Veysman BD, Carluccio A, Ohman-Strickland P, Arya R, Ostro B, Merlin MA/
UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ; Umiversity of
Medicine and Dentistry of New Jersey-School of Public Health, Piscataway, NJ
Study Objectives: Efficacy of high-flow oxygen is documented in cluster
headaches, but has not been studied in emergency department (ED) patients with
undifferentiated headaches. We hypothesized that an initial ED therapy of high-flow
oxygen would produce rapid and significant relief, decrease time to headache
resolution, length of stay, ordering of computed tomography (CT) of the head and
the need for headache pharmacotherapy.
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Methods: Evaluation of patients over 21 was conducted at our academic adult
emergency department with an annual census of 58,000. A convenience sample of 59
subjects whose complaints included a headache were approached, of whom 48
consented, met the inclusion criteria and completed the study. Seventeen subjects
were randomized to 100% oxygen at 15 L/min for 15 minutes, 14 subjects received
high flow air for 15 minutes, and 17 subjects received no intervention prior to
standard treatment. Headache intensity was assessed using a 10-point visual analog
scale (VAS). Kruskal-Wallis ANOVA test was used to assess differences between
treatments for continuous outcomes and Pearson’s chi-square for binary responses.
Results: Times to relief were significantly shorter (p⫽0.0003) for patients treated
with oxygen (median⫽40, Inter-quartile range, IQR⫽11– 45) relative to those
treated with high flow air (medians⫽110, IQR⫽100 –180) or nothing
(median⫽120, IQR⫽55–180). Length of stay was also significantly shorter
(p⫽0.016) for patients treated with oxygen (median⫽57.5, IQR⫽40, 196.5) than
for those with air (median⫽210, IQR⫽155–270) or nothing (median⫽180,
IQR⫽100 –210). In addition, CT scans were ordered less frequently (4/17⫽24% for
oxygen, 11/14⫽79% for air, and 8/17⫽47% with nothing, p-value⫽0.0094);
pharmacotherapy used less often (5/17⫽29% for oxygen, 12/14⫽86% for air, and
14/17⫽82% with nothing, p-value⫽0.0008); and narcotic therapy used less
frequently, although this association was not statistically significant (p⫽0.21).
Headache intensity was also significantly reduced at both 15 minutes and 30 minutes
(p⬍0.0001 and ⫽0.0002), with patients treated with Oxygen realizing greater
reductions in VAS scores (median⫽41 and 44, IQR⫽24 –56 and 24 –58) than
patients treated with air (medians⫽9.5 and 7, IQR⫽0 –16 and 0 –10) or nothing
(medians⫽0 and 7, IQR⫽0 –12 and 0 –16). (Median baseline VAS scores did not
differ significantly between treatments with p⫽0.23.)
Conclusion: High-flow oxygen therapy for 15 minutes is an effective treatment for
undifferentiated headache in emergency department patients. Initiating oxygen therapy
upon arrival to the ED and prior to standard therapy leads to faster headache resolution,
decreased use of CT imaging and pharmacotherapy, and shorter length of stay.
229
A Survey of Emergency Physician and Stroke
Specialist Beliefs and Expectations Regarding
Telestroke
Moskowitz A, Chan Y, Bruns J, Levine SR/Mount Sinai School of Medicine, New
York, NY
Study Objectives: Telestroke, the application of telemedicine to the treatment of
acute ischemic stroke (AIS), allows stroke specialists (SS) to remotely examine
patients and aid emergency physicians in making treatment decisions. The safety and
improved decisionmaking via Telestroke support broader implementation of the
technology. We aimed to identify and compare the barriers perceived by SSs and
emergency physicians preventing greater Telestroke adoption.
Methods: A Likert-style survey was developed based on a literature review and
semi-formal focus groups with SSs and emergency physicians. We distributed the
survey nationwide using an online survey system to 382 SSs identified during a
systemic review of academic stroke physicians at American academic medical centers
and from discussions with colleagues, and to 226 emergency physicians attending the
2008 American College of Emergency Physicians (ACEP) national conference.
Participants watched a 5-minute video of a Telestroke consult prior to completing the
survey to ensure a base level of familiarity with the technology.
Results: One hundred and thirty five (35%) of the SSs returned the survey via the
online survey system and 226 emergency physicians completed the survey at an
ACEP booth set up by one of the authors (AM). The average ages of the emergency
physicians and SSs were 40 and 47 respectively (p ⫽ ⬍0.001). The emergency
physicians were 73.1% male and the SSs were 79.5% male (p ⫽ NS). Fifty-five
percent of the emergency physicians were attendings for more than five years as
compared to 82% of SSs (p ⫽⬍0.001). SSs reported being more knowledgeable than
emergency physicians about telemedicine generally (p⬍0.001) and Telestroke
specifically (p⬍0.001). Participants in both specialties agreed that Telestroke has the
potential to reduce geographical differences in stroke care and is superior to standard
phone consultation. Emergency physicians indicated a stronger belief in the potential
of using Telestroke for physician and community stroke education than SSs
(p⫽0.003). On a scale of 1 (Very Significant) to 5 (No Barrier), the greatest barriers
perceived by SSs to expand Telestroke implementation were inadequacy of
reimbursement (2.0⫾1.0) and medical liability (2.3⫾1.1,). Emergency physicians
reported medical liability (2.3⫾1.2) and time and cost of installation (2.4⫾1.1) to be
the greatest obstacles. Emergency physicians perceived patient preference for physical
visits (p⬍0.001), inability to manage rt-PA side effects (p⫽0.001), level of
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Research Forum Abstracts
technology (p⫽0.011), and rt-PA not being widely considered the standard of care
for AIS (p⫽0.017) to be more significant barriers than SSs. SSs found the possibility
of increased personal work to be a greater barrier than emergency physicians
(p⬍0.001).
Conclusion: SSs and emergency physicians report positive beliefs regarding
Telestroke; however, a number of barriers exist to greater implementation. Medical
liability needs to be more rigidly defined and Telestroke installation processes
streamlined in order to encourage greater Telestroke adoption. Differences between
barriers perceived by emergency physicians and SSs need to be addressed and
reconciled where possible.
230
Out-of-Hospital Normobaric Oxygen Therapy in
Presumptive Acute Stroke Patients: A Preliminary
Study
Chan Y, Richardson L, Moskowitz A, Katz M, Chason K, Singhal A, Poojary I,
Kramer S, Levine SR/Mount Sinai School of Medicine, New York, NY;
Massachusetts General Hospital, Boston, MA; New York College of Osteopathic
Medicine, Old Westbury, NY
Study Objectives: Numerous recent studies demonstrated that normobaric oxygen
may significantly reduce cerebral infarct size and extend the reperfusion window after
stroke. The New York City (NYC) Regional Emergency Medical Advisory Committee
out-of-hospital protocol mandates administration of 10–15 L/min of 100% O2 via nonrebreather mask to all patients with a presumptive diagnosis of stroke. We examined the
frequency, feasibility, and safety of out-of-hospital normobaric oxygen use for acute stroke
including those found to have stroke mimics.
Methods: We conducted a retrospective review of the out-of-hospital call reports
of all patients transported by our (NYC) hospital’s ambulances with a presumptive
diagnosis of stroke. In total, 366 stroke calls between 2003 and 2008 matched these
criteria.
Results: The mean age of the patients was 70 (⫾15), 61% were female, and the
mean time of onset of symptoms was 247 (⫾690) minutes. The average on scene
time was 25 minutes (⫾9) and the average transport time was 5 minutes (⫾2). The
Cincinnati Pre-Hospital Stroke Scale (CPSS) was documented in 78% of patients. Of
the 307 patients (84%) with documentation in the “O 2 therapy” section of the outof-hospital call reports, 301 (98%) received O 2 therapy. Of those with documented
O2 administration by EMS, 248 (83%) received 15L/min 100% O2 via nonrebreather mask, 13 (4%) received 12L/min and 33 (11%) received 10L/min. Three
patients (1%) were treated using a bag valve mask and two (⬍1%) patients received
O 2 via nasal cannula at 4L/min and 6L/min. All patients had repeat out-of-hospital
call reports vital signs upon arrival to the emergency department and the means were
not significantly different from the initial measurements. With the exception of 1
patient, we found no documented respiratory distress, hypoventation, intubation, or
other complications related to normobaric oxygen use in the out-of-hospital phase
despite the approximately 30 minute administration of 10 –15L/min 100% O 2 via
non-rebreather mask to most of these patients. For those patients who had two CPSS
and/or Glasgow Coma Scale (GCS) assessments, there was no relationship between
oxygen administration and change in CPSS or GCS. We reviewed data on the 33
patients with a change in initial and final GCS scores; 28 had received documented
oxygen. Twenty-five of these patients had an improvement in GCS, whereas 3
patients had a lower repeat GCS. We found no reported cases of patient/caregiver
refusal of, disruption/premature termination of, or logistical/technical difficulty with
the delivery of supplemental O2.
Conclusion: Most of the presumptive stroke call patients in NYC receive 10 –15
L/min of 100% O2 via non-rebreather mark in the out-of-hospital setting. The
administration of out-of-hospital normobaric oxygen is feasible and appears safe.
However, given the relatively small sample size, incomplete clinical record,
confounders, and retrospective method, a prospective randomized control trial is
necessary to confirm the safety and efficacy of normobaric oxygen in AIS.
231
Predictors of Mortality in Patients Presenting to
Emergency Department with Stroke: A Developing
Nation Scenario
Chandra S, Agarwal D, Surana A, Singh V, Mohan A, Khan MA/All India Institute
of Medical Sciences, New Delhi, India; Mayo Clinic, Rochester, MN; Mysore
Medical College and Research Institute, Mysore, India
Study Objectives: Case fatality rate in stroke in Indian subcontinent is higher
compared to Western countries. Risk factors for poor outcome following stroke
S72 Annals of Emergency Medicine
include age, severity of stroke, low Glasgow Coma Scale, atrial fibrillation, previous
stroke, hyperglycemia, fever, urinary incontinence and abnormal breathing. Although
mortality in developing countries is higher, we have less knowledge about predictors.
Hence, we planned this study to determine the factors predicting inpatient case
fatality (ICF) rate for stroke.
Methods: This was a hospital-based prospective study on stroke conducted during
January 2005 to December 2006 in a teaching hospital catering predominantly to rural
population from South. Cohort of stroke patients admitted on two predetermined days of
every week to medical emergency ward, were enrolled and followed up till their discharge.
ICF rate for this study was taken as mortality occurring before discharge of patient from
hospital. Data has been analysed using SPSS version 11.5.
Results: 134 patients (65.7% were from rural population, 55.22%-smokers,
46.76%-alcoholics) with mean (SD) age of 53.83⫾18.02years [significantly lower in
females (mean difference⫺9.73years p⫽0.002)], were admitted and diagnosed to
have stroke.87.3% had first episode of stroke and 12.7 had more than one episode of
stroke. ICF rate was 26.1%. ICF rate has no relation with age (p⫽0.516), sex
(p⫽0.460), number of episodes (0.795), underlying hypertension (p⫽0.905). Odds
of diabetics dying were 12 times higher than non-diabetics. Inpatient mortality was
also significantly higher in smokers compared with non-smokers (p⫽0.004), in
patients with right-sided compared with left-sided hemiplegia (p⫽0.029) and who
couldn’t afford computed tomography (CT) scan (p⫽0.007). Kaplan Meier curve in
Image-1 shows the survival following admission to emergency ward.
Conclusion: Our study has shown that active smokers, involvement of the right side
and non performance of CT were independent predictors of mortality which have not
been shown earlier. Also, we found that diabetes mellitis is independent predictors of
mortality in stroke, which has been seen in earlier studies too (see graphic).
232
Emergency Department Hyperglycemia as a
Predictor of Mortality and Functional Outcome
After Intracerebral Hemorrhage by Diabetes
Mellitus Status
Odufuye AO, Bellolio M, Jain A, Dhillon R, Manivannan V, Gilmore R, Chandra R,
Palamari B, Decker W, Stead LG, Yerragondu N/Mayo Medical School,
Rochester, MN; Mayo Clinic, Rochester, MN; University of Rochester School of
Medicine and Dentistry, Rochester, NY
Study Objective: To explore the association between glycemia at presentation and
prognosis in intracerebral hemorrhage, and compare between those with and without
diabetes mellitus (DM).
Methods: This was an observational cohort study with 237 consecutive patients who
presented to the emergency department with intracerebral hemorrhage and had blood
glucose measurement within 24 hours of presentation. Medical records were reviewed and
stroke severity, functional outcome at discharge, and date of death were obtained.
Results: Median age was 73 years (IQR 59 – 82). There were 123 (51.9%)
females. Median blood glucose at presentation was 140 mg/dL (range 61– 600 mg/
dL). DM patients had higher glucose levels (median 202 mg/dL for DM versus 133
mg/dL for non-DM, p⬍0.0001, Wilcoxon test).
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Among patients without diabetes (non-DM), there was a linear relationship
between stroke severity (NIHSS) at presentation and glucose level; the higher the
glucose level, the higher NIHSS (worse stroke severity); p⬍0.0001, R-square 25.7%.
There was no significant relationship between blood glucose and stroke severity
among diabetic patients; p⫽0.298, R-square 2.4%.
In non-DM patients, hyperglycemia was associated with death within 7 days and
within 1 month; p⬍0.0001. In addition, there was a positive linear relationship
between glucose level at presentation and modified Rankin score (mRS) at discharge
among non-DM patients; the higher the glucose level, the higher the mRS (worse
functional outcome); R-square 22.6%, p⬍0.0001.
Although hyperglycemia was associated with death within 7 days (p⫽0.034) and
within 1 month (p⫽0.022) in diabetic patients, this association was not as strong as
that seen among non-DM patients. However, among diabetic patients, there was no
relationship between glucose level at presentation and mRS at discharge; R-square
5.3%, p⫽0.119.
In logistic regression model, after adjustment for stroke severity and age, glucose was
an independent predictor of death within 7 days (p⬍0.0001), death within 1 month
(p⬍0.0001) and poor functional outcome (p⬍0.0001) in non-DM patients. However,
among diabetic patients, glucose was not an independent predictor of death within 7 days
(p⫽0.20), death within 30 days (p⫽0.20) and functional outcome (p⫽0.38).
Conclusion: Hyperglycemia at presentation was associated with increased 7-day
and 1-month mortality regardless of diabetic status in the univariate analyses.
However, after adjustment by age and NIHSS, glucose was an independent predictor
of death in non-DM patients only. Hyperglycemia at presentation is associated with
worse stroke severity at presentation and worse functional outcome at discharge in
non-diabetic patients only.
233
Screening Electroencephalograms Are Feasible and
Identify Potential Subclinical Seizure Activity in
Emergency Department Patients
Bastani A, Young E, Hunt-Walch R, Kayyali H/Troy Beaumont Hospital, Troy, MI;
Cleveland Medical Devices, Cleveland, OH
Background: Seizures account for 1 million emergency department (ED) visits
annually. Due to the cost and expertise required to interpret and perform an
electroencephalogram (EEG) the majority of hospitals cannot provide EDs with EEG
coverage. Supported by the National Institute of Health initiative PA-04-006, a
portable, wireless multi-channel EEG device, the Crystal Monitor, was developed to
provide emergency physicians access to a screening EEG during the ED visit. The
Crystal Monitor generates a 20-minute screening EEG utilizing an abbreviated
montage to minimize set-up time. The EEG data is then digitized allowing a
neurologist anywhere in the world with Internet access to review the EEG and
provide an interpretation.
Study Objective: To evaluate the feasibility and utility of screening EEGs on
patients presenting to the ED with potential seizure activity.
Methods: We conducted a prospective observational study on patients presenting to
the Troy Beaumont ED between March 2004, and March 2009. Troy Beaumont is a
279-bed community hospital with a yearly ED census of 70,000 patients. Adult patients
(age ⬎ 18 years) with a preliminary diagnosis of syncope, potential partial-complex or
generalized seizure disorder, head injury with prolonged symptoms or acute undiagnosed
altered mental status were eligible for enrollment. Those patients with a confirmed nonneurologic diagnosis for their presenting complaint were excluded. Eligible patients were
then asked to complete an informed consent and had a screening EEG performed by a
trained ED research assistant during the ED stay. The EEG data was then password
protected and transmitted over the Internet for interpretation by the study neurologist.
The emergency physicians were blinded to the result; therefore, neither specific care nor
follow-up EEG was mandated by inclusion into the trial. Our primary outcome measures
were EEG quality and EEG diagnosis as reported by the study neurologist. EEG Quality
was evaluated using the following criteria: 1⫽poor quality/uninterpretable, 2⫽fair
quality/acceptable, 3⫽ good quality/acceptable or 4⫽excellent quality/acceptable.
Descriptive statistics were utilized to analyze the data.
Results: A total of 227 patients were enrolled of which 47.6% were female with a
mean age of 55.7 years. The indications for a screening EEG were: 1) a witnessed or
suspected seizure disorder 68.2% (155/227), 2) syncope 22.9% (52/227), 3) altered
mental status 7.5% (17/227), and 4) head injury with prolonged symptoms 1.3%
(3/227). EEG quality was acceptable in 92.5% of patients (See Table #1). The EEG
interpretation for all acceptable EEGs was: 1) normal in 64.9% (135/208), 2)
identified generalized or focal slowing in 23.6% (49/208), and 3) identified
epileptogenic foci in 11.5% (24/208) of patients.
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Conclusion: Screening electroencephalograms performed in the emergency
department are feasible, of acceptable quality, and able to diagnose seizure potential
in a significant number of patients.
234
Comparison of Blunt Versus Sharp Spinal Needles
Used in the Emergency Department in Rates of
Post-Lumbar Puncture Headache
Torbati S, Katz D, Silka P, Younessi S/Cedars-Sinai Medical Center, Los
Angeles, CA
Study Objectives: To compare rates of post-lumbar puncture headache (PLPHA)
in patients undergoing a diagnostic lumbar puncture (LP) in the emergency
department (ED) with blunt versus sharp spinal needles of the similar size.
Methods: This was retrospective review of consecutive series of adult patients
undergoing LP in the ED of a quaternary (Level I Trauma) medical center staffed
with full time emergency physicians between April 2008 and February 2009. As part
of a performance improvement project, physicians were encouraged to use blunt
spinal needles and had both 22 g blunt (Gertie Marx®) and 22 g sharp (Quinke)
needles available in their LP kits. Primary outcome was the incidence of PLPHA in
patients having a lumbar puncture with either blunt versus sharp needles. Secondary
outcome was LP procedural failure rates defined as the inability to obtain
cerebrospinal fluid with use of the first LP needle chosen by the emergency physician.
PLPHA was defined as a new or different headache worsened by sitting and standing,
improved when supine, which developed within 24 –72 hours of the LP. Inpatient
records were reviewed to determine the presence of PLPHA for admitted patients.
Outpatient records and phone follow-up data obtained within 3 weeks of ED visit
was used to determine presence of PLPHA for patients discharged home. Fisher test
was used to detect differences between the groups.
Results: Three hundred seventeen consecutive adult patients, ranging from 18 to 95
years of age, had diagnostic LPs during the study period, 56.8% of whom were female and
43.2% male. The major indications for the LP were to evaluate for meningitis and/or
subarrachnoid hemorrhage (94%). Blunt LP needles were used to obtain CSF in 45.4%
and sharp needles in 54.6% of the patients. Follow-up was available for 92% of the study
group. PLPHA was reported in 4.48% of patients in whom a blunt LP needle was used
compared with 11.32% of those with sharp needles (p⫽.017). Procedural failure rate was
26.3% for the blunt needles versus 9.4% for the sharp needles (p⬍.0001).
Conclusion: Use of blunt LP needles was associated with reduced rates of PLPHA
and higher rates of procedural failure compared with sharp LP needles of similar size
in an ED setting. The reduced rates of PLPHA with the blunt LP needle support
existing literature in non-ED setting recommending its use whenever feasible.
235
Can We Defer a Type and Screen for Pregnant
Patients With Vaginal Bleeding Who “Know” Their
Blood Type?
Shah K, Cavallo E, Kurobe A, Paisley J, Newman DH/St. Luke’s-Roosevelt
Hospital, New York, NY
Study Objective: Pregnant women with vaginal bleeding often require Type and
Screen testing for Rh positivity. We sought to determine if there is a subset of
pregnant women presenting to the emergency department who reliably know their
blood type and for whom a type and screen could safely be omitted/deferred in the
emergency department (ED).
Methods: This was a prospective, convenience sample cohort study at 2
associated urban academic centers from Jan 2007 through Jun 2008 with an annual
ED census of 150,000 patients. Pregnant patients who had a Type and Screen
obtained as part of their ED evaluation and were capable of consent were enrolled by
trained research associates working in the ED approximately 16 hours per day during
Annals of Emergency Medicine S73
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semester-based time blocks. Subjects completed a standardized data form in the ED
prior to the subject being informed of their blood type results. Information requested
included demographic information, pregnancy history and whether they knew their
blood type by selecting “no,” “maybe” or “yes, definitely.” Research associates entered
the subject data and the laboratory determined blood type into an Access Database.
Standard descriptive statistics with 95% confidence intervals were performed.
Results: Among the 319 pregnant women enrolled, the mean age was 27.8 (range
of 18 to 43), 26.1% had no prior pregnancy, 40.4% were receiving prenatal care and
the majority were Hispanic (50.8%). 106/319 (33.2%) subjects reported that “yes,
definitely” they knew their blood type; 103 (97.2%[.95CI⫽94.0 –100%]) identified
their correct blood type and 105 (99.1% [.95CI⫽97.2–100%]) identified their
correct Rh Factor. None of these subjects selected a positive Rh when they were in
fact a negative Rh.
49/319 (15.4%) subjects reported “maybe” they knew their blood type. 14/49
(28.6%) were incorrect and 6 selected a positive Rh when they were in fact a negative
Rh.
26/319 (8.2%) subjects had a negative Rh and none of these subjects thought
they had a positive blood type. 17 subjects stated they had a rhogam injection in the
past and all had a negative Rh except for 1.
Conclusion: Pregnant women reporting that “yes, definitely” they knew their
blood type are reliable, whereas those reporting “maybe” are not. Deferring an
expensive and time-consuming Type and Screen test for a subset of pregnant women
who “definitely” know their blood type may be reasonable.
236
An Analysis of Prolonged Length of Stay in a
Pediatric Emergency Department
Place R, Howell J, Malubay S, Kou M/Inova Fairfax Hospital, Falls Church, VA
Study Objective: The past decade has seen increased emphasis placed upon
process management and many emergency departments have begun to focus on
process times in an effort to improve patient satisfaction. More recently, as fewer
emergency departments are responsible for more patient visits, improving throughput
efficiency has become a matter of simple survival. One universally compared measure
of throughput is average length of stay. However, analysis of aggregate averages fails
to highlight the specifics of process inefficiency. In order to accomplish this, we
studied patient visits with prolonged throughput times.
Methods: Between June 1, 2009 and September 27, 2009, we examined a
consecutive, prospective cohort of pediatric patients at a suburban academic, level 1
pediatric trauma center. Time-stamped electronic medical records of all discharged
patients with a length of stay (LOS) exceeding 6 hours were manually reviewed. LOS
was defined as the time between arrival and discharge from the department. Admitted
patients were excluded. Demographic data including diagnosis, physician provider,
process intervals, and diagnostic studies were evaluated. Predetermined criteria
defining physician inefficiency included: time between decisions or clinical events (90
minutes), delayed disposition (60 minutes after all clinical data or treatment
completed), serial workup (secondary studies ordered after first round completed),
decisions that could have been made earlier.
Results: Average discharge LOS for 7199 seen during the study period was 163
minutes. One hundred sixty-seven patients (2.3%: 95% CI 2.0 –2.7%) required more
than 360 minutes to be discharged from the emergency department. The door-to-doc
interval was greater than 60 minutes in 56 (36%: 95% CI 29 – 44%) cases, while
arrival to triage was greater than 30 minutes in only 11 (6%: 95% CI 4 –12%) cases.
Inefficiencies in care provided by the ED attendings contributed to prolonged patient
stays in 110 (66%: 95% CI 32– 47%) cases: delayed in decisionmaking (15%),
decisions that could have been made earlier (22%), delayed disposition after
completed evaluation (27%), serial workup (32%). Only 34 (20%: 95% CI 15–27)
of prolonged LOS could be attributed to legitimate observation. Consultant delays of
greater than 2 hours were found in 14% of cases. When normalized for patient
volume, the individual rate of prolonged LOS between different attendings ranged
from 0.6% to 8.8%. The single most important patient-related factor was a chief
complaint of abdominal pain in 59 (35%: 95% CI 26 – 45%).
Conclusion: Excessive department throughput times can be objectively linked to
physician behavior. Most cases have some component of delayed decisionmaking,
serial evaluation, or inefficient response to clinical information. Significantly
variability exists between different physicians. Patients with abdominal pain comprise
a disproportionate number of prolonged stays.
S74 Annals of Emergency Medicine
237
Supplemented Triage and Rapid Treatment in the
Emergency Department
White BA, Brown DF, Sinclair J, Chang Y, Carignan S, McIntyre JA, Biddinger PD/
Massachusetts General Hospital, Boston, MA
Background: Emergency department (ED) crowding is a well-recognized problem
locally and nationally, and the burden of capacity constraints is predicted to worsen
in the future. Multiple studies have demonstrated the negative effect of hospital and
ED crowding on patient care metrics, including delayed care, increased diversion
rates, and increasing numbers of patients who leave the ED without complete
assessment. In 2006, the Institute of Medicine called for improved operations
management tools to be employed as a part of the solution, although it is not yet clear
which solutions will be most effective.
Study Objective: The study’s main goal was to assess the effect of a single
intervention, namely a physician-led screening program (START) on standard
performance measures of an urban, academic tertiary care emergency department.
The START program complemented a triage nurse with an ED attending physician
who initiated a diagnostic workup within one hour of patient arrival and selectively
triaged patients to the most appropriate areas of the ED. These performance measures
were quantified using standard operational metrics.
Methods: This before-and-after cohort study compared performance measures
over two 3-month periods (September–November 2007 and September–November
2008). The 3-month identical blocks were chosen to avoid any seasonal effect. Data
from an electronic patient tracking system (EDIS) were queried over 12982 patients
in the pre-intervention period, and 14254 patients in the post-intervention period.
The primary outcomes included: 1) the overall patient length of stay, 2) the length of
stay for discharged patients (ie, not admitted to inpatient service), and 3) the
percentage of patients who left without complete assessment (LWCA). Wilcoxon
rank sum tests and Chi-squared tests were used to compare the differences between
the two groups.
Results: In the post-intervention period, median overall ED LOS was decreased
by 28 minutes (8%, 360 minutes pre-intervention, 332 minutes post-intervention,
p⬍0.001). Median length of stay for patients discharged from the ED decreased by
23 minutes (7%, 318 minutes pre-intervention, 295 minutes post intervention,
p⬍0.001). LWCA was decreased by 1.7% (4.1% pre-intervention, 2.4 % post
intervention, p⬍0.001).
Conclusions: In this before-and-after study, a physician-led screening program
was associated with a 28-minute decrease in overall ED length of stay, despite an
increase in ED patient volume. Over the period studied, this equates to an increased
ED bed capacity of 73 bed-hours per day. In addition, ED LOS for discharged
patients was decreased by 7%. Finally, the proportion of patients who LWCA was
reduced by 1.7 %, or almost half. Since there were no other significant and
identifiable operation changes in the ED between these two intake periods, it appears
that this START intervention effected these improvements.
238
An Analysis of Emergency Department Observation
Units Impact on Patient Satisfaction Scores
Chandra A, Harrison D, Boardwine A, Villani J, Gerardo C, Hocker M,
Limkakeng A/Duke University Medical Center, Durham, NC
Background: Emergency department observation unit (EDOUs) have been
touted to be more efficient, help with crowding, and save money. Hospitals measure
patient satisfaction through Press Ganey surveys. The impact of an EDOU on patient
satisfaction has not been reported to date. We hypothesize that an EDOU will have a
positive impact on patient satisfaction results as measured by Press Ganey surveys.
Methods: This is a retrospective observational analysis of Press Ganey scores
collected for 8 quarters before the opening of a 13-bed EDOU in January 2002 and
compared to 6 quarters post-EDOU opening at a tertiary care, academic, urban
hospital. The facility, physician staffing, nursing, and wait times all remained the
same during this period. Mean values and a 95% CI are reported and statistical
significance is calculated using a T-test. Significance is defined as a p-value ⬍ 0.05.
Results: The mean overall Press Ganey scores pre-EDOU was 75.2 (CI95 74.2–
76.2) and post-EDOU was 78.2(CI95 75.4 – 81) which is statistically significant
(p⫽0.02). The mean EDOU score was 9% higher than the overall score. PostEDOU, 8 of 9 scoring categories increased (Table 1). Other than physician scores, all
other mean values were higher among the post-EDOU subcategories.
Conclusion: The introduction of an EDOU appears to be associated with a
statistically significant improvement in patient satisfaction scores as reported by Press
Ganey.
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ⴱStatistically significant.
239
The Impact of Emergency Department Boarding on
Hospital Revenues
Pines JM, Fieldston E, Hollander JE, Isserman JA, Lorch SA, Reilly PM,
Terwiesch C, Heckman JD/University of Pennsylvania, Philadelphia, PA;
Children’s Hospital of Philadelphia, Philadelphia, PA; Wharton School of
Business, Philadelphia, PA
Study Objective: Patients admitted to hospitals through the emergency
department (ED) are often required to board for long periods in the ED after
admission. This practice is associated with negative patient outcomes including higher
death rates. Concerns have been raised that this practice is profitable. We studied how
a “no-boarding” policy would have affected hospital revenues in a single, urban,
academic hospital during FY07 (July 1, 2006 –June 30, 2007).
Methods: We performed a retrospective study and built a financial model using
real hospital revenue data from a single hospital in FY07 with 55K annual visits, and
725 inpatient beds. The primary outcome was total net revenue, which was calculated
as actual net revenue plus potential gains from a “no-boarding” policy: completed
evaluations in 90% of left-without-being seen (LWBS) patients, additional patients
received without trauma and medical diversion, minus potential losses from “no
boarding”: a reduction in non-ED admissions (elective and transfer) with fewer
hospital days available given bed demand by ED admissions. Non-ED admissions
were excluded if they did not directly compete with the ED for inpatient beds
(psychiatry, newborn nursery, obstetrics, rehabilitation). We assumed that LWBS
patients had the same admission rate as those who stayed (26%), a constant arrival
and admission rate for trauma activations (0.3 per hour, 59%) and medical
ambulance patients (2.2 per hour, 40%) based on actual data during the study period.
Sensitivity analyses were performed to assess how changing the allowable boarding
time to 2 hours and the expected admission rate for LWBS to 10% affected revenue
calculations.
Results: Data were analyzed from 42,041 ED outpatient visits (with 3,159 leftwithout-being seen [7.5%], 14,039 ED admissions, and 18,192 non-ED admissions.
ED admissions accounted for 75,240 hospital-days while non-ED admissions
accounted for 111,825 hospital days. There were 5,213 ED boarding days during
FY07. Median boarding time was 7.7 hours (IQR 4.9 –11.3). In the base model,
potential gains from revenues from a “no-boarding” boarding were $13,003,394 and
potential losses were $(48,593,292). The potential net revenue from “no-boarding”
was a loss of $(35,589,898). When boarding was defined at 2-hours after bed request,
net revenue loss was $(31,215,847). When the LWBS admission rate was 10%, net
losses from boarding were $ (26,097,443) and $ (21,723,392) at 0 and 2-hour
boarding times, respectively.
Conclusion: A “no-boarding” policy would have resulted in $22–36 million less
in net revenue during FY07 in our hospital, depending on the definition of boarding
and the expected admission rate for LWBS patients.
240
Primary and Specialty Care Follow-Up for Uninsured
Emergency Department Patients
Ginde AA, Talley BE, Trent SA, Raja AS, Sullivan AF, Camargo Jr CA/University of
Colorado Denver School of Medicine, Aurora, CO; Denver Health Medical Center,
Denver, CO; Brigham and Women’s Hospital, Boston, MA; Massachusetts
General Hospital, Boston, MA
Study Objectives: Patients often need urgent outpatient primary or specialty care
follow-up after their emergency department (ED) visits, but access is particularly
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difficult for uninsured patients. Systems of ED referrals to primary and specialty care
may differ depending on the type of care required; the extent and factors associated
with these differences are unknown. In this study, we sought to characterize primary
and specialty care follow-up options for uninsured ED patients in Colorado and to
evaluate differences in these options based on ED characteristics.
Methods: We mailed a survey to physician or nurse directors of all 74 EDs in
Colorado during January to April 2009 and collected data on ED characteristics,
supplemented by the 2007 National Emergency Department Inventories (NEDI)USA (www.emnet-usa.org). Outpatient primary care follow-up was assessed by the
following question: “Where does your ED typically refer uninsured ED patients for
urgent (⬍2 weeks) primary care follow-up after the ED visit (eg, new onset type 2
diabetes stable for discharge)?” Specialty care follow-up was assessed by: “Where does
your ED typically refer uninsured ED patients for urgent (⬍2 weeks) specialty
follow-up after the ED visit (eg, orthopedics for fracture needing outpatient surgical
care)?” Using multiple choice responses, the follow-up options were classified as
private physician or clinic affiliated within the same hospital; public clinic or
university hospital; or no referral system/policy. Data analysis included chi-square test
to compare differences in follow-up options by ED characteristics.
Results: We received complete responses from 62 (84%) EDs. Referral to private
physicians or clinics at the same hospital was 40 (65%) EDs for primary care and 45
(73%) for specialty care. Referral to a public clinic or university hospital only was
endorsed by 16 (26%) EDs for primary care and 8 (13%) for specialty care, and 6
(10%) and 9 (15%) had no referral system for primary and specialty care,
respectively. The following factors were associated with higher reported access to
primary care follow-up at the same hospital: lower visit volume (79% for EDs with
⬍1 patient per hour vs. 45% for ⱖ3 patients per hour; p⫽0.02), rural area (79% vs.
63% for urban areas; p⫽0.04), and possibly critical access hospital status (77% vs.
58%; p⫽0.12). Conversely, higher visit volume (95% vs. 54%; p⬍0.01), urban
(88% vs. 54%; p⬍0.01), and non-critical access hospitals (83% vs. 55%; p⫽0.02)
had greater access to specialty follow-up at the same hospital. Rates of hospital
admission and uninsured patients seen were not significantly associated with
availability of either primary or specialty care follow-up options.
Conclusion: Referral patterns for uninsured patients differed by ED
characteristics in Colorado, and some reported having no referral system. Smaller,
rural EDs had higher ability to refer within their own hospital for primary care but
lower for specialty care. These data may have important implications in access to
timely follow-up care for uninsured ED patients, and future studies will correlate
observed differences in ED referral systems with actual patient access to care.
241
A Multifaceted Quality Improvement Program
Improves Hand Hygiene Compliance in the
Emergency Department
Schuur J, Crim H, Pandya D, Rosborough S, Venkatesh A, Villarreal R, Pallin D/
Brigham and Women’s Hospital, Boston, MA
Study Objectives: Proper hand hygiene (HH) is a key measure for preventing
health care-associated infections; however, health care staff often do not perform
proper HH. There is little evidence about which quality improvement (QI)
techniques are effective at improving HH compliance in the emergency department
(ED). We aimed to determine if a two-stage QI project would improve ED HH.
Specifically, we aimed to assess the impact of a HH educational campaign with
regular real-time feedback on HH compliance.
Methods: Observational HH data was collected prospectively, at an urban, level one
academic ED with 57,000 annual visits from Feb-08 onward by the hospital infection
control department. The HH QI initiative began with multidisciplinary team meetings in
June-08. Initially, the team identified and addressed barriers to HH compliance, such as
an inadequate number of disinfectant dispensers and frequently empty dispensers. In
Sept-08 the HH project was publicly introduced with multiple educational efforts and an
ED-wide staff awareness campaign. In Jan-09 daily ED auditing with feedback was added.
Auditing and feedback consisted of a research assistant performing direct observation of all
ED health care workers every weekday. At the end of each direct observation session, the
observer reported summary performance data by provider group to staff. Attending
physicians and charge nurses were asked to discuss the results at rounds. A weekly email
detailing the ED staff performance on HH was distributed and ED leadership
championed HH at regular meetings. We compared HH rates across the three periods of
the project: PRE (2–5/2008), EDUCATION (6–12/2008), and AUDIT (1–4/2009)
and between provider types (MD/PA, nurse, nursing aide, non-clinical staff) using chisquares tests and Cochran-Mantel-Haenszel test for trend.
Results: Over 15 months of the project, 2016 HH observations were collected
Annals of Emergency Medicine S75
Research Forum Abstracts
(154 PRE, 293 EDUCATION, 1569 AUDIT). Prior to the QI campaign (PRE),
HH compliance was 36% (95% CI 29%– 44%). During the educational period of
the project (EDUCATION), HH compliance was 68% (95% CI 63%–73%).
During the audit period HH compliance was 88% (95% CI 86%–90%). There was a
significant increase in performance across the three periods overall (P ⬍.0001) and a
20% absolute increase in HH compliance between the EDUCATION and AUDIT
phases (95% CI 14%–26%). All provider groups showed significant improvement
over the QI project: MDs/PAs improved by 48% (95% CI 34 – 62%), nurses by 56%
(95% CI 45– 68%), nursing techs by 43% (95% CI 24 – 62%) and non-clinical staff
by 63% (95% CI 39 – 87%).
Conclusion: A two-stage HH QI project that utilized an educational campaign
and audit and feedback significantly improved ED HH compliance. Each project
stage provided a distinct increase in HH compliance supporting the use of several QI
techniques when devising a HH improvement strategy. Audit and feedback with
active support from departmental leadership appear to increase HH compliance above
and beyond less direct QI techniques.
242
Validating an Emergency Medicine-Specific Tool to
Estimate Cognitive Impairment
Birkhahn R, Briigs WM, Bove J, Datillo PA, Arkun A, Parekh A, Gaeta TJ/New
York Methodist Hospital, Brooklyn, NY
Study Objectives: Long work hours, demanding schedules, and sleep deprivation
have long been associated with residency training; existence of sleepiness and fatigue
can result in decreased cognitive performance, impaired memory and focus,
inflexibility, and errors. Our goal was to adapt and validate an existing cognitive
assessment tool that could be used with emergency medicine residents to assess the
cognitive effects of resident fatigue.
Methods: Testing was conducted using faculty medical students associated with
an emergency medicine residency training program. We developed a computer-based
interactive test with two elements from the Walter Reed Performance Assessment
Battery: (1) number memory test: a series of digits is shown and then recalled
forwards and then backwards; (2) the addition and subtraction tasks give two-digit
numbers to be added and subtracted. To this, we added a 15-question ACLS quiz for
rhythm and ECG recognition and response, which was developed locally using a
Delphi panel of attending physicians. Three minutes per task were allotted for each
element of the battery. To assess the measure’s variability and understanding we
tested the new scale on separate cohorts of students and attending physicians. Serial
testing was conducted to establish learning interaction, extinction, and optimal
testing strategies. Reaction times and number of correct answers for each element,
and intra- and inter-individual variance of results, were measured.
Results: Seventeen students and 11 attending physicians completed multiple trials
(n ⫽ 79). In a test of extinction mean scores and reaction times did not change with
increasing trials per individual (p⫽0.33), except in the ACLS quiz portion where
improvements (in both correct answers and reaction times) which suggested that at
least 2 trials were needed to train the physicians (p⫽0.02). There were no differences
in variability in scores due to number of trials nor in whether the individual was a
student or attending (p⫽0.31). Mean scores were: 7.0 correct forward digits, 5.9
backward, 13 correct additions and subtractions, 13 correct ACLS questions for
attendings and 8 for students.
Conclusions: The cognitive battery performed as expected; it was quick and easy
to administer and showed little variability between individuals. Baseline reaction
S76 Annals of Emergency Medicine
times and accuracy scores were stable and can serve as reference for comparing scores
received while fatigued. It is important to control for the improvements (learning
curve) in the ACLS portion of the battery; thus to gauge the effect of fatigue, at least
two trials per individual should be run. The addition of an ACLS question bank to
create a novel test battery appears promising as an EM-specific tool to estimate
cognitive impairment. The ability to reliably and quickly measure impairment is an
important step in limiting the effects of resident fatigue.
243
The Use of an Expeditor and Its Impact on
Emergency Department Length of Stay
Handel DA, Ma OJ, Workman J, McConnell KJ/Oregon Health & Science
University, Portland, OR
Study Objectives: It is believed that the use of an individual whose primary role is
to help with patient flow will decrease emergency department (ED) lengths of stay
(LOS) and improve patient satisfaction. This pilot program in our ED used a group
of paramedics who were trained to initiate ED care, assist with patient admission
process, and facilitate discharges. The objective of this study was to measure how the
role of an “expeditor” affected LOS.
Methods: This was a pre-post observational study. Inclusion criteria were ED
patients: age ⬎ 21 years, non-ambulance arrival, and wait ⬎ 5 minutes. The
implementation of the expeditor role began on 12/15/08 at a level 1 trauma and
academic medical center with an annual census of 40,000 visits. The position was a
modification of the role of a paramedic already working in the ED and did not entail
additional personnel. The expeditor was on duty from 1300-0100 daily, historically
the busiest time in the ED. We evaluated the change in LOS for admitted patients
and patients discharged home, with November 2008 acting as the pre-intervention
period and January 2009 acting as the post-intervention period. We assessed the
effect of the expeditor using multiple linear regression. Variables in the analysis
included: daily census, patient age, triage acuity, the use of triage scripting
notification of wait times, the total number of hours of boarding that occurred while
waiting for inpatients beds during a day, and individual bed wait times. A day was
used as the smallest unit of comparison.
Results: A total of 1,809 patients were included in the analysis. There was no
significant change in LOS for patients discharged home. However, the LOS for
admitted patients decreased by 12.69 minutes (p⫽0.000) after the implementation of
the expeditor. Other variables associated with LOS included the use of scripting at
triage to notify patients of wait times, the wait times for beds for admitted patients,
and the number of hours of boarding.
Conclusion: The use of an expeditor improved the LOS for admitted patients but
not for discharged patients. This points to the positive impact that these individuals
have on improving the flow of higher acuity patients through the ED to inpatient
beds. Whether or not this amount of time is clinically significant remains to be seen,
and further analysis is needed to see if this trend continues over a longer period of
time.
244
Environmental Predictors of Hand Hygiene
Compliance in the Emergency Department
Venkatesh A, Pallin D, Crim H, Pandya D, Rosborough S, Villarreal R, Schuur J/
Brigham and Women’s Hospital, Boston, MA
Study Objective: Health care worker (HCW) hand hygiene (HH) prevents health
care-associated infections, and studies show that environmental factors such as room
visibility and availability of handwashing stations affect HH compliance. Little is
known about how the unique emergency department (ED) work environment affects
HH compliance. We aimed to determine the predictive value of HH opportunity
characteristics, ED layout, and ED crowding on HH.
Methods: Observational HH data was collected prospectively at an urban, level
one academic ED with approximately 57,000 annual visits. A trained research
assistant directly observed HH in the ED in accordance with regulatory standards.
HH compliance was defined as use of alcohol handrub or standard handwashing
before and after contact with each patient or patient environment. A standardized
data collection instrument was used to collect HH opportunity characteristics, ED
layout, and ED crowding data. HH opportunity characteristics included glove use,
HCW type, and room entry/exit. Predefined ED layout variables included ED unit
(ED unit vs. observation unit [OBS]), room visibility (high vs. low), and bed location
(private room vs. hallway). ED crowding variables included total ED census,
proximate ED unit census, and waiting room census. Chi square tests were used to
compare differences in HH based on categorical variables. The T-test was used to
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compare continuous ED crowding variables with HH compliance. Multivariate
logistic regression was used to adjust for multiple environmental and behavioral
predictive variables.
Results: A total of 1475 HH opportunities were available for analysis with overall
HH compliance of 88.2%. Reduced HH compliance was significantly associated with
glove use (84.9% vs. 89.2%, p⫽0.03), OBS unit location (80.1 vs 89.5%,
p⫽0.0002), and high visibility rooms (86.2% vs. 91.3%, p⫽0.003). A significant
difference was demonstrated when comparing HH across health care provider types:
MD (93.5%), nurse (88.0%), nurse’s assistant (84.7%) and other HCW (75.6%),
p⬍0.001. No significant bivariate difference in HH compliance was demonstrated
between room entry and exit, hallway location, or any ED crowding variable. After
adjustment for all covariates, OBS unit location (OR: 0.43, 95%CI: 0.23, 0.82), high
visibility room location (OR: 0.64, 95%CI: 0.45, 0.93), and hallway location (OR:
0.59, 95%CI: 0.34, 0.99) were significantly associated with lower HH compliance.
Conclusions: ED specific work environment characteristics such as hallway bed
location or OBS unit location impacted HH compliance, while other environmental
markers such as ED crowding were not associated with HH compliance. Individual
EDs should consider what local work environment barriers exist to effective ED HH.
245
Should the Deeply Comatose Trauma Patient Be
Intubated by EMS?
Irvin CB, Walters J, Sills R/St. John Hospital and Medical Center, Detroit, MI
Background: Previous studies have suggested increased mortality in trauma
patients intubated in the field. These studies have included heterogeneous
populations (GCS scores ⬍9). Deeply comatose patients (Scene GCS⫽3) may
comprise a population most likely to benefit from intubation in the field. No previous
study has evaluated the effects of intubation on the outcome of this sickest
population.
Study Objective: To compare the outcome of Scene Intubated and Not Scene
Intubated trauma patients in deep coma (GCS⫽3).
Methods: Using the National Trauma Data Base (V. 6.2), all trauma patients
with “Legitimate” (not intubated/sedated) initial scene GCS score⫽3 were analyzed.
Variables extracted included: Age, ISS score, Scene GCS score⫽3, ED GCS score,
Arrival ED intubation status, ED first systolic blood pressure, discharge status (alive
or dead), and Abbreviated injury score (AIS) for Head. Patients arriving in ED with
no blood pressure, or given paralytics or sedatives were excluded. Data was then
analyzed using logistic regression.
Results: There were 11109 patients with Legitimate GCS scene ⫽3 analyzed, and
only 23% (2538/11109) were scene intubated. The mortality rate for the Not
Intubated patients was 35% (ISS⫽24), and 62% (ISS⫽31) for the Scene Intubated
patients (p3). Regardless of arrival ED GCS, those Scene Intubated were still more
likely to die (ED GCS⫽3, Scene Intubated mortality ⫽67% compared to Not
Intubated mortality of 49% (p3, Scene Intubated mortality⫽ 36%, compared to Not
Intubated mortality of 14% (p⬍.001)). Of patients with recorded Head AIS scores of
3– 6 (serious, severe, critical, unsurvivable), those Scene Intubated had a mortality of
68% (979/1464) and those Not Intubated had a mortality rate of 46%
(1789/3844),p⬍.001. Using Logistic regression and controlling for the slightly higher
ISS score in those Scene Intubated, Scene Intubated patients were twice as likely to
die if their GCS remained at 3 in the ED (OR⫽2.03) and more than 3 times as likely
to die (OR⫽3.48) if the ED GCS was ⬎3 (ie, they improved en route).
Conclusion: Even severely comatose trauma patients have a much higher
mortality rate when Scene Intubated, versus those Not Scene Intubated. Although
the exact reasons for this remain unclear, these results suggest re-evaluation of
current policies for EMS intubation at the scene in these severely traumatized
patients.
246
Admission Rates for Walk-In Patients Differ
Between Suburban and Urban Emergency
Departments While Admission Rates for
Emergency Medical Services Arrivals Show No
Significant Difference
Matthews P, Nichols WL, Durie C, McGinnis-Hainsworth D, Hypes S, Reed III J,
Schofer J, Megargel R/Christiana Care Health Services, Newark, DE; State of
Delaware Office of Emergency Medical Services, Dover, DE
Study Objectives: Patients in an urban environment may utilize emergency
departments (ED) differently than patients in a suburban environment. Previous
Volume , .  : September 
research has demonstrated that significant differences exist among the percentage of
patients admitted dependent upon their mode of arrival to the ED. The purpose of
this study was to further investigate the admission rates of suburban versus urban
hospitals based on patient mode of arrival. The modes of arrival that were investigated
include walk-in patients, Basic Life Support (BLS) transports, and Advanced Life
Support (ALS) transports.
Methods: We used a retrospective cohort design. Data were collected from the
EDs of a suburban level I trauma center and an urban level IV trauma center in the
same health care system. These hospitals are located 14 miles apart and see a
cumulative annual volume of approximately 150,000 ED patients. The State’s out-ofhospital system is a two-tier structure with BLS and ALS. Patients presenting to the
ED from the first Wednesday of alternating months (January, March, May, July,
September, and November) in 2007 were reviewed. Medical record numbers and ED
patient tracking systems were used to determine patient disposition. Confidence
intervals were determined using the Agresti-Coull binomial method and p-values
were determined using Pearson’s chi-squared.
Results: A total of 2,438 ED encounters were reviewed. See Table for results.
Conclusion: Walk-in patients at the suburban ED required admission twice as
often as in the urban ED. No significant differences in suburban ED admission rates
between BLS or ALS transports existed when compared to the urban ED. This
suggests that urban patients are more likely to seek non emergent care from an ED
than their suburban counterparts. Patients activating emergency medical services had
similar rates of admission in these suburban and urban hospitals.
247
Baseline Carboxyhemoglobin Levels in Firefighters
Using the Masimo Rainbow SET Rad-57 Pulse COOximeter
Black A, Muniz J, Benitez FL, Burkhalter L, Isaacs M, Luber SD, Pepe PE,
Velez LI/University of Texas Southwestern Medical Center, Dallas, TX
Background: Carbon monoxide (CO) has been the leading cause of acute
poisoning death in the United States for the last 100 years. It is a potential hazard to
firefighters while engaging in fire ground activities. CO toxicity may present with
nonspecific signs and symptoms. Until recently, the only way to reliably diagnose CO
poisoning was using co-oximetry. With the introduction of the Masimo Rad-57,
testing for CO can now be performed rapidly and non-invasively, allowing for
prompt screening and treatment. To date, no data has been published regarding
baseline carboxyhemoglobin (COHb) levels in professional firefighters.
Study Objectives: To determine baseline COHb levels in professional firefighters
while not engaging in fire ground operations, inquiring about risk factors associated
to increased levels of COHb in this “high risk” population.
Methods: Professional firefighters (FFs) in the BioTel EMS system were
voluntarily enrolled in the study. Using a new product in the market (Masimo
Rainbow SET Rad-57 Pulse CO-Oximetry) a non-invasive finger probe measurement
of COHb was obtained in the participants. The device was applied to the individual’s
fingertip, and a measurement for COHb was recorded for each hand. A standardized
survey form was used to collect individual data regarding potential CO exposure
sources, such as cigarette smoking, exposure to exhaust fumes, and recent firefighting
operations.
Results: A total of 857 professional FFs were enrolled. The average time
working as a FF is 18 years. The COHb average in the right hand was 1.41% and
for the left hand was 1.28%; p⬍0.05. For the following group comparisons, the
average right hand value was used. Smokers (n⫽132; 16%) had a mean COHb of
1.68% (95% CI: 1.32–2.04) while non-smokers (n⫽735) had a mean COHb:
1.36% (95% CI: 1.23–1.48); p⫽0.057. FFs who fought a fire ⬍72 hrs prior to
measurement (n⫽113) had a mean COHb of 1.66% (95% CI: 1.33–2.00) while
those who fought fire ⬎72 hrs prior (n⫽683) had a mean COHb of 1.37% (95%
CI: 1.24 –1.51); p⫽0.119.
Annals of Emergency Medicine S77
Research Forum Abstracts
Conclusion: Baseline COHb levels were not elevated in the FFs of this large
urban EMS system. There was no statistically significant difference in baseline levels
between smokers and non-smokers; nor between FFs who fought a fire less than 72
hours prior to measurement and those who did not. The device is easy to use and was
well received by the FFs. More out-of hospital studies are required to determine how
this technology can best be applied as a out-of-hospital screening tool for individuals
with potential CO poisoning.
248
Predictors of Ambulance Use for Emergency
Department Patients Over 45 With Chest Pain
Meisel ZF, Branas C, Pines JM/University of Pennsylvania, Philadelphia, PA
Study Objectives: Chest pain in patients over the age of 45 may indicate the
presence of an urgent condition such as acute coronary syndrome (ACS).
Transport by Emergency Medical Services (EMS) has been demonstrated to be
associated with improved processes and outcomes for patients with ACS. Only
half of patients with acute myocardial infarction (AMI) are transported to the
hospital by ambulance. However, the predictors of ambulance arrival for patients
who present to emergency departments (EDs) with chest pain have not been
described. We sought to determine the impact of race, sex, location, and
insurance status on the usage of ambulance care for transport to the ED for
patients over age 45 with chest pain.
Methods: We performed a retrospective analysis of the National Hospital
Ambulatory Medical Care Survey (NHAMCS) from 2004 –2006, an annual
probability sample of US ED visits. Primary outcome was arrival by ambulance.
Included were patients over age 45 and for whom “chest pain and related symptoms”
was identified as a reason for visit according to the Visit Classification for Ambulatory
Care (RVC). Excluded were visits from patients who reside in a nursing home or
other institution since these characteristics are associated with both insurance status
and mode of arrival. We used logistic regression to determine the impact of race, sex,
insurance status, and urban hospital location (metropolitan statistical are [MSA]) on
mode of arrival.
Results: From 2004 –2006, there were 17,384 visits representing 57.2 million
(99% CI 53– 62 million) patient visits for patients over 45 with chest pain. Mean age
was 74, 80% white, 15% black, and 57% female. 6,002 (35%) of visits arrived by
ambulance. In the multivariable analysis, we adjusted for race, sex, age, MSA, triage
urgency, and insurance type. Male sex (OR 0.85 [99%CI 0.76 – 0.93]), lack of
insurance (self pay or charity care; OR 0.73 [99% CI 0.55– 0.98]) and private
insurance (OR 0.59 [99%CI 0.51– 0.68]) were associated with decreased odds of
ambulance use. The following characteristics were associated with increased odds of
ambulance arrival: urban location (OR 1.7 [95% CI 1.3–2.2]), Medicaid (OR 1.4
[95% CI 1.2–1.6]) and Medicare (OR 1.2 [99%CI 1.1–1.3]). Race was not
associated with differences in ambulance use.
Conclusions: Male sex, lack of any insurance, possession of private insurance,
and non-urban location are associated with lower rates of ambulance care as a
means of transport to the emergency department for patients over 45 with chest
pain.
249
Type of Insurance Is Associated With Ambulance
Use for Transport to Emergency Departments in
the United States
Meisel ZF, Branas C, Pines JM/University of Pennsylvania, Philadelphia, PA
Study Objectives: Utilization of emergency department (ED) care has been
associated with insurance type but not lack of insurance. The relationship between
insurance status and ambulance use for transport to EDs has not been fully explored.
Unnecessary ambulance use for patients with non-acute conditions has been
described; however, the relationship between insurance status and ambulance use for
low acuity ED visits has not been. We determined the impact of insurance status on
the ambulance use for transport among general ED visits and low acuity ED visits
using a nationwide sample.
Methods: We performed a retrospective analysis of the National Hospital
Ambulatory Medical Care Survey (NHAMCS) from 2004 –2006, an annual
probability sample of US ED visits. Primary outcome was arrival by ambulance. The
primary independent variable was the expected source of payment. Included were all
ED visits in the sample. Excluded were visits in patients who reside in nursing homes
or other institutions since these patients use ambulance transport almost exclusively.
S78 Annals of Emergency Medicine
We used logistic regression to assess the association between expected payment source
and ambulance transport. We repeated these methods for a low-acuity subgroup
which was defined as patient visits which did not result in a hospital admission or
transfer and which were assigned to the longest acceptable time to be seen by a
physician (2–24 hours).
Results: From 2004 –2006, there were 101,131 visits representing 320
million ED visits (99%CI 300 –355 million). Mean age was 35, 24% black, 72%
white, and 54% female. 14,505 (15%) of visits arrived by ambulance,
representing 46 million (99% CI 42–51 million) transports. In the univariate
analysis, increased odds of ambulance transport was associated with expected use
of any health insurance (OR 1.17 [95%CI 1.08 –1.27]) and Medicare (OR 3.09
[95%CI 2.9 –3.3]). Medicaid was associated with decreased odds of ambulance
use (OR 0.77 [95%CI .71–.85]) In multivariable analysis, after adjusting for
race, sex, age, urban location, triage urgency, and insurance type, the following
characteristics were statically associated with ambulance arrival: Medicare (OR
1.28 [95% CI 1.16 –1.40]) and Medicaid (1.21 [95% CI 1.11–1.32]). In the
adjusted low acuity subgroup only private insurance was associated with
decreased odds of ambulance use when compared to all other expected paytypes (OR 0.69 [95%CI .55–.88]). Race, sex and lack of insurance were not
associated with ambulance use in either the whole cohort or the low acuity
subgroup.
Conclusions: Insurance type is associated with ambulance use among general and
low-acuity ED patient visits while lack of insurance, race, or sex are not.
250
Collaborative to Decrease Ambulance Diversion:
The California ED Diversion Project
Castillo EM, Vilke GM, Williams M, Turner P, Boyle J, Chan TC/University of
California, San Diego, San Diego, CA; The Abaris Group, Walnut Creek, CA
Study Objectives: Ambulance diversion has become a national problem that
affects more than half of all emergency departments (EDs). The California ED
Diversion Project (CEDDP) was a state-wide initiative to reduce diversion in four
regions of the state by implementing ED, hospital and county emergency medical
services (EMS) measures to address ED crowding and ambulance diversion regionally.
The objective of this study is to assess the impact of CEDDP collaborative on ED
ambulance diversion rates.
Methods: This is a pre/post study investigating ED diversion rates in four regions
of California before and after CEDDP over a two-year period. As part the CEDDP
collaborative, EDs and hospitals instituted best practices to improved patient flow,
including input, throughput and output measures; EMS agencies also enacted regionwide diversion mitigation strategies and efforts. Monthly ED diversion data were
collected prospectively from hospital EDs and EMS agencies after initiation of
CEDDP, and compared with historical ED diversion data the year prior to CEDDP.
Data were also compared month-to-month to address anticipated seasonal changes.
Comparisons were made using a paired t-test. Means, standard deviations (SD), and
point estimates with associated confidence intervals are presented. Analysis was
performed using SPSS version 16.0.
Results: During the study period, there were a total of 31,735 diversion hours
in the four CEDDP study regions, with 17,618 during the pre-CEDDP period
and 14,117 in the post-initiation period. The monthly average of ambulance
diversion decreased from 1468 hours (SD⫽390.6) to 1176 hours (SD⫽605.8)
resulting in a significant decrease (difference of 292 hours; 95% CI⫽99, 484;
p⫽0.007). There was a decrease in diversion hours for every month-to-month
comparison except January and February (increases of 1% and 14.6%,
respectively).
Conclusion: By instituting regional ED, hospital and EMS agency patient flow
and mitigation strategies, the CEDDP collaborative appeared to significantly reduce
ambulance diversion hours in four large geographic regions. Continued
communication and emphasis on diversion are likely needed to sustain these
decreases.
251
Pharmacist Implementation in the Emergency
Department
Hong AL, Brozick A, Lam S, Parris M, Paine M, Flowers PW/Memorial Hermann
Katy Hospital, Katy, TX; Memorial Hermann Hospital System, Houston, TX
Background: Due to a recent increase in emergency department (ED) patients
and The Joint Commission’s National Patient Safety Goals requirement to
Volume , .  : September 
Research Forum Abstracts
“accurately and completely reconcile medications across the continuum of care,” an
opportunity for an ED pharmacist was offered. Additionally, Centers for Medicare
and Medicaid Services (CMS) identify core measures as a means to measure effective
evidence-based medicine. Thus, the ED pharmacist’s primary goal was to facilitate
home medication reconciliation (HMR) and to identify core measures patients to
assist in medication selection.
Study Objective: The purpose of implementing a pharmacist in the ED was to
conduct medication reconciliation, to identify core measure patients, and to provide
consultative services, which included recommending evidence-based medication
selection, identifying medication allergies, counseling patients on medication
compliance, and answering drug information questions to reduce potential
medication errors.
Method: During a three-month pilot program (March - May 2008), the
pharmacist worked in the ED Monday through Friday from 1:00-9:00p.m. Due
to the impact shown through monthly documented interventions and peak ED
visit times, approval was obtained for seven-day coverage from 2:30-11:00p.m.
The ED is set in a 127-bed non-profit hospital 20 miles west of Houston, Texas
serving both an urban and rural population. The ED averages greater than 3,300
visits on a monthly basis. Admission from the ED accounts for greater than 55%
of all hospital admissions. The ED pharmacist was responsible for completing
HMR for all patients who were admitted from the ED. The admitting team was
responsible for medication reconciliation for patients not seen by the pharmacist.
The ED pharmacist assisted in identifying possible core measure patients and
recommended evidence-based therapy.
Results: The post-audit pilot period data showed 100% completion for HMR
obtained by the pharmacist. The ED pharmacist completed more than 50% of
HMR for all hospital admissions, and documented at least 300 interventions
monthly. The five major intervention categories documented were drug
information (21.5%), medication recommendation (21.4%), patient care
(15.3%), error prevention (14.7%), and core measures identified (12%). From
September 2008 through January 2009, the ED pharmacist completed 2209
HMR, prevented 299 errors, and provided 436 medication recommendations to
ED physicians.
Conclusion: This study suggests the ED pharmacist improved compliance with
Joint Commission National Patient Safety Goals. The ED pharmacist provides safe
and effective care to patients by helping avoid medication errors and assisting health
care providers to make informative medication selections through evidence-based
medicine. This study validates the value of a pharmacist as an integral member of the
ED health care team.
252
Provider Impression of Cervical Spine Injury and Its
Effects on Quality of Out-of-Hospital Immobilization
Techniques
Dailey M, Prunty H, Frisch A, Martin T, Osborne B, Blank F, Barus R,
Fitzgerald T/Albany Medical Center, Albany, NY; University of Pittsburgh Medical
Center, Pittsburgh, PA; Baystate Medical Center, Spingfield, MA
Study Objective: Out-of-hospital trauma care frequently includes the application
of a cervical collar, yet little evidence currently exists about the quality of cervical
collar placement. The study objective is to assess the quality of cervical collar
application on immobilized patients arriving via ambulance (EMS) to the emergency
department (ED) and to see if there is a correlation with provider impression of
severity of mechanism of injury (MOI), provider likelihood for injury, or heightened
risk (NEXUS criteria).
Methods: A cross sectional observational study was performed at two tertiary care
academic medical centers. A convenience sample of non-critically ill, immobilized
patients, who had a cervical collar applied by EMS were enrolled. Out-of-hospital
providers were surveyed about patient’s presentation and exam, as well as likelihood
of cervical spine injury and the severity of the MOI. Each subject’s cervical collar was
evaluated based upon standardized manufacturer specifications for appropriate
application including: size, proper assembly, tightness, head position, and chin
location relative to the chin rest.
Results: Of 190 subjects enrolled, EMS considered high likelihood for neck
injury in 125 patients, although they considered 143 to have significant MOI. Thirty
patients arrived immobilized with neither significant MOI nor high likelihood of
injury. Of the patients with high likelihood of cervical spine injury, 29 (23%) had
collars applied correctly, and of the patients with significant mechanism, 36 (25%)
were applied correctly. One of the objective NEXUS Criteria (midline c-spine
tenderness, intoxication, level of alertness, focal neurologic deficit, painful distracting
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injury) was present in 138 patients, with 40 (29%) of the collars correctly applied.
There was no statistical difference found in rate of correctly applied collars, including
severity of mechanism of injury or NEXUS criteria (P⫽0.6). Notably, of the 136
patients with incorrectly applied collars, 30 arrived with an adjustable collar unlocked
and 3 arrived with a collar placed upside down.
Conclusions: This study demonstrates that many patients are being transported
to the ED with improperly applied cervical collars, regardless of provider suspicion of
injury, severity of mechanism of injury or objective physical examination criteria.
While we cannot comment on the outcomes of these patients, EMS agencies must
maintain an active quality improvement process to assure that out-of-hospital
providers are applying cervical collars correctly.
253
The C.I.N. Study: Is Contrast-Induced Nephropathy
a Problem in High-Risk Emergency Department
Patients?
Su M, Soohoo D, Lukin M, Patel S, Zhang S, O’Donnell MB, Messina J,
Ward M/North Shore University Hospital, Manhasset, NY
Study Objectives: 1)To determine the incidence of contrast-induced nephropathy
(CIN) in high-risk emergency department patients receiving IV contrast. 2)To
determine which comorbid risk factors (RF) are associated with the development of
CIN.
Methods: A retrospective chart review study was performed at a suburban
academic university-affiliated ED with over 72,000 visits per year. Charts were
reviewed for patients over an 18-month period. CIN was defined as 1) a
proportional rise of 25% or 2) 0.5 mg/dL increase in serum creatinine level 48
hours after contrast exposure 3) a decrease in glomerular filtration rate (GFR)
from a normal level above 90ml/min/1.73m^2 to a level below
60ml/min/1.73m^2 48 hours after contrast exposure. Inclusion criteria: Patients
⬎17 years of age presenting to the ED who received either an abdominal, head or
chest CT scan with IV contrast and were admitted to the hospital. The following
RFs for CIN were examined: hematocrit⬍39% for men or ⬍36% for women,
renal disease, proteinuria, prior renal surgery, diabetes, congestive heart failure
(CHF), hypertension (HTN) or gout. Exclusion criteria: Age ⬍18 yrs old or
incomplete data. Statistical Analysis: Estimated population midpoints and 95%
confidence intervals (CI) were obtained for sensitivity and specificity for each
HRF. Descriptive statistics and univariate analyses using the chi-square test or
Fisher’s exact test as deemed appropriate for the above categorical variables was
used to compare patients with CIN as compared to patients without CIN. Those
factors that appeared to be associated with CIN in the univariate analyses
(p⬍0.10) were included in a logistic regression model. Backwards selection was
used to remove variables which did not significantly contribute to each of the
models. Descriptive statistics and student t-tests were completed for relevant data
collected between groups with and without CIN.
Results: 70 subjects were enrolled, 51% male. Analysis was not completed for
CIN definitions 2 and 3 due to insufficient data. Sensitivity and specificity
reported respectively for the following high risk factors: gout, 25.00% (CI:4.4564.42) and 98.38% (CI:90.17-99.92), HTN, 87.50% (CI:46.68-99.34) and
29.03% (CI:18.55-42.13), CHF, 25.00% (CI:4.45-64.42) and 88.71% (CI:
77.51-94.96), diabetes, 25.00% (CI:4.45-64.42) and 72.58% (CI:59.56-82.78),
prior renal surgery, 0.00% (CI:0.00-40.23) and 96.77% (CI:87.83-99.44),
proteinuria, 25.00% (CI:4.45-64.42) and 82.26% (CI:70.05-90.40), renal
disease, 12.50% (CI:0.66-53.32) and 93.55% (CI:83.50-97.91), low hematocrit,
75.00% (CI:35.58-95.55) and 48.39% (CI:35.66-61.32). Comparing patients
with CIN vs. patients without CIN, there was a significant difference in patients
who had a history of gout (p⬍0.0327). Reported mean arterial pressure (MAP) of
patients without CIN was 95.9 mmHg (CI:90.0-100.9) vs. 110.0 mmHg (CI:
99.7-120.3) for patients with CIN.
Conclusion: Incidence of CIN was 11.43% (CI:5.41-21.82), 2.86% (CI:
0.50-10.86), 1.43% (CI:0.07-8.77) for each definition respectively. Patients with
gout are twenty times more likely to have CIN (OR⫽20.3, 95% confidence
interval: 1.6 to 258.5) compared to patients without CIN (p⬍0.0202). Baseline
MAP was also found to be significant between subjects who developed CIN
(p⬍0.0455). A past medical history of gout and HTN appear to be the only
significant RFs for CIN.
Annals of Emergency Medicine S79
Research Forum Abstracts
254
Epidemiology of Out-of-Hospital Emergencies in
Andhra Pradesh, India, 2007
Mahadevan SV, Strehlow MC, Emergency Management and Research
Institue (EMRI)/Stanford University School of Medicine, Palo Alto, CA
Study Objectives: EMRI (Emergency Management and Research Institute) began
emergency medical services (EMS) in the state of Andhra Pradesh (population 80
million) on August 15th, 2005. Unlike other Indian ambulance services, which are
typically hospital-based and urban, EMRI provides centralized EMS to the entire
state. This study describes the epidemiology of EMRI’s ambulance transports during
2007.
Methods: A retrospective analysis of the EMRI call center database and all
available PCRs (patient care records) was performed for patients with medical
emergencies transported by EMRI between January 1st and December 31st, 2007.
Results: In 2007, EMRI received 8,342,063 telephone calls and responded to
437,613 emergencies (medical/police/fire), of which 414,613 (94%) were medical.
Call center database records and all available PCRs (173,520) were analyzed. 57% of
patients were male and 43% female. 7.8% were pediatric (ages ⱕ17) and 7.3% were
geriatric (age ⱖ65). 79% of medical emergencies were from rural areas and 21% from
urban areas. The mean response time (call-scene) for all transports was 20.0 minutes:
14.5 minutes for urban areas and 21.1 minutes for rural areas. For urban areas, the
most common classifiable emergencies were vehicular trauma (46%), non-vehicular
trauma (8%), pregnancy-related (8%), cardiac (5%), respiratory (4%), and poisoning/
overdose (4%). For rural areas, the most frequent emergencies were vehicular trauma
(28%), pregnancy-related (21%), abdominal pain (7%), poisoning/overdose (7%),
non-vehicular trauma (6%) and cardiac (4%) and respiratory (4%). The most
common emergency occurring in men was vehicular trauma (47%); in women,
pregnancy-related (42%). Out-of-hospital treatments rendered included oxygen
(43%), local wound care (29%), IV fluids (18%) and splints (6%).
Conclusion: This epidemiologic study of Indian EMS, the largest on record,
describes important considerations of patients requiring out-of-hospital emergency
care in India. This valuable data will help guide health care development and resource
utilization, preventative public heath measures, and EMS expansion in India.
255
The Outcome of Out-of-Hospital Cardiopulmonary
Arrest in the Over 85-Year-Old Japanese Population
Taken to the Emergency Department.
Umezawa K, Branch J, Yamagami H, Ofuchi H, Ohta B, Uchida Y, Kitahara H/
Shounan Kamakura General Hospital, Kamakura, Japan; Shonan Kamakura
General Hospital, Kamakura, Japan; Chigasaki Tokusyuukai Medical Center,
Chigasaki, Japan
Study Objectives: Out-of-hospital cardiopulmonary arrest (CPA) in the
elderly (above 85 years old) has tended to increase particularly because of the
increase of the elderly population. The long-term prognosis following
cardiopulmonary resuscitation (CPR) in this selected population has recently
been called into question. We considered the outcome of out-of-hospital
cardiopulmonary arrest in a selected elderly population over 85 years of age taken
to two local emergency departments. We also identified the grade of the doctor
overseeing the patient and whether this reflected on the eventual treatment
administered and survival of this population.
Methods: This study was retrospective looking at the pooled results from two
local community hospitals. Only patients over the age of 85 having suffered out-ofhospital cardiac arrest were included in this study. 211 patients were selected between
January 2005 and November 2008 inclusive. We assessed the total time of the
advanced cardiac life support (ACLS), the rate of successful resuscitation and the
outcome attributed to the staff administering the treatment.
Results: The incidence of out-of-hospital CPA was 78.2% at the patient’s home and
17.5% at nursing homes. The rate of bystander CPR was 21.8%. Electrocardiographic
findings in the emergency department was 75.8% asystole, 22.7% pulseless electrical
activity and 1.4% ventricular fibrillation and ventricular tachycardia. Successful
resuscitation was 24.6% and “do not attempt resuscitation” following successful
resuscitation was 88.5%. The mean time of ACLS was 23.9 minutes by junior doctor and
22.0 minutes staff doctors respectively. The rate of successful resuscitation was 24.6% and
24.7% for patients treated by junior doctors and senior doctors respectively, and the mean
length of stay was 1.9 days and 2.6 days respectively.
Conclusion: The time of CPR was shorter when carried out by senior doctors
compared to junior doctors although the initial outcome of survival was unchanged.
If the resuscitation was successful but the family did not wish for continuation of
S80 Annals of Emergency Medicine
advanced life support, all of those patients subsequently died. In view of the results of
this study, we recommend that the elderly population consider making a Living Will
to incorporate an advanced directive to avoid invasive and futile treatment in the
event of a sudden cardiac arrest.
256
Hospitalizations of Older Human Immunodeficiency
Virus Patients in the United States From 2000-2006
Tadros A, Shaver E, Davis S/West Virginia University, Morgantown, WV
Background: There are increasing cases of human immunodeficiency virus (HIV)
patients who are 50 and older, but the unique characteristics of these patients
compared to younger adults are not well described.
Study Objective: We sought to estimate the number of hospitalizations of older
adults with HIV (age ⱖ 50) in the United States (US) from 2000-2006 and compare
selected clinical and demographic features of this population to younger adult (age
19-49) patients.
Methods: This was a retrospective cohort study using seven years (2000-2006) of
data in the Nationwide Inpatient Sample (NIS). The NIS is a stratified, multi-stage
sample designed to provide national estimates of hospitalizations in the US. It
contains approximately 8 million hospital discharges in each data year. Clinical
Classifications Software (CCS) was used to identify HIV patients. Cases were selected
if a CCS ⫽ 5 (“HIV Infection”) was present in any of the CCS discharge diagnoses
for each patient. The following comparisons between younger and older adults were
made: sex, number of admissions, hospital charges and procedures, and primary
diagnoses. SAS-Callable SUDAAN software was used to produce unbiased standard
errors.
Results: From 2000-2006 there were an estimated 1,664,823 hospitalizations of
adults with HIV in the US with the emergency department as the admission source in
66.22% of these cases. Most of these cases (67.14%) were hospitalized in teaching
hospitals located in urban areas. Almost one-quarter of these hospitalizations
(394,965) were by older adults. Admissions for older patients almost doubled from
2000 (42,732) to 2006 (80,139), while younger adults had similar admission rates
(188,544 versus 183,049). Older adults were more likely to be male (73.11%; 95%
CI 71.54-74.43) compared to younger adults (64.24; 62.84-65.61), and were
significantly more likely to die during hospitalization (5.58%; 5.29-5.90 versus
3.69%; 3.55-3.84, respectively). The following primary discharge diagnoses were
among the most common in both age groups: pneumonia (not tuberculosis),
substance-related mental disorders, and skin and subcutaneous tissue infections.
Other top primary diagnoses included affective disorders and alcohol-related mental
disorders in younger adults, and congestive heart failure (non-hypertensive) and
implant or graft complication in older adults. The top 5 principal procedures for both
groups included alcohol and drug rehabilitation, vascular catheterization, and blood
transfusion. Common procedures for the older group also included hemodialysis and
intubation/mechanical ventilation, and for the younger group included lumbar
puncture and bronchoscopy. Older adults had a significantly higher average hospital
charge compared to younger adults ($32,868; 95% CI 30,766-34,970 versus
$27,514; 95% CI 25,832-29,197, respectively).
Conclusions: HIV patients at least 50 years of age accounted for almost
400,000 hospitalizations in the US from 2000-2006. They were more likely to be
male and die during hospitalization compared to younger adults infected with
HIV. Psychiatric and substance abuse disorders were common diagnoses in both
age groups, as were skin and subcutaneous infections. Admissions for older HIV
patients almost doubled during the study period and future studies should
examine whether this is due to aging of the HIV population or new infections in
this age group.
257
Cognitive Impairment and Comprehension of
Emergency Department Discharge Instructions in
Older Patients
Bryce SN, Han JH, Kripalani S, Schnelle J, Storrow A, Ely EW/Vanderbilt
University School of Medicine, Nashville, TN
Study Objectives: Cognitive impairment (dementia and delirium) is common
in older emergency department (ED) patients, yet its effect on patient
comprehension of ED discharge instructions is unknown. We sought to
determine how cognitive impairment affects comprehension of discharge
instructions in older ED patients.
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Methods: This was a cross-sectional survey study conducted at a single ED
located in an academic, tertiary care level 1 trauma center. English-speaking patients
aged 65 years and older who were discharged from the ED were included. Patients
were excluded if they had resided in a nursing home, had severe dementia, or were
previously enrolled. A trained research assistant administered an open-ended survey
designed to evaluate patients’ comprehension of their discharge instructions in the
following domains: discharge diagnosis, medications prescribed by the emergency
physician, instructions to return to the ED, and follow-up. Each domain was rated by
two reviewers blinded to each other’s rating and to the patient’s cognitive status. A
5-point scale ranging from 1 (no understanding) to 5 (complete understanding) was
used to compare the patient’s response to the survey with the patient’s discharge
instructions located in the electronic medical record. The reviewers’ ratings were
averaged for final analysis. Cognitive impairment was defined as the presence of
delirium (as measured by the Confusion Assessment Method for the Intensive Care
Unit) or dementia (as measured by the Mini-Mental State examination, Information
Questionnaire on Cognitive Decline in the Elderly, or as documented in the medical
record). Comparisons between the cognitively impaired and non-cognitively impaired
groups were performed using the Wilcoxon Rank Sum Test. A p-value ⬍ 0.05 was
considered statistically significant.
Results: A total of 114 patients were enrolled. Median (IQR) age was 73 (69, 81)
years old. 67 (58.8%) were females, 28 (24.6%) were non-white, and 61 (53.8%) had
cognitive impairment. Level of comprehension ratings for each discharge instruction
domain can be seen in Table 1. Patients who were cognitively impaired were
significantly less likely to understand their discharge diagnosis, instructions to return
to the ED, and follow-up instructions. No significant difference in comprehension of
medications prescribed was observed between the 2 groups.
Conclusions: Older ED patients with cognitive impairment exhibited lower
comprehension of discharge instructions compared to patients without cognitive
impairment, especially in the domains of their diagnosis, reasons for returning to the
ED, and follow-up instructions.
Level of understanding ratings are expressed in median (interquartile ranges).
history, and evaluation of the following: social support, medications, vision, postural
blood pressure, cognition, continence, footwear, gait and balance. Upon identifying
the risk factors of fall, appropriate advice, immediate intervention and onward
referrals were rendered accordingly.
Patients were followed up at 3, 6, 9 and 12 months through telephone call. A
research assistant obtained basic and instrumental activities of daily living (ADL)
scores and number of subsequent falls. ED re-attendances and hospitalizations were
obtained though electronic medical records.
Patients were compared against historical controls collected between 7th April to
15th June 2008, based on the same criteria above, who received standard ED care.
Results: There were 179 in the control and 89 patients in the intervention group.
There was no difference in baseline characteristics (age, sex, baseline functional scores
and injuries) between the two groups. Seventy-one (79.%) of patients in the
intervention group required falls risk-factor modification. Only 6 (6.7%) patients did
not need any intervention, while 12 (13.5%) refused intervention. Forty-five (51%)
patients within the intervention group fell indoors and 29% experienced difficulties
in getting up after the fall. Common fall risk factors found included improper
footwear (69%), visual impairment (48%), gait (25%) and balance (28%)
disturbance.
At 3 months, there were only a small number of fallers in each group: 11 (6.9%)
in the controls and 7 (8.5%) in the intervention group. There was a reduction in ED
reattendance (21.7% vs 19.1%) and hospitalization (14.3% vs 10.1%). However,
none of these three-month variables were statistically significant.
Conclusions: The results of this study provide insight to the common risk factors
for falls in the elderly so that preventive and appropriate intervention can be made.
Early results, although not significant, are encouraging: there is a trend towards
reduced ED reattendance and hospitalisation rates. We look forward to follow-up
results at 6, 9 and 12 months.
259
Occult Cognitive Impairment in Admitted Older
Emergency Department Patients Is Not Identified
by Admitting Services
Heidt JW, Carpenter CR/Washington University in St. Louis, St. Louis, MO
*Only the 54 (47.4%) patients who received prescriptions were used in this analysis.
258
Preliminary Results of a Multidisciplinary Falls
Evaluation Program for Elderly Fallers Presenting
to the Emergency Department
Wong EM, Foo C/Tan Tock Seng Hospital, Singapore, Singapore
Background: A fall in an elderly is a sentinel event. It may be a harbinger to
future falls, which may result in injury, immobility, fear of falling, functional decline,
and even death. In a busy emergency department (ED), there is a tendency to focus
on the patient’s physical injury. However, if the culprit fall risk factors are not
addressed, the patient is at risk of falling again.
Study Objective: In this study, we provide a multidisciplinary assessment of
elderly fallers presenting to the ED. The objective is to identify risk factors for future
falls so that appropriate intervention may be provided to reduce further falls, ED
reattendance and hospitalisations.
Methods: This is a prospective study taking place in Tan Tock Seng Hospital’s
ED from June 16, 2008 to September 18, 2008. Patients 60 years and above who
presented to the ED with a fall, and were able to ambulate before and after the fall
were recruited. Excluded were nursing home residents, those who are already on
follow-up with a geriatrician, patients with cognitive impairment unable to give
consent, and patients who refused to participate.
Intervention involved assessment by an emergency doctor, an emergency nurse
trained in geriatric care, and a physiotherapist. Assessment included a detailed falls
Volume , .  : September 
Study Objectives: Unrecognized cognitive impairment can adversely impact older
adult outcomes in emergency medicine (EM). Admitted patients with occult
cognitive dysfunction may be recognized more often than discharged subsets, either
by EM staff or inpatient services. Our objectives were to compare the nurse and
physician EM and inpatient physician documented identification of potential
cognitive impairment in older adults.
Methods: A prospective, cross-sectional convenience sampling was conducted at
one urban medical center emergency department (ED). Eligible subjects were
consenting English-speaking patients over age 65 years who had not received
potentially sedating medications including anti-emetics, sedative-hypnotics, or
narcotic-analgesia prior to criterion standard testing. Research assistants obtained a
Mini Mental Status Exam (MMSE) on each subject. Two investigators, blinded to
the MMSE result, later conducted an electronic chart review of the emergency nurse
and physician note along with the inpatient physician admission and discharge notes
to identify any documentation of confusion, disorientation, memory deficits, or
potential cognitive dysfunction. Reliability was assessed with kappa analysis, while
proportions were compared with ␹2 tests.
Results: Over 5 months, 251 subjects were enrolled. Of these, 47% were male
with mean age 76-years and 55% were African-American with illness severity
stratified by Emergency Severity Index 32% B and 66% C. Admitted subjects were
58% of the cohort. Cognitive dysfunction (MMSE ⱕ 23) was identified in 35% of
the total cohort and 39% of the admitted subset. Two investigator chart review
reliability for emergency or inpatient physician documentation of dementia was good
(␬⫽0.724 for PMH, 0.597 for emergency physician note, and 0.688 for inpatient
physician note), but only fair for nursing documentation (␬ ⫽ 0.404). Past medical
history documented dementia in 4%, failing to identify 86% of those with an
abnormal MMSE during their ED evaluation. Emergency nurses and physicians
noted no cognitive abnormalities among 84% and 72%, respectively of those with an
abnormal MMSE. Inpatient physicians did not document any cognitive abnormality
in 60% of those with an impaired MMSE.
Conclusion: Occult cognitive dysfunction is prevalent in admitted and discharged
ED patients. Emergency nurses and physicians fail to document recognition
Annals of Emergency Medicine S81
Research Forum Abstracts
of this geriatric syndrome. Inpatient physicians rarely identify cognitive
impairment missed by the ED.
260
Geriatric Syndrome Screening in Emergency
Medicine: A Geriatric Technician Acceptability
Analysis
Carpenter CR, Griffey RT, Stark S, Coopersmith CM, Gage BF/Washington
University in St. Louis, St. Louis, MO
Study Objectives: Older adults routinely face social isolation and economic
stressors concurrently with increasing frailty and co-morbid burden, often
presenting atypically with multiple confounding processes. The demographic
imperative facing 21st century health care will challenge emergency medicine
(EM) to heighten evidence-based surveillance and focused interventions on a
historically unprecedented geriatric population. Our objectives were to evaluate
emergency physician and nurse acceptance of non-nurse, non-physician screening
for geriatric syndromes.
Methods: This was a single-center emergency department (ED) survey of EM
attending physicians and nurses following a pilot screening project. Geriatric screeners
were paid medical student research assistants evaluating consenting ED patients over
age 65 for cognitive dysfunction, fall risk, or functional decline. Potential patient
subjects were only approached after approval of the treating physician. Screening
results were not communicated to nurse or physician staff since this pilot project was
a feasibility trial and not an interventional trial. The anonymous survey was
completed after eight months of screening and evaluated perceptions about the
geriatric screener feasibility and barriers to implementation. In addition, respondents
reported their current practice for screening older adults using ED validated tools for
prognosis, fall risk, dementia, visual and hearing impairment, polypharmacy,
functional status, and immunizations.
Results: The survey was completed by 72% of physicians and 33% of nurses. Less
than 25% of physicians routinely screen for any geriatric syndromes. Nurses evaluate
for fall-risk significantly more often than physicians (97% vs. 24%, p⬍0.001), but no
other significant differences were noted in ongoing screening efforts. The majority of
nurses (85%; 95% CI 73%-97%) and physicians (71%; 95% CI 52%-91%)
identified geriatric screener assistants as beneficial to patients without impeding ED
throughput. Few physicians or nurses identified any barriers to ancillary screeners
evaluating for occult geriatric syndromes.
Conclusion: Most nurses and physicians are not currently screening for any
geriatric syndromes. Dedicated geriatric screeners are perceived by nurses and
physicians as beneficial to patients with the potential to improve patient safety and
clinical outcomes.
261
Restraint Use in the Elderly Emergency
Department Patient
Swickhamer C, Colvig C, Chan SB/Resurrection Medical Center, Chicago, IL
Study Objectives: The elderly frequently suffer from altered mental status and
other medical conditions requiring physical and/or chemical restraint for patient and
staff safety in the emergency department (ED). This study examine outcomes of
physically restrained ED elders.
Methods: Two-year retrospective study from an urban community teaching
hospital ED. Included were patients 65 years and older, physically restrained in the
ED, requiring inpatient hospitalization. Data included age, sex, restraints indications,
restraint type, restraint length, adverse outcomes, ED discharge diagnosis, ED
disposition, hospital length of stay and disposition.
Results: Eighty-three patients reviewed over 2 years. 56.6% were nursing
home residents. 86.7% had medical indications for restraints. 32.5% (27/83)
were admitted from the ED to the ICU. 42.2% (35/83) received both chemical
restraints and physical restraints. The median number of medications upon
patient arrival was 8.0, and three patients were on a medication which could
adversely interact with chemical restraint medication. The mean length of stay
(LOS) in the hospital was 7.2 days (SD: 5.7 days). 10 patients expired, 14 went
home, and 59 to a nursing facility (8 with new behavioral medications). Of the
36 patients originally from home, only 11 (30.6%) were discharged home. There
were no outcome differences between patients with both chemical and physical
restraints and patients with physical restraints alone.
S82 Annals of Emergency Medicine
Conclusion: In this 2-year retrospective study, elderly patients placed on
physical restraints in the ED were most often medically ill with high severity and
likely to required both physical and chemical restraints. Chemical restraints may
be contraindicated in some patients secondary to prior medications. Elderly
patients from home who require physical restraints in the ED are unlikely to
return home.
262
Yield of Head Computed Tomography in the
Alcohol-Intoxicated Patient
Shah K, Godbout B, Kwon A, Newman D, Wiener D/St. Luke’s-Roosevelt
Hospital, New York, NY
Study Objective: We aimed to determine the yield of positive cranial computed
tomography (CT) findings in alcohol-intoxicated patients presenting to the
emergency department. Our secondary aim was to determine if elderly patients were
more likely to have an intracranial injury.
Methods: An electronic chart review was performed at our inner city,
academic institution with an annual census of 165,000 patients and a 3-year
emergency medicine residency program. All patients with either a chief complaint
or diagnosis of alcohol intoxication who had a head CT performed in the
emergency department between the dates of January 2004 and December 2007
were identified. Specific, pre-determined data elements such as demographics, CT
scan results and disposition were extracted by 2 trained, hypothesis-blinded
extractors using a pre-formatted data form. “Positive” head CT was defined as
evidence of any type of intracranial hemorrhage. “Elderly” was defined a priori as
greater than or equal to 60 years of age. Standard statistical methods including
chi-square calculations were utilized for data analysis and group comparisons
(head CT yield between older and younger patients).
Results: There were a total of 2,673 subjects (82% male) with alcohol
intoxication and a head CT scan performed over our 4-year study period. A total of
50 (1.9%) subjects had a positive head CT with a mean age of 51 (range from 20 to
84) and 92% male predominance. Comparing elderly subjects (n⫽555) with those ⬍
60 years of age (n⫽2118), the yield of positive head CT was 2.70% (.95CI⫽1.44.1%) versus 1.65% (.95CI⫽1.1-2.2%), respectively.
Conclusion: The yield of positive head CT among alcohol-intoxicated
patients was 1.9%. Although CT scan of elderly patients had a higher yield than
those less than 60 years of age (2.7% vs. 1.7%), the difference was not statistically
significant.
263
Assessing Three-Month Fall Risk for Geriatric
Emergency Department Patients
Carpenter CR, DesPain RW, Keeling TN, Rothenberger MP, Shah MP/
Washington University in St. Louis, St. Louis, MO
Study Objectives: Older adult falls are a leading cause of injury often
precipitating rapid functional decline. Emergency department (ED)-initiated falls
prevention reduces subsequent fall-related morbidity, but limited resources
necessitate a focus on high-risk subsets. Recent synopses have suggested specific
clinical predictors lacking external validation in the ED. The objective of this
study was to validate previously reported risk-factors for geriatric falls in ED
patients.
Methods: A prospective observational study was conducted at one urban
medical center ED. Eligible subjects were consenting English-speaking patients
over age 65 years who had not received potentially sedating medications
including anti-emetics, sedative-hypnotics, or narcotic-analgesia prior to
prognostic variable testing. Variables assessed included self-reported dementia or
Parkinson’s; prior falls within the last month or year; recent prolonged bed
confinement; phenothiazine, benzodiazepine, anti-depressant, antihypertensive,
or narcotic analgesic use; bedside functional tests (chair stand, tandem gait); Mini
Mental Status Exam cognitive assessment; residual stroke deficits; fear of falling;
the Identification of Seniors at Risk and the Triage Risk Screening Tools. The
primary outcome was reported falls at three-month phone follow-up using a pretested script. Secondary outcomes included injurious falls and ED recidivism.
Proportions were compared with ␹2 tests.
Results: Over 9 months, 158 subjects were enrolled with three-month followup. Of these, 58% were female with mean age 77 years and 54% were AfricanAmerican. Admitted subjects were 54% of the cohort. Cognitive dysfunction
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Research Forum Abstracts
(MMSE ⱕ 23) was identified in 29% although dementia history was only selfreported in 4%. Falls in the preceding year were reported by 41%. Recommended
bedside functional tests could not be performed in 49% of subjects. Falls within
three months were reported in 17% (95% CI 12%-24%), while fall-related
injuries were reported in 6.3% and ED recidivism in 43.7%. Univariate analysis
identified only two-risk factors as significant: previous falls within one-month
(p⬍0.001) or one-year (p ⫽ 0.002).
Conclusion: Previous and future falls are prevalent among older ED patients.
Recommended functional bedside tests are impractical for half such patients and
are not significantly associated with self-reported three-month falls. Previously
suggested outpatient and inpatient fall risk factors fail to identify geriatric
patients with self-reported falls. ED-specific fall risk factors are need to identify
high-risk subsets.
264
Has Grandma Been Drinking?
Irvin CB, Kott I, Abuel V/St. John Hospital and Medical Center, Detroit, MI
Background: Seniors suffering trauma have a worse prognosis than younger
victims. Seniors may already be challenged (with slower response times, visual
challenges, etc) and the compounding effect of alcohol may contribute to even greater
mortality. No previous studies have evaluated the frequency of alcohol ingestion in
elderly trauma patients, or the effects on outcome when seniors are intoxicated.
Study Objective: To determine the proportion of elderly trauma victims with
alcohol ingestion, compared to younger victims, and evaluate if alcohol presence is
associated with worse outcome.
Methods: Using the National Trauma Data Bank (version 6.1), the following
variables were retrospectively analyzed in ACCESS: Age (⬎ 64 (Seniors), 40-64
(MidAge), and 18-39 (Young), Injury Severity Score (ISS), Alcohol present, Length
of Stay (LOS), and Discharge status (alive vs dead). Cases with missing data were
excluded.
Results: Of the 404,559 cases with complete data, 16% were Seniors, 35% were
MidAge, and 50% were Young. Seniors were more likely to die with a mortality rate
of 9.3%, compared to MidAge of 4.7% and Young of 3.9%, p⬍.01. Alcohol
presence was reported in 9.2% seniors, 31% MidAge, and 37% Young, p⬍.01.
Seniors with alcohol had an increased mortality (11%) compared to Seniors without
alcohol (9%, p⬍.01), MidAge with alcohol had an increased mortality (5%)
compared to MidAge without alcohol (4%, p⬍.01). The Young mortality did not
change with presence of alcohol (p⫽.4). Alcohol presence was also associated with
increased LOS ((approximately 1 day in all age groups, p⬍.01), and ISS (2 point
increase in ISS in all age groups, p⬍.01).
Conclusion: Alcohol presence in trauma patients decreases with age, but
when present, is associated with increased ISS, and LOS. Almost 10% of
traumatized seniors will have alcohol present. Additionally, when alcohol is
present, seniors have a higher ISS score and higher mortality. Injury prevention
programs for seniors need to address alcohol consumption as this may contribute
to increased death in trauma.
265
Guided Medication Dosing for Elderly Emergency
Department Patients Using a Real-Time,
Computerized Decision Support Tool
Griffey RT, Lo HG, Burdick E, Keohane C, Bates DW/Washington University
School of Medicine, Barnes-Jewish Hospital, St. Louis, MO; University of
Pennsylvania, Philadelphia, PA; Brigham and Women’s Hospital, Division of
General Medicine, Boston, MA; Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA
Study Objective: The elderly account for an increasing number of emergency
department (ED) visits, hospital admissions, and 1/3 of all prescribed
medications. Age-related differences in physiology and a high prescription rate
make the elderly more susceptible to adverse events including falls, hip fracture,
intracranial hemorrhage, gastrointestinal bleeding, oversedation, and altered
mentation. It is known that a number of common medications whose standard
dosages for otherwise healthy adults are potentially harmful in the elderly.
Recently, the use of real-time, computerized decision support tools in
conjunction with computerized order entry (CPOE) systems has been shown to
improve medication ordering and impact patient safety in elderly patients in the
inpatient setting. We implemented a similar intervention in the ED to study its
Volume , .  : September 
impact on physician ordering behavior and adverse drug events in elderly
emergency patients.
Methods: This study took place in an academic, urban emergency department
(ED) exclusively using CPOE. This was a prospective trial of 4 consecutive 6week blocks where the decision support tool was alternately inactive “OFF”
(periods 1 and 3) or active “ON” (periods 2 and 4). This was followed by chart
review for a sample of patients in each block using previously described explicit
chart review methodology to identify adverse drug events. When active, the
application made adjusted default dosing or alternate medication
recommendations in patients ⬎64 who were ordered selected benzodiazepines,
opiates, non-steroidal anti-inflammatory drugs (NSAIDs) or sedative-hypnotics
identified by a multidisciplinary expert panel as potentially harmful in the elderly
(based on modified Beers list). Physicians could accept or reject
recommendations. Outcome measures compared ON and OFF periods for: (1) %
agreement with recommended dosing (overall and broken down by drug and
class) for the initial order, and (2) rate of adverse drug events. Data analysis was
performed using t tests for continuous variables and chi-square test for discrete
data.
Results: There were 2419 orders among 1356 unique patients making 1548 total
visits. There were no differences between cohort demographics including race, age,
and sex. Overall agreement with recommended dosing was low, with a greater
percentage of initial orders consistent with recommendations during the ON (31.4%)
vs. OFF (23.0%) periods both overall (p⫽0.03) and for each drug class:
benzodiazepines (p⫽.03), opiates (p⫽0.04) and NSAIDs (p⫽.0009) (sedative
hypnotics had too few orders for reliable analysis). The pattern of agreement followed
the activation status of the decision support tool. With overall agreement increased
from periods 1 to 2 (p⫽.03), decreasing nonsignificantly from period 2-3 (p⫽.06)
and increasing from period 3-4 (p⬍.0001). Chart reviews were performed in 223
patients (16%) with no significant difference found in the rate of adverse events
during ON vs. OFF periods.
Conclusion: Real-time computerized decision support improved physician
ordering behavior consistent with recommendations for adjusted medication
dosing in the elderly, though overall agreement rates were low. This effect
appears to be dependent on the application being live. There was no clear effect
on adverse event rate in this study which was underpowered to detect a significant
change.
266
Do Non-English-Speaking Patients With an
Admitting Diagnosis of Pneumonia Experience a
Systematic Delay in Time to Antibiotics?
Green JP, Garg N, Berger T/New York Hospital Queens, Flushing, NY; Jacobi
Medical Center, Bronx, NY
Study Objective: To determine whether non-English-speaking (nEs) patients
with an admitting diagnosis of pneumonia experience a systematic delay in time to
first antibiotics.
Methods: A retrospective chart review was performed at an urban teaching
hospital for all adult patients admitted from the emergency department with a
diagnosis of pneumonia during a 6-month period (8/1/2007-1/31/2008). Primary
language spoken, demographics, time from arrival to chest x-ray and arrival to
antibiotics were collected. Compliance with institutional goals for arrival to first
antibiotics ⬍ 4 hours were reviewed. Mann Whitney U was used for continuous and
chi-square for categorical data.
Results: 391 patients were admitted from the emergency department for
pneumonia during the 6-month period. 147(37.6%) patients were nEs. Mean age
was 71.2 years, 51% were female. 377(96.4%) patients received antibiotics less than 4
hours from arrival. Median time to chest x-ray for English vs. nEs patients was 71.0
min [95% CI 64.0-80.0] vs. 76.0 min [64.0 to 86.7], p⫽0.61. Median time to first
antibiotic for English vs. nEs patients was 65.0 min [95% CI 57.0-75.9] vs. 74.0 min
[95% CI 59.6 to 83.0], p⫽0.64. Compliance with institutional goals for time to first
antibiotic for English vs. nEs patients was 3.6% [95% CI 1.1 to 6.1] vs. 4.5%
[95%CI 0.9 to 8.1] min, p⫽0.89.
Conclusion: There was no evidence of a systematic delay in time to chest x-ray or
time to first antibiotic for non-English-speaking patients in this population.
Limitations included a retrospective design and small sample size.
Annals of Emergency Medicine S83
Research Forum Abstracts
267
Emergency Department Nurse Workloads and Their
Contributors
Rabin E, Koita J, Salaam O, Richardson L/Mount Sinai School of Medicine, New
York, NY
Study Objectives: As evidence mounts that larger patient-to-nurse ratios (PT:Ns)
lead to patient morbidity and possibly mortality, over 20 states have developed safe
nurse staffing laws. It is unclear if, and how, many of the laws will apply to emergency
departments (EDs), where nurses are subject to growing and unpredictable patient
volumes. Laws that only limit inpatient PT:N could worsen ED PT:N by increasing
boarding. Existing research has not focused on ED nursing workloads or suggested
strategies to effectively limit them. We seek to quantify the magnitude and variability
of ED PT:N and to identify factors in Asplin et al’s input-throughput-output ED
crowding model that most affect ED PT:N.
Methods: Data on non-critical adult patients were collected prospectively in a
large urban public ED during randomly selected 8- and 12-hour shifts between
June and September 2008. Every two hours the following were recorded: number
of patients triaged over the previous 2 hours (input factor), patients awaiting
physician evaluation or radiology study (throughput factors), boarders (output
factor) and total number of patients and nurses. PT:N values were derived for
each observation. A mixed linear analytical model accounting for correlation of
temporal clusters of data points was used to identify significant contributors to
PT:N.
Results: Data were collected at 115 points in time during 20 shifts. Average PT:N
was 5.6 patients per nurse (min 2.2, max 10.3, var 2.8). PT:N was greater than 6 in
34.7% of cases. Significant contributors to PT:N included triaged patients (␤ 0.013
P⬍0.0001), patients awaiting physician (␤ 0.127 P⬍0.0001) and boarders (␤ 0.061
P⫽0.0016). Patients awaiting radiology studies did not contribute significantly (␤
0.052, P⫽0.139).
Conclusion: ED nurses frequently carry more than six patients, the number often
cited as the threshold for inpatient floor safety. Increases in ED crowding input,
throughput and output factors were significantly associated with greater ED nurse
workloads; strategies to limit any of these may decrease ED PT:N. Legislative
proposals for safe nursing standards and strategies to decrease crowding should
consider the effects on ED nurses’ workloads.
268
Change in Acuity of Emergency Department Visits
After Massachusetts Health Care Reform
Smulowitz PB, Baugh CW, Schuur JD, Liu SW, Lipton RB, Wharam JF,
Landon BE/Beth Israel Deaconess Medical Center, Boston, MA; Brigham and
Womens Hospital and Massachusetts General Hospital, Boston, MA; Brigham
and Womens Hospital, Boston, MA; Massachusetts General Hospital, Boston,
MA; Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA;
Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA
Study Objectives: Between October 1, 2006 and December 31, 2007
Massachusetts enrolled 439,000 individuals in health insurance products during the
implementation of its landmark near universal health care legislation. This reform
serves as a natural experiment with which to study the impact of health reform on
changes in emergency department (ED) use. Our objective was to determine the
relationship between health care reform in Massachusetts and ED use for low- and
high-acuity conditions for the population of patients who were previously in
government subsidized insurance or uninsured. A secondary objective was to
determine if a significant increase in total visits among all patients was observed. Since
access to health care depends on more than just insurance status, we hypothesized
that the rate of ED visits for low acuity conditions would not decrease after the
reform.
Methods: This retrospective pre-post study utilized data from administrative
databases at three urban tertiary care teaching hospitals. The baseline period was from
January 1st, 2006 to September 30th, 2006 and the comparison study period was
January 1st, 2008 to September 30th, 2008. We limited the analysis to include those
groups most affected by the health reform law, which were patients covered by
government subsidized insurance (ie, Medicaid, Free Care Pool and Commonwealth
Care) and the uninsured. Acuity of visits was determined using a modification of
Billings’ Emergency Department Algorithm. This modified algorithm clusters ICD-9
discharge codes into low, intermediate, and high acuity visits. We used chi square
tests to compare the proportion of low and high acuity ED visits before and after the
health reform implementation period.
S84 Annals of Emergency Medicine
Results: Total visits increased from 169,665 to 190,465 (p ⬍ .05) after the
reform period for all types of patients. There was no significant difference in the
pre- and post-reform ED visit rate for low acuity visits among patients who were
previously in government subsidized insurance or uninsured at two of the
hospitals (30.90% versus 29.24%, p ⫽ 0.12, and 33.82% versus 35.41% p ⫽
0.10, respectively). However, at the third hospital, a significant increase was
observed (34.22% versus 39.50%, p ⬍ .05). There was no significant change in
the proportion of high acuity visits observed for patients with any type of payer.
Conclusion: Massachusetts health care reform was temporally associated with an
increase in the volume of ED visits at 3 urban teaching hospitals. None of the
institutions demonstrated a decrease in low acuity visits in the time period following
health care reform. While this 3 site pre-post analysis is limited by its design, it
suggests that increased insurance coverage will not lead to an immediate reduction in
ED visits.
269
The Impact of Declining Emergency Department
Subspecialty Availability
Ladde J, Bullard T, Papa L/Orlando Regional Medical Center, Orlando, FL
Background: The availability of emergency specialty services is a significant
problem. Reasons cited include poor reimbursement, legal repercussions, and
disruptive on-call scheduling. The impact is particularly important for centers that
continue to provide these services.
Study Objective: This study compared the availability of emergency specialty
services during two discrete time points to assess the impact of declining emergency
services.
Methods: This cross-sectional study used 2003 and 2007 Florida State Registry
transfer data to compare availability of emergency specialty services per capita per
100,00 populations. Specialties examined included: burns, emergency medicine, ear
nose and throat, general surgery, hyperbarics, neurology, neurosurgery, obstetrics,
ophthalmology, oral and maxillofacial surgery, orthopedics, pediatrics, plastic,
thoracic surgery, trauma, urology, and vascular surgery. Data are expressed as per
capita per 100,000 population.
Results: The actual demand for specialty services from 2003 to 2007 did not
change significantly (p⫽0.97). However, overall, the total number of emergency
specialty services available per capita per 100,000 population declined from 52.4
(SD55.4) in 2003 to 36.6 (SD21.1) in 2007 (p⫽0.042). In particular, emergency
medicine and trauma services declined from 3.4 (SD2.8) to 2.2 (SD1.8) per capita
per 100,000 population respectively (p⬍0.001). The number of surgical specialties
(such as cardiovascular, general, neurosurgery, oro-maxillofacial, plastic, thoracic,
vascular and burns) available per capita per 100,000 population declined from 11.8
(SD14.1) in 2003 to 7.7 (SD4.5) in 2007 (p⫽0.033). The specialties with the most
significant decreases in services from 2003 to 2007 included trauma, burn, and oromaxillofacial surgery.
Conclusion: This study underscores the dramatic statewide shortage in ED
coverage for critical subspecialties and how the burden of these reductions has
been shifted to those still providing services. Further studies to evaluate the
impact these shortages create and how to alleviate the problem are needed.
270
The Impact of Health Care Reform in
Massachusetts on Emergency Department Use by
Uninsured and Publicly Subsidized Individuals
Smulowitz PB, Adelman L, Lipton R, Burke L, Weiner S, Sayah A, Baugh CW,
Burke MC, Landon BE/Beth Israel Deaconess Medical Center, Boston, MA;
Tufts Medical Center, Boston, MA; Cambridge Health Alliance, Cambridge, MA;
Massachusetts General Hospital, Boston, MA; Milford Regional Medical Center,
Milford, MA; Harvard Medical School, and Beth Israel Deaconess Medical
Center, Boston, MA
Study Objectives: Massachusetts enrolled 439,000 individuals in health
insurance plans during implementation of its landmark near-universal health care
legislation. From a population who was previously uninsured or part of the Free
Care Pool, 169,000 individuals were enrolled in a publicly subsidized program
(Commonwealth Care), and 76,000 individuals were enrolled in Medicaid
(Masshealth). Our objective was to determine if health care reform was associated
with a change in the rate of use of the ED by those patients most directly
impacted by the health reform legislation.
Methods: This was a retrospective pre-post study set using ED utilization
data from 6 hospitals in Massachusetts (3 tertiary care teaching hospitals and 3
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community hospitals). The baseline period was January 1 - September 30, 2006.
The comparison period after the implementation of health care reform was
January 1 - September 30, 2008. We first measured the total volume of ED visits
in the before and after periods. We then measured the percent of total visits in
each period that were either uninsured or in publicly subsidized programs. The
study group during the baseline period consisted of visits by individuals who were
Self Pay, Free Care, or in Masshealth. The study group during the comparison
period consisted of visits by individuals who were either in Self Pay, Free Care, in
Masshealth, or the newly created Commonwealth Care group. We used chisquare testing to compare the frequency of visits in these groups before and after
the implementation of health reform.
Results: In 2006 there were 179,557 total ED visits and 195,635 total visits in
2008. (p ⬍ .05) In the study group for 2006 there were 62,210 visits, accounting for
34.6% of total ED visits. A significant decrease was found in 2008 compared to 2006
(p ⬍ .05), where there were 60,383 visits in the study group, or 30.9% of total ED
visits. This is mainly a consequence of a reduction in the number of ED visits by self
pay and free care patients. Patients enrolled in Commonwealth Care accounted for
2.6% of the population in Massachusetts and 3.0% of all ED visits in these hospitals
in 2008.
Conclusion: Health care reform, for the hospitals in this study, was associated
with a decrease in the frequency of ED visits by patients who were either uninsured or
insured by publicly subsidized programs. There was, however, a significant increase in
overall ED visits during this time period. The results suggest that the uninsured are
not the primary cause of increasing ED volumes. This preliminary study highlights
some important trends in ED use after health care reform in Massachusetts. This
study was limited by the relatively small number of hospitals in the sample though it
includes both large teaching hospitals and community hospitals.
271
Accidents Waiting to Happen: Decreasing Access
to Emergency Departments in Rural Areas in the
U.S., 2001-2005
Hsia RY, Shen Y/University of California at San Francisco, San Francisco, CA;
Naval Postgraduate School, Monterey, CA
Study Objectives: The Institute of Medicine and other public health institutions
have voiced growing unease that there could be systemic disparities in access to
traditionally underserved patients. One important indicator is the availability of
critical services, such as those of emergency services, especially in rural areas. The
objective of this study is to determine if access to emergency departments (EDs), as
defined by geographic proximity, has increased or decreased in rural areas for specific
sub-populations over time between 2001 and 2005.
Methods: We obtained characteristics of communities using zip code level data
from the 2000 Census and further supplemented this dataset with longitude and
latitude coordinates of each zip code and hospital, and calculated the distance
between each community to the nearest ED. We extracted data regarding ED
availability between 2001-2005 from the American Hospital Association (AHA)
Annual Surveys. Our unit of analysis was community as defined by zip code. Our key
variables of interest were the proportion of underserved populations in each zip code
by the following categories: race/ethnicity (black, Hispanic), economically
disadvantaged (poor, near poor, and unemployed), and elderly (greater than 65 years
of age). We controlled for population, county, and hospital (and hospital market)
characteristics. We used multivariable regression with STATA to determine odds that
distance to the nearest ED increased between 2001 and 2005.
Results: A total of 9,754 zip codes were included in our sample, with an
estimated population size of 37.8 million. Between 2001 and 2005, access to the
nearest ED deteriorated for 7% of zip codes, equivalent to 3.1 million people. Two
groups experienced a deterioration in access: areas with high shares of Hispanic
population (2.72 times more likely to have decreased access to ED, p⬍0.01), and
those with medium and high shares of families below poverty (1.81 and 1.8 times
more likely to face decreased access to ED, p⬍0.01, p⬍0.05, respectively).
Conclusion: We find that there has been a decline in proximity to the nearest ED
for rural communities, and that this decline in access is not evenly distributed. These
findings of this study have serious implications regarding the continued evolution of
access to emergency departments for certain populations.
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272
Are Public Hospitals More Efficient in Providing
Health Care?
Roberts RR, Rodrigo Y, Kampe LM, Bowman SH, Ahmad I/Stroger Hospital of
Cook County, Chicago, IL; St. Mathew’s University, Grand Cayman, Cayman
Islands; Cermak Health Care System, Chicago, IL
Study Objectives: It is often remarked that public teaching hospitals operated less
efficiently than private or not-for-profit hospitals. Our study objective was to
determine the efficiency of ten public hospitals compared to the national average. A
second objective was to determine the relative costs for medical care in states with
dense urban populations versus more rural states.
Methods: The Resource Based Relative Value Scale (RBRVS) was used to
determine the total output for ten public hospitals in 2005. We measured total
hospital admissions, hospital inpatient days, ambulatory and ED visits, and inpatient
and ambulatory surgeries and multiplied the totals by their Relative Value Units
(RVUs). This total output was divided by the total number of full-time equivalent
employees (FTEs) to determine the facility efficiency. The same procedure was used
to determine the total output and efficiency of the U.S. hospital system as a whole in
2005. For all RBRVS we used the median value within each health care output
category. Because ambulatory care relative to inpatient care varied greatly between
facilities, a sensitivity analysis was performed. The highest and lowest RVUs for a
clinic visit were substituted for the average while all other services were scaled to the
clinic visit RVU. We also performed total measurements while sequentially excluding
ambulatory surgery and clinic visits and excluding national physician office FTEs.
Finally, a preliminary examination of the relative medical and business costs for
densely populated states - New York and Massachusetts - versus the more rural
Alabama and Nebraska was conducted.
Results: In the base case, the ten public hospitals achieved 252.9 RVUs per FTE
compared to 244.5 RVUs for the national total. In the sensitivity analysis using varied
ambulatory RVU’s, public hospitals provided 743.9 RVUs compared to 578.6 for
national facilities when using the lowest clinic RVU. When using the highest clinic
RVU, public hospitals provided 163.2 compared to 168.1 for national RVU. In the
rest of the analyses, the public hospitals had more RVUs per FTE than the national
Annals of Emergency Medicine S85
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average. The geographical regions varied greatly in the hourly wage for hospital
professionals such as nurses with the highest rate in Boston, MA at $36.95 vs. $24.29
in Lincoln. This was also true for infrastructure costs: $38.0 per square foot in New
York, $33.1 in Massachusetts versus $17.4 and $19.3 in Alabama and Nebraska,
respectively. In contrast, the total spent on pharmaceuticals as a proportion of total
health care was 29% higher in Nebraska compared to Massachusetts. Higher cost for
prescription drugs was confirmed by calling a national pharmacy in each state.
Conclusion: Using the RBRVS to value health care outputs, ten urban public
hospitals provided more health care units per FTE than the national average. All of
our public hospitals were in densely populated urban areas, are often crowded and
therefore may benefit from the efficiency of scale. Our preliminary work to determine
how geographical area affects hospital costs suggests that areas with low wage, salary
and real estate costs appear to pay similary or higher costs for pharmaceuticals- in
total and by individual prescription. This paradox may need examination as a cause of
health disparity and could impact the national cost-effectiveness for new
pharmaceuticals that save money by reducing health care encounters.
273
Association Between Emergency Department
Crowding on the Appropriateness of Resuscitation
Room Utilization: An Expert Panel Study in a
Single Emergency Center
Kim J, Choi H, Shin S, Kim D, Cha W/Seoul National University Hospital, Seoul,
Republic of Korea
Study Objectives: The aim of this study was to evaluate the appropriateness of
resuscitation room utilization and find their association with emergency department
(ED) crowding.
Methods: This study was carried out from July 1, 2008 to August 31, 2008 in a
single regional emergency center (level 1 center). Targets were patients with age of 15
years or older. Patients who died on arrival (DOA) were excluded.
The decision of putting patients into the resuscitation room was done by doctors,
nurses or paramedics or even by out-of-hospital caregivers. There was no written
protocol for entering the resuscitation room. The disposition of resuscitation patients
were made after they were clinically stabilized or died. The data of these patients were
recorded to the resuscitation room registry by emergency nurse specialists. Collected
data were physiologic parameters, diagnoses, interventions, clinical results, and time
variables.
Three emergency physicians reviewed every case independently afterward. They
categorized each case as appropriate, over-utilization, or delayed-utilization.
Agreements were made if at least two of the physicians agreed on a same category.
Calculation of visits per hour was regarded as crowding index. We categorized the
included hours into quartiles according to the calculated hourly visits.
Results: Total of 145 patients was included. 64.8% was male and mean age was
60.7 (57.8 - 63.6) years. 26 (17.9%) of these were discharged from the ED, 98
(67.6%) were admitted, 9 (6.2%) were transferred to another facility, and 11 (7.6%)
died in the ED. Overall hospital mortality was 37 (25.5%). The panel decided that
utilization of the resuscitation room was appropriate for 88 (60.7%) of patients, overutilized for 39 (26.9%), and delayed-utilized for 18 (12.4%).
When compared by the crowding factor, the hourly visits, there was significant
association. The rate of appropriate utilization was 100% when there were less than
two visits per hour, 75% when two or three visits per hour, 61.2% when four to six
visits per hour, and 54.8% when more than 7 visits per hour (p⬍0.05).
Conclusion: The resuscitation room was utilized appropriately only for 60.7% of
all cases. The rate of appropriate utilization showed negative association with
crowding state of the ED.
274
Multi-Center Study of Left Without Treatment
Rates From Emergency Departments Serving a
Large Metropolitan Region
Lev R, Castillo EM, Vilke GM, Chan TC/Scripps Mercy Hospital, San Diego, CA;
University of California, San Diego, San Diego, CA
Study Objectives: Emergency department (ED) crowding is a growing problem
that threatens the safety net function of EDs nationwide. ED patients who leave
without treatment (LWOT, without being seen by a physician or against medical
advice) may represent a significant problem of the health care safety net of a
community. The objective of this study was to investigate the association between ED
S86 Annals of Emergency Medicine
crowding and throughput on LWOT rates in EDs serving a large metropolitan
region.
Methods: Design: Multi-center observational study as part of a county-wide ED
crowding initiative and annual summit. Setting: All 19 EDs serving a large
metropolitan area of 2.7 million people. Participants: All patients seen in the 19 EDs
during a 1-year period (July 1, 2007-June 30, 2008). Data was collected from each
ED on patient volume, ED beds, LOS for admitted and discharged patients, payor
mix, admission and psychiatric patient hold rates, specialty service availability, and
LWOT rates. EDs were stratified by size and capacity as either small (⬍20 beds) or
large (⬎20 beds). Differences in means, standard deviations (SD), parameter
estimates and associated 95% confidence intervals [CI] are reported. The association
between LWOT and LOS was assessed using unadjusted linear regression.
Differences in LWOT and LOS measures by ED size were compared using t-tests.
Data analysis was conducted using a statistical software program (SPSS 16).
Results: During the one-year study period, there were 893,000 ED patient visits
for the region cumulatively at the 19 EDs, which varied in size from 8 to 89 beds.
Mean annual census for each ED varied from 10,944 to 100,764 visits and monthly
patient volume/bed varied from 94 to 344 patients/bed. The mean LOS was 6.0
hours (SD⫽1.8) for admitted patients and 3.3 hours (SD⫽0.8) for discharged
patients. The mean LWOT rate was 3.2% (SD⫽2.0) with a range of 1 to 8%. Ten
EDs had ⬎20 beds (52.6%) and nine ⬍20 beds (47.4%). Small EDs had
significantly lower LWOT rates and means LOSs (LWOT difference⫽2.6%,
CI⫽1.1, 4.1, p⫽0.002; LOS admit difference ⫽1.6 hours, CI⫽0.02, 3.1, p⫽0.048;
and LOS for discharged patients difference ⫽1.0 hours, CI⫽0.4, 1.6, p⫽0.002). The
relationship between LOS discharged patients and LWOT in an unadjusted linear
regression model was ␤: 2.07 (95% CI: 1.33, 2.81). There was an increase of 1% in
the LWOT rate for each 2.1 hour increase in LOS for discharged patients.
Conclusion: In a regional study of all EDs serving a large metropolitan area,
LWOT rate was associated with ED size and LOS, with a progressive increase in
LWOT rate with longer ED LOS for discharged patients.
275
A Classification System for Emergency
Departments: Massachusetts, 2008
Camargo Jr CA, Ginde AA, Handel DA, Keadey MT, Raja AS, Rogers J,
Sullivan AF, Espinola JA/Massachusetts General Hospital, Boston, MA;
University of Colorado Denver School of Medicine, Aurora, CO; Oregon Health &
Science University Hospital, Portland, OR; Emory University Hospital, Atlanta,
GA; Brigham & Women’s Hospital, Boston, MA; Monroe County Hospital,
Forsyth, GA
Study Objectives: A standard national approach to the classification of emergency
departments (EDs) is “essential for the optimal allocation of resources and provision
of critical information to an informed public” (2006 Institute of Medicine report on
the “Future of Emergency Care”). To inform future nation-wide efforts, we applied a
capabilities-based classification to Massachusetts (MA) EDs.
Methods: We mailed a survey to all ED directors in MA, excluding federal
hospitals; 85% (n⫽63) responded. Questions were designed to classify EDs into 5
tiers: Level 1 EDs offer continuous (24/7) on-site physician coverage and consults in
medicine, surgery, orthopedics, obstetrics/gynecology, pediatrics, and anesthesia in
⬍30 minutes with specialty consults (cardiology, neurosurgery, and neurology) in ⬍1
hour; Level 2 EDs have a physician on-site 24/7 and consults in ⬍1 hour; Level 3
EDs have a physician on-site 24/7 and consults are not available in ⬍1 hour; Level 4
EDs are open 24/7 with a physician available to the ED from within hospital and
variable consult availability; and Level 5 EDs are open 24/7 with a physician available
to the ED from outside the hospital. Data analyses used chi square, Fisher’s exact, and
Kruskal-Wallis tests.
Results: In 2008, 11% of MA EDs were Level 1, 33% Level 2, 56% Level 3, and 0%
were Level 4 or 5. Level 1, 2 and 3 EDs differed in median annual visits (52k [IQR 4786k], 54k [IQR 42-67k], 28k [IQR 20-46k], respectively; p⫽⬍0.001) and other factors:
staffing (e.g., median # of full-time ED attendings: 20 (IQR 12-35), 16 (IQR 12-20), 10
(IQR 7-14); p⬍0.001), resources (eg, presence of a dedicated CT scanner in 86, 38, 9%;
p⬍0.001), and acuity (eg, admission rates: 25% (IQR 23-33%), 19% (IQR 15-20%),
15% (IQR 11-18%); p⬍0.001). Crowding was a concern at all levels, with most ED
directors stating that they were either “at” or “over” capacity (100, 95, 81%; p⫽0.30) and
provided care for patients in the hallway (100, 86, 54%; p⫽0.08). Nevertheless, EDs
differed by report of “boarding” patients for ⬎2 hours while waiting for inpatient beds to
become available (100, 100, 74%; p⫽0.02).
Conclusion: By investigating the basic characteristics of MA EDs, we were able to
classify EDs. The levels identify potential gaps in available services but also highlight
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the challenges shared by MA EDs. Data from other states would provide important
state comparisons. This project provides a framework for developing a future nationwide ED classification system.
276
Nurse-Operated Ultrasound for Difficult Intravenous
Access: A Randomized Trial
River G, Hebig A, McAlpine I, Stein J/UCSF School of Medicine, San Francisco,
CA; Stanford University, Palo Alto, CA
Study Objectives: We sought to compare ultrasonographically versus nonultrasonographically guided peripheral intravenous access performed by emergency
nurses on emergency department patients with difficult intravenous access.
Methods: We conducted a prospective, randomized control trial at an academic,
tertiary care hospital. Nurses were trained in ultrasound guidance for peripheral
intravenous access, and were allowed to practice using ultrasound for several months
before commencing the study. Patients with difficult intravenous access, defined as
those who had two prior unsuccessful cannulation attempts by nursing staff, were
randomized to 2 groups: (1) intravenous access obtained through an
ultrasonographically guided technique or (2) intravenous access obtained through
non-ultrasonographically guided methods. Outcomes measured included success rate,
total number of cannulation attempts, time to successful intravenous access, and both
patient and nurse satisfactions on a Likert scale. Groups were compared using
Wilcoxon rank-sum test for non-normal data.
Results: During the study period, 47 patients were randomized in the trial: 26 to
the ultrasound group and 21 to the control group. The ultrasound group had 87%
cannulation success while the control group had 72% success (difference of 15%,
Chi2 P⫽0.237.) In the ultrasound and control groups, respectively, an average of 1.5
and 2.0 further intravenous attempts were required before successful cannulation
(mean difference of 0.5 attempts, 95% CI -.07-1.03, P⫽0.09.) Average time to
cannulation in the ultrasound group was 26 minutes compared to 22 minutes in the
control group (mean difference 4 minutes, 95% CI-7.43-14.9, P⫽0.50). Patients in
the ultrasound group had average Likert satisfaction score of 4.2 compared with 3.4
for the control group (average increase of 0.8 in the ultrasound group, 95% CI -.371.8, P⫽0.184) while nurses in the ultrasound group recorded an average satisfaction
of 4.5 compared to 2.7 in the control group (average difference of 1.8, 95% CI .922.55, P⫽0.0001).
Conclusion: This small study was not able to demonstrate that nursing
ultrasound leads to improvement in success rate or number of attempts required to
place intravenous lines in patients with difficult intravenous access. It is possible that
with a larger study, the difference in success would become clinically significant. It is
unlikely, however, that a larger study would produce a relevant improvement in the
number of cannulation attempts or time to cannulation based on the confidence
intervals of our study.
277
Teaching Focused Obstetric Ultrasound to
Midwives in Rural Zambia
Kimberly H, Murray A, Mennicke M, Ngoma B, Chisanga C, Ngoma E,
Tyer-Viola L, Ahn R, Liteplo A, Burke T, Noble VE/Massachusetts General
Hospital, Boston, MA; Royal Infirmary Edinburgh, Edinburgh, United Kingdom;
Brigham and Women’s Hospital, Boston, MA; Kapiri-Mposhi District Hospital,
Kapiri, Zambia; Nkole Rural Health Center, Nkole, Zambia
Study Objectives: There is increasing interest in using point-of-care ultrasound in
developing countries with limited access to imaging diagnostics. We developed a
focused obstetric ultrasound training program for midwives in a rural health district
in Zambia. Our objectives were to assess the ability of midwives to learn basic
obstetric ultrasound and to evaluate whether the use of ultrasound changed the
clinical management of patients.
Methods: Twenty-one nurse midwives from 3 rural sites in the Central District of
Zambia underwent focused obstetric ultrasound training. The training was carried
out by three emergency ultrasound-trained physicians over a 6-month period from
October 2008 to March 2009. The initial instruction involved 2 hours of interactive
teaching and 3 weeks of supervised hands-on scanning. This was followed up at 2 and
6 months with 2- and 3-week periods of evaluation and hands-on scanning. Midwives
were trained to identify the following fetal pulse rate (FHR), fetal presentation,
placental location, number of gestations and gestational age. All scans and data sheets
were reviewed by the study physicians. Midwives were evaluated for their ability to
operate the machine, and to acquire and interpret images.
Results: Four hundred forty-one scans were performed by 21 midwives over a
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6-month period. The mean number of scans per midwife was 21 (range 1 - 170). The
majority of scans were performed in the second and third trimester and 182 (41%)
were supervised by the study physicians. Some of the findings included non-vertex
presentation 76 (17%), multiple gestations 30 (7%), no FHR 10 (2%) and low lying
placenta 3 (⬍1%). In 73 of the 441 scans (16.5%) the ultrasound findings prompted
a change in patient management. These changes included repeat ultrasound 26
(36%), increased antenatal visits 17 (23%), referral to provincial hospital 13 (18%),
advised delivery in clinic 5 (7%), and other 12 (16%). To measure ultrasound ability
and skill retention, 7 of the midwives were evaluated with a 14-question observed
structured clinical exam (OSCE) 2 months after their initial training and then again
at 6 months. Under direct observation, they were assessed in their abilities to operate
the machine and to acquire and identify basic obstetric ultrasound findings as detailed
above. The OSCE demonstrated an overall improvement in the midwives’ scanning
abilities over the time studied with mean scores at 2 and 6 months of 9.7 (69%) and
11.6 (83%) respectively.
Conclusion: Midwives in rural Zambia can be trained to use a portable
ultrasound machine to perform basic obstetric ultrasound including identifying
multiple gestations, calculating fetal pulse rate and identifying fetal presentation. The
skills learned improved over the 6-month study period. Introduction of ultrasound
machines caused a change in clinical management in 16.5% of the patients scanned
by the midwives. More data is necessary to assess the sustainability of the skills
learned and to determine whether the introduction of ultrasound can ultimately
improve obstetric care in rural Zambia.
278
Comparative Extravasation Rates of 1.75-Inch and
2.5-Inch Ultrasound-Guided Peripheral Vascular
Catheters
Bauman MJ, Nomura JT, Schofer JM, Resurreccion D, Toulson K, Reed III J,
Sierzenski P/Christiana Care Health System, Newark, DE
Study Objectives: We compared the extravasation rates of 1.75-inch (4.5cm) and
2.5-inch (6.4 cm) intravenous catheters (IVs) used for ultrasound (US)-guided
peripheral venous access. We also calculated the minimum length of catheter required
in the vein to minimize extravasation.
Methods: Twenty-two subjects were randomized to receive a 1.75-inch or 2.5inch 18-gauge IV for US-guided peripheral vascular access in the emergency
department (ED). The IVs were assessed for extravasation hourly for 4 hours and
then every 4 hours for up to 12 hours or until the subject left the ED. Subjects
admitted to the hospital had a 24- and 48-hour chart review for a new IV start as an
indication of initial IV failure. The distance from skin surface to the edge of target
vein was also recorded. Assuming a 45o angle of the needle track to the skin, the
length of catheter in the vein was calculated. Data are presented with standard
deviation and were analyzed using Student’s t-test and Pearson’s chi-square.
Results: The 1.75-inch IVs extravasated at a significantly higher rate than the
2.5-inch IVs, 50% (6/12) versus 10% (1/10), p ⫽ 0.045. The mean depth of the
target vein was not significantly different for 1.75-inch and 2.5-inch IVs, 0.94 cm
(⫹/- 0.42 cm) vs. 0.98 cm (⫹/- 0.52 cm) respectively, p ⫽ 0.839. The mean length
of catheter in the vein was significantly shorter for 1.75-inch catheters than for 2.5inch catheters, 3.2 cm (⫹/- 0.6 cm) versus 5.0 cm (⫹/- 0.7cm), p⫽ 0.001. The mean
length of catheter in the vessel was also significantly shorter in the extravasated group
than the not extravasated group, 3.15 cm (⫾0.95) vs. 4.38 cm (⫾ 0.98), p⫽0.012.
The 1.75-inch IVs that extravasated trended towards a shorter amount of catheter in
the vessel than those that did not extravasate, 2.9 cm (⫹/- 0.6 cm) versus 3.5 cm (⫹/0.4 cm), p⫽ 0.053. The mean time to extravasation for the 1.75-inch IVs was 2.0
hours (⫹/- 1.1 hours). The one extravasation on the 2.5-inch catheter group occurred
at 36.3 hours.
Conclusion: 1.75-inch IVs extravasate more often than 2.5-inch IVs when used
for US-guided peripheral venous access. A length of catheter in the vessel of greater
than 3.5 cm is recommended for US-guided peripheral venous access.
279
Optic Nerve Sheath Ultrasound for the Evaluation
of Children With Suspected Ventriculo-Peritoneal
Shunt Failure
Hall MK, Sabbaj A, Spiro D, Meckler GD/Oregon Health & Science University,
Portland, OR
Background: Ventriculo-peritoneal shunts (VPS) are the most common
neurosurgical procedure in children. Up to 80% of VPS fail in the first 10 years.
Annals of Emergency Medicine S87
Research Forum Abstracts
Symptoms and signs of VPS failure are non-specific and insensitive, and current
standard of care includes radiologic neuro-imaging (NI) such as CT, MRI and plain
films. NI is expensive, time consuming, and exposes children to ionizing radiation.
Moreover, NI remains insensitive in up to 1/3 of shunt failures. Recently, optic nerve
sheath diameter (ONSD) has been proposed as a safe and efficient surrogate for
elevated intracranial pressure (ICP) and may be a useful screening tool in children
with suspected VPS failure.
Study Objectives: 1. Determine the utility of ONSD in predicting clinical VPS
failure. 2. Determine the feasibility of ONSD in the emergency department (ED).
Methods: Prospective, single blinded observational study of children 6 months to
18 years presenting to an urban tertiary children’s ED with suspected VPS failure.
The primary outcome measure was surgical shunt revision. The experimental variable
was mean ONSD in mm, measured 3mm posterior to the optic disc. Additional
variables included demographics, past medical history, symptoms, signs, and standard
imaging results as well as parental prediction of shunt failure.
Results: ONSD was completed in 36 patients, of whom 16 had VPS failure. The
mean age was 10 years (range 6 months to 18 years), and 46% were male. Using agebased upper limits for ONSD of 40 mm for infants ⬍ 1 and 45mm for older
children, the sensitivity of ONSD was 61% and the specificity was 17%. Traditional
NI, and clinical symptoms and signs were equally unreliable (see table 1). Parental
prediction of shunt failure had a sensitivity of 100% and a specificity of 21%.
Conclusion: Though feasible in the ED, ONSD is neither sensitive nor specific as
a screening tool for suspect VPS failure in children.
Table 1: Traditional Neuro-imaging in VPS Failure
280
Comparison of Web- Versus Classroom-Based Basic
Ultrasound and Extended Focused Assessment
With Sonography for Trauma Training in Two
European Hospitals
Platz E, Goldflam K, Mennicke M, Parisini E, Christ M, Hohenstein C/Brigham
and Women’s Hospital, Boston, MA; Harvard School of Public Health, Boston,
MA; Klinikum Nuremberg, Nuremberg, Germany; Klinikum Kempten Oberallgäu,
Kempten, Germany
Study Objectives: Training practicing physicians in new skills presents a major
challenge both in the United States and in countries where emergency medicine is an
emerging specialty. Because classroom-based training is associated with higher costs
and less flexibility we sought to evaluate whether it is superior to blended learning, in
the format of Web-based lectures combined with a hands-on workshop, and whether
it results in better knowledge retention of basic ultrasound techniques and the EFAST
(Extended Focused Assessment with Sonography for Trauma).
Methods: Physicians from various specialties practicing in two German
emergency departments were enrolled and randomized into two didactic groups. The
classroom group attended traditional lectures, while the Web group watched narrated
lectures online. Identical slides were used for both groups. All participants completed
the same Web-based 29-item multiple choice test before and after their didactic
sessions, as well as a second post-test eight weeks after the practical training. After
completion of the first post-test, both groups participated in hands-on EFAST
training. A control group of physicians also completed the pre-test and first post-test
without receiving any didactic intervention or practical training. Given the
longitudinal nature of the data and the balanced study design, an analysis of the
response profiles in the two study groups was carried out to assess the significance of
differences in mean score patterns.
Results: Fifty-five subjects participated in the study. 63.6% subjects were male,
S88 Annals of Emergency Medicine
79.6% were resident physicians and 9.3% had no prior ultrasound training. Both the
classroom (n⫽19) and Web group (n⫽23) showed significant improvement in scores
between the pre- and post-test 1 (75.9% vs. 93.9% and 77.8% vs. 92.5%, p ⬍
0.001), as well as similar retention of knowledge after eight weeks in the post-test 2
(88.6% and 88.9%, p ⫽ 0.72). There was no statistically significant difference in
mean score profile between the two groups, suggesting comparable efficacy of the
Web-based lectures as an educational method (p⫽0.572). The control group (n⫽13)
did not show any significant change in test scores for pre- and post-test 1 (83.3% and
82.8%, p ⫽ 0.88), indicating that there was no learning effect without intervention.
There was no difference between the Web and classroom group in access to
ultrasound machines or number of patients scanned by the participants after
completion of the course. Both groups rated their enjoyment of the course, their
perception of its effectiveness and their comfort with ultrasound use after the didactic
training similarly.
Conclusion: Blended learning provides the opportunity to teach practicing
physicians through a combination of Web-based lectures and practical workshops,
potentially allowing for lower cost and greater flexibility than with classroom
instruction. Our data suggest that Web-based didactic training of basic ultrasound
techniques and the EFAST is comparable to traditional classroom lectures and results
in similar knowledge retention.
281
Impact of Image Processing on the Pleural Sliding
Sign
Holm M, Reardon R, Caroon L/Hennepin County Medical Center, Minneapolis,
MN
Study Objective: Sonographic identification of pleural sliding is a quick and
simple means to rule out pneumothorax in any critically ill patient. Ultrasound is
much more sensitive than physical exam or chest radiography for detecting
pneumothorax. Evaluation for pneumothorax is now a routine part of the FAST
(Focused Assessment with Sonography for Trauma) exam. We noticed that it is often
easier to identify pleural sliding using older ultrasound equipment. Modern
ultrasound machines use several image processing features to improve image quality,
and all of these features are typically activated during a FAST exam. We evaluated the
combined effect of tissue harmonics, SonoMB (spatial compounding) and SonoHD
processing on the identification of pleural sliding.
Methods: This was a prospective study in which twenty-five physicians (residents
and faculty) were asked to evaluate for pleural sliding in a healthy 70 Kg male.
Physicians had variable ultrasound experience but all had some experience using the
pleural sliding sign in a clinical setting. Using a SonoSite M-Turbo with a C60x 5-2
MHz curved array transducer (SonoSite, Inc. Bothel, WA) each physician scanned
the right side of the volunteer’s chest in the 3rd to 4th intercostal space in the midclavicular line. Each physician was asked to look for pleural sliding with the image
processing features in two different configurations. First, with tissue harmonics,
SonoMB and SonoHD activated, then with all three of these features deactivated.
Physicians were then asked if it was easier to see pleural sliding with all of these
features on or off, or if it made no difference. Physicians were not blinded to the
configuration of the machines.
Results: 23/25 physicians (92%) thought it was easier to see pleural sliding with
all image processing features deactivated, 1/25 thought it was easier to see pleural
sliding with all image processing features activated and 1/25 saw no difference (p⬍
0.001).
Conclusion: Some processing features that improve abdominal and cardiac
imaging make it more difficult to recognize pleural sliding. To our knowledge, this is
the first study of the impact of image processing on the pleural sliding sign. More
research is needed to determine optimum image processing configurations for each
part of the FAST exam.
282
Correlation of Bedside Ultrasound Measurement of
the Respiratory Variation of Internal Jugular
Venous Diameter With Invasive Central Venous
Pressure Measurement in Patients With Severe
Sepsis
Bigler JB, Berkeley RP, Puchala G/University of Nevada School of Medicine, Las
Vegas, NV; University of Nevada, Las Vegas, NV
Background: Identifying patients with severe sepsis and initiating prompt
resuscitation via early goal-directed therapy (EGDT) guidelines continues to be a
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Research Forum Abstracts
challenge in many emergency departments (EDs). This study evaluated the
collapsibility or distensibility of the internal jugular (IJ) vein and its correlation with
central venous pressure (CVP), a key end-point of resuscitation in EGDT. The study
hypothesis was that bedside ultrasound can be utilized to identify volume underresuscitated patients, with CVP ⬍8 as per EGDT guidelines, prior to the initiation of
invasive CVP monitoring.
Study Objective: To evaluate the correlation of the respiratory variability of
internal jugular venous diameter, measured by bedside ultrasound, compared with
invasively measured central venous pressure.
Methods: This was an institutional review board-approved prospective clinical
study, utilizing convenience sampling, of adult patients (age ⱖ18 years) who
presented to an academic, urban ED with 70,000 patient visits per year. Inclusion
criteria consisted of ED patients with ⱖ2 systematic inflammatory response
syndrome criteria and a suspected or identified source of infection, who required
central venous access for resuscitation and CVP monitoring per a standardized
institutional EGDT management protocol for severe sepsis. Bedside ultrasound was
utilized to measure the maximal internal height and width of the IJ vein, followed by
the minimal height and width with respiratory variation, at the time of central venous
catheter insertion; measurements were repeated ⱖ45 minutes later. Patients were
supine while ultrasound was performed by emergency medicine residents and/or
attendings. Images were paused and measured, followed by printing of hard copies for
data analysis. All physicians involved in the study had previously received training in
the method of IJ measurement by the lead investigator. Clinical variables recorded
included the corresponding vital signs at the time of each IJ measurement, CVP and
ScvO2 immediately following measurement, the concomitant use of vasopressors
and/or sedatives, volume of crystalloid infused prior to each measurement, and
comorbidities. Formulae utilized for calculation of the IJ collapsibility or distensibility
were:
Collapsibility Index ⫽ [((Max Height ⫹ Max Width)/2) - ((Min Height ⫹ Min
Width)/2)] / ((Max Height ⫹ Max Width)/2).
Distensibility Index ⫽ [((Max Height ⫹ Max Width)/2) - ((Min Height ⫹ Min
Width)/2)] / ((Min Height ⫹ Min Width)/2).
Results: We enrolled 17 patients; 2 were excluded due to incomplete data. The
mean (⫾SEM) age was 48 (4.4) years, and 11/15 (73%) were male. 50% had
significant comorbidities. Initial mean (⫾SEM) lactate was 2.9 (0.59) mmol/L. Initial
median (95% CI) CVP was 10.2 (8.65,11.8) mmHg and initial median collapsibility/
distensibility index was 0.068 (⫾SEM ⫽ 0.124); range ⫽ (0.01-3.0). Primary
measure: The Pearson correlation coefficient (95% CI) was ⫺0.306 (0.061,-0.593),
r-squared ⫽ 0.094. Limitations: Small study size, convenience sampling, inter-rater
reliability was not measured.
Conclusion: There is a fair to moderate correlation between
IJ collapsibility/distensibility index and measured CVP. If this relationship is
validated with a larger prospective study, this may have the potential to positively
impact severe sepsis management via non-invasive identification of low CVP.
283
Utility of Bedside Biliary Ultrasound in the
Evaluation of Emergency Department Patients With
Isolated Epigastric Pain
Adhikari S, Morrison D, Zeger W, Chandwani D, Krueger A/University of
Nebraska Medical Center, Omaha, NE; Detroit Medical Center, Detroit, MI; Loma
Linda University Medical Center, Loma Linda, CA
Study Objectives: A biliary ultrasound is not routinely performed on patients
presenting with isolated epigastric pain to emergency department (ED). Some of
these patients are initially misdiagnosed with gastritis, gastroesophageal reflux disease
and peptic ulcer disease only to return later to be diagnosed with cholelithiasis or
cholecystitis after a more complete evaluation. The objective of this study is to
determine the utility of bedside biliary ultrasound (US) in the evaluation of ED
patients presenting with isolated epigastric pain.
Methods: This is an institutional review board-approved prospective
observational study of adult patients presenting to two academic EDs with isolated
epigastric pain. Patients with history of gallstones, cholecystectomy, gastrointestinal
bleeding and chronic abdominal pain were excluded. Patients were enrolled if an
emergency physician other than the study investigator determined that patient had
isolated epigastric pain and tenderness. emergency physician investigators who were
not involved in the clinical care of these patients performed bedside biliary US using
either a GE Logiq or Philips Envisor system with a 5-2 MHz curvilinear probe. The
US images obtained in ED were subsequently reviewed by another sonologist who is
blinded to the study hypothesis, ED US interpretations and other clinical
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information. History, physical examination findings, laboratory results, additional
diagnostic tests, and disposition data were obtained from the treating emergency
physician and ED chart. Descriptive statistics are used to analyze the data.
Continuous data are presented as means with standard deviations and dichotomous
data are presented as percent frequency of occurrence with 95% confidence intervals.
Results: A total of 33 patients (female-25, male-8) were enrolled. The mean age
of the patients was 36 years ⫹/- 14.9 (SD). 15/33 (45% CI 28-62%) reported similar
symptoms in the past. 22/33 (67% CI 50-82%) had associated vomiting. All subjects
had isolated epigastric tenderness. Gallstones were found in 9/33 (27% CI 12-42%)
on bedside US. Three of these patients had sonographic signs of chloecystitis. All 9
patients had normal liver function tests and only 2 had leucocytosis. The treating
emergency physician’s initial evaluation didn’t include an US in 6/9 (67% CI 3697%) patients with cholelithiasis on bedside US. Three of these 6 patients were
hospitalized. All 9 patients were initially given GI cocktail by the treating emergency
physician. There is 100% agreement between emergency physician investigator and
blinded sonologist US interpretations.
Conclusion: Bedside biliary ultrasound detected gallstones in almost one-third of
our ED patients with isolated epigastric pain. It can avoid misdiagnosis and expedite
management in these patients.
284
Intra-Articular Foreign Body Evaluation: Ultrasound
versus Fluoroscopy
Illston B, Lyon M, Caudell MJ, DiCarlo J/Medical College of Georgia, Augusta,
GA
Study Objectives: In out-of-hospital settings, evaluating for soft tissue foreign
bodies can be challenging with management options consisting of delayed removal or
local surgical exploration. However, when an intra-articular foreign body (FB) is
suspected, transfer to a hospital setting is often required for radiographic evaluation.
Ultrasound (US) evaluation may allow for determination if joint involvement is
present, possibly eliminating or delaying transfer. Our objective is to evaluate the
effectiveness of bedside US in accurately determining the absence of an intra-articular
FB in comparison to fluoroscopy and computerized tomography (CT).
Methods: This was a prospective blinded study to determine the utility of US and
fluoroscopy to detect intra-articular FB. The largest joint in a skin-on chicken quarter
(thigh-leg) was the target for the FB insertion. A single spine from a freshly harvested
Uni sea urchin was introduced through the skin of the chicken, directed towards the
joint. The spines were very fragile, and introduction caused the spine to break leaving
no evidence of the location of insertion. As a result, the investigator was unable to
determine the final position of the spinous tip. Each chicken quarter was evaluated
for the presence of an intra-articular foreign body by 3 methods: bedside US,
fluoroscopy, and CT. A separate investigator performed each modality and was
blinded to the other’s results. US evaluation was performed by an emergency
physician with hospital credentials for emergency US using a SonoSite MicroMaxx
US machine with a linear probe. Fluoroscopy was performed by a second emergency
physician using a GE series 9600 fluoroscopy system. There was no time limit for the
evaluation of the chicken quarter by either fluoroscopy or US. Using a GE Lightspeed
VCT2 scanner, 0.625 mm slices (joint protocol) were acquired to evaluate the
location of the foreign body. If the FB violated the joint capsule, then the interpreting
radiologist classified the FB as intra-articular. Descriptive statistics were used to report
the accuracy of each modality for the detection of intra-articular foreign body. All
values are reported with a 95% confidence interval.
Results: Six of the 10 trials resulted in the spine penetrating the joint capsule.
Ultrasound detected 9 of the 10 foreign bodies. There was one false positive result for
joint penetration yielding a sensitivity, specificity and negative predictive value for
detecting the intra-articular foreign body of 100% (72.6, 100%), 75.0% (40.7,
75.0%), 100% (54.3, 100%) respectively. Fluoroscopy detected all 10 foreign bodies,
but had one false positive result for joint penetration yielding a sensitivity, specificity
and positive predictive value of 100% (76.8, 100%), 75.0% (40.1, 75.0%), 100%
(53.5, 100%) respectively. The false positive result of both US and fluoroscopy
occurred with the same foreign body.
Conclusion: CT remains the gold standard for FB joint penetration. However,
US may prove to be a valuable tool in identifying out-of-hospital joint penetration,
thereby reducing unnecessary delay in treatment or hospital transfer.
Annals of Emergency Medicine S89
Research Forum Abstracts
285
The Significance of Peripheral White Blood Cell
Count in Cases of Acute Otitis Media in Children
Between 2 to 17 Years of Age
Nibhanipudi Sr KV, Hassan Jr G/NY Medical College Metropolitan Hospital
Center, New York, NY
Background: AOM is a common clinical condition frequently encountered in
pediatric emergency department. Watchful waiting has been advocated in recent years
for the treatment of uncomplicated AOM in children less than 2 years. In our study
we like to evaluate WBC count as an objective parameter to make the decision of
treating AOM with antibiotics.
Study Objective: To determine whether peripheral white blood cell count (WBC
count) may help/aids making treatment decisions in children with uncomplicated
acute otitis media (AOM).
Methods and Materials: Children with a clinical diagnosis of AOM between the
ages of 2 and 17 years of age were included in the study after obtaining the informed
consent from their parents and also signed assent form from children ⬎6 years of age.
All patients were subjected to a venepuncture and a complete blood count (CBC)
with differential was performed. Pain was assessed using Pain Analog Scale as
developed by the New York City Health and Hospitals Corporation. Patients with a
WBC count ⬎15,000 were given amoxicillin. Patients with WBC counts ⬍15,000
were not given any antibiotics but were given analgesic ear drops. Patients in both
groups were given either acetaminophen or ibuprofen for pain relief/or fever
reduction in the appropriate dosages. The parents were instructed for a follow-up
appointment on 3rd day and were reevaluated both clinically and also for pain using
the same pain analog scale. Children who did not receive antibiotics initially and still
have otalgia using the pain analog scale antibiotics were prescribed and those already
receiving antibiotics were considered for change of antibiotic regimen. Pain relief is
the primary parameter of the study.
Results: A total of 100 patients were enrolled in the study. Seven patients with
WBC counts ⬎15,000 were given antibiotics. Six out of 7, the pain resolved
completely. (0 pain score on day 3). One out of the 7 patients (14%) treated with
antibiotics had a score of 8 on day 1 and pain remained at 4 on day 3. His antibiotics
was changed to augmentin. 93 out of 100 patients had WBC counts ⬍15,000, and
were not given antibiotics initially. Ninety out of 93 patients had significant
improvement in pain severity which came down to 0 on day 3. Three patients out of
93 (3.2%) did not have significant pain relief on day 3. All these 3 patients were given
amoxacillin. Comparison of the proportions between the groups was analyzed using
Fishers Exact test.
Conclusions: The outcome of our study with an objective parameter (WBC
count) could help physicians to treat AOM appropriately by avoiding the unnecessary
use of antibiotics without causing significant complication from the disease. This
could also reduce the adverse effects of antibiotics as well as the increasing bacterial
resistance to common antibiotics.
Table 1
Table 2
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286
Evaluation of Emergency Medicine Discharge
Instructions in Pediatric Head Injury
Sarsfield MJ, Callahan JM, Grant WD, Morley EJ/SUNY Upstate Medical
University, Syracuse, NY; Children’s Hospital of Philadelphia, Philadelphia, PA
Study Objectives: Pediatric head injury is a common occurrence. There is
mounting evidence that patients require removal from sports and play to help speed
recovery and limit the morbidity from their initial injury. The objective of this study
was to determine how often discharge instructions given to children who had
sustained head injuries included information regarding activity restrictions, activity
time constraints, and specifics of follow-up care.
Methods: A retrospective chart review of patients aged 2-18 years evaluated and
treated for head injury during a 4-month period at a tertiary care center, level 1
trauma center which sees approximately 14,000 pediatric patients per year. Included
were those children seen, evaluated, and diagnosed with any of the following: mild
head injury, concussion, minor head trauma, or mild traumatic brain injury. Subjects
were excluded if there was a positive acute CT finding (other than findings of a
simple linear skull fracture) related to the head injury or if the subject required
admission. Data was collected using a structured data extraction form. Percentages
were compared for significance using Chi-Square. The study was approved by the
institutional review board and HIPAA offices.
Results: A total of 204 patients met eligibility. Among these patients 95.1%
received instruction to follow-up with a physician, 82.8% received anticipatory
guidance regarding expected symptoms, 15.2% received specific restriction time from
sports, and 21.5% were removed from sports.
One-hundred and thirteen (113) patients were determined to have sustained a
concussion from the chart review. Patients with sports-related concussion were
significantly more likely to receive discharge with return-to-sports restrictions (chi
square ⫽ 11.225, p ⬍0.008) and instructions to remove the child from play (Chi
square ⫽ 9.781, p ⬍ 0.004) than patients with motor vehicle crash or other types
mechanisms of injury.
Conclusion: Children sustaining head injury were inadequately instructed to
restrict athletic activities upon discharge. This is particularly true for patients who
sustain a concussion from non-sports-related activity.
287
Does Insurance Status Make a Difference in
Pediatric Trauma Patients?
Irvin CB, Hakmeh W, Fox JM/St. John Hospital and Medical Center, Detroit, MI
Background: A recent study in Archives of Surgery found that uninsured trauma
patients had a higher mortality. One limitation of this study is that uninsured
patients may also have chronic health problems, and may generally be in poorer
health, predisposing them to worse outcomes after trauma.
Children tend to be healthier with less chronic health problems when compared
to adults. This study sought to determine if the trend of increased mortality in
uninsured patients was also true in the pediatric population.
Study Objective: To compare the outcome of Insured an Uninsured pediatric
trauma patients.
Methods: Using the National Trauma Data Bank (v6.2), the following variables
were extracted: Age (age 1-18), Payment type, First Systolic Blood pressure,
emergency department Glasgow Coma Score, ED disposition, Injury Severity Score
(ISS), Length of Stay (LOS), ICU days, and discharge status. Insurance was divided
into BlueCross-BlueShield (BCBS), Uninsured (self pay, charity), or Other
(Medicaid, HMO, Medicare, government, Auto Insurance, etc).
Results: Of the 156,848 patients in the study, 13% were uninsured, 6% were
BCBS, and 66% had Other insurance. Uninsured had a higher mortality overall
(2.8% compared to BCBS at 1.3% or Other at 1.4%, p⬍.001). Additionally, when a
sicker subset of patients was evaluated (GCS 3-13), the mortality rate for uninsured
was 21.4% (542/2537) compared to BCBS at 10.9% (120/1101) and Other at
11.9% (1407/11812), p⬍.001. For patients with GCS 3-13, the ISS scores were
lower in the uninsured group (20.2) compared to BCBS (22.1), p⬍.001. In the
population of GCS 3-13, Uninsured had shorter LOS (6.4 days) compared to BCBS
(9.9 days) and Other (9.0 days), p⬍.001. In the GCS 3-13, Uninsured also had less
ICU days (3.9 days) compared to BCBS (5.5 days) and Other (5.5 days), p⬍001.
The statistical trend of lower ISS with higher mortality and lower LOS and ICU days
for Uninsured compared to BCBS or Other persisted in the total group (all GCS
scores) and also in the GCS scores of 14-15.
Conclusion: Mortality disparity exists for uninsured pediatric trauma patients.
Although Uninsured pediatric patients have lower ISS scores, they have higher
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Research Forum Abstracts
mortality, shorter LOS, and less ICU care. Although the exact reasons for this
disparity are unclear, efforts to provide health insurance for all children may be one
means to address this disparity.
288
A Rise in Emergency Department Visits of
Pediatric Patients for Renal Colic From 1999-2008
Kairam N, Allegra JR, Eskin B/Morristown Memorial Hospital, Morristown, NJ
Study Objective: Renal colic is predominantly a disease of adults with only
occasional cases occurring in the pediatric population. A recent report from a single
hospital showed a rise in the number of children with renal colic. Our objective was
to confirm this in a large multihospital database of emergency department (ED) visits.
Methods: Design: Retrospective cohort. Setting: Consecutive pediatric patients
(age less than 18 years) with the ICD-9 diagnosis of “renal colic, calculus kidney,
calculus ureter, urinary calculus, or uretheral calculus” seen by emergency physicians
in 29 urban, suburban and rural EDs in New Jersey and New York between 1/1/1999
and 12/31/2008. We analyzed the number of renal colic visits as a percent of total
ED pediatric visits in yearly intervals using the Student t test and performed a
regression analysis. Alpha was set at 0.05.
Results: The database contained 6,497,458 total ED visits of which 1,312,487
(20%) were pediatric visits. Of these, 1028 (0.078%) were for renal colic. The
median age was 16 years (inter quartile range: 13 years - 17 years) and 61% were
female. The percentage of ED pediatric visits for renal colic increased from 0.050%
in 1999 to 0.089% in 2008, an increase of 78% (95% CI: 31% to 224%, p ⬍0.003).
The correlation coefficient for this upward trend was R2 ⫽ 0.63 (p⬍0.007).
Conclusion: We found a marked increase in ED pediatric visits for renal colic
over the past decade. This may reflect a real increase in the incidence of renal colic in
the pediatric population or an increased use of imaging modalities for abdominal and
flank pain.
289
Ultrasound Assessment of Dehydration in Children
With Gastroenteritis
Levine AC, Shah S, Noble VE, Epino H/Brigham and Women’s Hospital, Boston,
MA; Alameda County Medical Center, Oakland, CA; Massachusetts General
Hospital, Boston, MA
Study Objectives: Acute gastroenteritis remains a major cause of morbidity and
mortality in children around the world, accounting for 1.8 million deaths annually in
children under five years of age, or roughly 17% of all child deaths. While oral
rehydration solution (ORS) has been shown to be an effective, safe, and inexpensive
method of treating children with mild to moderate dehydration, IV fluids are
required to treat children with severe dehydration. The World Health Organization
(WHO) recommends using four clinical signs to determine the severity of
dehydration, however, prior studies have found that these signs lack adequate
sensitivity, specificity, and reliability. We attempt to determine whether ultrasound
assessment of the inferior vena cava (IVC) to aorta ratio can be used to determine the
severity of dehydration in children presenting with acute gastroenteritis, and whether
it performs better than the WHO criteria.
Methods: We enrolled a prospective cohort of children under 15 years of age
presenting with diarrhea or vomiting to three rural hospitals in Rwanda. Upon
arrival, study coordinators consented the parent of all eligible children and performed
an ultrasound of the IVC and aorta. Children were also assessed clinically by a second
clinician using the standard criteria recommended by WHO. All children were
weighed on admission to the hospital and then rehydrated according to standard
Rwandan Ministry of Health protocols. Patients were weighed again just prior to
discharge, and a percent weight change of greater than 10% was considered the gold
standard for severe dehydration, according to the standard practice in the pediatric
literature. We used ROC curves to determine the maximum sensitivity and specificity
for the IVC to aorta ratio compared to our gold standard. We also determined the
sensitivity and specificity of the WHO criteria compared to the same standard.
Results: 28 children were enrolled in an initial pilot study, of which 25 have
complete data available. The median age for children enrolled in the study was 9
months (range 1 - 42 months). 60% (15/25) of patients enrolled were male and 20%
(5/25) had severe dehydration according to our gold standard. We found the WHO
criteria to have a sensitivity of 80% (95% CI: 45-100%), a specificity of 55% (95%
CI: 33-77%), a LR positive of 1.8 (95% CI: 0.9-3.4), and a LR negative of 0.36
(95% CI: 0.06-2.2) for detecting severe dehydration. In comparison, ultrasound of
the IVC to aorta ratio had a sensitivity of 80% (95% CI: 45-100%), a specificity of
Volume , .  : September 
75% (95% CI: 56-94%), a LR positive of 3.2 (95% CI: 1.3-7.7), and a LR negative
of 0.27 (95% CI: 0.05-1.6).
Conclusion: In a prospective cohort of children presenting to three separate
developing world hospitals with symptoms of acute gastroenteritis, we found
ultrasound of the IVC to aorta ratio to have similar sensitivity and better specificity
than the WHO criteria for assessing the severity of dehydration. While this pilot
study remains too small to draw definitive conclusions, we expect our larger,
upcoming study of 260 children will produce similar results. If ultrasound is found to
be an accurate and reliable tool for determining severity of dehydration in children
with gastroenteritis, it could be used to improve triage for children presenting to
hospitals in both the developed and developing world, which in turn could translate
into reduced morbidity and safer, more cost-effective care for patients.
290
A Teaspoon of Medication: How Much Is Really in
It?
Mir M, Palta A, Eden A, Kondamudi N/Wycoff Heights Hospital, Brooklyn, NY;
The Brooklyn Hospital Center, Brooklyn, NY
Study Objectives: Dosing errors are by far the most common type of medication
errors in pediatrics and are attributed to calculation errors, illegible handwriting, and
inability of some caregivers to understand instructions. Language barriers play a major
role in the occurrence of dosing errors. It is common practice to prescribe liquid
medications in teaspoonfuls rather than the actual quantity in milliliters. Our
hypothesis is that the “understanding” of the volume per teaspoonful may be variable
in our caregivers of children, contributing to dosing errors. Our objectives were to
determine the prevalence of teaspoon use and knowledge of medication volumes in
them among caregivers and health care personnel.
Methods: A survey questionnaire was mailed to 400 randomly selected
pediatricians (Brooklyn/Queens area) and 100 area pharmacists. Another
questionnaire (English and Spanish) was administered to a convenience sample of
398 caretakers at the pediatric unit/ED (n⫽245) and an affiliated private office
(n⫽153). The same questionnaire was then administered to a convenience sample of
health care workers (nurses and resident physicians; n⫽64).One hundred caretakers
were asked to bring a teaspoon used for administration of medication to their
children from their homes and volume of these was measured. Statistical analysis was
done using SPSS for Windows, version 11.0.
Results: A total of 148 pediatricians responded to the survey (response
rate⫽37%) despite three mailings. Prescription of medications by teaspoonfuls was
reported in 45%, prescription using milliliters in 42%, and 13% used both. Of the
100 mailings to the area pharmacists, 55% responded (response rate⫽55%) of whom
93% recommend medication dosing in units of teaspoonfuls. Survey of care givers
revealed that 31% of English-speaking responders used teaspoons for medication
administration compared to 43% of Spanish-speaking responders (p⫽0.025). Only
55% of English-speaking caregivers knew that 5ml equaled a teaspoon compared to
59% in the Spanish-speaking group (p⫽NS). Correct identification of a teaspoon
among a set of various spoons occurred in 43% of English-speaking responders and
only 23% of Spanish-speaking responders(p⫽⬍0.01). Among the health care
personnel, 47% reported use of teaspoon for medication administration. Caregivers
brought out a total of 53 spoons used at home for medication measurement and only
three teaspoons measured to be 5ml.
Conclusion: A large proportion of health care providers still recommended use of
teaspoonfuls to administer liquid medication, despite TJC recommendation to use
milliliters. Most caregivers used teaspoons for dosing medication and most teaspoons
had inaccurate volumes when measured.
291
Spectrum of Bacterial Pathogens Seen in a
Community Pediatric Emergency Department
Kondamudi N, Bai H, Thumalapalli M, Rawstron S/The Brooklyn Hospital Center,
Brooklyn, NY
Study Objectives: To determine the spectrum of bacterial pathogens encountered
in a pediatric emergency department (PED) of a community hospital.
Methods: The study was conducted in a community hospital PED with 16,000
annual visits. All cultures sent for patients ⬍ 18 years to the microbiology lab from
the PED between Jan 1, 2005 and June 30, 2006 (18 months) were identified.
Medical records of these patients were reviewed to extract demographic and clinical
data, lab findings, initial and final diagnosis and recorded into a database. The culture
system used for aerobic and anaerobic culture was BD Bactec 9240 (Bacton &
Dockinson Company) and the sensitivity tests system used were from BioMerieux,
Annals of Emergency Medicine S91
Research Forum Abstracts
Inc. VITEK GNS-106 was used for Gram-Positive susceptibility and GNS-128 was
used for Gram-Negative susceptibility.SPSS for window 16.0 was used for statistical
analysis⬍br .
Results: The total number of cultures sent was 519 from 23562 PED visits for a
rate of 2.2%. The overall rate of performance of blood, urine and throat culture was
0.7% each (n⫽163, 164, 160 respectively). The most common age group was 4-12
year group, mostly for throat cultures (41%, n⫽165), followed by the 3 month to 3
year group, mostly blood and urine cultures (31%, n⫽125). Cerebrospinal fluid
cultures were done in only 0.02% cases (n⫽13). The positive culture rate for blood
was 9% (14/163; for urine was 21% (35/164;) and for throat was 21% (35/160).
There was significant association in performance of blood culture with age 3 years
(p⬎0.05). The most common organisms identified in blood were contaminants (7),
Staph aureus in 4,and Strep Pneumoniae in three cultures. The most common
organism in the urine was E.coli (n⫽23), which was resistant to ampicillin (16/23 ⫽
70%), amp/sulbactam (10/23, 45%) and cotrimoxazole (13/23, 56%). S. aureus,
Klebsiella sp., Enterobacter sp., P. aeruginosa had 100% resistant rates to ampicillin.
The prevalence of MRSA in this survey was 14%. The most common organism
identified was group A streptococci in throat cultures. There were 5 contaminated
blood cultures for a 4.3% contamination rate.
Conclusions: The performance of cultures in this study was low compared to the
published literature, representing underutilization. Contamination rate exceeded true
bacterial growth among blood cultures indicating low prevalence rates of bacteremia.
urinary tract infection is much more prevalent than bacteremia and the identified
urinary pathogens are usually resistant to ampicillin. Knowledge of local prevalence of
bacterial pathogens and their sensitivity will aid in more appropriate selection of
antibiotic therapy.
292
Perceptions and Practices of Fever: Survey for
Parents With Febrile Child Visiting Pediatric
Emergency Department
Kim D, Lee Y, Lee J, Jeong J, Kim J, Choi M/Seoul National University Hospital,
Seoul, Republic of Korea
Study Objectives: Fever is one of the most common presenting complaints for
pediatric emergency department (ED) visits. Previous studies showed that fever
phobia, exaggerated concerns about fever, is common among parents. Our object is to
evaluate parents’ perceptions and patterns of management for fever in their child.
Methods: During the 2 months of 2008, we conducted a questionnaire survey
among 746 parents of children visiting to ED because of fever. The main outcome
results were answers to questions about variable aspects of the knowledge, perception
and management of fever.
Results: Most participants were college-educated and lived in an urban area. Two
thirds of participants were female (mean age 34.7 years). Twenty eight percent of the
parents considered temperatures less than 38.0°C to be “fever.” Seventy-eight parents
(10.5%) believed that, left untreated, temperature could rise to over 42.0°C. Most
common concerns about refractory fever in their child were febrile seizure (35.5%)
and brain damage (39.5%). Four hundred fifty-five parents (60.7%) said that they
would check their child’s temperature ⬍30 min when their child had a fever.
Surprisingly, 66.2% of parents said that they would awaken their child to take an
antipyretic. Parents’ experiences of alternating uses of antipyretics were common
(32.7%) and frequently were done without medical advices. About a half of parents
(46.0%) said that they usually decide the dosage of antipyretics according to the
doctor’s advice. Parents were worried about the harmful effects of antipyretics; the
development of tolerance (41.9%) and dependency to drugs (39.7%).
Conclusion: Many parents who visited the ED with a febrile child had a poor
understanding of fever. There is a big need for systematic educational efforts to
reduce fever phobia and to use antipyretics adequately.
293
Respiratory Distress Assessment Instrument as a
Predictor of Hospital Admission and Severity in
Children With Bronchiolitis
Dhillon RK, Bellolio M, Wickremasinghe AC, Anderson JL/Mayo Clinic,
Rochester, MN
Study Objectives: To investigate the relationship between Respiratory Distress
Assessment Instrument (RDAI) score and treatment administered in infants
presenting to a pediatric emergency department (ED) with acute bronchiolitis and
S92 Annals of Emergency Medicine
clinical severity as graded by the RDAI. To investigate the relationship between the
RDAI score and disposition from the pediatric ED.
Methods: This is an ongoing prospective cohort study of previously healthy infants
aged 0 to 23 months who present to a tertiary care ED with acute bronchiolitis, defined as
first time wheezing associated with cough, coryza and respiratory distress. Infants with
previously diagnosed heart or lung disease, or recent (⬍6 hours) albuterol or epinephrine
treatment are excluded. Data collected includes a prospectively evaluated RDAI score,
demographics, medical history and vital signs (oxygen saturation, respiratory rate,
ETCO2, pulse rate). Data are captured every 5 seconds. Discharged patients are being
followed by phone 2 weeks after ED discharge.
Results: Twenty-two patients have been enrolled until date, with a median age
6.4 months (IQR 3.4-11), 64% males, 91% Caucasian, and 27.3% had history of
premature birth. The median RDAI score at presentation was 6 (IQR 5-9).
None of the patients had past medical history of recurrent respiratory tract
infections, multiple births or airway abnormalities such as tracheomalacia. Smoking
in the home was prevalent in 23% of the study population and 46% attended day
care. Bronchodilators had been given to 32% of the patients and corticosteroids to
9% prior to ED presentation. There was no significant relationship between oxygen
saturation on arrival and initial RDAI score (R-square 35.3%, p⫽0.16). There was
no significant relationship between the ETCO2 measured on arrival to ED and initial
RDAI (R-square 6.5%, p⫽0.399). Children on steroid therapy had higher initial
RDAI scores (median 9.5 for those on steroids vs 6 for those not on steroids). This
difference was clinically significant, however, not statistically significant (p⫽0.199).
There was no relationship between admission RDAI score and admission to the
hospital (p⫽0.819). There was a significant relationship between post bronchodilator
RDAI score and admission to the hospital. Children with higher scores were more
likely to be admitted (p⫽0.047).
Conclusion: The RDAI score after bronchodilator treatment is a predictor of
hospital admission. Patients on chronic steroids have higher RDAI scores which
reflect more severe clinical presentation with bronchiolitis.
294
The Effects of Skin Pigmentation on the Detection
of Genital Injury From Sexual Assault: A
Population-Based Study
Rechtin C, Rossman L, Jones JS, Wynn B/MERC/Michigan State University
Program in Emergency Medicine, Grand Rapids, MI; YWCA West Central
Michigan Nurse Examiner Program, Grand Rapids, MI
Background: Little is known about the role of race on the prevalence of genital
injury following rape or sexual assault. A recent study suggested that individuals with
darker skin may be at a disadvantage for injury identification with the current
examination strategies (direct visualization, contrast media, colposcopy), and color
awareness may be an important component of the sexual assault forensic examination.
Study Objective: To investigate the role of skin pigmentation in the visual
identification of genital injury following rape in women 13 years and older.
Methods: This retrospective cohort trial evaluated consecutive female patients
presenting to a community-based Nurse Examiner Program (NEP) during a 10-year
study period. Sexual assault victims presenting directly to four downtown emergency
departments are routinely referred to the NEP for evaluation after triage and initial
assessment. The clinic is associated with a university-affiliated emergency medicine
residency program and is staffed by forensic nurses trained to perform medical-legal
examinations using colposcopy with nuclear staining. Patient demographics, assault
characteristics, and injury patterns were recorded using a standardized classification form.
For the purposes of this study, injury was defined as any tissue trauma visible on
inspection which was then subsequently classified using the TEARS classification (tears,
ecchymoses, abrasions, redness, and swelling) system. Primary outcome of interest was the
documentation of physical injuries from sexual assault in whites versus backs living in the
same urban community. Chi-square and ANOVA tests were used to compare anogenital
findings in victims examined.
Results: Case files of 2234 patients were reviewed; 83% were white and 17% were
black. The two cohorts were comparable in terms of age, marital status, type of sexual
assault, alcohol and drug use, known assailant, and time to physical exam. Whites had
a greater prevalence of documented non-genital (39% vs. 26%, p⬍.001), as well as
anogenital injuries (64% vs. 54%, p⬍.001). The localized pattern of anogenital
injuries was similar in both cohorts; typically involving the fossa navicularis, followed
by the posterior fourchette, labia and hymen. The most common type of injury in all
patients was lacerations; however, whites had a greater incidence of documented
erythema (32% vs. 23%, p⬍.001).
Conclusions: Despite the use of colposcopy with nuclear staining and digital
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Research Forum Abstracts
imaging, forensic examiners in this community-based study consistently documented
fewer anogenital injuries in black women. These findings suggest that individuals
with darker skin may be at a disadvantage for injury identification with current
forensic examination techniques.
295
What Happens at the 72-Hour Mark? Physical
Findings in Sexual Assault Cases When Victims
Delay Reporting
Burger C, Olson M, Dykstra D, Jones JS, Rossman L/Michigan State University
College of Human Medicine, Grand Rapids, MI; MERC/Michigan State University
Program in Emergency Medicine, Grand Rapids, MI; YWCA West Central
Michigan Nurse Examiner Program, Grand Rapids, MI
Background: Most of the literature regarding anogenital injuries resulting from
sexual assault is limited to victims examined within a 24-48 hour time frame. As a
result, a 72-hour post-assault window is usually suggested as the maximum time
interval for documentation of anogenital injuries.
Study Objectives: To analyze the frequency, location and types of anogenital
trauma in sexual assault victims as a function of the victim’s age and the time interval
between the assault and the forensic examination. A secondary objective was to
analyze demographic factors that may be associated with a delay in forensic
examination in adolescent (ages 13-19 years) and adult victims (⬎19 years old).
Methods: This retrospective cohort trial evaluated consecutive female patients
presenting to a community-based Nurse Examiner Program (NEP) during a 10-year
study period. Sexual assault victims presenting directly to four downtown emergency
departments are routinely referred to the NEP for evaluation after triage and initial
assessment. The clinic is associated with a university-affiliated emergency medicine
residency program and is staffed by forensic nurses trained to perform medical-legal
examinations. The patients were stratified based on age (adolescent vs. adult) and the
time interval between the assault and the forensic examination. Patient demographics,
assault characteristics, and injury patterns were recorded using a standardized
classification form. Chi-square and ANOVA tests were used to compare clinical
features among separate cohorts.
Results: A total of 2799 cases met the inclusion criteria of the study; 28% (776)
delayed seeking medical care for at least 24 hours following the assault. Victims who
delayed seeking medical examination were younger (20.7 vs. 23.6 years, p ⬍.001),
more likely to be assaulted by a known acquaintance or family member (86% vs.
79%, p⬍.001), and were less likely to report the assault to police (64% vs. 84%,
p⬍.001). The frequency of anogenital lacerations and abrasions decreased from 71%
at less than 24 hours to 28% at greater than 96 hours after the assault (p⬍.001). Out
of the total study population, 43% (1192) were 19 years of age or younger.
Adolescent victims who delayed seeking medical care were more likely to report more
alcohol or drug use prior to the assault (58% vs. 47%, P⬍.001). Across all time
periods adolescents had a consistently higher frequency of genital injuries compared
to adults, but in both populations documented anogenital injuries steadily decreased
each day after the assault by approximately 8% (95% CI, 6% to 10%). At the 72hour mark, 50% of adolescents and 38% of adult victims had documented anogenital
injuries.
Conclusions: Twenty-eight percent of adult women and 33% of adolescent
victims presented to an urban sexual assault clinic more than 24 hours after their
assault. The frequency and types of anogenital injuries vary significantly depending
on timing of the forensic examination. Approximately half of young women had
injuries documented 72 hours after a sexual assault.
296
Early Treatment of Hypertonic Saline and Arginine
Is Important in Restoration of T Cell Dysfunction
Choi S, Hong Y, Cho H, Yun Y, Kim J, Moon S, Han C, Shin J, Kim S, Cho Y/
Korea University Guro Hispital, Seoul, Republic of Korea; Korea University Anam
Hospital, Seoul, Republic of Korea; Korea university Guro Hispital, Seoul,
Republic of Korea; Korea University Ansan Hospital, Ansan, Kyounggi-do,
Republic of Korea
Study Objectives: Immunological suppression is a well-recognized consequence of
trauma and hemorrhagic shock and contributes to infectious complications,
ultimately leading to sepsis and multi-system organ failure. Several mechanisms of
post-traumatic immune impairment, including T cell dysfunction, have been
proposed. T cell dysfunction after traumatic stress is characterized by a decrease in T
cell proliferation. The addition of prostaglandin E2 (PGE2), which depressed immune
function after hemorrhage and trauma, to T cells decreases T cell proliferation and
Volume , .  : September 
that Hypertonic saline (HS) restores PGE2-induced T cell suppression. Besides,
arginine is essential in restoring T cell proliferation by HS. Therefore, we are to know
if there is any differences in T cell proliferation according to the concentration of
arginine, if HS restores PGE2-induced T cell suppression in 80uM of arginine,
clinically relevant since serum arginine concentration, and whether HS restoration of
T cell dysfunction is dependent on the injection time of HS.
Methods: Jurkat cells were cultured in 0uM, 40uM, 80uM, 400uM, 800uM,
1600uM arginine media, final concentration of 2.5 ⫻ 106 cell/ml. Cell proliferation
was measured. Jurkat cells were cultured in 80uM arginine media, clinically relevant
since serum arginine concentration. Cell proliferation was detemined in both PGE2
stimulated and HS treated group by the MTT cell proliferation assay and arginase
activity were measured. Besides, according to treated time of HS, cell proliferation
was measured.
Results: Increased concentration of arginine media increased MTT cell
proliferation. In 80uM of arginine, which concentration in the serum of human, HS
did not restore Jurkat cell proliferation suppressed by PGE2 as measured by MTT cell
proliferation assay. In 1.14mM arginine media, HS restore PGE2 suppressed Jurkat
cell proliferation to normal. However, HS could not restore Jurkat cell suppressed by
PGE2 in case of 2 hour after adding PGE2.
Conclusion: Jurkat cell proliferation was increased by the increase of arginine
concentration. And, in order to restore PGE2-suppressed Jurkat cell proliferation, HS
must be added quickly and also require proper amount of arginine.
297
Injury Patterns Are Different for Older and Younger
Patients in Equestrian Accidents
Bilaniuk JW, Gage AM, Adams JM, Siegel BK, Cockburn MI, DiFazio LT,
Allegra JR/Morristown Memorial Hospital, Morristown, NJ
Study Objective: Horseback riding has been identified as a higher-risk activity
than motorcycle riding, football and skiing. There has been little research of injuries
associated with equestrian accidents. Examining injury patterns may give clues for
prevention of injuries. We hypothesized that there are different patterns of injury for
older and younger patients in equestrian accidents.
Methods: Design: Retrospective cohort. Setting: Level two trauma center in
suburban northern New Jersey. Population: Consecutive visits from January 1, 2004
to Dec. 31, 2007. Protocol: We searched the trauma registry and the E- codes from
the hospital information system to identify patients with equestrian injuries. We
grouped injuries into categories based on regions of the body. We a priori chose to
compare patients less than 50 years with those greater or equal to 50 years. Chi-square
was used to test for statistical significance with alpha set at ⬍ 0.005 using the
Bonferroni correction for multiple comparisons.
Results: Of 277,000 visits in the database, 285 patients (0.1%) had equestrian
injuries. The median age was 30 years (inter quartile range 14 - 50 years) with 27%
⬎ 50 years. Female comprised 84%. The 2 most common injuries as a percentage of
injured patients for each age group were: ⬎ 50 years - rib fractures (23%) and T-L-S
spine fractures (18%) and ⬍ 50 years - concussion (22%) and upper extremity
fractures (16%). Comparing the 2 groups we found: statistically significant greater
percentages in the older population for rib fractures 23% vs. 5% (p ⫽ 0.00001) and
spinal fractures 18% vs. 6% (p⫽0.004). There were no statistically significant
differences for other injuries between the 2 age groups.
Conclusions: We found different patterns of injuries associated with equestrian
accidents for older and younger patients. There were a statistically significant greater
percentage of rib and spinal fractures for ages ⬎ 50. Older horseback riders may
benefit from steps to prevent osteoporosis and by using chest protector vests.
298
Admission Fibrin Degradation Product Level
Predicts the Need for Massive Transfusion and
Mortality in Adult Blunt Trauma Patients
Maekawa K, Hirayama S, Uemura S, Nara S, Mori K, Asai Y/Sapporo Medical
University, Sapporo, Japan
Study Objectives: When a large volume of coagulum generates in body cavity
after blunt trauma, secondary fibrinolysis occurs and the serum level of fibrin
degradation product (FDP) elevates immediately. Acute trauma coagulopathy
associated with massive transfusion (MT) and mortality is characterized by
anticoagulation and hyperfibrinolysis. On the hypothesis the admission FDP level
correlates with the volume of coagulum and hyperfibrinolysis, we evaluated whether
the admission FDP level is predictive of the need for MT and mortality in adult blunt
trauma patients.
Annals of Emergency Medicine S93
Research Forum Abstracts
Methods: A retrospective study was done on blunt trauma patients ⬎/⫽18 years
old, referred to a single tertiary care center at the university hospital over a 2-year
period. Baseline demographic data (age, sex), physiological variables on admission
(respiratory rate (RR), systolic blood pressure (SBP), Glasgow Coma Scale (GCS)
score), hematological variables on admission (hemoglobin (Hgb), platelet counts
(Plt), fibrinogen (Fbg), antithrombin (AT), FDP), Revised Trauma Score (RTS),
Injury Severity Score (ISS), time interval from injury to ED were collected. These
hematological variables were examined in relation to the need for MT and mortality.
MT was defined as transfusion volume ⬎/⫽10 units packed red blood cells in 24
hours of hospitalization. Multiple logistic regression analysis were used to determine
level of significance. Receiver-operator characteristic (ROC) curve analysis was used
to evaluate predictive factors.
Results: From 1/06-12/07, 157 eligible patients were admitted to the ICU after
injury. Multiple logistic regression to control for the effect of possible confounding
variable (age, sex, RR, systolic BP, GCS score, RTS, ISS, time interval) found FDP to
be an independent predictor of the need of MT (adjusted odds ratio 1.01, 95%CI
1.01-1.02). ROC analysis showed an area under the curve of 0.76 (95%CI 0.67 0.84) and identified FDP value ⬎106 ␮g/dL as an optimal cut-off point, with a
negative predictive value of 88%. A similar multiple logistic analysis found FDP to be
an independent predictor of mortality (adjusted odds ratio 1.02, 95%CI 1.01-1.03).
ROC analysis showed an area under the curve of 0.84 (95%CI 0.77 - 0.92) and
identified FDP value ⬎89 ␮g/dL as an optimal cut-off point, with a negative
predictive value of 93%.
Conclusion: An admission FDP level is predictive of the need for MT and
mortality in adult blunt trauma patients. Because it is easily obtainable, it may
become a preferable and practical marker for early identifying severely injured
patients likely to require MT.
299
Can Coagulation Markers on Arrival Predict
Neurological Outcome in Patients With Traumatic
Brain Injury?
Shimizu T, Takahashi I, Morishita Y, Kamoshida H, Onishi S, Naito Y, Oshiro A,
Henzan N, Mizuno H, Ozaki Y/Teine Keijinkai Hospital, Sapporo, Japan
Study Objectives: Several studies have suggested a correlation between neurological
outcome after traumatic brain injury and coagulation test results at initial evaluation.
There is, however, presently no test established for clinical use. This study is a
retrospective observational study designed to identify commonly used diagnostic tests that
can help predict neurological outcomes of patients with traumatic brain injury.
Methods: 183 patients (126 men and 57 women; mean age 60 years, range 0-94)
with an Abbreviated Injury Score (AIS) ⬎ or ⫽ 3 in the head and AIS score ⬍ 3
elsewhere in the body were included in the study. We reviewed the international
normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen
(Fib), fibrinogen degradation products (FDP), and platelet count (Plt) of all subjects.
Neurological outcome was assessed by using the Pittsburgh Cerebral Performance
Category (CPC) score. We defined CPC 1-2 as the favorable outcome group and
CPC 3-5 as the poor outcome group. INR, aPTT, Fib, FDP, and Plt were compared
across the respective groups. Statistical significance was accepted at p⬍0.05.
Results: 116 of 183 patients (63.4%) were discharged with favorable neurological
outcome. INR, aPTT, and FDP were significantly higher and Plt was significantly
lower in patients in the poor outcome group as determined by the Mann-Whitney U
test. Multiple logistic regression and ROC curves of each serum marker revealed FDP
to be most statistically significant for prediction of poor neurologic outcome. Using
an FDP cutoff value of 80mcg/ml, the sensitivity and specificity were 53% and 86%
respectively and the positive likelihood ratio was 3.8.
Conclusion: Of the coagulation markers we measured, FDP demonstrated the
most statistically significant correlation with poor neurological outcome in traumatic
brain injury patients. The cutoff of FDP should be 80mcg/ml as this has a reasonably
good specificity of 86%. A prospective cohort study with larger sample size could
validate and warrant the usefulness of this diagnostic test.
300
Fishing-Related Infections in the United States
Krieg C, Samlan SR, Chan SB/Resurrection Medical Center, Chicago, IL
these type of injuries in the literature and almost no studies reviewing subsequent
post-injury infections or use of prophylactic antibiotics. The objective of this study is
to provide evidence of infections associated with puncture wounds, lacerations, or
foreign body from fish or fishhooks.
Methods: The National Electronic Injury Surveillance System (NEISS) was queried
for all fishing-related injuries between 2002 and 2006. Data abstracted include age, sex,
type and location of injuries, whether related to fish hooks or other fish wounds. All cases
were reviewed for evidence of infections related to the fishing injuries.
Results: There were 6661 cases reported over five years, 70.0% were caused by fish
hooks, 2.5% caused by fish bites, and 27.5% other injuries related to fishing. There were
38/4662 (0.8%) infection associated with fish hooks and32/165(19.4%) infections
associated with fish wounds. 70.0% of the infections involved the hand or fingers.
Conclusion: The incidence of infections related to fishhooks is less than 1% while
the incidence of infections related to fish wounds is much higher. We believe that by
demonstrating this low risk of infection, we offer evidence that no prophylactic
antibiotics are required in fishhook injuries. We also show that the rate of infection
by fish wound injuries is higher and it would be advantageous to consider the
administration of prophylactic antibiotics involving fish wound injuries.
301
The Effect of the Repeal of the Pennsylvania
Helmet Law on the Severity of Head and Neck
Injuries Sustained in Motorcycle Accidents
Mersky A, Eberhardt M, Overfield P, Melanson S, Stoltzfus J, Prestosh J/St.
Luke’s Hospital, Bethelehem, PA
Study Objectives: Previous studies have shown helmets to prevent brain injuries
in motorcycle crashes. Although not substantiated, opponents to helmet laws have
cited increased risk of neck injuries while wearing helmets as one reason to repeal
helmet laws. In September 2003 Pennsylvania weakened its motorcycle helmet law,
requiring only inexperienced riders and those under the age of 21 to wear helmets.
We analyzed data to determine if fatalities as well as head and neck injuries have been
affected by the change to this law.
Methods: Utilizing data obtained from the Pennsylvania Trauma Systems
Foundation State Registry (PTSF) and the Pennsylvania Department of Transportation
(PenDOT), we retrospectively analyzed fatalities, head and neck injuries caused by
motorcycle crashes. We compared data from the period prior to the weakening of the law
(August 2000 to August 2003) (PRE) and immediately after the change was enacted
(October 2003 to October 2006) (POST). In addition in the POST period, we analyzed
the affects of the change in the helmet law on the presence of severe head injuries in
MCAs. Chi square and Bonferroni statistical analysis were used to analyze the data.
Results: In the POST period, 1465 more individuals were admitted to trauma
centers than during the PRE period (4229 vs 2764) as a result of MCA. The
percentage of theses patients that were known to be wearing helmets decreased from
89.3% PRE (2309/2585) to 57.2% POST (2295/4014) p⬍ .0001. The absolute
number of fatalities due to motorcycle crashes both at the scene of the accident (451
PRE vs 537 POST) and in trauma centers (152 PRE vs 210 POST) increased in the
POST period but the percentage of deaths did not change (PRE 4% (451/10,731),
5.5% (152/2764) vs POST 4% (537/12,955), 5% (210/4229)) (p ⫽ .83, p⫽ .33).
Of the individuals who died in the POST period, the percentage of deaths that
occurred in the unhelmeted (UH)patients was greater than helmeted (H) patients ( H
4.4% 101/2295 vs UH 6% 103/1719; p⫽ .02). Serious head injuries, defined as AIS
scores 3 to 6, occurred more frequently in the POST period than in the PRE (PRE
21% 581/2764 vs POST 25.5% 1080/4229) (p⬍ .0001) and within the POST
period UH patients were more likely to experience a serious head injury than H
patients (H 18.3% 420/2295 vs. UH 36.4% 625/1719). In addition, the number of
patients who sustained serious neck injuries, defined as fractures of C1 - C7, were
greater in the POST period (PRE 2.7% 75/2764 vs POST 4% 171/4229; p⫽.003).
Conclusion: While the use of a helmet does not appear to decrease the percentage
of deaths from motorcycle accidents, it does decrease the number of serious head
injuries. This data also supports the use of helmets to prevent neck injuries although
further study is needed.
302
Characteristics of Fragment Wounds in a Combat
Setting
Givens ML/Carl R Darnall Army Medical Center, Fort Hood, TX
Study Objectives: Fishing injuries are a common injury seen everyday in clinics
and emergency departments around the world. These injuries consist of lacerations,
puncture wounds, and retained foreign bodies. There is very limited reporting of
S94 Annals of Emergency Medicine
Study Objectives: Fragment wounds are a common injury in combat settings and
many of these fragments are left in place. There is currently no literature which
Volume , .  : September 
Research Forum Abstracts
describes the outcomes of patients with retained fragments. The purpose of this study
was to describe the outcomes of combat zone inflicted penetrating wounds with
retained fragments after treatment in a combat support hospital.
Methods: An institutional review board-approved prospective observational study
was performed involving United States Military patients who presented to the combat
support hospital in Baghdad, Iraq with retained fragments from combat injury.
Unstable patients or patients with emergent injuries requiring operative intervention
were excluded. Patients were enrolled in the emergency department and one week
and one month follow-up was obtained by phone or email.
Results: Seventy-four patients were enrolled (ages 19-48, 71 men and 3 women).
Forty-nine fragment injuries were due to improvised explosive devices (IEDs), 9 from
mortars, 7 from gunshot wounds (GSWs), 4 from rockets, 2 from grenades and 1
unidentified. Twenty-eight patients had fragments less than 0.5cm, 21 with
fragments 0.5-1.0cm and 17 with fragments ⬎1.0cm (8 not described). Sixty-seven
patients received antibiotics in the ED. Of the 7 patients who did not receive
antibiotics in the ED, only 2 did not receive antibiotics on admission or prescribed at
discharge. The average pain score at presentation was 8. One-week follow-up was
obtained on 49/74 patients (66%). All but one patient saw a health care provider for
follow-up. Twenty-seven (55%) patients described redness at the injury site one week
after injury, 4 reported fever, and 20 patients (40%) described pus or discharge from
the wound. The average pain score at one week was 5. Thirty-five (71%) patients had
limitations on their activity at one week. One-month follow-up was obtained on 37/
74 (50%) patients. The average pain score at one month was 3. Nineteen of the 37
(51%) patients described activity limitation at one month post injury. Eighteen of the
37 patient followed up at one month felt their injury was cosmetically disfiguring.
One patient had his fragment removed between the one-week and one-month followup.
Conclusion: This study found that pain, redness and wound discharge are
common one week post injury. For many patients pain may persist and activity
limitation may be present even at 6 months post injury. While the data was not
robust enough to determine predictors of infections, ongoing pain, or function loss;
this study offers some insight into what the anticipated clinical course for fragment
wounds may involve. Further research needs to be done to determine predictors of
outcomes and further define the proper care of patients with retained fragments.
303
An Analysis of Emergency Department Revisit
Rates Based on Patient Satisfaction Scores
Yang A, Liu J, Merlin M/UMDNJ-Robert Wood Johnson, New Brunswick, NJ;
UMDNJ-CINJ, New Brunswick, NJ
Study Objectives: The objective is to determine correlation between patient
satisfaction scores and return visit rates to the emergency department (ED). The null
hypothesis is: patients who have higher satisfaction scores will have higher return visit
rates.
Methods: The study was conducted at a regional emergency department that
served and urban and suburban population. The study hospital was one of five
hospitals in a tem mile radius. All patients that were discharged from the emergency
department were sent a questionnaire about their emergency department experience
within 2 days of their visit. The patients were asked to score their satisfaction on a
scale of one to five with: ED environment, Nurses, Doctors, Family issues, Ancillary
staff, Clerical staff, Personal issues, and overall ED experience. All patients 21 years
and older who were treated in the ED and discharged were included. Patients that
were admitted to the hospital and patients younger than 21 were excluded. The ED
re-visits of patients who had completed the surveys were collected for a period of one
year following the initial visit.
Results: 313 surveys were collected during the study period. 104 of these patients
returned to the ED over the following year with 194 individual re-visits.
A test for goodness of fit yielded a deviance value/DF of 2.0835. A Poisson
regression model was used for analysis. Results of the data analysis are shown in the
table.
Conclusion: Almost none of the parameters measured in the patient satisfaction
survey had any statistically significant correlation with ED patient re-visits. Only the
personal issues category had a statistically significant correlation with ED revisits. Our
findings call into question the validity of improving patient satisfaction as a means to
increase return visits and revenue.
Volume , .  : September 
304
The Use of Scripting at Triage and Its Impact on
Elopements
Handel DA, Daya M, York J, Larson E, McConnell KJ/Oregon Health & Science
University, Portland, OR
Study Objectives: Prior studies have demonstrated that scripting that lets the
patient know their expected waiting time at triage have improved patient satisfaction,
and elopements (also known as left without being seen) have been proposed as one
possible measure of patient satisfaction. The purpose of this study is to measure the
impact of scripting language at triage on the rates of elopements, controlling for
patient volume and other potential confounding variables.
Methods: All patients 21 years of age and older who presented to the triage
window in the ED waiting room (not by ambulance), waited greater than 5 minutes,
and were not immediately brought back were included in the analysis. The study
setting is an academic, level 1 trauma center with approximately 40,000 visits a year.
This was a pre and post intervention study with, the same three-month period
(November-January) used for comparison purposes. The triage nurses were trained to
notify patients of the wait time. The wait time provided was the longest time for a
patient waiting at that moment in the waiting room. A button was created in the
electronic health record to track that scripting was provided after implementation of
the plan. For those patients who did not have the button clicked, it was assumed they
had not received the information. After the implementation of triage scripting, a onemonth washout period was excluded (October 2008) allowing comparison of
November 2007-January 2008 (pre-scripting period), with November 2008-January
2009 (post scripting period). A multiple logistic regression model was used to control
for confounding factors such as daily patient volume, patient age, length of stay
(LOS) for admitted and discharged patients, weekend vs. weekday visits, and triage
acuity using the Emergency Severity Index scale.
Results: 7,201 patients were included in this analysis. 2.5% of patients who received
the scripting eloped (45/1,782), compared to 4.7% (266/5,612) who did not. Based on
univariate analysis, this difference was statistically significant (p⫽0.000). However, the use
of scripting was not found to have a significant impact on whether or not patients eloped
prior to evaluation (p⫽-.375) when adjusting for confounding factors in the regression
model. Significant confounders in the model include the daily census, patient age, triage
acuity, LOS for admitted and discharged patients, and weekday visits.
Conclusion: The use of triage scripting was not found to significantly reduce the
rates of elopement in patients stable enough to be placed in the ED waiting room.
Further longitudinal data comparison are warranted to see if any impact on
elopement rates can be detected and to evaluate impact on other outcome measures
such as patient satisfaction scores.
305
Reliability of Emergency Severity Index Version 4
Choi M, Kim J, Choi H, Lee J, Shin S, Kim D, Ro Y/Seoul
National University Hospital, Seoul, Republic of Korea
Study Objectives: The aim of this study is to test the reliability of Emergency
Severity Index 4 (ESI-4) in different setting, Korea from North America. We also
tried to evaluate the effect of implementing the ESI-4 and its effect on self-efficacy.
Methods: This study was carried out from August 1, 2008 to August 31, 2008 in
a single regional emergency center (level 1 center). Target patients for the validation
were those who visited the center with age of 15 years or older. The study for effect of
ESI-4 had been done for 5 days from January 12, 2009.
The collection of the ESI-4 data was done by triage nurses. These nurses had finished
the standardized course and had gone through multiple conferences with emergency
physicians about clinical cases regarding the ESI-4. The convenience sampling method
Annals of Emergency Medicine S95
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was used to select participants. Four research nurses and one third year resident scored the
ESI-4 to the selected patients as references, independently. We calculated the weighted
kappa between the triage nurses and research nurses, and between triage nurses and the
emergency resident to evaluate the consistency of the ESI-4. We also measured internal
consistency of the ESI according to their clinical experience.
We took a survey, which consisted of 13 questions for implementation effect and
5 questions for self-efficacy. The results of the survey were analyzed by three groups
according to their clinical experience (junior group versus senior group).
Results: Total of 2,982 patients visited the emergency center during the study
period. We enrolled 478 (16.2%) patients to evaluate the ESI-4 between triage nurses
and research nurses, and another 442 (14.8%) patients for triage nurses and the
emergency resident. The weighted kappa was 0.49 (0.39-0.55), and 0.47 (0.39-0.55),
respectively. Triage nurses were divided into two groups by their clinical experience (3
years), the weighted kappa was 0.47 (0.35-0.58) for the junior group, and 0.50 (0.410.59) for the senior group.
The analysis of survey showed relatively high scores on “Faster intervention for
high-priority patients,” and “Higher accuracy of triage” after implementing the ESI4. The longer clinical experience they had, the higher self-efficacy was scored.
Conclusion: For validating the ESI-4, moderate level of reliability was measured
among nurses and between nurses and an emergency physician in a Korean single
ED. Analysis of the effect of the ESI-4 showed similar effects for each group, but
higher self-efficacy for more experience group.
306
Video Technologies in Emergency Health Research
in Assessing Quality of Care: A Study of Trauma
Resuscitation Milestones
Sen A, Hu P, Mackenzie C, Xiao Y, Dutton R/Henry Ford Hospital, Detroit, MI; R
Adams Cowley Shock Trauma Center, Baltimore, MD
Study Objective: Studies have demonstrated that trauma resuscitation times are
predictive of patient outcome and increased delays were detrimental to patient care.
Use of video technologies in emergency research is a novel way of identifying system
roadblocks and ensuring quality of care and efficiency. We assessed resuscitation
times, milestones and factors which influence golden hour trauma patient care in the
emergency department (ED).
Methods: Following institutional review board-approval, video-recorded images
were retrospectively analysed over a 4-week period, in 145 patients presenting with
major trauma. Time to CT scan, conventional x-rays, Lodox Statscan, endotracheal
intubation (ETI), insertion of chest tubes, central venous access was measured from
time of patient admission. Multivariate analysis was performed to account for the
influence of diurnal and on-call teams, patient census, Injury Severity Score (ISS) and
the effect of patient GCS on time to resuscitation milestones. Statistical analysis was
conducted using JMP SAS (SAS Institute, Cary, NC, USA).
Results: Our video analysis of trauma resuscitation showed 100% compliance
with time to CT within 2 hrs in patients with GCS⬍⫽13. Reduced GCS and high
ISS were strongly predictive of time to CT and ETI in a multivariate regression
analysis (p⬍0.001). Use of Lodox Imaging, low ED census was associated with
significantly reduced resuscitation times (p⬍0.05).
Conclusions: Video recording has the advantages of providing accurate times to
interventions that are not hindered by poor documentation or the memory of those
involved. It can be a useful tool in resuscitation quality evaluation and identify
variances in process flow helping in addressing inefficiencies in emergency care.
307
Customer Service and Communication Training
Initiative for Emergency Physicians Improves
Patient Satisfaction Despite Crowding in the
Emergency Department
Katz GR, Schwaab J, Pestrue J, Moseley MG, Caterino J/The Ohio State
University, Columbus, OH
Study Objectives: To evaluate the effect of a physician-oriented customer service
and communication training program on emergency department (ED) patient
satisfaction in a crowded ED.
Methods: A retrospective cohort study was conducted at this university ED with
an emergency medicine residency program. In preparation, three faculty physicians
attended a health care-oriented customer service training program offered by The
Disney Institute. Using this knowledge base and incorporating industry best
practices, these physicians developed a customer service training program for
S96 Annals of Emergency Medicine
widespread implementation in an academic ED. All faculty and resident physicians
either participated in the program during allotted conference periods or watched a
video of the program, resulting in 4 hours of customer service lectures annually. The
curriculum focused on the use of communication tools, such as scripted responses
and personalized provider information cards, and the importance of consistent
caregiver messages with respect to patient care plan and anticipated waiting and
testing times. An outside speaker was recruited to increase the perception of
credibility and value of customer service training; however, the curriculum was
directed by previously trained faculty physicians. The effectiveness of this program
was assessed by evaluating trends in patient satisfaction scores post-intervention.
Results: Sixty-six resident and faculty physicians participated in the customer
service training program in 2007 and again in 2008. During the study period the
annual ED census exceeded 58,000 visits, hours of diversion averaged over 740 per
year, and the “Left Without Being Seen” rate was 4.7%. Patient satisfaction was
measured using a one-to-ten scale in a variety of domains. Analysis of 2,972 patient
satisfaction surveys collected before and after the intervention revealed significant
improvement in patient perceptions. Overall satisfaction with the ED experience
improved from 58.4% of patients rating their experience a 9 or 10 in the fiscal year
ending June 30th 2006 to 65.5% for the year ending June 30th, 2008 (p⫽.001). The
primary driver of satisfaction was communication, accounting for 29.7% of the
change in overall satisfaction. Additionally, care provided by physicians accounted for
23.6%. Post-intervention satisfaction scores also showed significant improvement in
“satisfaction with physician” (69.6% vs. 74.7%, p⫽.002), “satisfaction with
communication” (64.9% vs. 69.7%, p⫽.005), and “physician courtesy and respect”
(75.8% vs. 79.0%, p⫽.023).
Conclusion: Despite ED crowding, which is purported to be a service dissatisfier,
physicians can improve patient satisfaction and impact the perception of the care they
provide with customer service-oriented communication tools.
308
A Lean-Based Triage Redesign Process Improves
Door-to-Room Times and Decreases Number of
Patients at Triage
Farley H, Hines D, Ross E, Massucci JL, Alders V, Reed J, Sweeney T, Jasani N,
Reese CL/Christiana Care Health Systems, Newark, DE
Study Objective: To determine if a Lean-based triage redesign process improves
the mean door-to-room time of Emergency Severity Index (ESI) 4 and 5 patients and
decreases the mean number of these patients waiting at triage.
Methods: A prospective analytic cohort study of ESI 4 and 5 patients presenting
to an academic emergency department (ED) with an annual volume ⬎100,000 was
conducted in 2008. All ESI 4 and 5 patients presenting to the ED during the study
period were included. The mean door to room time was calculated for each of the
following time periods: 2300-0700, 0700-1500, and 1500-2300. The number of ESI
4 and 5 patients waiting to be seen at triage was collected on an hourly basis by an
electronic patient tracking system and means were calculated for each of the same
time periods. Utilizing Lean principles to reduce non-value-added activities in patient
care, a triage redesign process was progressively implemented from May-August,
2008. The mean door-to-room time and the mean number of ESI 4 and 5 patients at
triage were compared before (1/1/08-4/30/08) and after (9/1/08-12/31/08) the
intervention using Student’s t-test, with a p-value of ⱕ 0.05 considered significant.
Results: 28,446 pre-intervention patient visits and 32,099 post-intervention
patient visits were analyzed. There was a significant improvement in door-to-room
time overall (64.2 vs. 43.5 min, p⬍0.001), from 2300-0700 (72.6 vs. 41.8 min,
p⬍0.001), 0700-1500 (48.2 vs. 38.4 min, p⬍0.001), and 1500-2300 (77.4 vs. 50
min, p⬍0.001). There was also a significant decrease in the mean number of ESI 4
and 5 patients waiting at triage overall (4.2 vs. 2.9, p⬍0.001), from 2300-0700 (3.9
vs 2.6, p⬍0.001), and from 1500-2300 (6.7 vs. 4.9, p⬍0.001). There was no
significant difference observed from 0700-1500 (2.6 vs. 2.2, p⫽0.179).
Conclusion: Implementation of a Lean-based triage redesign effort resulted in a
significant decrease in the mean door-to-room time, as well as in the mean number of
ESI 4 and 5 patients waiting at triage.
309
Validation of Modified Emergency Severity Index
Version 4
Lee J, Choi H, Shin S, Kim D, Ro Y/Seoul National University Hospital, Seoul,
Republic of Korea
Study Objectives: Emergency Severity Index (ESI) has been used widely in US,
which categorize the emergency patients according to acuity and need for resources to
Volume , .  : September 
Research Forum Abstracts
manage them. To make successful triage, trained providers should decide on the basis
of their experience. To increase inter-rater reliability, we modified ESI and tested its
validity.
Methods: This study was done in an urban teaching hospital emergency
department (ED), which has about 45000 annual visit. Triage nurses were trained
and implemented from July to September in 2008. Data were collected from
electronic medical record, which include all components to be needed for ESI and
ED results from November to December in 2008 for more than 15 years old patients.
To compare with original ESI, we modified it as followings;
M1: Level three with mildly abnormal vital sign (HR⬎100, RR⬎20) is
automatically categorized as level two.
M2: Level three with severely abnormal vital sign (HR⬍⫽40, HR⬎⫽120,
RR⬍⫽10, RR⬎⫽25) is automatically categorized as level two.
M3: Level three with abnormal vital sign (HR⬍⫽40, HR⬎⫽120, RR⬍⫽10,
RR⬎⫽25) is automatically categorized as level 2. If number of expected resources is
over than three, one to two, and zero, the cases are categorized as level three, level two
and level one, respectively.
Validity was compared using the area under the receiver operating characteristic
curve (AUC) and 95% confidence interval (95% CI) to predict the outcome, which
defined as hospital death, intensive care (admission to intensive care unit or hospital
death).
Results: Total number of patients was 5,478 (male 51.4%. mean age 53.3⫾
18.2). Of these, mortality was 1.6%. The distribution by original ESI was level one
(2.70%), level two (13.16%), level three (74.66%), level four (8.63%), and level five
(0.84%). In M1, M2, and M3, proportions were changed to 32.69%, 15.20%,
15.20% for level two, 55.11%, 72.21, 54.78% for level three, 8.65%, 8.65%,
26.58% for level four, respectively.
The AUCs of original ESI, M1, M2, and M3 for mortality was 0.822 (95% CI,
0.772⬃0.872), 0.848 (95% CI, 0.808⬃0.889), 0.829 (95% CI, 0.779⬃0.879), and
0.845 (95% CI, 0.801⬃0.889), respectively. The AUCs of original ESI, M1, M2,
and M3 for intensive care was 0.830 (95% CI, 0.806⬃0.854), 0.827 (95% CI,
0.794⬃0.840), 0.817 (95% CI, 0.803⬃0.851), and 0.830 (95% CI, 0.806⬃0.854),
respectively. There was no significant difference among original ESI and modified
ESIs.
Conclusion: More objective decisionmaking tools, modified ESIs showed very
similar performance to predict outcomes compared to original ESI.
310
Impact of Mandated Nurse-Patient Ratios on Time
to Antibiotic Administration in the Emergency
Department
Chan TC, Vilke GM, Killeen JP, Guss DA, Marshall J, Edward CM/University of
California, San Diego, San Diego, CA
Study Objectives: Mandated nurse-patient ratios (NPRs) are gaining attention as
a means of improving the quality of health care. The impact of NPRs in the
emergency department (ED) where patient acuity and census fluctuate are unclear.
Our study objective was to assess the effect of mandated NPRs on ED patient care.
Our null hypothesis was that NPRs would have no impact on timeliness of patient
care, specifically time to antibiotic administration for pneumonia patients.
Methods: Design: Multi-center prospective observational study on the effects of
mandated NPRs. Setting: Two EDs, an academic, urban center and suburban,
community hospital, with combined census 61,000. Participants: All patients seen in
the EDs for a 12-month period (January 2008 through December 2008) following
implementation of State-mandated NPRs. We developed an automated electronic
tracking system to track changing patient acuity and staffing, and to calculate realtime NPRs every 10 minutes. “Out of ratio” (OOR) was defined as a patient whose
ED nurse had patient responsibilities greater than current State-mandated NPRs for
more than 20 minutes of care time. Patient data collected included real-time patient
acuity, diagnosis, length of stay, NPR status of the nurse, and physician order-toadministration time for antibiotics. ED data included daily census, admissions and
overall NPR compliance. Log-linear regression models were used to assess the effect of
NPR status on medication administration time after controlling for ED census,
admission rate and acuity. Beta coefficients and associated with 95% confidence
intervals [CI] are reported.
Results: Overall, during the study period in both EDs, 92.5% of patients were
cared for by ED staff while “In-Ratio” (IR) and 7.5% were cared for when staff was
OOR. More patients had nurse staff OOR when admitted to an inpatient service
(11.1%) compared to discharged (6.6%). A total of 5,318 (9.3%) patients received
antibiotics during their ED stay, of which 5.8% were diagnosed with pneumonia.
Volume , .  : September 
Medication administration time (physician order-to-administration) was 24 minutes
(IQR⫽11, 49) for all patients who received antibiotics. Time to antibiotic
administration was 24 minutes (IQR⫽11, 49) when nurse staff was IR, and 29
minutes (IQR⫽ 15, 60) when OOR. For patients diagnosed with pneumonia, time
to antibiotics was 28 minutes (IQR⫽14, 54) overall, 27.5 minutes (IQR⫽14, 53)
when IR, and 30 minutes (IQR⫽15, 71) when OOR. Using log-linear regression,
after controlling for patient acuity at time of triage, hospital, and census at time of
ED admission, there was no significant difference in terms of time to antibiotics
overall or for patients diagnosed with pneumonia (8.2%, [CI ⫺4.9 to 21.3%],
p⫽0.221 overall and ⫺16.0%, [CI ⫺66.2 to 34.2%], p⫽0.531).
Conclusion: In this study, NPR status did not significantly impact timeliness of
antibiotic administration (order-to-administration time) for ED patients, including
those treated for pneumonia.
311
Care Plan Program Reduces the Number of Visits
for High-utilizing Psychiatric Patients in the
Emergency Department
Abello A, Brieger B, Ziebell C, Dear K, Milling Jr T, King B/University Medical
Center at Brackenridge, Austin, TX
Background: A small number of patients representing a significant demand on
emergency department (ED) services present regularly for a variety of reasons,
including psychiatric or behavioral complaints and lack of access to other services.
The care plan program was created in 2001 as a database of ED high-utilizers and
patients of concern, as identified by ED staff and reviewed and approved by program
administrators. Care plans were generated and discussed with the patients and visual
cues inform providers of care plan availability. This program has been implemented
to improve their care and mitigate local ED strain.
Study Objectives: To determine whether enrollment in the care plan program
reduces the frequency of ED visits for high-utilizing psychiatric patients, whether
patients utilized other appropriate avenues of psychiatric treatment in lieu of ED
visits, and to identify which psychiatric conditions or demographic groups respond
most favorably in terms of compliance and better treatment pattern outcomes.
Methods: A list of medical record numbers was assembled by searching the
program database and ED registration databases for adult patients initially enrolled
between the dates of 11/1/06 and 10/31/07. Inclusion criteria were occurrence of a
psychiatric ICD9 code in their medical record or a care plan code of 1 or 2, implying
a serious psychiatric disorder causing harmful behavior. Additional data was acquired
using an indigent care tracking database and electronic medical records. Variables
collected from these sources were analyzed to identify changes before and after
program enrollment.
Results: Forty-eight patients were chosen for the cohort. The median age was
38.5 [19-63; SD⫽11.3], non-normal distribution. The cohort was 24% uninsured,
and 23% had unpaid medical bills or related collection agency debt; 43.5% were
enrolled in federal insurance coverage (Medicaid/Medicare), while only 13% of the
cohort received coverage from the local county insurance program; and another 13%
were privately insured. During the visit immediately prior to High Alert Program
enrollment 25% of patients reported pain without injury on presentation, and an
additional 11.4% presented specifically with chest pain, while only 20.5% were given
a psychiatric chief complaint and an additional 7% presented with poisoning/
overdose. There was a significant reduction in the number of visits to the ED from
the year prior to program enrollment to the year following enrollment (8.9 prior to
5.9 post, p⬍0.05). There was also an increase in psychiatric hospital visits (2% prior
to 25% post, p⬍0.05). Patients with uninsured financial status were found to be
more likely to respond to enrollment with a reduction in visits (p⬍0.05).
Conclusion: An alert program that identifies ED high-utilizers with psychiatric
conditions and creates a care plan reduces visits and leads to more appropriate use of
other resources.
312
Patient Satisfaction Is Associated With Clinical
Quality and Hospital Outcomes in Acute
Myocardial Infarction
Glickman S, Boulding W, Manary M, Staelin R, Cairns C, Schulman K/University
of North Carolina, Chapel Hill, NC; Duke University, Durham, NC
Background: Many hospitals now routinely utilize patient satisfaction surveys
instruments and data to assess the quality of their care. Despite their popularity, it is
unclear whether patient satisfaction data provides any useful information about the
Annals of Emergency Medicine S97
Research Forum Abstracts
medically related quality of hospital care (ie, the performance of evidence-based
treatments) or if it provides independent information on the overall quality of patient
care above that obtained from the more accepted clinical performance measures.
Study Objectives: To determine 1) whether patient satisfaction data is associated
with the quality of cardiac care, as measured by adherence to evidence-based
guidelines; and 2) whether patient satisfaction data is an independent predictor of a
hospital’s risk-adjusted inpatient mortality rate.
Methods: Clinical processes of care and patient outcomes for patients with acute
non-ST segment elevation myocardial infarction were obtained from the CRUSADE
registry. Patient satisfaction data for cardiac admissions were obtained from patient
surveys administered by a large corporate provider of satisfaction data. Pairwise
Pearson product moment correlation coefficients and weighted least squares linear
regression were used to evaluate the association of hospital patient satisfaction scores
with clinical quality with hospital risk adjusted in-patient mortality rates.
Results: Twenty-five hospitals (203 hospital quarterly observations), comprising
3,562 completed patient satisfaction surveys and clinical data on 6,411 patients in the
CRUSADE registry were included in the analysis. Higher hospital-level patient
satisfaction scores were positively correlated with adherence to evidence-based
treatments for acute myocardial infarction. (R⫽0.20, p⬍0.01 for a composite
measure of 6 acute measures including aspirin and beta blocker at arrival, EKG
within 10 minutes, heparin use, glycoprotein IIb/IIIa inhibitor use, and cardiac
catheterization within 48 hours). Higher hospital-level satisfaction scores were
associated with lower inpatient mortality (R⫽-0.19, p⬍0.01). In multivariable
analysis, after controlling for a hospital’s clinical performance, patient satisfaction was
an independent predictor of inpatient mortality (p⫽0.02). A 10% absolute increase
in a hospital’s average patient satisfaction score was associated with a 37.7% relative
reduction in hospital risk-adjusted mortality.
Conclusion: Patients’ assessments of their care may provide important,
independent information to consumers and hospital managers about the overall
quality of emergency department and hospital care for acute myocardial infarction.
313
Effect of IV Deferoxamine on Burn Wound
Progression
Lim T, Lin F, Taira BR, Singer AJ, McClain SA, Clark RA/Stony Brook University,
Stony Brook, NY
Study Objectives: We have previously shown that pretreatment with curcumin
reduces burn wound progression in a rat comb burn model. While the exact
mechanism of curcumin is unknown, some have proposed that it acts as an iron
chelator, reducing free oxygen radical generation that can lead to cell injury.
Deferoxamine is an iron-chelating agent used in the treatment of acute iron
intoxication and chronic iron overload. We hypothesized that treatment of burns
with IV deferoxamine would reduce the conversion of the burn zone of stasis to full
necrosis.
Methods: Design - Randomized controlled experiment. Subjects - 15 SpragueDawley rats. Interventions - Two burns were created on each animal’s dorsum using a
brass comb with four rectangular prongs preheated in boiling water and applied for
30 seconds resulting in four rectangular 10 x 20 mm full thickness burns separated by
three 5 x 20 mm unburned interspaces (zone of ischemia). The interspaces represent
the zone of stasis and left untreated most progress to necrosis over 1-3 days. Animals
were randomized to receive one of three doses of deferoxamine or vehicle one hour
and 24 hours after injury. Outcomes - Wounds were observed at 7 days after injury
for visual evidence of necrosis in the unburned interspaces. Full thickness biopsies
from the interspaces were evaluated with hematoxylin and eosin staining 7 days after
injury for evidence of necrosis. Data Analysis - The percentage of interspaces that
progressed to necrosis were compared with ⌾2 tests.
Results: Thirty comb burns with 90 unburned interspaces were created and
distributed between control, three doses of deferoxamine, and vehicle. The number of
interspaces that progressed to full thickness necrosis were 27/33 (0.82) in the control
group, 15/18 (0.83) in the low dose (10mg/kg), 12/18 (0.67) in the intermediate
dose (30 mg/kg), and 13/18 (0.72) in the high dose (100mg/kg) treatment groups.
When compared to controls, there was no significant difference in the percentage of
interspaces undergoing necrosis in the low, intermediate, and high dose treatment
groups respectively (p⫽ 0.892, 0.228, 0.426).
Conclusion: Treatment with IV deferoxamine has not reduced the percentage of
unburned skin interspaces that progress to full necrosis in a rat comb burn model.
S98 Annals of Emergency Medicine
314
Effect of IV Pentoxifylline on Burn Wound
Progression
Lim T, Taira BR, Singer AJ, Lin F, McClain SA, Clark RA/Stony Brook University,
Stony Brook, NY
Study Objectives: Cutaneous burns are dynamic injuries with a central zone of
necrosis surrounded by a zone of ischemia. Progression of this ischemic zone to full
necrosis over the days following injury is due in part to free oxygen radicals and
impaired perfusion due to vasoconstriction and micro-thrombosis. Pentoxifylline
(PTX) is synthetic xanthine derivative that has been shown to have anti-platelet and
anticoagulant activities, decrease blood viscosity and inhibit thrombus formation. We
hypothesized that treatment of burns with PTX would reduce the conversion of the
ischemic zone to full necrosis.
Methods: Design - Randomized controlled experiment. Subjects - Eighteen
Sprague-Dawley rats. Interventions - Two burns were created on each animal’s
dorsum using a brass comb with four rectangular prongs preheated in boiling water
and applied for 30 seconds resulting in four rectangular 10 x 20 mm full thickness
burns separated by three 5 x 20 mm unburned interspaces (zone of ischemia). Left
untreated, most interspaces undergo necrosis within 1-3 days. Animals were
randomized to receive one of three doses of PTX or vehicle 1 hour and 24 hours after
injury. Outcomes - Wounds were observed at 7 days after injury for visual evidence of
necrosis in the unburned interspaces. Full thickness biopsies from the interspaces were
evaluated with hematoxylin and eosin staining 7 days after injury for evidence of
necrosis. Data Analysis - The percentages of interspaces that progressed to necrosis
were compared among groups with ⌾2 tests.
Results: Thirty-six comb burns with 108 unburned interspaces were created
and distributed between control, 3 doses of PTX and vehicle. The number of
interspaces that progressed to full thickness necrosis was 27/33 (0.82) in the
control group, 15/24 (0.63) in the low dose (4mg/kg), 21/24 (0.88) in the
intermediate dose (8 mg/kg), and 22/24 (0.92) in the high dose (12mg/kg)
treatment groups. When compared to controls, there were no significant
differences in percentage necrosis in the low, intermediate and high dose
treatment groups respectively (p⫽ 0.102, 0.557, 0.291).
Conclusion: Treatment with IV PTX does not reduce the percentage of
unburned skin interspaces that progress to full necrosis in a rat comb burn
model.
315
Catecholamines in Simulated Arrest Scenarios
Lundin EJ, Dawes DM, Ho JD, Ryan FJ, Miner JR/University of Louisville,
Louisville, KY; Hennepin County Medical Center, Minneapolis, MN; Lab Corp,
Phoenix, AZ
Study Objectives: The mechanisms of death in many arrest-related deaths are
unclear. Law enforcement devices or tactics are often scrutinized in these unexplained
cases. Unexplained arrest-related deaths have occurred after the use of electronic
control devices. The primary concern has been direct cardiac arrhythmias induced by
the delivered charge. Some authors have opined that the temporal relationship
between electronic control device use and arrest-related deaths may be related to an
acute stress cardiomyopathy induced by high circulating catecholamines, rather than
an immediate electrically induced arrhythmia. In this study, we compared the stress
response during several simulated use of force encounters.
Methods: This was a prospective, observational study of human subjects. The
subjects were a convenience sample of law enforcements officers receiving a training
exposure or TASER employees. Subjects were randomized to one of five groups: 1) a
150 meter sprint, simulating flight from law enforcement officers, 2) 45 seconds of
hitting and kicking a heavy bag, simulating physical combat with law enforcement
officers, 3) a 10-second TASER X26 exposure, 4) a K-9 training exercise of
approximately 30 seconds, and 5) an oleoresin capsicum (O.C.) exposure to the face.
Subjects had an intravenous catheter placed by a physician or paramedic prior to the
test. Baseline catecholamines (epinephrine, norepinephrine, dopamine, and total)
were drawn at that time. Subjects then participated in their assigned task.
Catecholamines were drawn immediately (within 30 seconds) after the task and every
2 minutes for 10 minutes.
Results: Sixty subjects completed the testing. The median age was 35 (range 19 to
67), 85% were male, and the median body mass index was 27.8. For total catecholamines,
there was no difference between the groups at baseline and the median pre-task was 474
(range 241 to 1348, IQR 296 to 824). Immediately after the task, the highest median was
the heavy bag group at 3621 (range 1359 to 11669, IQR 3177 to 4891). The next highest
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Research Forum Abstracts
was the sprint group at 2070 (range 1466 to 3606, IQR 1794 to 2518). The K-9 group
was next at 1503 (range 803 to 2001, IQR 1299 to 1642). The TASER group and O.C.
groups were last at 1038 (range 653 to 1363, IQR 955 to 1089) and 1032 (range 545 to
1233, IQR 736 to 1085). These differences persisted for all time points. Fractionated
results followed the same pattern.
Conclusions: The comparison of use of force encounters demonstrated that the
TASER X26 was one of the least activating of catecholamines while the simulated
combat was one of the most activating of catecholamines. The authors recommend
further study in this area to assist law enforcements officers in determining the best
tactics and devices to utilize in arrest scenarios that have higher likelihood of being
associated with an arrest-related death.
316
Visualization of Intraosseous Flow Paths by
Angiography, Computed Tomography and Vital Dye
Techniques
De Lorenzo RA, Rubal BJ, Ward JA, Jordan BS, Hanson CE,
Holbrook-Emmons VL, Medina JS/Brooke Army Medical Center, Fort Sam
Houston, TX; Brooke Army Medical Center, San Antonio, TX
Study Objective: Visualization of intraosseous flow paths by angiography,
computed tomography and vital dye techniques.
Background: Understanding the dynamic flow characteristics of intraosseous (IO)
infusions is important to understanding the nature of drug and fluid delivery using
this route. We employed angiography and selective ante mortem and post mortem
contrast computed tomography (CT) to define IO venous conduits, late
intramedullary flow phenomena, and extraosseous extravasation.
Methods: Twenty-seven IO sites (N⫽36) (EZ-IO 9001 AD, Vidacare, San
Antonio, TX) were established in 4 female swine (Sus scrofa, 39.6 ⫾ 1.7 Kg) in the
proximal tibia, distal femur, distal humerus, sternum, proximal ulna and proximal
tibia under fluoroscopic guidance. The adequacy of IO needle placement was
determined by withdrawal of medullary blood and/or infusion of normal saline.
Following ⬎ 2 hours of hemodynamic recording from each IO site, IO flow was
assessed by cine angiography at 30 frames per second (OEC, Medical Systems Inc,
Salt Lake City, UT) using high flow ⱖ3ml/sec ⱖ150 psi, Mark V power injector,
MedRAD, Pittsburgh, PA) or low flow (gravity flow at 55cm or slow hand infusion)
contrast infusion (Iohexol, 300mg/ml, GE Health care, Princeton, NJ). CT
angiography was performed in two animals antemortem and in two animals
postmortem. 5-10cc of tissue marking dye (TMD-5, TBS, Durham, NC) was infused
post mortem at IO sites for visualization of extravasations and medullary flow.
Representative bone samples were demineralized with 17% HCL and longitudinally
sectioned for direct correlate with angiography.
Results: Adequate IO placement was achieved in 90% of attempts. Failures were
identified by extraosseous extravasation of contrast agent. Evidence of local contrast
infiltration of cancellous regions near the IO site was observed in all successfully
placed IO needles. Low pressure contrast infusions revealed a web of venous channels
that drained to a single nutrient foramen with needle placement within the diaphysis.
However, IO placement near the metaphysis (n⫽3) or within epiphysis (n⫽1)
revealed multiple outflow channels. The number of outflow foramen could not be
determined at 4 sites. Retrograde medullary filling (flow away from nutrient foramen)
was consistently observed with high contrast flow rates often with a late sudden
expansion of venous channels. Antemortem and post mortem CT or vital dye
infusion confirmed the presence retrograde venous perfusion within the IO
compartment.
Conclusions: In this animal model of an immature skeleton, observations of
retrograde contrast flow within the intraosseous compartment suggest that nutrient
foramen may offer significant resistance at high flow rates during intraosseous
infusion.
317
A Manometric Method for Evaluating Flow
Dynamics and Thrombus Burden of Intraosseous
Devices: Theory and Application
Rubal BJ, Ward JA, Jordan BS, Hanson CE, Medina JS, Holbrook-Emmons VL,
De Lorenzo RA/Brooke Army Medical Center, Fort Sam Houston, TX
Study Objective: It is well recognized that intraosseous (IO) devices provide the
benefit of rapid vascular access in cases of trauma, hemorrhage and cardiopulmonary
resuscitation when intravascular access cannot be achieved. In spite of the impact of a
new generation of IO devices for out-of-hospital care and battlefield injuries, few
methods are available for investigating IO perfusion dynamics. This study provides
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the theory and applications for a novel method for assessing IO compartment flow
dynamics and resistances that should prove useful for elucidating IO fluid- and
pharmaco-dynamics and failures.
Methods: A manometer is a fluid-filled tube used to directly measure
compartment pressures by the height of a fluid column. When a saline-filled
manometer is attached to an IO access port, the fluid in the manometer discharges
until manometer pressure equals pressure within the marrow compartment. These
changes in pressure were modeled by a three parameter exponential decay model
(Pman ⫽ Po e-bt ⫹ Pbone). Where Pman ⫽ the height of the manometer column during
discharge into the IO compartment, Po ⫽ initial height of the manometer fluid
column, b ⫽ decay constant, t ⫽ time in minutes, and Pbone ⫽ the height of
manomometer column when equilibrated with pressures in the IO compartment.
Because the manometer is of uniform diameter, changes in manometer height with
time also represent calibrated fluid flow into the I/O compartment. The decay
constant (b) may be used as an index of outflow resistance and outflow and inflow
resistances can be calculated given central venous pressure and arterial pressure,
respectively. In this study, manometer discharge pressures were recorded from the
proximal tibia (EZ-IO 9001 AD, Vidacare, San Antonio, TX) using a 55cm x 2mm
saline-filled manometer (Cardinal Health, Dublin, OH) from 4 female swine (Sus
scrofa, 39.6 ⫾ 1.7 Kg) under general anesthesia.
Results: Under baseline conditions, aortic blood pressure was 83/52 mmHg
(mean ⫽ 64 mmHg) and mean central venous pressure was 3 mmHg. An
excellent fit (R2 ⫽ 0.999, P⬍0.001) was noted with the three parameter model.
In series of observations, the initial decay constant with saline discharge through
the manometer was (b⫽ 0.0008), following a 3cc saline flush IO flow improved
(b⫽0.003). Further improvement was observed with a 3 cc heparin flush (b ⫽
0.040), and with a heparin flush followed by the infusion of heparin saline
through the manometer (b ⫽ 0.200). IO thrombus depressed the decay constant
and increased IO outflow resistance.
Conclusions: These data suggest that manometer discharge pressures may prove
useful in assessing the flow dynamics of the IO compartment and in characterizing
the time course of IO failures. Preliminary results at low infusion pressures (⬍55cm
saline) followed by heparin infusion suggest that IO flow is influenced by the
activation of the clotting cascade. Furthermore, results suggest that a heparin
challenge following standard IO infusion protocols may prove useful for assessing
intraosseous thrombus burden.
318
Fetuin Protects Mice Against Lethal Sepsis by
Modulating Bacterial Endotoxin-Induced HMGB1
Release and Autophagy
Wang H, Lam L, Li W, Ashok M, Zhu S, Ward MF, Li J, Yang H, Tracey K,
Sama A/North Shore University Hospital, Manhasset, NY
Background: The pathogenesis of sepsis is complex, but in part mediated by
bacterial endotoxin, which stimulates macrophages to release early (eg, TNF, IL-1)
and late (eg, HMGB1) pro-inflammatory mediators. Various inflammatory stimuli
(eg, endotoxin, cytokines, and oxidative stress) similarly induce autophagy, a catabolic
degradation process responsible for eliminating damaged cytoplasmic components
during infection. A negative acute phase protein, fetuin (fetus protein in Greek), was
recently characterized as a negative regulator of inflammation by opsonizing cationic
anti-inflammatory molecules (eg, spermine).
Study Objectives: To further elucidate the role of fetuin in lethal experimental sepsis.
Methods: We examined its effects on endotoxin-induced HMGB1 release and
autophagy in vitro, and determined whether administration of exogenous fetuin
protects mice against lethal experimental sepsis (induced by cecal ligation and
puncture, CLP) in vivo.
Results: In vitro, fetuin (25 - 100 microgram/ml) effectively inhibited
endotoxin-induced (100 ng/ml) HMGB1 release (by 60-90%), but enhanced
endotoxin-induced autophagy in macrophage cultures. In vivo, intraperitoneal
administration of fetuin (100 mg/kg, once daily, for three days) beginning at ⫹
24 hour post CLP, significantly increased animal survival rates from 40% (in
saline vehicle group, N ⫽ 22 mice/ group) to 90% (in fetuin group, N ⫽ 22
mice/group, P ⬍ 0.05).
Conclusion: Fetuin occupies a protective role in experimental sepsis by
attenuating a late mediator of lethal systemic inflammation.
Annals of Emergency Medicine S99
Research Forum Abstracts
319
Intracranial Constructive Interference of Low
Frequency Ultrasound: An In-Vitro Pilot Study of
Parameter Dependence
Smith DA, Shaw III GJ/University of Cincinnati, Cincinnati, OH
Study Objectives: The only FDA-approved therapy for acute ischemic stroke is
the administration of recombinant tissue plasminogen activator (rt-PA). However,
this therapy has a 6.4% rate of intracranial hemorrhage leading to interest in other
adjunctive therapies such as ultrasound-enhanced thrombolysis (UET).
UET was recently studied in several clinical trials, whereby ultrasound (US) is
applied to the skull of the stroke patient exposing the clot to US while administering
rt-PA therapy. In a trial of 2 MHz UET was shown to increase vessel recanalization in
acute ischemic stroke patients, and there was a trend towards improved neurologic
outcome at 3 months. A trial of 300 kHz UET resulted in a significant increase in the
intracranial hemorrhage rate (⬃25%), with no improvement in patient outcome.
Ultrasound is altered by the skull; the incident wave passes through the temporal
bone and is attenuated. The pulse then travels to the opposite side, and reflects from
the inner table adding to the incident pulse. This phenomenon is called “constructive
interference,” and may lead to larger pressures than expected from attenuation alone.
In a previous work, it was shown that 120 kHz ultrasound pressure amplitude is
reduced by 23% by the temporal bone. It is desirable to minimize the acoustic
pressure in UET-based therapies, as high amplitudes can cause substantial bioeffects;
such bioeffects may explain the results of the 300 kHz UET study.
In this work, we measure the acoustic field of 120 kHz ultrasound within a
human skull for various ultrasound parameters. We hypothesized that constructive
interference within the skull occurs at 120 kHz, resulting in larger pressure
amplitudes than would be expected by attenuation alone by the temporal bone.
Methods: A skull with the top removed was degassed and placed in a water tank
filled with deionized distilled water. A custom-made 120 kHz transducer (Sonic
Concepts, Bothell, WA), was used to generate the ultrasound, and oriented such that
the ultrasound was incident normal to the temporal bone. A hydrophone (Reson
TC4308) was placed in a computer-controlled 3 axis positioning system, and the
acoustic pressure field mapped as a function of position within the skull, and in the
“free field” configuration. The ultrasound parameters used were: a duty cycle (DC) of
50% or 80%, a pulse repetition frequency (PRF) of 1.6, 5.4 or 8 kHz, and a peak to
peak pressure amplitude (Pp-p) of 0.23 or 0.33 MPa. Two measurements were made
for each setting, and the primary parameter of interest was the ratio R of the largest
Pp-p in the skull and the largest “free field” Pp-p for the same parameters. Data are
presented as means with standard deviations.
Results: Overall, the average R for all ultrasound treatments was 92⫾4%; larger
than the value of 77% that would result from temporal bone attenuation. Increasing
PRF, which would increase constructive interference, increased R from 87⫾2% to
94⫾1% for PRF values of 1.6 and 8 kHz respectively. There was no obvious
dependence of R on the remaining parameters.
Conclusions: Constructive interference of 120 kHz ultrasound within the skull
increases the pressure amplitude to a greater degree than would be predicted from
attenuation of the signal through the temporal bone. The interaction of ultrasound
and the skull is complex, and much work is needed to optimize UET-based therapies
while minimizing potential bioeffects.
320
0.62) for brightness, and 4.57 (SD 0.73) for contrast. All residents reported a score of
5 for anatomical identification.
Of 326 patients with USG guided CVC, 186 were eligible and incidence rate for post
CVC local/systemic infection was 0%. 16 patients received post CVC prophylactic
antibiotics. The average hospital infection rate post CVC was 7.56% over 2 years.
The cost of equipment/CVC was $2.80 compared to existing estimates of $22 for
prevalent techniques.
Conclusion: The use of Tegaderm®, and povidone iodine antiseptic solution, is a
cheap, reproducible, technique for maintaining asepsis during guided CVC. The
adaptability of Tegaderm® to most probe types makes it potentially universally
applicable for all USG guided procedures.
Asepsis in Ultrasound-Guided Central Venous
Access: A New Technique
Subhan I, Jain A, Joshi M/Apollo Health City, Hyderabad, India; University of
Rochester, Rochester, NY
Study Objective: Development of a new cost-effective technique for maintaining
asepsis during ultrasound (USG)-guided central venous catheterization (CVC).
Methods: A 2-operator technique for aseptic precautions during USG-guided
CVC was developed using sterile self-adhesive plastic (Tegaderm® 10x12 cm), and
povidone iodine solution. To gauge coherence, a 5-point Likert scale questionnaire
for comparing 4 pairs of images (each pair comprising images obtained using standard
gel and the new technique) was answered by 30 emergency medicine residents.
Following this patients undergoing USG-guided CVC with the new technique
from Jun/07-May/08 were prospectively followed for 4 days. Patients ⬍15 years,
undergoing re-catheterization, receiving oral/intravenous antibiotics prior to
procedure, with sepsis prior to CVC; catheter removal, death or discharge within 4
days, were excluded. Post-CVC infection criteria were pre-defined.
Results: Mean Likert scores were 4.73 (SD 0.45) for image coherence, 4.9 (SD
S100 Annals of Emergency Medicine
321
Out-of-Hospital Critical Care Providers’ Retention of
Ultrasound Skills for Diagnosis of Pneumothoraces:
A Nine-Month Follow-Up
Lyon M, Walton P, Bloch A, Shiver SA/Medical College of Georgia, Augusta, GA
Study Objectives: A prior study demonstrated that out-of-hospital critical care
providers (PHCP) can accurately determine the presence or absence of sonographic sliding
lung sign (SLS) for the diagnosis of pneumothorax (PTX). Our objective is to determine
the PHCP’s accuracy to detect the SLS after 9 months of clinical usage.
Methods: This was a blinded randomized observational trial assessing the ability
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Research Forum Abstracts
of PHCPs to identify SLS with ultrasound (US). After training in the use of US for
the diagnosis of PTX, the PHCPs, were allowed to use the technique during aeromedical transport for patient care. After a 9-month period of clinical usage, the
PHCPs were reevaluated using the same cadaveric model used in the prior training.
No further instruction was given concerning the technique. Participants used a
SonoSite 180 PLUS machine with a microconvex transducer in clinical practice and
in evaluation of the cadaveric model. A fresh warmed cadaver was used as a model for
demonstrating the presence or absence of the SLS. With ventilation and endotracheal
intubation, the pleural movements of the cadaver result in the appearance of the SLS.
With esophageal intubation, no pleural movement and no SLS are seen with
ventilation. This model has been validated in other research projects. The cadavers
were randomly intubated in the trachea (SLS) or in the esophagus (no SLS) as
determined by a random number generator. The intubations were accomplished
using direct laryngoscopy and fiber optic confirmation when necessary. Participants
were excluded from the room during the intubations, and the cadaver was completely
covered except for the chest area, thus blinding the participant to the location of
intubation. Each trial consisted of evaluation of the right hemithorax for the presence
or absence of the SLS. The participants were isolated from one another during the
data collection process, with each participant evaluating the cadaver independently.
No time limits were placed on the participants performing the US. Both M-mode
and Doppler US were also available for use at the participant’s discretion.
Results: Eight PHCP enrolled in the original study (4 RN and 4 CCEMT-P).
With 16 trials displaying no SLS and 32 displaying SLS, the presence or absence of
the SLS was correctly identified in 46 of the 48 trials for a sensitivity and specificity of
96.9% (95% CI, 89.6%, 99.1%) and 93.8% (93%, 79.3%) respectively. At the 9month follow-up study, 7 of the original PHCP were employed by the aeromedical
service, and all agreed to participate in the study. All reported clinical usage of US for
detection of SLS, but at a rate of less than 1 occurrence/month. The presence or
absence of the SLS was correctly identified in all 56 trials with 28 trials each showing
SLS or no SLS. The sensitivity was 100% (95% CI, 93.6%, 100%) and the specificity
was 100% (95% CI, 93.6%, 100%).
Conclusion: While complex diagnostic applications using US may not become
part of the critical care transporter’s skills in the near future, this study shows that all
members of a critical care transport team are able to retain this valuable skill with
varying amounts of clinical use over a nine-month period.
322
Rate and Outcome of First Trimester Indeterminate
Pelvic Ultrasounds in an Urban Emergency
Department
Phillips C, Bendeck K, Layman K, Milzman D, Antonis M/Washington Hospital
Center, Washington, DC
Study Objectives: To determine the rate of indeterminate pelvic ultrasounds on
pregnant patients by emergency department (ED) providers in an urban ED and
outcome if follow-up was done as instructed.
Methods: Design: A retrospective review of a prospectively collected Azyxxi
database (Smith and Feied; Redmond, Washington Microsoft). All patients found to
have a positive urine pregnancy and/or a serum quantitative beta human chorionic
gonadotropin (BHCG) level ⬎5 between March 1, 2009 and March 31, 2009 and
had a pelvic ultrasound by the emergency physician were included in the study. The
charts were reviewed by the blinded (other data) author for record of ultrasound
findings, BHCG level, discharge diagnosis, and any repeat visits to the ED.
Ultrasound findings were defined as intrauterine pregnancy (IUP) seen (yolk sac ⫹/fetal pole seen in the uterus), fetal demise, molar pregnancy, definite ectopic or
indeterminate (anything other than the above).
Setting: A 901-bed, community teaching and Level I trauma hospital with 84,000
ED visits annually staffed by ED attendings and emergency medicine residents.
Type of Participants: Consecutive ED patients with a positive urine or blood
pregnancy test and an ultrasound performed by the ED provider.
Results: Over the month included in the study, we found 103 pregnant patients
with an ultrasound performed by the ED provider. Thirty-six of the ultrasounds
(35%) were indeterminate. 19/36 (53%) had another study by an OB attending and
eight of those patients had a definitive ultrasound including IUP (4), blighted ovum
(2), fetal demise (1), and twin IUP (1).
In the remaining 28 patients, definitive diagnosis was made on the first visit in 11
by clinical exam and history including spontaneous abortion (8) and ectopic
pregnancy (3). There was also one patient admitted with pyelonephritis with no
definitive ultrasound finding. Sixteen remaining patients were instructed to follow up
in 48 hours in the ED. Of those, 7 never returned (43.8%). Nine patients did return
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as instructed and were diagnosed with spontaneous abortion or fetal demise (4 or
44.4%), IUP (4 or 44.4%) or ectopic pregnancy (1 or 11.1%). Of note, a total of 4 of
36 (11.1%) patients with an indeterminate ultrasound by the ED provider were
diagnosed with ectopic pregnancy on first or second visit.
Conclusion: Ectopic pregnancy occurs in 2% of all pregnancies, and is the
diagnosis to be excluded in the ED in a pregnant woman presenting with pain and/or
bleeding. Most patients had definitive diagnosis by the ED ultrasound (65%) without
OB involvement. Of the remaining patients with an ED ultrasound read as
indeterminate, 55% were still able to be diagnosed in one visit by OB ultrasound or
clinical exam. Ultimately 16 of 103 (15.5%) patients were told to follow up in the
ED for repeat testing. Our patients did not follow those instructions 43.8% of the
time, which points to a systemic problem. Of those who did follow the instructions, 1
of 9 or 11.1% had ectopic pregnancy diagnosed. Limitations of the study included
small sample size as most patients had a definitive ultrasound or diagnosis clinically.
Also, lacking the follow-up on almost half of patients points to a need for a better
follow-up system and also further study on a prospective basis for clarification of what
happens to patients with indeterminate ultrasound findings in the ED.
323
Technical and Interpretive Error Rates for the
Focused Assessment With Sonography in Trauma
Exam
Montoya AM, Gaspari RJ, Mendoza M, Resop D/University of Massachusetts
Medical School, Worcester, MA
Background: Integrating ultrasound into clinical practice requires that emergency
physicians possess an understanding of the images required to make an informed
decision, the technical skills to acquire an interpretable image, and the cognitive skills
necessary to interpret that image. Prior studies of ultrasound education have failed to
separate these different cognitive processes. It has been unclear which types of errors
are more common when learning emergency ultrasound, and therefore what areas
should be emphasized in training.
Methods: We conducted a retrospective analysis of prospectively collected data on
Focused Assessment with Sonography for Trauma (FAST) exams performed by
emergency medicine residents, fellows and attending physicians from June 2007 to
August 2008. The data was collected at an urban, academic medical center with
approximately 85,000 patient visits per year. All ultrasound studies performed in the
emergency department were recorded on DVD and reviewed by one of three emergency
physicians with extensive experience in emergency ultrasound. The acquired images were
scored for overall technical quality and for the inclusion of all required views. Technique
was graded using an 8-point scale of image quality with a score of 1 being regarded as
uninterpretable and a score of 8 being technically perfect images with all required
landmarks.
Results: A total of 2962 FAST exams were performed during the course of this study.
Of these studies, 9% were positive for the presence of free fluid. Interpretative error was
observed in 192 (6%) cases. There were 62 (2%) studies mistakenly interpreted as
negative by the physician performing the scan. The most frequently misinterpreted view
was the right upper quadrant (RUQ), which accounted for 32% of the false negative
readings. 130 (4%) studies were misinterpreted as being positive. Errors of interpretation
decreased as the experience of the physician performing the scan increased. Physicians that
had previously performed less than 25 FAST exams accounted for 16 (26%) false negative
interpretative errors. Those with 26-50 prior exams also committed 16 errors (26%) while
those with 51-75 and 76-100 prior exams committed 8 (13%) errors each.
The most difficult view to acquire was the left upper quadrant (LUQ) with 632
(36%) individual technical errors. All four required quadrants were included 91% of
the time with the supra-pubic (SP) view being omitted most frequently (14%).
Physicians that performed more FAST exams committed fewer technical errors.
Those that had completed 1-25 FAST exams committed 12% of the observed
technical errors, 26-50 scans accounted for 9%, 51-75 scans 6%, and 76-100 4%.
The most common technical score was a 6 (excellent technique on most views),
which accounted for 25% of all the studies, followed by 20% with a score of 7
(excellent technique on all views), and 16% with 8 (perfect technique).
Conclusion: Some views of the FAST exam are more difficult to acquire and interpret
than others. The SP view was most commonly missed, the LUQ view was the most
difficult to image and the RUQ view was the most difficult to interpret. As expected, the
number of errors decreased as the number of scans performed by the physician increased.
Education of the FAST exam should stress acquisition skills and interpretive skills
independently.
Annals of Emergency Medicine S101
Research Forum Abstracts
324
The Significance of the Wall Echo Shadow Triad on
Ultrasonography in Emergency Department
Patients
Singla A, Gupta S, Garg N, Bharati A, Chun P/New York Hospital Queens,
Flushing, NY
Study Objective: The wall-echo-shadow (WES) triad results from visualization of
the gallbladder wall, echoes from gallstones located immediately beneath the wall, and
posterior acoustic shadows. It represents a large stone or multiple small stones filling
the lumen of the gallbladder. The presence of a WES triad has been reported to
suggest the diagnosis of cholecystitis, but this has yet to be proven. The objective of
this study is to determine if the presence of a WES sign on gallbladder ultrasound
(US) carries an increased risk of infection, obstruction, or other complications.
Methods: This is a retrospective, cross-sectional, observational study. The subjects
were a convenience sample of patients who received a right upper quadrant abdominal US
in an urban, Level I emergency department (ED) with ⬎100,000 annual visits from 1/
2006 to 3/2009. The investigators were US trained registered diagnostic medical
sonographer-eligible or registered diagnostic medical sonographer-certified emergency
physicians. All 3,701 biliary US performed in the ED in that time period were reviewed
by the investigators and all patients with the WES triad were identified and then
confirmed by a registered diagnostic medical sonographer-certified emergency
sonographer. A chart review was then performed. Lab values, vital signs, admission
information, patient demographic information, intraoperative findings, pathology results,
and revisits to the emergency department for symptoms related to biliary disease were
documented for patients identified with the WES triad. Analysis was performed utilizing a
logistical regression model.
Results: Of 3, 701 US exams reviewed, 55 patients were identified to have the
WES sign. Thirty-eight of the 55 patients with a WES sign were admitted for
surgery. All of these admitted patients (100%) had abnormal intraoperative findings
and pathology reports: including acute cholecystitis, chronic cholecystitis, significant
adhesions or scarring secondary to ongoing inflammation, cystic duct stone, common
bile duct stone and cholecystoduodenal fistula. Of the 17 discharged patients, 8
patients had a repeat visits due to biliary disease. Patients with the WES triad were
more likely to be admitted based on age p⫽0.034, OR 1.030 (95% CI 1.002-1.058)
and elevated white blood cell count p⫽0.018, OR 1.41 (95% CI 1.062-1.878). No
other patient demographic, lab, vital sign, or ultrasound factors achieved significance.
Conclusion: Ultrasound of the gallbladder is a common procedure performed in
the emergency department. The significance of the WES triad has been hypothesized,
but not yet proven. We found that a large percentage of patients with the WES triad
on ultrasound have acute and chronic cholecystitis. Factors that support admission
include age and elevated white cell count. This suggests that the presence of a WES
sign may be a clinically significant finding for inpatient surgical evaluation and
treatment of gallbladder infection.
325
Access to Immediate Bedside Ultrasound in the
Emergency Department
Talley B, Ginde A, Raja A, Sullivan A, Camargo Jr C/Denver Health Medical
Center, Denver, CO; University of Colorado Denver School of Medicine, Aurora,
CO; Brigham and Woman’s Hospital, Boston, MA; Massachusetts General
Hospital, Boston, MA
Study Objectives: The use of bedside emergency department (ED) ultrasound has
become increasingly important for emergency physicians because of its ability to
provide rapid and real-time information to assist in clinical decisionmaking and
patient care, including trauma assessment and central line placement. In this study,
we sought to evaluate differences in the availability of bedside ultrasound based on
basic ED characteristics (eg, annual visit volume) and on physician staffing.
Methods: We surveyed physician or nurse directors of all 74 EDs in the state of
Colorado between January and April of 2009 and included supplemental data from the
2007 National Emergency Department Inventories (NEDI)-USA (www.emnet-usa.org).
We assessed access to bedside ED ultrasound by the following question: “Is bedside
ultrasound available immediately in the ED?” ED characteristics included ED visit
volume, location in an urban or rural area, hospital admission rate, total emergency
physician full-time equivalents (FTEs), and proportion of emergency physicians who were
board-prepared or board-certified (BC) by the American Board of Emergency Medicine,
American Osteopathic Board of Emergency Medicine, or the American Board of
Pediatrics. Data analysis used chi-square test to compare differences in access to bedside
ED ultrasound by ED characteristics and physician staffing.
Results: We received complete responses from 62 (84%) EDs. Immediate access to
S102 Annals of Emergency Medicine
bedside ultrasound was available in 42 (68%) EDs. The following ED characteristics were
associated with greater reported access to bedside ultrasound: higher visit volume (100%
for EDs with ⱖ3 patients per hour vs. 43% for ⬍1 patient per hour; p⬍0.001) and
urban location (85% vs 46% for rural areas; p⫽0.001). The following ED staffing factors
were associated with higher reported access to bedside ultrasound: greater number of
emergency physicians (100% for EDs with ⬎10 emergency physician FTEs vs 41% for
EDs with 0-4 emergency physician FTEs; p⬍0.001) and the percentage of board
certified/board prepared emergency physicians (97% for EDs with ⬎75% of emergency
BP/BC physicians vs 37% for EDs with 0-24% emergency medicine BP/BC physicians;
p⬍0.001). Hospital admission rates were not significantly associated with access to ED
bedside ultrasound.
Conclusion: Immediate access to ED bedside ultrasound was available in 68% of
Colorado EDs with significant differences according to basic ED characteristics and
physician staffing. Smaller, rural EDs and those staffed by fewer emergency BP/BC
physicians had less access to immediate ED bedside ultrasound. Given the proven utility
of bedside ultrasound in the evaluation and treatment of ED patients, the observed
differences in access should encourage emergency medicine educators and administrators
to focus on the diffusion of bedside ultrasound into both small and rural EDs.
326
Ultrasound of the Inferior Vena Cava Can Assess
Volume Status in Pediatric Patients
Ayvazyan S, Dickman E, Likourezos A, Wu S, Hannan H, Fromm C, Marshall J/
Maimonides Medical Center, Brooklyn, NY
Study Objective: Although approximately 9% of patients presenting to a pediatric
emergency department (ED) are dehydrated, there is no reliable method to measure
objectively the degree of intravascular dehydration. Respiratory changes in inferior vena
cava (IVC) diameter have been shown to predict volume status in adults. Previous
research has demonstrated correlation between IVC diameter and volume status in
children undergoing hemodialysis. Other studies have shown that IVC diameter in
children can be sonographically measured rapidly and accurately by emergency physicians.
If we can establish that IVC diameter predicts volume status in dehydrated children, this
tool could assist the emergency physician in rapid diagnosis and prompt resuscitation
without the need to wait for blood or urine tests. In this study we use the “dehydrated
patient” as a model for hypovolemia, with the idea that the data could ultimately be used
in the setting of any hypovolemic state. We aim to evaluate whether ultrasound of the
pediatric IVC can be used to reliably assess volume status.
Methods: This is a prospective cohort study. Pediatric ED patients ranging in age
from 1 to 41 months were assessed by a pediatric emergency physician and stratified
as either clinically euvolemic or hypovolemic. After consent was obtained, one of
three emergency medicine residents performed trans-abdominal sonographic
measurements of the IVC diameter. Measurements of the IVC diameter just caudal to
the insertion of the hepatic veins were obtained in a longitudinal orientation.
Results: 75 pediatric ED patients were enrolled in the study; 63 hydrated patients
(Group 1) and 12 dehydrated patients (Group 2). There were no statistically
significant demographic differences between the groups (age, P⫽0.132; sex,
P⫽0.206; weight, P⫽0.217). There was a statistically significant difference with
regards to pulse rate (group 1: median pulse rate ⫽ 128.5 beats/minute (range: 92 to
178) and Group 2: 145.0 beats/minute [(range: 114 to 184); P⬍.05].
Sonographycally, Group 1 had statistically significant higher median longitudinal
IVC maximum and minimum diameters, and showed a trend toward a greater
difference in diameter between the maximum and minimum, as compared to Group
2: Maximum ⫽ 64mm vs. 38mm, P⬍.001; Minimum ⫽ 45mm vs. 32mm, P⬍.05;
with a median difference ⫽ 20mm vs. 12mm, P⫽.095 respectively. In addition, 0%
of Group 1 demonstrated IVC collapse during inspiration whereas 25% of Group 2
showed complete collapse of the IVC during inspiration (P⬍.005); in other words
complete IVC collapse during inspiration was seen only in the dehydrated patients.
Conclusion: Maximum and minimum IVC diameters, as measured during
respiration by bedside ED ultrasonography, were lower in clinically dehydrated
pediatric patients. Moreover, sonographic visualization of a collapsed IVC may
rapidly and reliably predict dehydration status.
327
Correlation of ␤-hCG and Ultrasound Diagnosis of
Ectopic Pregnancy in the Emergency Department
Bloch AJ, Lyon M, Humphries F, Stoeber J, Shiver S/MCG, Augusta, GA
Study Objective: Women with ectopic pregnancies tend to have lower ␤-hCG
levels than women with intrauterine pregnancies (IUP). Transvaginal ultrasound is
capable of detecting IUPs when ␤-hCG levels are ⬎1500 mIU/mL, the so-called
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discriminatory zone. When serum ␤-hCG levels are ⬍1500 mIU/mL and no IUP is
detected, the possibility of an ectopic pregnancy or an early IUP exists. Because of the
discriminatory zone, emergency physicians often opt not to perform ultrasound on
patients whose ␤-hCG level is ⬍1500 mIU/mL. Many ectopic pregnancies, however,
are detected by emergency transvaginal ultrasound with ␤-hCG levels ⬍1500 mIU/
mL. The frequency of detection of ectopic pregnancy at levels ⬍1500 mIU/mL has
not been established. Our objective is to determine this frequency.
Methods: A retrospective chart review at an academic center with emergency
physicians trained and credentialed in transvaginal ultrasound was performed. Charts
with discharge diagnosis of ectopic pregnancy, miscarriage, pregnancy, abdominal
pain, and vaginal bleeding were reviewed. Inclusion criteria were positive pregnancy
with ␤-hCG and ultrasound performed in the emergency department at the time of
the visit. There were no exclusion criteria. Ectopic pregnancy was defined by
sonographic criteria and discharge diagnosis of ectopic pregnancy. Ultrasounds
performed by emergency physicians as well as radiology or Obstetrics-Gynecology
(OB) were included. The ␤-hCG level at which an ectopic pregnancy was diagnosed
was recorded and analyzed.
Results: From Oct 2007 until Sept 2008, 859 charts were identified and
reviewed. Data was recorded on a standardized data sheet, with 20% of charts
reviewed by two individuals for verification of concordance. Out of these charts, 176
patients met inclusion criteria. Of the 176 patients, 11 ectopic pregnancies were
identified; representing 6.3% of the total pregnancies. Emergency physicians
diagnosed 8 of the 11 ectopics by emergency ultrasound. Three of the 11 ectopics
were diagnosed by ultrasounds performed by OB. ␤-hCG’s for the ectopics ranged
from 456 - 68,138 mIU/mL. Two ectopic pregnancies were diagnosed with a ␤hCG ⬍ 500; one between 500-1000 and none between 1000-1500. Overall, 27% of
the ectopic pregnancies diagnosed by emergency transvaginal ultrasound had ␤hCG’s ⬍1000 mIU/ml.
Conclusion: Our initial data confirms that ectopic pregnancies can be diagnosed
at ␤-hCG levels much less than 1500 mIU/mL by emergency ultrasound. Therefore,
␤-hCG levels should not be used to determine the need for an emergency
transvaginal ultrasound in a patient at risk for an ectopic pregnancy. Since 27% of the
ectopic pregnancies diagnosed in our sample had a ␤-hCG ⬍1000 mIU/mL,
emergency transvaginal ultrasound should be performed regardless of ␤-hCG level in
any pregnant woman with suspicion of an ectopic pregnancy.
328
Thromboembolic Events During Venous
Compression Ultrasound of the Lower Extremity in
Patients With Deep Venous Thrombosis
patients were excluded from the analysis due to missing data. Interobserver agreement
among chart reviewers was high (k ⫽ 0.90). DVT was identified in 363 (15%, CI
13-16%) patients. Common femoral vein was most commonly involved (77%, CI
72-81%). 45/363 (12%, CI 9-15%) were noted to have chronic DVT. No
thromboembolic events occurred from compression ultrasound in patients with
DVT. All patients with acute DVT were discharged on anticoagulation therapy.
Conclusions: There was no evidence of thromboembolic events from venous
compression ultrasound in our study. Risk of pulmonary embolism from compression
ultrasound is extremely low.
329
Bedside Urinary Bladder Duplex Ultrasonography
for the Detection of Obstructing Ureteral Calculi in
the Emergency Department
Summers S, Fox J, Chin E, Patel B, Shahin G/University of California, Irvine
Medical Center, Orange, CA
Study Objective: To determine the test characteristics of emergency department
(ED) bedside urinary bladder ultrasonography for the diagnosis of obstructing
ureteral calculus.
Methods: We conducted a prospective observational pilot study on a convenience
sample of adult ED patients with suspected renal colic. All patients received duplex
urinary bladder ultrasound (CDBU) at the bedside. Non-clinician research assistants
were trained how to perform CDBU during two 30-minute sessions. CDBU
consisted of counting the number of ureteral jets emanating from each ureterovesicle
junction (UVJ) over a 4-min period. The total jet frequency (TJF) was defined as the
total number of jets counted from each UVJ over 4 minutes. The relative jet
frequency (RJF) was defined as the number of bladder jets on the symptomatic side
divided by the TJF. RJF ⱕ 35% was considered an abnormal test. Patients were
excluded if they had an empty bladder on ultrasound or if the TJF was ⱕ 3. CDBU
was compared to computed tomography (CT) urogram for the diagnosis of
obstructing ureteral calculus. The ultrasound operator was blinded to CT results.
Results: 17 patients were enrolled, and 5 were excluded. The test characteristics of
CDBU were as follows: sensitivity 87.5% (95% CI 0.68-0.88), specificity 100%
(95% CI 0.62-1), positive predictive value 100% (95% CI 0.78-1), and negative
predictive value 80% (0.49-0.8). Both patients with a ureteral calculus ⱖ 10 mm had
an RJF of 0%.
Conclusions: CDBU may be a useful bedside diagnostic test for the detection of
obstructing ureteral calculus.
Adhikari S, Zeger W, Frrokaj I, Blaivas M/University of Nebraska Medical Center,
Omaha, NE; Northside Hospital Forsyth, Cuming, GA
Study Objectives: Emergency physicians are increasingly utilizing venous
compression ultrasound in the evaluation of lower extremity for deep venous
thrombosis (DVT). Focused compression ultrasound has proven to be highly sensitive
and specific for identifying DVT. Few case reports have been published describing
the occurrence of pulmonary embolism caused by dislodging a DVT during
compression ultrasound. To our knowledge, no prior studies investigated the risk of
thromboembolic events during venous compression ultrasound. The objective of this
study is to determine the risk of thromboembolic events during compression
ultrasound in patients with DVT.
Methods: This was a retrospective review of all emergency department (ED)
patients who underwent venous compression ultrasound of the lower extremity for
evaluation of DVT over a 6-year period. This study took place at an academic urban
ED with an annual census of 48,000 visits. The ultrasound protocol included Bmode and Doppler color flow analysis of deep veins of lower extremity along with
compression of common femoral, superficial femoral, deep femoral, popliteal,
posterior tibial, peroneal, and greater saphenous veins. Three chart reviewers
performed data collection using a standardized data extraction form. A systematic
review of medical records was accomplished for patients diagnosed with DVT.
Presence of any one of these clinical features is used to identify a thromboembolic
event: new onset or worsening shortness of breath, chest pain, palpitations, syncope,
hypotension, hypoxia and death within 24 hours after compression ultrasound.
Descriptive statistics are used to analyze the data. Continuous data are presented as
means with standard deviations and dichotomous data are presented as percent
frequency of occurrence with 95% confidence intervals. Interobserver agreement
among chart reviewers was assessed by kappa analysis.
Results: A total of 2451 patients (female-1595, male-856) were identified over a
six-year period. The mean age of the patients was 60 years ⫹/- 19 (SD). Three
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330
Antibiotic Prescription by Emergency and ICU
Physicians in Patients Admitted to the Intensive
Care Unit With the Diagnosis of Septic Shock
Capp R, Brown D/Massachusetts General Hospital, Boston, MA
Study Objectives: International guidelines recommend that appropriate
antibiotics should be administered within an hour of recognition of septic shock.
Antibiotic choice should be broad spectrum, based on clinical presentation and local
Annals of Emergency Medicine S103
Research Forum Abstracts
hospital/community microorganisms susceptibility patterns (MSP). A recent study
has shown significant decrease in survival rate in patients diagnosed with septic shock
who were not treated with appropriate antibiotics. Here, we evaluated the
appropriateness of accuracy of antibiotic ordering by emergency physicians and ICU
doctors for patients with septic shock.
Methods: Retrospective study looking at all ICU admissions (577) from Nov 1,
2006 to April 01, 2007. All charts were reviewed in order to determine whether they
met specific criteria for septic shock as described by the 1991 Society of Critical Care
Medicine Consensus Statement on Sepsis Definitions. 84 patients were identified.
Appropriate antibiotic regimens were defined as those which complied with
Infectious Diseases Society of America guidelines. Final culture data results were used
in order to identify appropriate antibiotic coverage.
Results: The mean age was 67; 70% were male. 84 patients were pan-cultured. 67
cultures were positive (80%) and provided MSP for appropriate treatment within 48
hours of admission. Initial choice of antibiotics made in the ED covered offending
microorganism in 53% of patients. Antibiotic choices were changed within 2 hours of
admission to the ICU approximately 67% of time and covered 53% patients
correctly. These changes usually provided broader gram negative coverage with use of
ceftazidime and cefepime.
Conclusion: For patients presenting with septic shock, most are pan-cultured in
the ED prior to initiation of antibiotics. Initial ED antibiotic selection covered the
offending microorganism in less than 2/3 of septic shock cases. Antibiotic choices
were changed within two hours of arrival to the ICU in 67% of the cases. However,
these changes did not improve overall coverage of organisms, despite the broader
gram negative coverage with cefepime and ceftazidime. This occurred mostly because
the organisms not covered were found to be ESBL gram negatives, cephalosporin
resistant pseudomonas, fungi, or vancomysin-resistant enterococci. Given we are
covering only less than 2/3 of microorganisms, perhaps we should consider using
broader coverage antibiotics, such as linezolid/meropenem in the ED in patients
presenting with septic shock.
331
Prospective Randomized Trial of TrimethoprimSulfamethoxazole vs Placebo on 30-Day
Recurrence Rates for Uncomplicated Skin
Abscesses in Patients at Risk for CommunityAcquired Methicillin-Resistant Staphylococcus
Aureus Infection: An Interim Analysis
Schmitz GR, Pitotti R, Olderog C, Livengood T, Williams J/Wilford Hall Medical
Center, San Antonio, TX; Brooks Army Medical Center, San Antonio, TX
Study Objectives: Community-acquired methicillin-resistant Staphylococcus
aureus (cMRSA) skin and soft tissue infections are becoming increasingly prevalent in
the patient population in the emergency department. Currently, conflicting data exist
on the utility of antibiotics to treat uncomplicated cMRSA abscesses. No previous
studies have investigated the recurrence rates of abscesses after antibiotics. The
primary outcome was to determine whether administration of trimethoprimsulfamethoxazole, in addition to incision and drainage, may prevent recurrence of
abscesses at 30 days. A subset analysis was performed to evaluate patients who were
MRSA positive and patients with abscesses with overlying cellulitis.
Methods: The study is a double blinded, randomized controlled trial on
trimethoprim-sulfamethoxazole vs placebo on immunocompetent patients ages 18-65
with uncomplicated cutaneous abscesses requiring incision and drainage. It is a multicenter trial conducted at Wilford Hall Medical Center and Brooks Army Medical
Center. All patients received incision and drainage and were randomized to receive
either one week of trimethoprim-sulfamethoxazole or matched placebo. Exclusion
criteria included patients who were immunocompromised, allergic to sulfa, pregnant
or breast feeeding, and any patient who had been hospitalized in the previous month
or received antibiotics one week before presentation. Patients with perirectal abscesses
or other complicated abscesses with fistulas or tracks requiring surgical evaluation
were excluded. At the end of 30 days the patients were contacted by investigators,
who were blinded to the study groups, and asked whether or not they had formed a
new abscess. Recurrence was defined as a new abscess in the same or different location
requiring additional incision and drainage or treatment.
Results: One hundred eleven patients were enrolled and 30-day recurrence data is
available for 58 patients at interim analysis. 33 patients had been randomized to
placebo and 25 patients were randomized to trimethoprim-sulfamethoxazole. There
was a significant difference between recurrence rates in patients on placebo (33%,
with 95% confidence interval of 17 to 49%) vs. patients on trimethoprimsulfamethoxazole (8%, with a 95% confidence interval of ⫺3 to 11%). (p⬍.006).
S104 Annals of Emergency Medicine
The MRSA prevalence rate was 54%. Of the subset of 29 patients who were
MRSA positive, 17 patients received placebo and 12 received trimethoprimsulfamethoxazole. There was a trend towards recurrence patients on placebo (29%) vs
patients on trimethoprim-sulfamethoxazole (8%), but this difference was not
statistically significant because of small sample size. (p⫽0.168).
There were 42 patients with abscesses and overlying cellulitis. Of the subset with
surrounding cellulitis, 23 patients received placebo and 19 received trimethoprimsulfamethoxazole. A significant difference of recurrence was detected in patients on
placebo (30%) vs. patients on trimethoprim-sulfamethoxazole (5%). (p⬍0.039).
Conclusion: Our preliminary data suggests that trimethoprim-sulfamethoxazole,
in addition to incision and drainage, may have some benefit in the prevention of
recurrence of uncomplicated abscesses.
332
A Survey of Provider Opinions Regarding
Implementing Rapid HIV Testing in the Emergency
Department of a Safety Net Hospital
Schechter-Perkins E, Murray K, St. George J, Mitchell P/Boston University
School of Medicine, Boston, MA; Massachusetts General Hospital Institute of
Health Professions, Boston, MA
Background: It is estimated that 1 in 4 HIV-positive people in the United States are
unaware of their positive status. Centers for Disease Control and Prevention (CDC) in
November 2006 changed their recommendations to advise more widespread HIV testing,
including the adoption of screening programs at all points of contact with the health care
system. Despite the revised guidelines and the availability of rapid HIV testing,
implementation of HIV screening in emergency departments (EDs) is not widespread.
Study Objectives: To determine ED personnel awareness of the 2006 CDC
recommendations regarding HIV testing, perception of HIV as a problem among ED
patients, and elucidate how these factors and others impact attitudes towards
implementing HIV testing in the ED.
Methods: This study was a cross-sectional survey conducted in 2009 of ED nurses
and physicians at Boston Medical Center. This ED sees approximately 130,000 patient
visits per year and is the main safety net care provider in Boston. ED staff were asked to
complete a 10-question, anonymous survey regarding their attitudes toward rapid HIV
testing in the ED. Likert scale responses were analyzed by dichotomizing into (strongly)
agree and neutral/(strongly) disagree. The relationship between ED position and CDC
recommendation familiarity, perception of HIV as a major problem, and attitudes
regarding HIV testing in the ED were assessed using chi square statistics. Potential barriers
were identified by multiple choice answers and qualitative responses.
Results: The survey was completed by 124/132 (94%) of staff members,
including 60 MDs, 61 RNs, and 3 that did not identify position. The majority of
respondents, 115/124 (93%) agree HIV is a major problem in the patient population,
but only 55/124 (44%) report familiarity with the 2006 CDC recommendations.
MDs v RNs somewhat or strongly agree with: HIV is a major problem in this
population (96% v 88% p⫽0.16); universal ED HIV testing should be offered (58%
v 31% p⫽0.003); testing should be offered only when clinically indicated (88% v
75% p⫽0.06); testing should be offered only for high risk patients (78% v 54%
p⫽0.01); testing should be offered by physicians (59% v 38% p⫽0.02); testing
should be offered by nurses (63% v 31% p⬍0.001); testing should be offered by
counselors (93% v 77% p⫽0.01). There was not a significant relationship between
familiarity with CDC guidelines and attitude toward implementing HIV screening
(p⫽.27). At least one barrier was identified by 56% of respondents. Reported barriers
include: confidentiality concerns, cost, patient flow and lack of follow-up.
Conclusion: Concern for HIV in the ED population was reported to be high while
knowledge about CDC testing recommendation was limited. Attitudes about HIV testing
differed significantly between MDs and RNs across most questions. Further research
should explore overcoming barriers to opposition, particularly among nurses, to
widespread ED HIV testing, despite reported concern about HIV in this population.
333
Screening Strategies for Early Identification of
Spine Infections in Patients Presenting to
Emergency Departments With Severe Back or
Neck Pain
Shroyer SR, Mehta S/Greater San Antonio Emergency Physicians, San Antonio,
TX
Study Objectives: Spinal epidural abscess (SEA) is an intraspinal infection that is
typically not detected by physicians until the classic triad of symptoms is evident;
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however, this is only present in 8-13% of cases. Numerous studies have quantified
how poor physician judgment alone is at detecting SEA (0-26% sensitivity). Delay in
recognition of SEA occurs frequently, resulting in disease progression which may
subsequently lead to permanent paralysis, sepsis, meningitis and death in a tragic
number of these cases. The primary objective in this series was to identify clinical
strategy(s) for the early identification of patients at risk for spine infections.
Methods: Eighty-seven patients presenting to a community ED with severe back
or neck pain were evaluated for potential spine infections using data gathered
prospectively on a standardized data collection form. A combination of three clinical
strategies were used to identify spine infections using four variables which included:
fever (or recent history of fever), spine infection risk factors, progressive neurologic
deficit and C-reactive protein. All patients not undergoing imaging were followed up
by telephone, medical records or primary physician contact for up to six months. The
primary outcome measure was the presence of any of the following spine pathology:
SEA, vertebral osteomyelitis, paravertebral abscess, paraspinous pyomyositis, psoas
pyomyositis, discitis, septic facet or spinal metastasis being diagnosed within 24 hours
of presentation to the emergency department.
Results: There was a 29% (25/87) prevalence of spinal infections in our patient
population. Three strategies were found that more accurately evaluate patients who
present to the ED with back or neck pain from spine infection. The first strategy
mandated a C-reactive protein if the patient with severe spine pain had any risk
factors for spine infection. If the C-reactive protein was 50mg/L or greater then an
MRI was required; this strategy was moderately sensitive and specific (88% sensitive;
CI, 70-96% and 84% specific; CI, 73-91%) for diagnosing spine infections. The
second strategy utilized a risk stratification tool, SIRCH (Spine Infection Risk
Calculation Heuristic). It detected 96% (CI, 81-99%) of spine infections and had a
specificity of 71% (CI, 59-81%). This strategy resulted in more MRI orders (42 out
of 87) than the former strategy (32 out of 87). A third strategy effectively ruled out
spine infection without any lab testing or imaging. Patients who presented with all
negative variables in SIRCH (ie, no spine infection risk factors, no fever, no history of
fever and no progressive neurologic deficit) (12 out of 87) required no C-reactive
protein or imaging. The negative predictive value of this last strategy was 98% (CI,
89%-99%).
Conclusion: The use of either of the first 2 strategies as well as the rule-out
strategy (SIRCH negative) in patients presenting to the ED with severe spine pain are
likely to detect spine infection earlier and more accurately. Early detection will likely
improve morbidity and mortality in patients with spine infection.
334
A Two-Year Experience of Patients Receiving NonOccupational Post-Exposure Prophylaxis Against
HIV in a NYC Emergency Department
Egan D, Urbina A, Galatowitsch P/St. Luke’s Roosevelt Hospital Center, New
York, NY; St. Vincent’s Catholic Medical Center, New York, NY
Study Objectives: To identify key characteristics of patients presenting to a NYC
emergency department for non-occupational post-exposure prophylaxis (nPEP)
against HIV.
Methods: The study was conducted in a NYC ED located in a section of
Manhattan with a high prevalence of HIV infection. We conducted a retrospective
chart review of ED visits between 12/04 and 12/06 of patients presenting with ICD9
codes that would identify possible HIV exposures. Patients eligible for nPEP were
identified, and data were abstracted from the electronic medical record. Statistical
analyses included frequencies, ␹2 and ANOVA models.
Results: A total of 179 patients were identified, of whom 55.6% were men. The
risk partner was also male in 87% of cases. The most common exposures were with
partners of unknown HIV status: unprotected receptive vaginal intercourse with
ejaculation (13.9%), followed by the same with unknown ejaculation (12.2%), and
unprotected receptive anal intercourse with ejaculation (8.3%). More than 70% of
patients were 37 or younger, with the largest percentage between 23 and 27 years of
age (32.2%). Caucasians made up 63.9% of patients followed next by Hispanics
(12.8%). nPEP was offered in 96.1% of cases. Almost all patients (97.6%) with
medical insurance accepted treatment compared with only 85% of uninsured patients
(␹2 ⫽30.864; df⫽10; p⫽.001). Notably, while non-whites were significantly less
likely to be insured 46% vs. 34% (␹2 ⫽13.77; df⫽5; p⫽.017) than whites, this
difference did not influence rates of nPEP acceptance. Almost 1/3 of patients
presented within 1-5 hours of exposure (32%). A total of 17.5% of patients presented
after 36 hours of exposure (NYS guideline for initiation of nPEP) and 2.3%
presented after 72 hours (CDC guideline). Victims of sexual assault (39% of study
population) presented more rapidly for nPEP than non-victims: 12-17 hours vs. 18-
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23 hours (f⫽5.04; p⫽.026). Patients who reported an HIV-positive partner delayed
their presentation to the ED compared with partners of unknown status: 18-23 hours
vs. 12-17 hours (f⫽3.862, p⫽.05). Patients with insurance presented sooner to the
ED than uninsured patients, 18-23 hours vs. 12-17 hours (f⫽6.82, p⫽.01).
Conclusion: In our ED, men presented slightly more frequently than women.
There appears to be an association between sexual assault, partner HIV status, if
known, and insurance status with time to presentation. Many patients presented
beyond NYS-recommended treatment times. These data suggest community
education and public health efforts on safer sex practices and access to timely nPEP
may be targeted to specific populations. In areas of high HIV prevalence, patients
frequently present past the ideal 2-hour window, and EDs should establish nPEP
protocols to minimize intradepartmental delays of first medication dose
administration.
335
Double-Blind, Randomized, Controlled Multi-Center
Trial of Antibiotic Treatment for Uncomplicated
Skin Abscesses in Patients at Risk for CommunityAcquired Methicillin-Resistant Staphylococcus
aureus Infection: An Interim Analysis
Olderog CK, Schmitz G, Pitotti R, Williams J, Huebner K, Livengood T, Ritz B/
Brooke Army Medical Center, San Antonio, TX; Wilford Hall Medical Center, San
Antonio, TX; Darnell Army Medical Center, Killeen, TX
Study Objective: Community-acquired methicillin-resistant Staphylococcus aureus
(CA-MRSA) is emerging as a major cause of skin and soft tissue infections. The role
of antibiotics in the treatment of these infections is debated and has not been
adequately studied. We evaluated treatment failure at seven days of skin abscesses
treated with incision and drainage plus placebo versus incision and drainage plus
sulfamethoxazole/trimethoprim.
Methods: Patients between 18-65 years old with skin abscesses were prospectively
enrolled at a three different military academic emergency departments in Texas.
Exclusion criteria included pregnancy, sulfa allergy, antibiotics in the last seven days,
diabetes, and immunocompromise-including HIV. Abscesses were excluded if they
were facial or perirectal. Patients were randomized to receive incision and drainage
plus placebo or incision and drainage plus a 7 day course of
sulfamethoxazole/trimethoprim. Physicians were blinded on patient re-evaluation at
day three and seven. Treatment failure was defined as need to start antibiotics based
on the discretion of the treating physician. P values were calculated using the Pearson
Chi-squared Test.
Results: 111 patients were enrolled. 85 patients completed the 7-day re-check
(76.5%). 12/46 (26%) of patients randomized to receive placebo failed treatment at 7
days. 6/39 (15%) of patients randomized to receive sulfamethoxazole/trimethoprim
failed treatment at 7 days (p⫽0.229).
There were 44 patients in the subset of CA-MRSA patients. 9/20 (45%) on
placebo failed treatment and 6/24 (25%) on sulfamethoxazole/trimethoprim failed
treatment (p⫽0.163).
In the subset of 61 patients with cellulitis, 10/30 (33%) on placebo failed
treatment while 6/31 (19%) on sulfamethoxazole/trimethoprim failed therapy
(p⫽0.215).
Conclusion: There is no significant difference between patients who received
placebo or antibiotics in the treatment of skin abscesses; however, the study is not
significantly powered to conclude there is no difference. There is a trend toward
improved outcome with antibiotics, but it is not significant. The presence of CAMRSA and the presence of cellulitis do not appear to alter outcomes.
336
Respiratory Syncytial Virus Is Not Protective of
Urinary Tract Infections in Febrile Infants Less
Than 90 Days Old
Muñiz AE/The University of Texas Health Sciences Center at Houston, Houston,
TX
Study Objective: The prevalence of significant bacterial infections in infant’s ⬍
90 days-old who have respiratory syncytial virus (RSV) is unknown in the era after
the introduction of H. influenzae and S. pneumoniae vaccinations. The evaluation of
these infants is still controversial. We hypothesize that infants with fever and RSV are
at low risk for secondary bacterial infections and may not require extensive and
invasive laboratory evaluations. Infants were excluded if there was an obvious source
for fever (excluding otitis media) and those with previous antibiotic use.
Annals of Emergency Medicine S105
Research Forum Abstracts
Methods: Prospective evaluations of all infants ⬍ 90 days-old from 10/98 to
12/07 who had a sepsis evaluation for fever and an RSV antigen test performed
were eligible. Data was analyzed using Statistica 6.0 with continuous variables
expressed as means and categorical variables as percentages of occurrence.
Results: There were 180 infants, 70 (38.8%) were RSV (⫹) and 110 (61.1%)
infants were RSV (-). Median age in the RSV (⫹) group was 44.3 ⫹ 19.4 days
old, and RSV (-) 43.6 ⫹ 19.2 days old. In the RSV (⫹) group there were 42
(60%) males, 15 (21.4%) Caucasians, 41 (58.5%) African Americans, and 14
(20%) Hispanics. In the RSV (-) group there were 59 (53.6%) males, 17 (15.4%)
Caucasians, 77 (70.0%) African Americans, 16 (14.5%) Hispanics. In the RSV
(⫹) median temperature was 38.6 ⫹ 0.6°C, while RSV (-) 38.5 ⫹ 0.5°C. In the
RSV (⫹) mean HR were 170.7 ⫹ 18.5/minute with a HR ⬎ 160/minute in 37
(52.8%). In the RSV (-) mean HR was 165.9 ⫹ 21.1/minute with a HR ⬎ 160/
minute in 52 (47.2%). In the RSV (⫹) mean RR were 48.2 ⫹ 18/minute with a
RR ⬎ 60/minute in 14 (20.0%). In the RSV (-) mean RR was 44.2 ⫹
15.9/minute with a RR ⬎ 60/minute in 11 (10.0%) infants. There was no
significant difference in vital signs between groups. There were more URI
symptoms and coughing in the RSV (⫹) group (p ⬍ 0.05). The number
admitted in RSV (⫹) group was 53 (75.7%) versus 89 (80.9%) in RSV (-). There
were 8 (11.4%) infants admitted to the PICU in the RSV (⫹) group versus 2
(1.8%) in the RSV (-). The laboratory evaluation in the RSV (⫹) included a
CBC 65 (92.8%), urinalysis and culture 62 (88.5%), blood culture 63 (90.0%),
chest radiograph 30 (42.8%) and cerebrospinal fluid analysis 31 (44.2%). In the
RSV (-) the laboratory evaluation included a CBC 100 (90.9%), urinalysis and
urine culture 100 (90.9%), blood culture 102 (92.7%), chest radiograph 50
(45.4%) and cerebrospinal fluid analysis 74 (67.2%). There were more chest
radiographs performed in the RSV (⫹) group (p ⬍ 0.05), while all other tests
were similar. There were 10 (14.2%) significant infections in the RSV (⫹) group
versus 12 (10.9%) in the RSV (-) group. In the RSV (⫹) group there were 7
(10%) pneumonias, 3 (4.2%) urinary tract infection. There were no significant
(⫹) blood cultures in the RSV (⫹) group, but there were 6 (8.5%) contaminants.
In the RSV (-) group there were 6 (5.4%) pneumonias, 4 (3.6%) urinary tract
infection, 1 (0.9%) bacteremia with group B streptococcus, and 1 (0.9%)
meningitis with enterococcus.
Conclusion: The risk of serious bacterial infection is low in both RSV (⫹) group,
especially if one excludes pneumonias. The prevalence of urinary tract infection is
significant. Therefore, it may be prudent to exclude a urinary tract infection in febrile
infants with or without (⫹) RSV antigen test.
337
Significant Bacterial Infections in Febrile Children
Less Than 2 Years of Age With Influenza A
Muñiz AE/The University of Texas Health Science Center at Houston, Houston, TX
Study Objectives: The prevalence of coexisting significant bacterial infections in
young infants and children who have Influenza A is unknown in the era after the
introduction of H. influenzae and S. pneumoniae vaccinations. The evaluation of
these infants is still controversial. We hypothesize that infants with fever due to
Influenza A are at low risk for secondary bacterial infection and may not require
extensive and invasive laboratory evaluations. Infants were excluded if there was an
obvious source for fever (excluding otitis media) and those with previous antibiotic
use.
Methods: Prospective evaluations of all infants ⬍ 2 years-old who presented with
fever during 7 consecutive Influenzae A seasons who had a laboratory evaluation for
their fever and an Influenza A antigen test performed were eligible. Data was analyzed
using Statistica 6.0 with continuous variables expressed as means and categorical
variables as percentages of occurrence.
Results: There were 330 children, 84 (25.4%) were Influenza A (⫹) and 246
(74.5%) were Influenza A (-). Median age in the Influenza A (⫹) group was 9.9 ⫹
8.4 months old and Influenza A (-) 10.3 ⫹ 8.4 months old. In the Influenza A (⫹)
group there were 43 (51.1%) males, 8 (9.5%) Caucasians, 57 (67.8%) African
Americans, and 18 (21.4%) Hispanics. In the Influenza A (-) group there were 148
(60.1%) males, 37 (15.0%) Caucasians, 170 (69.1%) African Americans, 38 (15.4%)
Hispanics, and 1 Middle eastern. In the Influenza A (⫹) group median temperature
was 39.5 ⫹ 0.8°C which was significantly greater than the Influenza A (-) 38.9 ⫹
0.7°C (p ⬍ 0.05). There was no significant difference in the other vital signs between
groups. There were more upper respiratory infection symptoms and coughing in the
respiratory syncytial virus (⫹) group (p ⬍ 0.05). In the Influenza A (⫹) group there
were 22 (26.1%) with (⫹) respiratory syncytial virus antigen, while in the Influenza A
(-) there were 95 (38.1%) with (⫹) respiratory syncytial virus. Admissions occurred
S106 Annals of Emergency Medicine
more commonly in the Influenza A (-) group 127 (51.6%) versus in the Influenza A
(⫹) 21 (25.0%) (p ⬍ 0.05). There were 14 (16.6%) significant infections in the
Influenza A (⫹) group versus 52 (21.1%) in the Influenza A (-) group. In the
Influenza A (⫹) group there were 10 (11.9%) pneumonias, 4 (34.7%) urinary tract
infections, and 1 (1.1%) meningitis (Enterococcus) in a 24-day-old. There were no
significant (⫹) blood cultures in the Influenza A (⫹) group, but there were 2 (2.3%)
contaminants. In the Influenza A (-) group there were 39 (15.8%) pneumonias, 9
(3.6%) urinary tract infections, and 4 (1.6%) (⫹) blood cultures (K. pneumoniae, S.
marcesens, S. pneumoniae).
Conclusion: The risk of serious bacterial infection is low in the Influenzae (⫹)
group, especially if one excludes pneumonias. There were no cases of bact