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2nd
Annual SAEM Great Plains Regional
Research Forum
Saturday, September 10, 2011
Farrell Learning and Teaching Center at Washington University in St. Louis
School of Medicine
SAEM Great Plains Regional Research Forum
Schedule of Events
Time Event Location
7:00am - 7:45am Continental Breakfast FTLC 2nd
Floor
7:45am - 8:00am Welcome Moore Auditorium (1st floor)
8:00am - 9:00am Keynote Address
John Younger, MD, University of Michigan
Moore Auditorium (1st floor)
9:10am - 10:45am Oral Presentation Session 1 (Abstracts #1-9) Moore Auditorium (1st floor)
9:10am - 10:45am Lightning Oral Presentation Session 1 (Abstracts #10-24 ) Holden Auditorium (FTLC 1st Floor)
10:45am – 11:00am Break
11:00am – 12:00am Oral Presentation Session 2 (Abstracts #25-30) Moore Auditorium (1st floor)
12:00pm - 12:30pm Lunch (pick up and bring to next event) FTLC 2nd
Floor lobby
12:00pm – 5:00pm SimWars Competition Holden Auditorium (FTLC 1st Floor)
12:30pm – 1:30pm Keynote Address
Past SAEM President Jeffrey Kline, MD
Moore Auditorium (1st floor)
1:30pm – 3:30pm Resident and Medical Student Breakout Sessions FTLC 213A and 213B
1:40pm – 3:00pm Lightning Oral Presentation Session 2 (Abstracts #31-45) Moore Auditorium (1st floor)
3:00pm – 4:20pm Poster Presentations (Abstracts #46-78) FTLC 210 and 211
4:30pm – 5:00pm Awards and Closing Remarks Moore Auditorium (1st floor)
Detailed Schedule of Events
7:00am - 7:45am, Breakfast
Continental breakfast will be available in the 2nd
floor lobby of the Farrell Teaching and Learning Center.
7:45am – 8:00am, Welcome and Opening Remarks, Moore Auditorium
8:00am – 9:00am, Keynote Address, Moore Auditorium
John Younger, MD, University of Michigan
9:10am - 10:45am, Oral Presentation Session 1, Moore Auditorium
Moderator – Larry Lewis MD, Washington University in St. Louis
1. ISAR and TRST Do Not Predict Short-Term Adverse Outcomes in Geriatric Patients. Steven Abboud1 and
Christopher Carpenter2.
1Saint Louis University School of Medicine, St. Louis, MO;
2Washington University
School of Medicine, St. Louis, MO
2. Usefulness of Pediatric Lactic Acid Screening in the Emergency Department. Antonio Cummings, Loren Reed,
Jennifer Carroll, Stephen Markwell, Jarrod Wall and Myto Duong. Southern Illinois University, Springfield, IL
3. Waiting is Frustrating: A Comparison of the Emergency Severity Index to the Australasian Triage Scale for
Psychiatric Patient Assessment. Andrew S Deutsch1, Leslie Zun
2, LaVonne Downey
3 and Trena Burke
2.
1Rosalind Franklin University of Medicine and Science / Chicago Medical School, North Chicago, IL;
2Mt. Sinai
Hospital Emergency Department, Chicago, IL; 3Roosevelt University, Chicago, IL
4. The Effect of Cognitive Dysfunction and Health Literacy on Patient Comprehension of ED Care among Geriatric
Patients. Jessie Hu1, Owais Nadeem
1, and Christopher R. Carpenter
2.
1Saint Louis University School of
Medicine, St. Louis, MO; 2Washington University School of Medicine, St. Louis, MO
5. Comparing Emergency Medicine Practices for Central Venous Catheter Placement to Existing ICU Checklists. Rob
Klemisch and Daniel L Theodoro. Washington University School of Medicine in St. Louis, St. Louis, MO
6. Improved Interpretation of Coagulase Negative Staphylococcal Blood Culture Results Using Limited Genomic
Resequencing. Ashley Satorius, Adriana Rivera, Marika Raff, Duane Newton and John Younger. University
of Michigan, Ann Arbor, MI
7. Evaluating Quality of Life in Cognitively Impaired Geriatric Patients in the Emergency Department. Lila S. Wahidi
and Christopher R. Carpenter. Washington University School of Medicine in St. Louis, St. Louis, MO
8. Patients With Suicide Ideation Presenting To The Emergency Department: A New Characterization Of Mortality
And Outcomes. David Milzman, Hahn Soe-Lin, Laura Baldassari, Han Huang and Nick Echevarria.
Georgetown University School of Medicine, Washington, DC
9. Comparing Urine Acetoacetate Values With Serum 3-beta-hydroxybutyrate Values In Pregnant Women With
Nausea And Vomiting In The Emergency Department. Ian T Ferguson and Michael Mullins. Washington
University in St. Louis, St. Louis, MO
9:10am – 10:45am, Lightning Oral Presentation Session 1, Holden Auditorium
Moderator – Chris Holthaus MD, Washington University in St. Louis
10. Do Admission Check Sheets Improve Compliance with Pneumonia Core Measures? Andrew Abbeg, Sr., Steven
Lorber, Preeti Dalawari and Stacy Revelle. St Louis University Hospital, St Louis, MO
11. Grip Strength as a Brief Diagnostic Test for Frailty and Pre-Frailty in Geriatric Emergency Department Patients.
Grant M. Fischer and Christopher R. Carpenter. Washington University in St. Louis School of Medicine, St.
Louis, MO
12. Are They Working? The Effects Of UI And Community-Based Interventions On Thursday Night Binge Drinking.
Nicholas J Edwards and Michael Takacs. University of Iowa Carver College of Medicine, Iowa City, IA
13. Short QTc in Emergency Department Patients. Stacey House, Peta-Gay Laird and S. Eliza Halcomb.
Washington University in St. Louis, St. Louis, MO
14. Data Based on All-terrain Vehicle (ATV) Crash Site Informs Rural Health and Safety Policy. Gerene M Denning,
Kari Harland, Kevin Kremer, Charles Jennissen and Christopher Buresh. University of Iowa, Iowa City, IA
15. A Comparison of Two Hospital Electronic Medical Record Systems and Their Effects on the Relationship Between
Physician Charting and Patient Contact. John Shabosky, Jonathan dela Cruz and Matthew Albrecht. Southern
Illinois University School of Medicine, Springfield, IL
16. A Mobile Lightly-embalmed Cadaver Lab: A Possible Model For Training Rural Providers. Wesley Zeger1, Paul
Travis2, Michael Wadman
1, Carol Lomneth
1, Sara Keim
1 and Stephanie Vandermuelen
1.
1UNMC, Omaha, NE;
2Creighton University, Omaha, NE
17. Utilization Of Computed Tomography In Blunt Trauma: When Is Thoracic And Lumbar Imaging Warranted?
Aalap Mehta, Laurie Byrne, Vicki Moran and Eric Armbrecht. St. Louis University, St. Louis, MO
18. Changing Presentation Rates For Mtbi (Concussion) And Changing Imaging Rates. Han Huang1, Nick
Echevarria1, David Milzman
1, Carla Tilchin
1 and Ronny Song
2.
1Georgetown University School of Medicine,
Bethesda, MD; 2Georgetown University, Bethesda, MD
19. Validity of the Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) Instrument As
Predictors for Mortality, ED Revisits, Hospital Admission, Nursing Home Admission, and Functional Decline in
Cognitively Normal and Cognitively Impaired Geriatric ED Patients. Dan Feng, Sophia Li and Christopher R
Carpenter. Washington University School of Medicine, St Louis, MO
20. Diagnostic Accuracy of Various Health Literacy Screening Tools in the Emergency Department. Andrew Melson,
Christopher Carpenter and Richard Griffey. Washington University in St. Louis School of Medicine, Saint
Louis, MO
21. "What Did You Say?” Noise: Does It Distract From Patient Care In The Emergency Department? Laurie E Byrne,
Peter Anaradian and Preeti Dalawari. St. Louis University, St. Louis, MO
22. Undiagnosed Mental Illness in Children and Adolescents in the Emergency Department. Yanika Wolfe and
Dane M. Doctor. Rosalind Franklin University/Chicago Medical School, North Chicago, IL
23. A Comparison of Diversion and No Diversion and the Effect on patient Safety and Outcomes in the Emergency
Department. Eman Spaulding, Laurie Byrne, Eric Armbrecht and Collin Jackson. Saint Louis University,
Saint Louis, MO
24. Impact Of Presence Of Third Molars On Mandible Fractures Following Facial Trauma. David Milzman1, David
Weiner2 and Ryan Murray
1.
1Georgetown University School of Medicine, Washington, DC;
2Georgetown
University School of Medicine, Bethesda, MD
11:00am – 12:00 pm, Oral Presentation Session 2, Moore Auditorium
Moderator – Dan Theodoro MD, Washington University in St. Louis
25. Mild Cognitive Impairment: A Pilot Study To Evaluate The Montreal Cognitive Assessment Screening Tool For
Use In Urban Aging African Americans Who Present To The Emergency Department. Kanika A Turner and
Christopher R Carpenter. Washington University School of Medicine, St. Louis, MO
26. Cardioprotection by Endogenous Fibroblast Growth Factor 2 in Cardiac Ischemia-Reperfusion Injury In Vivo.
Stacey L House, Carla Weinheimer, Attila Kovacs and David Ornitz. Washington University in St. Louis, St.
Louis, MO
27. The Correlation between Health Literacy and Numeracy in the Emergency Department. Andrew Melson,
Christopher Carpenter and Richard Griffey. Washington University in St. Louis School of Medicine, Saint
Louis, MO
28. Cost-Benefit Analysis of Specialized Screeners in the Emergency Department and of Memory and Aging Project
Satellite Intervention. Charlene W Lai1 and Christopher R Carpenter
2.
1Saint Louis University School of
Medicine, St. Louis, MO; 2Washington University School of Medicine in St. Louis, St. Louis, MO
29. Ultrasound Simulation Training: Location of Central Venous Catheter Guide Wire Position. Melissa Thomas1,
Charles Schmier2 and Michael Wadman
1.
1University of Nebraska Medical Center, Omaha, NE;
2University of
Arizona Medical Center, Tucson, AZ
30. Application of Lean Principles of the Toyota Production System Lead to Greatly Improved Door to Needle Times.
Matthew Rudy1, Andria L Ford
1, Jennifer A. Williams
2, Naim Khoury
1, Tomoko Sampson
1, Craig McCammon
2,
Shawn O'Connor1, Jin-Moo Lee
1 and Peter Panagos
1.
1Washington University, Saint Louis, MO;
2Barnes Jewish
Hospital, Saint Louis, MO
12:00pm - 12:30pm Lunch
Pick up lunch in 2nd
floor lobby and take to your next event.
12:00pm - 4:00pm Medical Student SimWars Competition, Holden Auditorium
SimWars is a national competition pitting teams against each other solving cases using medical simulators. Midwest
Regional SAEM takes a new twist on SimWars by tailoring it for medical students. This first ever Medical Student
SimWars consists of two pools of 3 teams facing each other in a round-robin format. The winner of each pool will
then face off in the finals where the first Medical Student SimWars Champion will be crowned.
12:30pm – 1:30pm, Keynote Address, Moore Auditorium
Jeffrey Kline, MD, Past President of SAEM, Carolinas Medical Center
1:30pm – 3:30pm Medical Student and Resident Breakout Session, FTLC 213A and 213B
1:30pm-1:45 pm – Welcome and Introduction
Nathan Deal, MD, President of EMRA
1:45pm-2:30pm – Post Residency EM Subspecialty and Academic Career Options
Panel discussion of subspecialty fellowship training and various academic career options. Panelists include:
Stacey House, MD, PhD, Washington University in St. Louis – Research Careers
Preeti Delawari, MD, MSPH, St. Louis University - Research Careers
Evan Schwarz, MD, Washington University in St. Louis – Toxicology
William Gilmore, MD, Washington University in St. Louis – EMS
Brian Wessman, MD, Washington University in St. Louis – Critical Care
2:30pm-3:30pm – Starting a Career in Academic Emergency Medicine
Douglas Char, MD, Washington University in St. Louis
1:40pm – 3:00 pm, Lightning Oral Presentation Session 2, Moore Auditorium
Moderator – Michael Mullins MD, Washington University in St. Louis
31. Impact Of Teaching Life Saving Procedures To First Year Medical Students. Michael Ybarra, Ryan Murray,
David Weiner and David Milzman. Georgetown University School of Medicine, Bethesda, MD
32. Association of Falls with Sarcopenia and Frailty in Older Adults Presenting to The Emergency Department. Denis
T.K. Balaban, Steven Abboud, BS, Stephanie Chang, BS, Dan Feng, BS, Grant M. Fischer, BS, Jessie Hu, BS,
Charlene Lai, BA, Sophia Li, BS, Owais Nadeem, Ross Passo, Taylor Real, Kanika Taylor, BS, Lila Wahidi,
Christopher R. Carpenter, MD, MS
33. Impact Of Airline Flight On Professional Athletes Following Minor Traumatic Brain Injury (mtbi) In Terms Of
Total Games Missed Due To Injury. David Milzman1, Jeremy Altman
2, Matt Milzman
2, Chris Fleury
2 and Carla
Tilchin3.
1Georgetown University School of Medicine, Bethesda, MD;
2Georgetown University, Bethesda,
DC;3Bates college, Bethesda, ME
34. Can Ambulances Be Triaged To Urgent Care Centers Based On Chief Complaint? Tina Khosla, Joseph Delucia,
Ting Zhang and William Terrin. St. Louis University Hospital, St. Louis, MO
35. A Cost Benefit Analysis Of Ultrasound Programs For Central Venous Cannulation. Daniel L Theodoro.
Washington University School of Medicine in St. Louis, St. Louis, MO
36. Airway Management at a Regional Trauma Center: An Analysis of Resident Experience. Jordan Sullivan and
James McClay. University of Nebraska Medical Center, Omaha, NE
37. A Comparison of 3 Forms of Procedural Sedation for the Reduction of Dislocated Total Hip Arthroplasty. Scott
Burdette, Jonathan dela Cruz, Donald Sullivan, Eric Varboncouer, Daniel O'Keefe, Joe Milbrandt, Myto
Duong, Steven Scaife, David Griffen and Khaled Saleh. Southern Illinois University School of Medicine,
Springfield, IL
38. Knowledge of Alcohol Impairment in Boaters. Maria L Scarbrough and Preeti Dalawari. St. Louis University, St.
Louis, MO
39. Got Wheels?--Adolescent Exposure to ATVs and Their Driving Practices. Charles A Jennissen1, Denning Gerene
1,
Hoogerwerf Pam1, Peck Jeffrey
2 and Wetgen Kristel
1.
1University of Iowa Hospitals and Clinics, Iowa City, IA;
2U.S. Army Corps of Engineers, Iowa City, IA
40. Feasibility of Using Health Literacy Screening Tools in an Urban Emergency Department. Andrew Melson,
Christopher Carpenter and Richard Griffey. Washington University in St. Louis School of Medicine, Saint
Louis, MO
41. Frequency and Mortality of Non-Contiguous Spine Fractures with CT Scan Use. Vijai Chauhan1, Neelaysh
Vukkadala2, Howard Place
1, Laura Sicking
1, Lauren Segelhorst
1, Eric Armbrecht
2, Camelia Guild
2 and Preeti
Dalawari1.
1Saint Louis University SOM, Saint Louis, MO;
2Saint Louis University, Saint Louis, MO
42. Self-rated Health As A Predictor Of Emergency Department Recidivism And Functional Decline Among Geriatric
Patients. Stephanie K Chang1 and Christopher R Carpenter
2.
1St. Louis University, St. Louis, MO;
2Washington
University in St. Louis, St. Louis, MO
43. Stroke Volume Changes in ED Patients with Shock Undergoing Serial Passive Leg Raising and Fluid Challenges.
Stephanie Charshafian1, Ashley Janssen
1, Christopher Holthaus
1, Brian Fuller
1, Kevin Williams
1, Enyo
Ablordeppey1, Brian Wessman
1, Daniel Theodoro
1, Ronald Chang
1, Jennifer Williams
2, Thomas Ahrens
2 and
Richard Hotchkiss1.
1Washington University in St Louis, St Louis, MO;
2Barnes-Jewish Hospital, St Louis, MO
44. Seeking a Functional Definition of Drug-Seeking Behavior. Benjamin Scallon, Mark Graber, Azeemuddin Ahmed,
Kari Harland and Gerene Denning. University of Iowa, Iowa City, IA.
45. Disposition Variability For Patients with Chest Pain Among Emergency Department Physicians. David J
Gresback and Michael D Zwank. Regions Hospital, Saint Paul, MN
3:00pm - 4:00pm, Poster Presentations, FTLC 210 and 211
46. Characterization Of On-road ATV Crashes In Iowa From 2002-2009. Kevin Kremer, Gerene Denning, PhD and
Christopher Buresh, MD. University of Iowa, Iowa City, IA
47. Differences In Perception About Access To Care Between Patients Who Choose An Urban Academic Emergency
Department Over A Community-based Student-run Free Clinic For Non-urgent Care. Matthew Dettmer1,
Cerrone Cohen2, Edward Jauch
3, Kit N Simpson
3, Brenda Walker
3, Wanda Gonsalves
3, Kathryn Koval
3, Joshua
Gray3 and Steven Saef
3.
1Washington University Medical Center/Barnes-Jewish Hospital, St. Louis, MO;
2UC
Davis Health System, Sacramento, CA; 3Medical University of South Carolina, Charleston, SC
48. Preliminary Report On Factors Associated With Inadequate Or Uninterpretable Cervical Spine Radiographs And
Need For Ct In Cervical Spine Trauma. Richard Griffey, Betty Chen and Steven Katz. Barnes-
Jewish/Washington University in St. Louis, Saint Louis, MO
49. All Terrain Vehicle (ATV) Crash Fatality Surveillance through Press Clipping. Gretchen McCall and Charles
Jennissen, MD. University of Iowa, Iowa City, IA
50. A Quality Curriculum: A Novel Approach To Addressing The ACGME Core Competencies. Jonathan dela Cruz,
Antonio Cummings, James Waymack, David Griffen and Christopher McDowell. Southern Illinois University
School of Medicine, Springfield, IL
51. Emergency Department Interruptions in the Age of Electronic Health Records. Matthew Albrecht, Jonathan dela
Cruz and John Shabosky. Southern Illinois University School of Medicine, Springfield, IL
52. Ct Scanning Practice In Minor Pediatric Head Injury At A Community Emergency Department. Myto Duong,
Varshita Pande and Joseph Milbrandt. Southern Illinois University, Springfield, IL
53. Comparison Of Interpreters In Emergency Medicine: Video Conference Vs. In-person. Yanika Wolfe1, Leslie
Zun2, LaVonne Downey
3 and Trena Burke
4.
1Rosalind Franklin University/Chicago Medical School, North
Chicago, IL; 2Mount Sinai Hospital Emergency Department, Chicago, IL;
3Roosevelt University, Chicago, IL;
4Mount Sinai Hospital Emergency Medicine, Chicago, IL
54. Impact Of The Use Of A Standardized Order Set For Asthma Patients In The Emergency Department. Daniel D
Ofori1, Leslie Zun
1 and LaVonne Downey
2.
1Rosalind Franklin University of Medicine and Sciences, North
Chicago, IL; 2Roosevelt University, Chicago, IL
55. Same Patient. Same Overdose. Different Treatment. Different Outcome. Jon B Cole1, Heather Ellsworth
2 and
Samuel J Stellpflug2.
1Hennepin Regional Poison Center, Minneapolis, MN;
2Regions Hospital, St. Paul, MN
56. Effect of Protocol Implementation on Emergency Department Observation Unit Length of Stay and Charges.
Adam E Stenger, Robert Poirier and Jennifer Wiler. Washington University, St. Louis, MO
57. Retrospective Study of Underage Drinking and Emergency Department (ED) Visits: Before and After the 21
Ordinance. Christopher R Peterson and Michael Takacs. University of Iowa, Iowa City, IA
58. A Retrospective Review of the Use and Safety of Sedation for Agitated Patients with Hepatic Encephalopathy in the
Emergency Department. Jason West1 and Vijai Chauhan
2.
1Albert Einstein School of Medicine,
Jacobi/Montefiore Hospitals, Bronx, NY; 2Saint Louis University School of Medicine, St. Louis, MO
59. A Cost Comparison of Fomepizole and Hemodialysis in the Treatment of Methanol and Ethylene Glycol Toxicity.
Heather Ellsworth, Kristin M Engebretsen, Lisa M Hlavenka, Andy K Kim, Jon B Cole, Carson R Harris and
Samuel J Stellpflug. Regions Hospital, St. Paul, MN
60. Equestrian Helmet Use in Horse Organization Promotional Material. Charles A Jennissen1 and Suleimaan
Waheed2.
1University of Iowa Hospitals and Clinics, Iowa City, IA;
2University of Iowa, Iowa City, IA
61. Facilitators of Evidence-Based Pediatric Pain Management in Emergency Departments: Similarities and
Differences Between Rural and Urban Hospitals. Charles A Jennissen1, Sarah Wente
2, Charmaine Kleiber
2 and
Ryoko Furukawa2.
1University of Iowa Hospitals and Clinics, Iowa City, IA;
2University of Iowa College of
Nursing, Iowa City, IA
62. Characterization of Clinical Rotations in Three and Four Year Emergency Medicine Residency Training
Programs. Kenneth D Grosz, Robert Muelleman, Lance Hoffman and Michael Wadman. University of
Nebraska Medical Center, Omaha, NE
63. Let The Good Times Roll: Computer Modeling to Investigate Risk of ATV Rollover While Turning. Charles A
Jennissen1, Gerene Denning
1, John Steffen
2, Jonathon Marsico
2, Thomas Schnell
2 and Daniel McGehee
2.
1University of Iowa Hospitals and Clinics, Iowa City, IA;
2University of Iowa College of Engineering, Iowa City,
IA
64. A Picture’s Worth a Thousand Words: Utilizing Social Media to Better Understand ATV Crash Mechanisms.
Morgan Price1, Gerene Denning
2 and Charles A Jennissen
2.
1University of Iowa Emergency Department, Iowa
City, IA;2University of Iowa Hospitals and Clinics, Iowa City, IA
65. Complications of Extremity Computed Tomography Angiogram Completed in Emergency Department. Emily
Tilzer and Vijai Chauhan. Saint Louis University Hospital, Saint Louis, MO
66. Safety Depictions on Primetime TV: Lack of Seat belts and Helmets. David Milzman. Georgetown University
School of Medicine, Bethesda, MD
67. Agreement Between Physician and CT Scan in High Energy Mechanism Stable Trauma Patients. Michael D
Zwank1, Eric A Gross
2, Mary J Hughes
3, David J Castle
3, Amanda C Miller
3, William P Hughes
3 and Christopher
P Anderson4.
1Regions Hospital, Saint Paul, MN;
2Hennepin County Medical Center, Minneapolis,
MN;3Michigan State University, East Lansing, MI;
4Healthpartners Research Foundation, Bloomington, MN
68. Padding the Slider Transfer Board and Patient Comfort in the Emergency Department. Jerome R Walker1,
Christopher P Anderson2 and Michael D Zwank
1.
1Regions Hospital, Saint Paul, MN;
2Healthpartners Research
Foundation, Bloomington, MN
69. The Utility of Computed Tomography in the Diagnosis of Renal Colic in the Emergency Department. Michael D
Zwank1, David J Gresback
1 and Benjamin M Ho
2.
1Regions Hospital, Saint Paul, MN;
2University of Wisconsin,
Madison, WI
70. The True Impact Of A Left Vs. A Right Shift In Assessing A White Blood Cell Count: Bacterial Viral And The True
Infectious Source. David Milzman1, Anchal Ghai
1, Jenika Ferritti-gallon
2 and Stephan Chang
1.
1Georgetown
University School of Medicine, Bethesda, DC; 2Georgetown University, Washington, DC
71. Pre-Arrest Characteristics and Use of Advance Directives among Out-of-Hospital Cardiac Arrest Victims. David
Milzman1, Erwin Wang
2 and Han Huang
3.
1Georgetown University School of Medicine, Bethesda,
MD;2Georgetown University School of Medicine, Bethesda, DC;
3Georgetown University School of Medicine,
Washington, DC
72. Comparison of Data Collection Using Real Time Observers to Subsequent Review of Video Data for Airway
Management Research. James Miner, Megan Terrebonne, Robert Reardon and John McGill. Hennepin
County Medical Center, Minneapolis, MN
73. Correlation Between Exercise Levels and Medical School Board Scores. Vijai Chauhan and Sean Cavanaugh.
Saint Louis University SOM, Saint Louis, MO
74. Pain Medication Delivery In The Ed For Extremity Fractures: Correlation Of Prescribers' And Patients' Gender
And Ethnicity. David Milzman1, Valerie Huckabee
1, Bill Dirkes
1, Julie Vieth
2 and Collier Wright
1.
1Georgetown
University School of Medicine, Washington, DC; 2Georgetown U / Georgetown WHC EM Residency,
Washington, DC
75. Protein Expression Of M2 Receptor In Atria And Ventricles Of Sham Rats. Elizabeth M Spartz, Huiyin Tu, T. Paul
Tran and Yu-Long Li. University of Nebraska Medical Center, Omaha, NE
76. Rates of Selected Procedures and High-Acuity Diagnoses in Urban and Rural Emergency Departments. James
Waymack, Steve Markwell and Ted Clark. Southern Illinois University, Springfield, IL.
77. Do Alcohol-Related Emergency Department (ED) Visits Mirror Police Data? A Retrospective Study. Greg Pelc,
Michael Takacs and Hans House. University of Iowa, Iowa City, IA
78. Acute Disaster Response: Lessons Learned from a Small-scale Event. Kathy Lehman-Huskamp and Anthony
Scalzo. Southern Illinois University, Springfield, IL; Saint Louis University, Saint Louis, MO
4:30pm – 5:00pm, Awards and Closing Remarks, Moore Auditorium.
Oral Presentation Session 1
9:10am-10:45am
1. ISAR and TRST Do Not Predict Short-Term Adverse
Outcomes in Geriatric Patients
Steven Abboud1 and Christopher Carpenter2. 1Saint Louis University
School of Medicine, St. Louis, MO; 2Washington University School
of Medicine, St. Louis, MO
Background: Acute exacerbations of chronic illnesses cause the
geriatric adult to seek emergency medicine care at constantly
increasing numbers. These patients often have complex medical
problems that require more time and care from emergency
department (ED) staff to treat which strain available resources.
Mechanisms to focus finite resources on higher risk subsets would be
of great value in this setting. Two instruments, the Identification of
Seniors at Risk (ISAR) and Triage Risk Screening Tool (TRST) have
been created to stratify seniors at higher risk for adverse outcomes
such as death, institutionalization, functional decline, and ED revisit.
Because both instruments have validity limited to the institutions they
were created at, the National Institutes of Health has prioritized
research of ISAR and TRST.
Objectives: To validate and compare the prognostic accuracy of the
ISAR and TRST for the composite outcome of one-month ED revisit,
institutionalization, death, and functional decline.
Methods: This was a prospective, observational cohort study of
consenting English speaking patients ≥ 65yrs old presenting to the
Barnes Jewish Hospital ED in St. Louis MO between June 1 and July
31 2011. Patients ≥ 65 years old that did not live in a nursing home or
> 30 miles from the hospital were screened using ISAR and TRST.
Patient follow up was at 30 days post screening. Patients were
evaluated for a correlation between ISAR and TRST score and the
composite outcomes of 1) unscheduled ED visit or hospital admission
2) institutionalization, defined as admission to a nursing home or
chronic care hospital or assisted living facility 3) death 4) functional
decline defined as ≥ 3 point decline on 28 point OARS ADL.
Results: Among the 168 patients, the mean age was 74 years, 43.1%
were men, and 62% were African American. Overall predictive
values were summarized using ROC curves that yielded AUCs of
0.702 and 0.641 for ISAR and TRST respectively.
Conclusion: In the validation of both ISAR and TRST we found that
both tests have poor predictive value for composite outcomes of ED
revisit, institutionalization, death, and functional decline as indicated
by unremarkable positive or negative LR‟s and the high proportion of
patients identified as high risk. Future trials should evaluate these
outcomes at 3 months and include ROC curves for each individual
outcome.
2. Usefulness of Pediatric Lactic Acid Screening in the
Emergency Department
Antonio Cummings, Loren Reed, Jennifer Carroll, Stephen
Markwell, Jarrod Wall and Myto Duong. Southern Illinois
University, Springfield, IL
Background: The benefits of lactic acid (LA) assays for adults in the
emergency department (ED) are well known. LA has been used to
monitor hydration status, acid base anomalies and in early goal
directed therapy for sepsis. In pediatric patients, however, LA
screening is not well established. In 2010, our ED initiated a sepsis
protocol in which LA was drawn concurrently with blood cultures.
Objectives: The objective of this study was to determine the
usefulness of ED LA levels in a select group of pediatric patients,
assessing correlation with illness severity, laboratory tests, admission
rates and outcome.
Methods: A retrospective chart review included 158 patients </=2
years old who had features of sepsis and had LA level (mmole/L)
drawn from June 2010 to June 2011. This was performed in a
community ED with 18000 annual pediatric visits. Data collected
included: vitals, labs, cultures, length of stay, admission, and return
to ED within 3 days. Descriptive statistics were examined for
variables of interest and analyzed for relevance. Pearson correlation
coefficients were used to examine relationships between continuous
variables. To further assess the impact of having an elevated LA,
patients were dichotomized into those falling above or below 75th
percentile LA level. T-tests were used to compare LA groups based
on age, temperature, pulse, respiratory rate (RR), white blood cell
(WBC), bicarbonate level, creatinine, blood urea nitrogen, and
platelet count. P<0.05 was considered significant.
Results: Mean LA was 2.26 with a standard deviation of 1.34. A
statistically significant correlation was found between LA level and
RR, WBC, platelet count, and rate of admission. An inverse
relationship was found between LA level and age and temperature.
Admitted patients on average had a LA level of 2.65 and those not
admitted 1.97 (p<0.05). There was one death (11 months old who
was ventilator dependent and was discharged home without returning
within 72 hours, but died 24 days later).
Conclusion: While patients with LA levels >2.7 (at or above the 75th
percentile), were significantly younger, had higher RR, WBC‟s,
platelets and were more likely to be admitted, the mean values for
these variables were not clinically important (e.g. RR 42 and WBC
13.8 in a 9 month old is not abnormal). The usefulness of LA levels,
obtained in the ED for suspicion of sepsis in children, could be
predictive of hospitalization.
3. Waiting is Frustrating: A Comparison of the Emergency
Severity Index to the Australasian Triage Scale for Psychiatric
Patient Assessment
Andrew S Deutsch1, Leslie Zun2, LaVonne Downey3 and Trena
Burke2. 1Rosalind Franklin University of Medicine and Science /
Chicago Medical School, North Chicago, IL; 2Mt. Sinai Hospital
Emergency Department, Chicago, IL; 3Roosevelt University,
Chicago, IL
Background: Psychiatric Emergency Department (ED) visits are
increasing each year, yet there is a lack of mental health descriptors
in the Emergency Severity Index (ESI) triage scale, diminishing the
triage staff‟s ability to properly assess psychiatric patients. The
Australasian Triage Scale (ATS) includes mental health descriptors
and has been shown to increase the competence and confidence of
triage staff.
Objectives: The objective of this study is to compare the Emergency
Nurses Association (ENA) 5-tier ESI to the ATS to determine which
better evaluates a psychiatric patient‟s need for intervention.
Methods: This was a prospective cohort study consisting of a
convenience sample of 58 medically stable consenting adults who
presented with a psychiatric complaint to the level 1 trauma ED in
one urban community teaching hospital during an 8 week period. As
approved by the IRB, subjects were triaged according to the ESI
system by the triage nurse. A second triage assessment was
conducted by a research fellow using the ATS, which included
observed and reported elements. Following admission to the ED, a
Richmond Agitation Sedation Scale (RASS) score was assigned, and
a psychiatric self-assessment was completed by each subject to
determine the degree of distress and anxiety.
Results: A majority of the subjects (> 50%) were single, African
American, and admitted with a throughput time over 4 hours. A
significant correlation was identified between ATS and RASS scores
(p = 0.035): however, no correlation was identified between RASS
and the ESI. ATS scores predicted 6 psychiatric self-assessment
questions that had to do with level of agitation, violence, and self
harm (p < 0.05). The ESI ranked a majority (> 60%) of subjects
as a 3-urgent and only predicted patients‟ intent on hurting
themselves (p = 0.024).
Conclusion: The ESI only correlates with determining risk of harm
to one‟s self, while the ATS was shown to be reliable and valid in
assessing RASS and 6 core questions that determine risk of harm to
self and others. Further, the ATS provided a more even distribution
of triage scores, thus more appropriately coordinating patient
throughput time and providing a more meaningful ranking than the
ESI.
4. The Effect of Cognitive Dysfunction and Health Literacy on
Patient Comprehension of ED Care among Geriatric Patients
Jessie Hu1, Owais Nadeem
1, and Christopher R. Carpenter
2. Saint
Louis University School of Medicine, St. Louis, MO; 2Washington
University School of Medicine, St. Louis, MO
Background: The rate of geriatric patients in the ED has been
steadily increasing over the past several years, and this trend is
expected to continue with the aging baby-boomers. Approximately
one third of older patients who are discharged will return to the ED
within 14 days, with 90% presenting with the same problem that
prompted the first visit, making it essential to identify factors which
contribute to this population‟s high rates of unnecessary recidivism.
Objectives: The objective of this study is to assess the effect of
cognitive dysfunction and health literacy on comprehension of
Emergency Department (ED) encounter among geriatric adults in
four domains: (1) diagnosis, (2) tests and treatments in the ED, (3)
prescriptions and follow-up recommendations, and (4) return
instructions.
Methods: We conducted a cross sectional study on patients over the
age of 65. Thirteen research assistants (RA) screened consecutive
patients from June 1, 2011 to July 31, 2011 at the Barnes Jewish
Hospital ED. Exclusion criteria included failure to consent, residence
more than 30 miles away, residence in a nursing home, and non-
English speakers. The SBT, BAS, and cAD8 questionnaires were
administered to assess cognitive function and the REALM-SF was
used to assess health literacy. At the time of discharge, patients were
also asked to rate their subjective understanding of their ED
encounter for all four domains of ED care.
Results: We enrolled 165 patients. Around 47% of the patients
perceived low comprehension in at least 1 domain of ED visit.
Geriatric patients seemed to most often misunderstand elements of
their ED care, such as tests and treatments received. Greater cognitive
dysfunction was moderately correlated with self-rated lack of
understanding of elements of ED care (Spearman r= -.393; P < .01).
Health literacy had a statistically significant effect (P < .001) on
comprehension of ED care as well. When stratified by level of health
literacy, 81% of patients with less than 9th grade reading level
expressed a lack of understanding in this domain, whereas only 23%
of patients with greater than 9th grade reading level perceived this
lack of understanding.
Conclusion: Cognitive dysfunction and low health literacy in
patients are significantly correlated with lower self-perceived
comprehension of ED care.
5. Comparing Emergency Medicine Practices for Central Venous
Catheter Placement to Existing ICU Checklists
Rob Klemisch and Daniel L Theodoro. Washington University
School of Medicine in St. Louis, St. Louis, MO
Background: The incidence of Central Venous Catheter (CVC)
insertion is increasing in the Emergency Department (ED). Checklists
for CVC placement have been shown to increase adherence to best
practices and reduce central line associated blood stream infections.
Though multiple checklists have been published for use in the
Intensive Care Unit (ICU), none has been tailored to the ED.
Objectives: Perform a pilot study to assess ED utilization of well
accepted CVC checklists and determine adherence to specific
checklist elements related to infection control.
Methods: This was a convenience sample of CVC insertions in an
urban Level I trauma ED performed between June and August 2011.
CVC insertions by ED physicians were captured by an independent,
trained observer on staggered shifts including days, evenings, and
overnights. “Crash” CVC insertions (defined as placed under
imminent life or death conditions) were excluded. Observed ED CVC
placements were compared to elements of four non-ED checklists.
We used descriptive statistics to identify areas of high and low
adherence.
Results: The CVC “bundle” was used by 19 of 19 operators (100%,
95%CI 0.83 to 1) and in 19 of 19 (100%, 95%CI 0.83 to 1) cases the
included checklist was discarded. No operator completed all elements
on any of the four checklists. Sterile gloves were used in 19 of 19
insertions (100%, 95%CI 0.83 to 1), sedation or local anesthetic was
used in 18 of 18 (100%, 95%CI 0.83 to 1), and maintenance of a
sterile field throughout the procedure was observed in 17 of 17
(100%, 95%CI 0.82 to 1). Operators wore caps and masks during 16
of 19 insertions (84%, 95%CI 0.62 to 0.94) and gowns during 18 of
19 insertions (95%, 95%CI 0.75 to 0.99). In 9 of 19 insertions (47%,
95%CI 0.27 to 0.68) patients were not draped from head to toe, 8 of
18 insertion sites (44% 95%CI 0.25 to 0.66) were not scrubbed for a
full 30 seconds, 7 of 17 (41% 95%CI 0.21 to 0.64) operators did not
clamp all unused lumens, and in 9 of 16 insertions Trendelenburg
position was not used (56%, 95%CI 0.33 to 0.77).
Conclusion: This small pilot study demonstrated that ED physicians
have not adopted CVC checklists. In addition, adherence to some
aspects of established checklist practices are poor. Outcomes of ED
central lines may benefit from an ED developed, structured checklist.
6. Improved Interpretation of Coagulase Negative Staphylococcal
Blood Culture Results Using Limited Genomic Resequencing
Ashley Satorius, Adriana Rivera, Marika Raff, Duane Newton and
John Younger. University of Michigan, Ann Arbor, MI
Background: Coagulase-negative staphylococci are the most
common cause of catheter and implanted device infection. They are
also the most common cause of false positive blood cultures. Thus,
patients from whose blood these organisms are recovered often face
mandatory hospitalization and broad spectrum antibiotics until the
clinical significance of the culture can be determined (usually days).
Improved means of discriminating pathogenic from contaminating
organisms are greatly needed.
Objectives: We examined the utility of limited genetic sequencing of
bacterial isolates using multilocus sequence typing (MLST) to
discriminate between known pathogenic blood culture isolates of S.
epidermidis and isolates recovered from skin.
Methods: Ten blood culture isolates from patients meeting CDC
criteria for clinically significant S. epidermidis bacteremia and ten
isolates from the skin of healthy volunteers were studied. MLST was
performed by sequencing ~ 400 bp regions of 7 genes (arc, aroE, gtR,
mutS, pyr, tpiA, and yqiL). Genetic variability at these sites was
compared to an international database (www.sepidermidis.mlst.net)
and each strain was then categorized into a genotype on the basis of
known genetic variation. The ability of the gene sequences to
correctly classify strains was quantified using the support vector
machine function in the statistical package R. 1,000 bootstrap
resamples were performed to generate confidence bounds around the
accuracy estimates.
Results: Between strain variability was considerable, with yqiL
being most variable (6 alleles) and tpiA being least (1 allele). The
mutS gene, responsible for DNA repair in S. epidermidis, showed
almost complete separation between pathogenic and commensal
strains. When the 7 genes were used in a joint model, they correctly
predicted bacterial strain type with 90% accuracy (IQR 85, 95%).
Conclusion: Multilocus sequence typing shows excellent early
promise as a means of distinguishing contaminant versus truly
pathogenic isolates of S. epidermidis from clinical samples. Near-
term future goals will involve developing more rapid means of
sequencing and enrolling a larger cohort to verify assay performance.
7. Evaluating Quality of Life in Cognitively Impaired Geriatric
Patients in the Emergency Department
Lila S. Wahidi and Christopher R. Carpenter. Washington University
School of Medicine in St. Louis, St. Louis, MO
Background: An aging population has resulted in a rising prevalence
of age-related conditions, such as cognitive dysfunction, which can
affect one's quality of life (QOL). It is important to study geriatric
QOL in the emergency department (ED) to guide medical care in the
ED and after discharge.
Objectives: To determine correlations between cognitive dysfunction
and geriatric patient QOL ratings in an ED setting and to investigate
the ability of cognitively impaired patients to rate their QOL by
comparing self-ratings to those of a caregiver.
Methods: In this prospective, cross-sectional study at one urban
academic medical center, trained researchers collected patients'
responses on the Short Blessed Test (SBT) and the Quality of Life-
Alzheimer's Disease (QOL-AD) Subject Report. Caregivers
completed the QOL-AD Caregiver Report. Consenting subjects were
non-critically ill, English-speaking, community-dwelling adults over
65 years. Spearman rho coefficient and Wilcoxon signed-rank test
evaluated relationships between patient and caregiver QOL-AD
scores with regard to the patients' level of cognition.
Results: Patient QOL ratings were obtained from 60 patient-
caregiver pairs. QOL evaluations by patients and caregivers were
more highly correlated in patients of normal cognition. Mean total
QOL scores were lower for cognitively impaired patients than
patients of normal cognition. The difference between mean total QOL
scores for patients and caregivers was greater for patients of
abnormal cognition.
Conclusion: Fewer significant correlations for cognitively impaired
patients and their caregivers can explained by several reasons
including patient lack of insight, denial of impairment, adaptation to
the condition, or the fact that cognitive impairment may not
negatively impact quality of life. Understanding patient QOL is
important for referral to multidisciplinary programs with the goal of
reducing preventable hospitalizations and ED recidivism.
QOL-AD
Patients of Normal SBT (n=27) Patients of Abnormal SBT (n=33)
Wilcoxon Patient Ratings
Caregiver Ratings
Spearman coefficient
Patient Ratings
Caregiver Ratings
Spearman coefficient
Mean (SD) Mean (SD) rho p Mean (SD) Mean (SD) rho p p
Physical health Energy Mood
Living situation Memory Family Marriage Friends Self as a whole Ability to do chores Ability to do things
for fun Money Life as a whole Total Score
2.41 (1.01) 2.41 (1.01) 2.96 (0.90) 3.52 (0.75) 2.93 (0.96) 3.41 (0.69) 3.52 (0.58)
3.44 (0.58) 3.22 (0.51) 2.81 (1.14) 3.04 (1.02) 3.19 (1.00) 3.48 (0.58) 40.33 (7.66)
2.41 (0.97) 2.67 (0.88) 2.63 (1.08) 3.41 (0.84) 3.04 (0.81) 3.37 (0.79) 3.22 (0.93)
3.33 (0.73) 3.04 (0.90) 2.81 (1.21) 2.96 (1.02) 3.26 (0.98) 3.44 (0.75) 39.59 (9.07)
0.766 0.757 0.813 0.288 0.253 0.230 0.550
0.379 0.348 0.513 0.173 0.255 0.414 0.677
0.000 0.000 0.000 0.145 0.204 0.249 0.003
0.051 0.076 0.006 0.388 0.200 0.032 0.000
2.39 (0.97) 2.06 (1.00) 2.12 (0.93) 2.70 (0.88) 2.24 (0.87) 2.91 (0.95) 3.33 (0.89)
2.97 (0.92) 2.76 (1.03) 2.55 (1.03) 2.64 (1.06) 2.36 (1.08) 2.97 (0.85) 34.00 (8.60)
2.06 (0.86) 2.30 (1.02) 1.97 (0.88) 3.03 (0.81) 2.21 (0.74) 3.00 (0.87) 3.03 (0.88)
3.06 (0.75) 2.70 (0.88) 1.97 (0.88) 2.18 (0.81) 2.48 (0.76) 2.88 (0.74) 32.88 (7.17)
0.287 0.356 0.517 0.066 0.299 -0.017 0.349
0.044 0.292 0.269 0.169 0.309 0.149 0.351
0.106 0.042 0.002 0.715 0.091 0.926 0.047
0.808 0.099 0.129 0.348 0.080 0.406 0.045
0.012 0.120 0.531 0.174 0.686 0.127 0.059
0.175 0.128 0.256 0.812 0.276 0.071 0.112
8. Patients With Suicide Ideation Presenting To The Emergency
Department: A New Characterization Of Mortality And
Outcomes.
David Milzman, Hahn Soe-Lin, Laura Baldassari, Han Huang and
Nick Echevarria. Georgetown University School of Medicine,
Washington, DC
Background: Psychiatric patients exhibit increased suicide risk
shortly after discharge, but little is known about the fate of patients
who are discharged after presentation with Suicidal Ideation (SI). In
the U.S. there is furthermore a lack of supporting documentation for
outcomes following admits from Emergency Department (ED)
presentations for SI.
Objectives: To determine if patients who present to the ED with
Suicidal Ideation are at increased risk for death by suicide than those
patients presenting with other acute complaints.
Methods: Setting: urban hospital, 950 patient beds, ED with 80,000
annual visits
•Retrospective data collection using Azyxxi data record developed by
Smith and Feeid (Microsoft, Redmond WA)
•Patients included presented with triage complaint or ED diagnosis of
suicide or spelling variants between 2002-2007.
•Cohort of 3742 patient records (SI Cohort) screened against Social
Security Death Registry (http://ssdi.rootsweb.com/cgi-bin/ssdi.cgi) to
obtain mortality statistics.
•Subcohort of 108 patients with a positive match for death on the
SSNDR (Death Cohort) was identified and sociodemographics and
co-morbidities were characterized.
•True suicides as primary cause of death were then ruled in by cross-
referencing of this subcohort with the District of Columbia‟s Medical
Examiners Office
Results: 3,625 pts with SI presented to the ED during the study
period over 5 years accounting for 53,217 ED visits with a mean of
13.4 visits for SI alone (95%CI: 10/5-17.1) with an overall mortality
rate of 4.8%. for all comers in the ED population. The mean time to
death for the 122 deaths in the suicide group was 2.9 years from the
initial suicide ideation visits. for all suicidal patients, there was a
mean of 11 visits and an average of 5.1 years from first ED visit( all
cause) till death for those that died in the study period. 50% of the
death cohort were found to abuse alcohol and/or substances and 32%
were HIV positive. Only 10% of those that died during the study
period were determined to have died from OD or self -inflicted
wounds; this results in an overall true suicide rate of 0.5 percent for
the entire suicidal patient presenting to the ED.
Conclusion: SI is still a serious problem, However; the deaths for
these patients presenting to the ED do not come at any increased rate
in this preliminary study.
9. Comparing Urine Acetoacetate Values With Serum 3-beta-
hydroxybutyrate Values In Pregnant Women With Nausea And
Vomiting In The Emergency Department.
Ian T Ferguson and Michael Mullins. Washington University in St.
Louis, St. Louis, MO
Background: Nausea and vomiting affect upwards of 80% of
pregnant women and are frequent causes of emergency department
visits. The ED physician must distinguish between uncomplicated
nausea/vomiting (“morning sickness”) and hyperemesis gravidarum
(HG) because this affects treatments decisions, including type and
quantity of IV fluids, and length of stay.
Objectives: Our aim of this study was to determine whether
fingerstick 3-beta-hydroxybutryrate (BHB) predicts ketonuria in
pregnant women with nausea and vomiting.
Methods: We enrolled 77 pregnant women who presented to the
Barnes-Jewish Emergency Department with complaints of
nausea/vomiting. All procedures were completed under IRB
approval. Exclusion criteria were: 38.3°C or altered mental status,
prisoners, and >1 liter of IV fluid before screening. All subjects had a
fingerstick BHB test, with results reported in increments of 0.1
mmol/L. Urine ketone results were made available once reported as
part of standard of care and varied from 0 (trace) to +4 values.
Results: We constructed a contingency table and receiver-operating
curve for comparing the BHB values to those urine ketone values for
each patient. We used a cut-off urine ketone value of +3 or +4 to
sufficiently indicate severe nausea/vomiting or hyperemesis as these
values necessitate aggressive fluid management to reduce ketonemia
and improve ketone urine clearance.
Mean BHB was 0.435 mmol/L and median urine was +1 for the
cohort as a whole. The ROC gives an area under the curve of .94. The
sensitivity and specificity for a fingerstick test of >.4 mmol/L are
85% and 94% respectively. The PPV is .88 and the NPV is .92. The
positive likelihood ratio is 14 and the negative likelihood ratio is .16.
Conclusion: Fingerstick BHB provides a rapid and reliable
diagnostic tool to correlate ketonemia (3-beta-hydroxybutyrate)
levels with ketonuria (acetoacetate) levels in pregnant women with
nausea/vomiting. Fingerstick BHB results may be obtained earlier in
the course of care than urine samples and as a result, may increase
triage efficacy, lower length of stay times, and positively affect
patient outcomes in an emergency department setting.
Lightning Oral Presentation Session 1
9:10am-10:45am
10. Do Admission Check Sheets Improve Compliance with
Pneumonia Core Measures?
Andrew Abbeg, Sr., Steven Lorber, Preeti Dalawari and Stacy
Revelle. St Louis University Hospital, St Louis, MO
Background: The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) includes antibiotics given within 6 hours of
arrival to the emergency department (ED) for patients diagnosed with
pneumonia as a performance measure. The Center for Medicaid and
Medicare Services (CMS) uses this as one of its core measures to
continue funding to hospitals; a 97% compliance rate is expected.
However, atypical pneumonia presentations may cause a delay in
antibiotic treatment and will be considered an outlier if an
explanation of the delay is not given.
Objectives: The objective of this study was to assess the monthly
compliance rate with this measure before and after the institution of a
checklist.
Methods: This was a review of aggregate data of ED pneumonia
compliance for public reporting at an academic tertiary center. A
preliminary data analysis compared 8 months before and 4 months
after the checklist was instituted in March 2010 (final analysis will
include 8 months post checklist). The checklist, developed by the
institutional pneumonia committee, enables physicians to indicate
typical versus atypical presentation, time to antibiotics, and
explanations for delays in treatment. A t test for independent samples
was used to analyze differences in compliance rate between groups.
Results: There were 143 reportable pneumonia cases in the
preliminary time period; 88 (62%) prior to checklist and
55 (38%) after. After the institution of the checklist all pneumonia
patients received timely antibiotics with 100% average monthly
compliance compared to before checklist of 94.1% (p value <0.027).
Conclusion: The preliminary data suggests that using a pneumonia
checklist is one way that an emergency department can improve
compliance with the time to antibiotic CMS core measure.
11. Grip Strength as a Brief Diagnostic Test for Frailty and Pre-
Frailty in Geriatric Emergency Department Patients
Grant M. Fischer and Christopher R. Carpenter. Washington
University in St. Louis School of Medicine, St. Louis, MO
Background: Linda Fried et al.‟s well-established definition of
frailty classifies geriatric adults as frail if they meet 3 of the
following 5 criteria: unintentional weight loss, exhaustion, low grip
strength, slow walking speed, and low physical activity level. It
categorizes them as pre-frail if they meet 1 or 2 of these criteria. ED-
case finding for frailty could offer opportunities for intervention. A
brief, effective tool for identifying frailty must be developed in order
for frailty-specific ED-case finding to be possible.
Objectives: The purpose of this study was to determine if grip
strength could serve as a brief diagnostic test for frailty and/or pre-
frailty in geriatric ED patients.
Methods: An observational, cross-sectional study was conducted on
a consecutive sample of eligible subjects at the ED of Barnes-Jewish
Hospital (BJH). Eligible subjects included consenting English-
speaking, community-dwelling patients at least age 65 years who
presented to BJH‟s ED from June 1, 2011 to July 31, 2011 and did
not reside over 30 miles from BJH. Trained geriatric technicians
evaluated subjects for adherence to all of the Fried criteria except
walking speed. For data analysis, subjects were considered frail if
they had unintentionally lost at least 10 lbs in the year prior to testing,
felt exhausted in the week prior to testing, and were found to have a
low physical activity level (as determined by the Stanford Brief
Activity Survey). They were classified as pre-frail if they tested
positive for 1 or 2 of these criteria. Grip strength values, measured by
a JAMAR® Plus Hand Dynamometer, were adjusted for age and
height based upon population norms for each gender. The diagnostic
test characteristics of grip strength were determined using SPSS and
MEDCALC.
Results: Overall, 165 patients were enrolled with complete data
collection. The mean age of the subjects was 74 years. 43% of the
subjects were male. 27.1% of males and 11.7% of females tested
below their age and height adjusted grip strength norms. Grip
strength demonstrated poor diagnostic test characteristics with
regards to identifying frail and pre-frail geriatric ED patients.
Diagnostic Test Characteristics of Grip Strength for Females
Sen % (95% CI) Spec % (95% CI) LR+ (95% CI) LR- (95% CI) AUC (95% CI)
1 Fried criterion 12 (-4-27) 83 (73-94) 0.71 (0.17-3.00) 1.06 (0.85-1.31) 0.49 (0.35-0.62)
2 Fried criteria 29 (9-48) 91 (82-99) 3.14 (0.99-9.96) 0.79 (0.59-1.05) 0.47 (0.32-0.63)
3 Fried criteria 11 (-9-32) 84 (74-94) 0.69 (0.10-4.82) 1.06 (0.82-1.37) 0.49 (0.32-0.66)
Diagnostic Test Characteristics of Grip Strength for Males
Sen % (95% CI) Spec % (95% CI) LR+ (95% CI) LR- (95% CI) AUC (95% CI)
1 Fried criterion 21 (0-43) 69 (55-83) 0.69 (0.23-2.08) 1.14 (0.81-1.60) 0.41 (0.25-0.57)
2 Fried criteria 40 (10-70) 74 (61-87) 1.53 (0.62-3.78) 0.81 (0.48-1.39) 0.48 (0.30-0.67)
3 Fried criteria 55 (25-84) 78 (66-90) 2.46 (1.14-5.29) 0.58 (0.30-1.14) 0.44 (0.25-0.63)
Conclusion: Low sensitivities and ROC AUCs indicated that grip
strength poorly detected frailty and pre-frailty in geriatric ED
patients. A brief, effective screening tool for frailty should still be
researched to improve care for geriatric ED patients.
12. Are They Working? The Effects Of UI And Community-
Based Interventions On Thursday Night Binge Drinking
Nicholas J Edwards and Michael Takacs. University of Iowa Carver
College of Medicine, Iowa City, IA
Background: 2011 survey data indicates that 65% of UI students
engage in binge drinking; down from 70% in 2006, but staggering
when compared to 44% of college students nationwide. At this time,
the impact of UI and community-based interventions on this decrease
in self-reported risky drinking is unclear. Nonetheless, emergency
departments (ED) continue to play an important role in injury
surveillance and can capitalize on “teachable moments” during
alcohol-related ED visits.
Objectives: Compare numbers of alcohol-related ED visits before
and after the start of alcohol-interventions (more Friday classes, 21-
Only Ordinance) to determine the efficacy of these programs, with
trends among students and across genders being focal points.
Methods: 18-22 year-olds, who presented to the ETC for alcohol-
related injuries on Thursday nights from Fall 2006 to Spring 2011,
were eligible for this retrospective study. Data were compiled from
patients‟ medical records, and FERPA-approved access to the UI
Provost‟s database determined the patients‟ UI academic status. Non-
students served as controls. Data were analyzed via chi-square and
ANOVA.
Results: On Thursday nights from Fall 2009-Spring 2011, 127
patients presented to the ED for alcohol related-injuries; 76 males
(60%), 51 females (40%), and 78 UI-students (61%) versus 49 non-
students (39%). 25 males presented with violence-related injuries,
compared to 0 females (p<0.0001). A study of semesters before and
after implementation of alcohol-interventions showed a 15% decrease
in Thursday night alcohol-related ED visits following increases in
Friday classes, and a 54% decrease following onset of the 21-Only
Ordinance (p<0.02 when comparing interventions). Among UI-
students, 31% and 53% decreases were seen, respectively (p<0.01
when comparing semesters).
Conclusion: Further research is indicated to effectively study
correlations between alcohol-related ED visits and alcohol-
interventions, as retrospective studies cannot provide direct causation
for observed changes. Observed differences between male and female
incidence and mechanism of injury may warrant future interventions
and educational means that are gender-specific.
13. Short QTc in Emergency Department Patients
Stacey House, Peta-Gay Laird and S. Eliza Halcomb. Washington
University in St. Louis, St. Louis, MO
Background: A short QTc interval has been shown to predispose
patients to arrhythmias and sudden death. Electrolyte abnormalities,
hyperthermia, and some medications are associated with shortened
QTc. As the importance of short QTc has only recently been
appreciated, there is limited literature describing patients with short
QTc especially in the ED.
Objectives: The study objective was to characterize the ED
population with short QTc.
Methods: This study was a retrospective review of ED patients (pts)
who received an ECG from April - September 2009 at a large
volume, tertiary care center. Inclusion criteria were pts with a
QTc≤390ms. Exclusion criteria included pts with an ECG showing
bradycardia (HR<60bpm), tachycardia (HR>100bpm), QRS>120ms,
or non-sinus rhythm. ED electronic medical records were reviewed
for multiple comorbid conditions, presenting symptoms, electrolyte
abnormalities, medications, and disposition.
Results: 13,494 pts received ECGs during the six month period. Of
these, 281 had a QTc≤390ms (2%, 95%CI 1.8-2.3%). 136 were
excluded, leaving 145 eligible pts. Of these, 108 (75%) had a QTc
380-390ms, 26 (18%) had a QTc 370-379ms, and 10 (7%) had a
QTc≤369ms. These pts were 39±2 years old and were predominantly
male (71%, 95%CI 63-78%). Hypertension (22%), psychiatric
conditions (17%), and drug abuse (22%) were the most common
comorbidities. The most common symptoms were chest pain (56%),
shortness of breath (40%), and dizziness (19%). 18% (95%CI 10-
25%) had abnormal serum potassium, and 13% (95%CI 6-19%) had
abnormal serum calcium. 4% (95CI 1-7%) were hyperthermic. Only
3% (95%CI 1-5%) were on home medications which shortened QTc
interval including <1% on digoxin, the most commonly described
cause of medication-induced short QTc. 70% (95%CI 63-78%) were
discharged from the ED. There were no significant differences among
the different length QTc groups with regards to comorbidities,
symptoms, electrolyte abnormalities, QTc shortening medications, or
disposition.
Conclusion: Shortened QTc occurs in 1-2% of ED pts with <0.1%
having a QTc<369ms. Even though hypercalcemia, hyperthermia,
and digoxin therapy are commonly reported causes of shortened QTc,
a very small portion of ED pts with shortened QTc had these
findings. As the majority of these pts are discharged from the ED,
further studies are needed to determine the cardiac event rates in ED
pts with shortened QTc.
14. Data Based on All-terrain Vehicle (ATV) Crash Site Informs
Rural Health and Safety Policy
Gerene M Denning, Kari Harland, Kevin Kremer, Charles Jennissen
and Christopher Buresh. University of Iowa, Iowa City, IA
Background: Every year, U.S. ATV crashes result in over 500
deaths, 130,000 ED visits, and $4 billion in lost life and healthcare
costs. One in three victims are under the age of 16. Because the vast
majority of ATV crashes occur in or near rural communities, they
represent a serious threat to rural health and safety.
Objectives: The objectives of this project were to compare Iowa
ATV crashes by crash location, and to develop public policy
recommendations based on these results.
Methods: Data for these studies were generated from our Iowa ATV
Injury Surveillance Database (2002-2009). Proportions were
compared using the chi-square test. Injury severity scores for on and
off-road crashes were compared using the Mann-Whitney test.
Results: Females (23%) and children under sixteen (32%) were a
higher percentage of on-road crash victims as compared to crashes in
Off-Highway Vehicle (OHV) parks (females, 8%; children 10%; p <
0.05). There were also significantly higher proportions of on-road
(17%) and off-road (15%) crashes that involved passengers, when
compared to crashes in the parks (3.8%, p < 0.05). Monitoring and
enforcement of helmet requirements in the parks appeared to increase
helmet use (91%) relative to other sites (on-road, 13%; off-road,
25%; p < 0.0001); Iowa does not currently have a statewide helmet
law. On-road crashes were 8-fold more likely to involve a collision
with another vehicle relative to off-road crashes. On-road fatalities
averaged two per year, whereas a single fatality was recorded in the
parks over the 8-year period. Injury severity scores were higher for
on-road crashes relative to off-road locations (p < 0.0001), and
victims from on-road crashes were 3 times more likely to suffer
traumatic brain injury relative to off-road victims.
Conclusion: Iowa law allows cities and counties to designate
streets/roads for general ATV use; however, our data indicate that on-
road ATV crashes pose a serious injury risk and traffic safety hazard.
Based on these findings, we would strongly advise policy makers
against increasing ATV road use. Conversely, enforcement of OHV
park regulations, including no passenger rules and required helmet
use, appears to promote safer behaviors and better outcomes.
Expanding safe, controlled places for recreational riding would be a
potential way to reduce ATV-related deaths and injuries.
15. A Comparison of Two Hospital Electronic Medical Record
Systems and Their Effects on the Relationship Between Physician
Charting and Patient Contact
John Shabosky, Jonathan dela Cruz and Matthew Albrecht.
Southern Illinois University School of Medicine, Springfield, IL
Background: Recent health care reform has placed an emphasis on
the electronic health record (EHR). With the advent of the EHR it is
common to see ED providers spending more time in front of
computers documenting and away from patients. Finding strategies to
decrease provider interaction with computers and increase time with
patients may lead to improved patient outcomes and satisfaction.
Computerized charting adjuncts, such as voice recognition software,
have been marketed as ways to improve provider efficiency and
patient contact.
Objectives: We present here observational data comparing two
separate ED sites, one where computerized charting is done by
conventional techniques and one that is assisted with voice
recognition dictation, and their effects on physican charting and
patient contact.
Methods: A prospective observational quality initiative was
conducted at two teaching hospitals located less than 1 mile from
each other. One site primarily uses conventional computerized
charting while the other uses voice recognition dictation. Four trained
quality assistants observed ED physicians for 180 minutes during
shifts. The tasks each physician performed were noted and logged in
30 second intervals. Tasks listed were identified from a
predetermined standardized list presented at observer training. A total
of 4140 minutes were logged. Time allocated to charting and that
allocated to direct patient care were then compared between sites.
Results: ED physicians spent 28.6% of their time charting using
conventional techniques vs 25.7% using voice recognition dictation
(p=0.4349). Time allocated to direct patient care was found to be
22.8% with conventional charting vs 25.1% using dictation (p=4887).
In total, ED physicians using conventional charting techniques spent
668/2340 minutes charting. ED physicians using voice recognition
dictation spent 333/1800 minutes dictating and an additional
129.5/1800 minutes reviewing or correcting their dictations.
Conclusion: The use of voice recognition assisted dictation rather
than conventional techniques did not significantly change the amount
of time physicians spent charting or with direct patient care.
Although voice recognition dictation decreased initial input time of
documenting data, a considerable amount of time was required to
review and correct these dictations.
16. A Mobile Lightly-embalmed Cadaver Lab: A Possible Model
For Training Rural Providers
Wesley Zeger1, Paul Travis2, Michael Wadman1, Carol Lomneth1,
Sara Keim1 and Stephanie Vandermuelen1. 1UNMC, Omaha, NE; 2Creighton University, Omaha, NE
Background: In Nebraska, 80% of emergency departments have
annual visits less than 10,000, the predominance are in rural settings.
General practitioners working in rural emergency medicine
departments have reported low confidence in several emergency
medicine skills. Current staffing patterns include using midlevels as
the primary provider with non-emergency medicine trained
physicians as back-up. Lightly-embalmed cadaver labs are used for
resident‟s procedural training.
Objectives: To describe the impact of a lightly-embalmed cadaver
workshop on physician assistant‟s (PA) reported level of confidence
in selected emergency medicine procedures.
Methods: An emergency medicine procedure lab was offered at the
Nebraska Association of Physician Assistants annual conference.
Each lab consisted of a 2 hour hand‟s on session teaching
endotracheal intubation techniques, tube thoracostomy, intraosseous
access, and arthrocentesis of the knee, shoulder, ankle, and wrist to
PA‟s. IRB approved surveys were distributed pre-lab and a post-lab
survey was distributed after lab completion. Baseline demographic
experience was collected. Pre- and post-lab procedural confidence
was rated on a 6-point likert scale (1-6) with p values calculated
using the Wilcoxon Signed-Rank Test.
Results: 26 PA‟s participated in the course. All completed a pre and
post-lab assessment. No PA had done any one procedure more than 5
times in their career. Pre-lab modes of confidence level were ≤ 3 for
each procedure. Post-lab modes were ≥ 4 for each procedure except
arthrocentesis of the ankle and wrist. However, post lab assessments
of procedural confidence improvement was statistically significantly
for all procedures with p values < 0.05.
Conclusion: Midlevel provider‟s level of confidence improved for
emergent procedures after completion of a procedure lab using
lightly-embalmed cadavers. A mobile cadaver lab would be
beneficial to train rural providers with minimal experience.
17. Utilization Of Computed Tomography In Blunt Trauma:
When Is Thoracic And Lumbar Imaging Warranted?
Aalap Mehta, Laurie Byrne, Vicki Moran and Eric Armbrecht. St.
Louis University, St. Louis, MO
Background: Computed tomography (CT) is becoming the standard
of care for evaluating blunt trauma patients. Some clinicians argue
that all level I and II trauma patients should undergo whole-body
imaging even with a glascow coma score (GCS) of 15 and no clinical
evidence for spinal injury. Insufficient evidence exists to support
routine use of thoracic and lumbar CT in blunt trauma.
Objectives: To explore the association between available clinical
indicators and thoracolumbar fracture (TLfx) in the trauma setting
and determine if utilization of thoracolumbar imaging can be
modified.
Methods: This retrospective study included all level I/II blunt trauma
patients with spine fracture and GCS of 13+ presenting to St. Louis
University Hospital in 2009. The positive predictive values (PPV) for
TLfx was determined independently for clinical indicators (no back
pain and no other injury) and their combination. In addition, the
association between TLfx and cervical spine fracture (CSfx) was
estimated by phi coefficient of association. Subtypes of non-spinal
injuries (e.g., lower extremity, upper extremity, intrathoracic) were
assessed by descriptive statistics.
Results: Of the 216 adult patients with complete registry data records
included in this study, 72.2% had TLfx. The PPVs (and 95%
confidence interval) for clinical indicators of no back pain and no
other injury were 0.58 (0.34, 0.47) and 0.60 (0.47, 0.72), respectively.
The PPV for the combination of information about back pain or
injury was 0.63 (0.54, 0.71), indicating 63% of cases with no back
pain or no injury had a TLfx per CT. Of the 87 cases with CSfx, 38
(or 44%) also had TLfx. By comparison, 91% of the 129 cases
without CSfx had TLfx. The phi coefficient between TLfx and CSfx
was 0.52 (p < 0.001), indicating a weak positive association.
Intrathoracic and upper extremity were the two most common injury
subtypes associated with TLfx.
Conclusion: In this study of trauma patients with GCS 13+, having
no back pain was unreliable in ruling out TLfx for 59% of patients.
The overlap between TLfx and CSfx was relatively weak and
unrelated to known clinical factors, such as no back pain. This study
did not reveal back pain or injury as reliable clinical indicators to
rule-out TLfx. The study provides no evidence against the routine use
of thoracic and lumbar CT in blunt trauma patients.
18. Changing Presentation Rates For Mtbi (Concussion) And
Changing Imaging Rates
Han Huang1, Nick Echevarria1, David Milzman1, Carla Tilchin1 and
Ronny Song2. 1Georgetown University School of Medicine,
Bethesda, MD; 2Georgetown University, Bethesda, MD
Background: : Minor traumatic brain injury (mTBI or concussion)
has seen changes in resources devoted to education, and awareness as
well as structured limitations on athletic concerns. Few studies to
date have attempted to determine whether, increased occurrence is
related to change in injury patterns or improvements in physician
awareness and diagnosis.
Objectives: : To determine if mTBI rates are increasing faster than
all trauma and whether detection is related to better diagnosis or
increased occurrence including the use of advanced imaging rates
related to any possible increase in detection and utility.
Methods: the Emergency Department and Trauma Center records
were analyzed at ED and Trauma Centers in 2 metropolitan areas for
the past decade 2000-2010. Trauma registries and the AZYXXI
database (Microsoft; Redmond,WA) were analyzed for trauma
admits, and mTBI rates and treatment interventions including use of
radiographic study and dispositions. IRB approval and data analysis
was obtained and performed, respectively.
Results: : A 10 year study found rapid rise in past 5 year with
number of concussions which increased by 140% compared to ED
and Trauma patients increased only by 23.9%; p< 0.02.
(Figure 1) There were also increases in use of CT for concussion:
25.8% with less than 2% of mTBI having a positive finding on Head
CT and none requiring neurosurgical intervention.
Both number of concussions and admitted concussions experienced
the same rate of rise as number of concussions and equal AUC.
Conclusion: There has been an effective impact on mTBI
presentation and admission to our trauma centers in the past five
years. CT increased in use with no improved treatment intervention.
Future studies will need to determine utility of admit compared to
outpatient observation and neuropsychiatric intervention for isolated
mTBI.
19. Validity of the Triage Risk Screening Tool (TRST) and
Identification of Seniors at Risk (ISAR) Instrument As Predictors
for Mortality, ED Revisits, Hospital Admission, Nursing Home
Admission, and Functional Decline in Cognitively Normal and
Cognitively Impaired Geriatric ED Patients
Dan Feng, Sophia Li and Christopher R Carpenter. Washington
University School of Medicine, St Louis, MO
Background: ED revisit and post-ED hospitalization, nursing home
(NH) admission, and functional decline are key challenges for
improving geriatric medical care and quality of life. The Triage Risk
Screening Tool (TRST) and Identification of Seniors at Risk (ISAR)
were developed as prognostic tools to predict suboptimal post-ED
geriatric outcomes. These have only been validated in the regions
where they were derived, and the NIH has recommended further
research to confirm their ED applicability. In addition, TRST and
ISAR are not specifically validated for cognitively impaired
individuals, who comprise a majority of geriatric ED visits.
Objectives: To test the predictive validity of TRST and ISAR for
mortality, ED revisit, hospitalization, NH admission, and functional
decline at 30 days post ED in geriatric ED patients with 1) no
cognitive impairment and 2) suspected cognitive impairment.
Methods: This was a prospective, observational cohort study of all
consenting ED patients age 65 and older in a private, urban, academic
hospital between June 1 and July 31, 2011. Within a larger RCT,
trained geriatric technicians administered the Older American
Resources and Services Activities of Daily Living (OARS-ADL)
scale, Short Blessed Test (SBT) for dementia, TRST, and ISAR. At
30 days post enrollment, mortality, ED revisit, hospitalization, NH
admission, functional decline (a ≥3-point decline on OARS-ADL),
and the composite outcome were measured via telephone follow-up.
Participants were excluded at follow-up if they had received a
cognitive intervention used in the larger RCT. ROC curves with area
under the curve (AUC) and likelihood ratios were calculated for the
predictive validity of TRST and ISAR in individuals with no
evidence (SBT score≤4) and evidence (SBT>4) of cognitive
impairment.
Results: Participants (N=168) had a mean age of 74, were 43.1%
male, and 62% African-American. TRST and ISAR stratified 81%
and 79% at high risk for composite outcome (score>2). TRST and
ISAR had AUCs of 0.64 and 0.70 for composite outcome in all
participants at 30 days, exhibiting poor and moderate validity,
respectively. ISAR had moderate predictive validity for composite
outcome in patients with no cognitive impairment (-LR = 0.20,
N=25).
Conclusion: ISAR has some validity for suboptimal outcomes in
geriatric ED patients with no cognitive impairment. Further study is
necessary to verify precision.
20. Diagnostic Accuracy of Various Health Literacy Screening
Tools in the Emergency Department
Andrew Melson, Christopher Carpenter and Richard Griffey.
Washington University in St. Louis School of Medicine, Saint Louis,
MO
Background: Health literacy is an important determinant of health
outcomes that concerns how well a patient can obtain, process and
understand health information needed to make appropriate health
decisions. Inadequate health literacy has been linked to poor
medication adherence, increased, longer hospital stays and greater
emergency department (ED) utilization. A recent systematic review
of health literacy and ED outcomes identified only one study using
more than one screening tool. We are not aware of any studies
comparing the diagnostic accuracy of various screening tools in the
ED setting.
Objectives: We compare the diagnostic accuracy of commonly used
health literacy screening tools in ED patients.
Methods: We performed a prospective, observational convenience
sample study of adult ED patients presenting from March - July 2011
to an urban, academic ED with 97,000 annual visits. Exclusion
criteria included: patients with aphasia, known dementia, mental
retardation, inability to communicate, non-English speaking or too ill
to interview as determined by physicians. We screened participants
using the short versions of the Test of Functional Health Literacy in
Adults (S-TOHFLA) and the Rapid Estimation of Adult Literacy in
Medicine (REALM-R), the Newest Vital Sign (NVS) and a panel of
3 single item literacy screens (SILS) used in prior studies. Results for
S-TOFHLA were dichotomized, combining marginal and low health
literacy strata. Three separate Likert-style SILS questions were asked
such as: How confident are you filling out medical forms by
yourself? Primary outcome measures were screening test
characteristics, comparing each with the S-TOFHLA as the criterion
standard, based primarily on its wide use for this purpose.
Results: 262 patients participated. Participants were 55% female,
31% white, 68% black and 1% other race, with an average age of
43.8 years. The S-TOFHLA, REALM-R and NVS identified 20.2%
49.6% and 75.6% respectively as having inadequate or marginal
health literacy.
Conclusion: In ED patients, when compared to the S-TOFHLA, the
NVS and SILS3 had the highest sensitivity (100%) and specificity
(95%) respectively in identifying low health literacy. The importance
of these test characteristics depends on the goals in performing health
literacy screening and must be balanced against other considerations
for screening in the ED such as feasibility and usability.
Diagnostic Accuracy of Screening Tools Compared to S-TOFHLA
Sensitivity
95% Confidence
Interval
Specificity 95% Confidence
Interval
Positive Likelihood
Ratio
95% Confidence
Interval
Negative Likelihood
Ratio
95% Confidence
Interval
REALM-
R 85% 72-93 59% 52-66 2.1 1.7-2.5 0.25 0.13-0.5
NVS 100% 92-100 31% 25-37 1.4 1.3-1.6 0 0
SILS1 33% 21-47 86% 80-90 2.3 1.4-3.8 0.8 0.65-0.95
SILS2 51% 37-65 81% 75-86 2.7 1.8-3.9 0.6 0.46-0.80
SILS3 32% 20-46 95% 91-97 6.1 3.0-12.2 0.7 0.60-0.86
21. "What Did You Say?” Noise: Does It Distract From Patient
Care In The Emergency Department?
Laurie E Byrne, Peter Anaradian and Preeti Dalawari. St. Louis
University, St. Louis, MO
Background: Research in critical care units have shown that noise
exposure contributes to increased levels of stress and sleep
deprivation in patients. Noise has also shown to negatively impact
staff by increasing levels of stress and interfering with patient care.
The Environmental Protection Agency (EPA) recommends that
hospital noise levels should not exceed 40 decibels (dB). Previous
studies indicate that noise levels in the emergency department (ED)
have consistently exceeded this level. However, no studies evaluated
both ED staff and patients on the affects of noise on their care.
Objectives: The purpose of this study was to evaluate patient and
staff perceptions of noise exposure and quality of care in the ED.
Methods: The study was a cross sectional survey of a convenience
sample of ED patients and staff at an academic tertiary center during
three standard 8 hour ED shifts (day, evening, and overnight). The
questionnaire asked about perception of noise level, potential sources
of noise, and how it affected the quality of care using a 10-point
rating scale. A dosimeter was used to measure the noise level at the
time the questionnaires were distributed. Independent t-test was used
to evaluate differences in perception between staff and patients;
ANOVA was used to evaluate differences among shifts.
Results: In this study, 106 people participated; 57% were patients.
There was no difference in the perception of overall noise level
between patients and staff or by shift. Each group reported the noise
level to be moderately loud (5 out of 10). Both groups thought the
noise level interfered with patient care, but not to a significant degree
(3 out of 10). Both groups cited voices from people‟s conversations
and intercom use as a leading contributor to noise. The perception of
the telephone contributing to the noise level was reported by staff but
not by patients (p=0.001). There was a significant difference in noise
level among shifts with the evening shift noise level higher at an
average dosimeter reading of 80 dB (p value < 0.05).
Conclusion: The emergency department noise level was consistently
above the EPA‟s recommended noise level. However, both patients
and staff did not perceive any significant impact in care.
22. Undiagnosed Mental Illness in Children and Adolescents in
the Emergency Department
Yanika Wolfe and Dane M. Doctor. Rosalind Franklin
University/Chicago Medical School, North Chicago, IL
Background: Many patients present to the emergency department
with undiagnosed psychiatric illness that may cause or exacerbate
their presenting complaint. Pediatric and adolescent mental health
concerns are also particularly unaddressed, even though they
represent a key risk factor for later psychiatric problems. Early
diagnosis of these illnesses may improve treatment and referral for
patients with these problems.
Objectives: The objective of this study was to identify unsuspected
psychiatric illness in child and adolescent patients presenting to the
emergency department with non-psychiatric related complaints.
Methods: This IRB approved study involved enrolling a convenience
sample of 100 patients from a level I inner city teaching emergency
department, which sees 60,000 patients per year. The validated
interview tool, M.I.N.I. KID (MINI International Neuropsychiatric
Interview for Children and Adolescents) was administered to English
speaking patients between the ages of 12-17 presenting to the
emergency department with non-psychiatric complaints. Written
consent was required from both the patient (minor) and
parent/guardian. All consenting patients were given the MINI
Neuropsychiatric interview in the emergency department. Once
completed, the researcher scored the results. If the patient tested
positive for any disease modules, the researcher informed the
attending physician.
Results: A total of 40 patients were enrolled. The enrolled patient
body was 52.5% African American, 47.5% Hispanic, and 55%
Female. Overall, 40% of patients tested positive for one or more
undiagnosed mental illness. Of those that did test positive for
psychiatric illness based on the results of the MINI, the majority
62.5% had only one psychiatric illness. The most frequently
identified disorders were Oppositional Defiant Disorder (10%),
(Hypo)Manic Episodes (7.5%), ADHD (7.5%) and Hypomanic
Symptoms (25.0%). Only one patient was classified by the MINI as a
suicide risk. The physician and mental health crisis worker were
notified and the patient was given a suicide resource pamphlet.
Conclusion: This study gives strength to the argument that there is
significant undiagnosed psychiatric illness in young patients
presenting to the emergency department. Additionally, the notion that
the ED may be a good place to identify undiagnosed mental health
illnesses was also reinforced.
23. A Comparison of Diversion and No Diversion and the Effect
on patient Safety and Outcomes in the Emergency Department
Eman Spaulding, Laurie Byrne, Eric Armbrecht and Collin
Jackson. Saint Louis University, Saint Louis, MO
Background: Diversion is a controversial topic in emergency
medicine that produces debate on institution-specific and regional-
level policy. Our literature review revealed no prior studies on the
association between diversion and overall quality of care.
Objectives: The Emergency Department (ED) at Saint Louis
University, as well as all EDs in the region, adopted a new regional
zero diversion policy, effective Oct 2009. In this study we examine
how ED performance measures, including left without treatment
(LWOT), left without being seen (LWBS), left against medical
advice (AMA), deaths, and the average length of stay, changed after
the new policy.
Methods: We selected a six-month period (April through Sept)
before and after the zero diversion policy change to limit effect of
seasonal variation. A two-sided z-ratio was used to test the difference
between hospital-option and zero diversion policy periods for
LWOT, LWBS, AMA, deaths, and admission rate. Mean monthly
length of stay (in minutes) was assessed by a t-test for independent
samples.
Results: The total ED census during the two periods was
approximately the same. During the hospital-option period, diversion
was activated for an average of 7.0 hours per month. LWOT and
LWBS rates were 19.4% (p < 0.001) and 18.2% (p = 0.002) lower,
respectively, during zero diversion. There were no differences in
observed AMA (p = 0.183) or death rates (p = 0.653). Inpatient
admission rate was 4.4% higher during zero diversion (p = 0.009).
Diversion Policy Period
Hospital-option
(n = 18,108)
Zero
(n = 18,698)
Rates (per 1,000 Census)
P
LWOT
70.8 57.1 < 0.001
LWBS
28.7 23.5 0.002
AMA
13.3 11.7 0.183
Deaths
3.5 3.2 0.653
Inpatient
Admission 280.59 292.87 0.009
Length of Stay (minutes, mean + sd)
Admitted
334 + 11.0 329 + 11.8 0.496
Discharged
242 + 9.0 228 + 8.0 0.015
While there was no significant difference in average monthly length
of stay for admitted patients, discharged patients had faster treatment
times during zero diversion (228 + 8.0 minutes) versus hospital-
option (242 + 9.0 minutes), p = 0.015.
Conclusion: Adopting a zero diversion policy was not associated
with increased rates of death, AMA or overall ED length of stay. Our
results revealed improvements in key performance measures,
including rates of patients leaving without being seen or treated, and
decreased length of stay for discharged patients.
24. Impact Of Presence Of Third Molars On Mandible Fractures
Following Facial Trauma
David Milzman1, David Weiner2 and Ryan Murray1. 1Georgetown
University School of Medicine, Washington, DC; 2Georgetown
University School of Medicine, Bethesda, MD
Background: Facial trauma is a common cause of Mandible fracture.
The majority are young men, and the mechanism of injury is often
due to assault, vehicular accident, or falls.
Objectives: To determine if the presence of third molars particularly,
impacted teeth create a increased risk for mandible fracture compared
to persons with an already extracted third molar due to ossification
and stronger mandible in that region.
Methods: Retrospective analysis of four years of consecutive
presentations of mandible fractures to the emergency and trauma
center was performed. Radiographic analysis by expert reviewers
confirmed the presence and location of fractures and third molars as
well as the angulation of the third molar.
Results: A total of 569 patients were evaluated with 34 excluded due
to incomplete data. The mean age of patients was 29.6 (95% CI: 26.7
to 31.5) with 87% male, 71.5% AA and 12.1% Caucasian were
included. 312 Pts were admitted for immediate fixation (54.8%).
82.4% had third molars present, with 53% impacted and 47% non-
impacted. 95.9% (513) sent for evaluation had a fracture, with 82%
requiring operative repair and fixation. 62.4% of pts underwent
ORIF, 52.4% were fitted with arch bars, and 36% also required
extraction.
Sensitivity of third molars predicting angle fractures was 88.31%. An
odds ratio of 2.4 was calculated for the presence of impacted third
molars and mandible angle fractures (95% CI: 1.664-3.448). An odds
ratio of 3.6 was calculated or presence of all impacted and non-
impacted third molars and mandible angle fractures (95% CI: 2.52-
5.347)
Conclusion: The presence of a third molar increases the likelihood
of a mandible angle fracture following trauma. The presence of an
impacted third molar results in the leading point for a fracture site.
Strong recommendations for prophylactic removal of third molars
may be indicated for all student and professional athletes alike who
participate in contact sports.
Oral Presentation Session 2
11:00am-12:00pm
25. Mild Cognitive Impairment: A Pilot Study To Evaluate The
Montreal Cognitive Assessment Screening Tool For Use In Urban
Aging African Americans Who Present To The Emergency
Department
Kanika A Turner and Christopher R Carpenter. Washington
University School of Medicine, St. Louis, MO
Background: Mild cognitive impairment (MCI) is a transitional state
between normal aging and dementia with preserved activities of daily
living. Detecting MCI in aging adults who present to the Emergency
Department (ED) is critical for prevention and treatment of
dementing illnesses. Additionally, disparities in cognitive
impairments exist between aging African Americans (AA) and
Caucasian Americans (CA). The Montreal Cognitive Assessment
(MoCA) is a screening tool used to detect MCI.
Objectives: To evaluate and compare the diagnostic accuracy
between AA and CA of the MoCA in an ED setting for detection of
MCI.
Methods: This was a cross sectional, consecutive sampling study.
Eligible subjects were consenting English-speaking community
dwelling patients over age 65. Exclusion was based on ED physician
judgment, caregiver‟s refusal, or residence >30 miles from hospital.
Trained researchers administered the Brief Alzheimer‟s Screen
(BAS), Short Blessed Test (SBT), AD8, and MoCA. MCI was
defined as a MoCA score <26. Chi-square analyses were performed
with MoCA scores. Diagnostic accuracy of the BAS, SBT, and AD8
to detect MoCA-defined MCI was assessed using SPSS.
Results: We enrolled 165 patients: 61% AA, mean age 74 years,
39% with < 12th grade education, and 57% female. MCI was
detected in 85% of patients who completed the MoCA with 97%
MCI incidence in AA and 66% in CA.
Conclusion: The MoCA is not an ideal MCI-screening instrument in
the ED. The incidence of MCI as judged by the MoCA is
unacceptably high and likely an epiphenomenon reflective of the
difficulty of administering the test in ED settings, particularly for
AA, but also for CA. The incidence of MCI should not be >50% in
either ethnic group.
Diagnostic Test Characteristics of BAS, SBT, and cAD8 using MoCA as gold standard
Sensitivity
(95% CI)
Specificity
(95% CI)
Positive
Likelihood
(95% CI)
Negative
Likelihood
Ratio (95%)
AUC-All
(95% CI)
AUC-AA
(95% CI)
AUC-CA
(95% CI)
BAS,
n=128 85 (63-96) 61 (57-63) 2.2 (1.5-2.6) 0.25 (0.06-0.65)
0.781
(0.676-
0.887)
0.906
(0.797-
1.00)
0.676
(0.524-
0.828)
SBT,
n=127 90 (69-98) 45 (41-47) 1.6 (1.2-1.8) 0.22 (0.04-0.77)
0.697
(0.599-
0.794)
0.837
(0.697-
0.977)
0.559
(0.403-
0.714)
cAD8
, n=61 67 (38-88) 49 (42-54) 1.3 (0.65-1.9) 0.68 (0.22-1.5)
0.557
(0.387-
0.726)
N/A
0.508
(0.305-
0.710)
26. Cardioprotection by Endogenous Fibroblast Growth Factor
2 in Cardiac Ischemia-Reperfusion Injury In Vivo
Stacey L House, Carla Weinheimer, Attila Kovacs and David
Ornitz. Washington University in St. Louis, St. Louis, MO
Background: Fibroblast growth factor 2 (FGF2) has been shown to
be cardioprotective in many in vitro and ex vivo models of cardiac
ischemia. Limited data is available on the ability of FGF2 to protect
the heart in vivo.
Objectives: The objective of this study was to determine the
cardioprotective efficacy of endogenous FGF2 in a closed chest
model of regional cardiac ischemia-reperfusion (IR) injury.
Methods: Mice with a targeted ablation of the Fgf2 gene (Fgf2
knockout) and wildtype controls were subjected to a closed chest
model of regional cardiac IR injury to assess the cardioprotective
efficacy of endogenous FGF2. In this model, mice were subjected to
90 minutes of occlusion of the left anterior descending artery
followed by reperfusion for 7 days. Transthoracic echocardiography
was performed on post-ischemic day 1 and day 7 to assess for cardiac
function (ejection fraction) and myocardial infarct size (wall motion
abnormalities). Histological analysis of myocyte cross-sectional area
and vessel density and size was performed.
Results: Mice with a targeted ablation of the Fgf2 gene do not show
any abnormalities in cardiac morphometry or function. When
subjected to closed chest regional cardiac IR injury, Fgf2 knockout
mice had significantly increased myocardial infarct size as measured
by echocardiography compared to wildtype mice at both 1 day and 7
days post-IR injury (p<0.05). In addition, Fgf2 knockout animals
showed significantly worsened cardiac function at 1 day and 7 days
post-IR injury (p<0.05). Myocyte cross-sectional area in the peri-
infarct area showed no difference between Fgf2 knockout and
wildtype mice suggesting no difference in post-ischemic cardiac
hypertrophy. Fgf2 knockout mice have normal vessel density
compared to wildtype controls in the non-injured state. After cardiac
IR injury, Fgf2 knockout hearts showed significantly decreased
vessel density and increased vessel diameter compared to wildtype
controls (p<0.05) suggesting a defect in vascular remodeling in the
Fgf2 knockout mice after IR injury.
Conclusion: Endogenous FGF2 improves cardiac function, reduces
myocardial infarct size, and mediates vascular remodeling after
cardiac IR injury. These data show the cardioprotective potential of
endogenous FGF2 in a clinically relevant, in vivo, closed chest
regional cardiac ischemia-reperfusion model which mimics acute
myocardial infarction.
27. The Correlation between Health Literacy and Numeracy in
the Emergency Department
Andrew Melson, Christopher Carpenter and Richard Griffey.
Washington University in St. Louis School of Medicine, Saint Louis,
MO
Background: Although health numeracy is often considered a subset
or domain of health literacy, very little research has been done
showing a direct relationship between the two.
Objectives: To explore the correlation between health literacy and
numeracy in an emergency department (ED) setting.
Methods: We performed a prospective, observational convenience
sample study of adult ED patients presenting from March - July 2011
to an urban, academic ED with 97,000 annual visits. We enrolled 262
patients with sub-acute illness. Measurements of numeracy and
health literacy consisted of 4 validated questions and 3 commonly-
used screening tools (Short Test of Functional Health Literacy in
Adults (S-TOFHLA), Rapid Estimate of Adult Literacy in Medicine-
Revised (REALM-R), and Newest Vital Sign (NVS)) respectively.
Results: Numeracy performance was universally poor, with 11/262
subjects (4.2%, 95% CI 2.3,7.5) correctly answering all questions,
and a mean proportion of correct responses of 36.8%. Proportions of
low or marginal health literacy as determined by the 3 screening tools
varied significantly (S-TOHFLA: 20.2%, REALM-R: 49.6% , NVS:
75.6%, n=262 for all). However, correlation of each with health
numeracy was low-to-moderate (S-TOFHLA: 0.416, REALM-R:
0.363, NVS: 0.499. p<0.001).
Conclusion: We observed varying degrees of health literacy but
near-universal poor performance on numeracy testing. Correlations
between numeracy and health literacy were low to moderate. Insofar
as numeracy is considered a subset of health literacy, our results
suggest that commonly used health literacy screening tools in ED-
based studies inadequately evaluate and overestimate numeracy. This
suggests the need for separate numeracy screening. Providers should
be sensitive to potential numeracy deficits among those who may
otherwise have normal health literacy.
28. Cost-Benefit Analysis of Specialized Screeners in the
Emergency Department and of Memory and Aging Project
Satellite Intervention
Charlene W Lai1 and Christopher R Carpenter2. 1Saint Louis
University School of Medicine, St. Louis, MO; 2Washington
University School of Medicine in St. Louis, St. Louis, MO
Background: Cognitive dysfunction is an expensive diagnosis that is
increasing in the United States. The lack of health care providers able
to correctly diagnose dementia and delirium creates a missed
opportunity to decrease costs and slow disease progression.
Objectives: The purpose of this study is to evaluate the costs and
benefits of training screeners to detect cognitive dysfunction in older
adults in the Emergency Department (ED) and the subsequent referral
to the Memory and Aging Project Satellite (MAPS).
Methods: In a blinded, randomized controlled study at one urban
academic medical center, geriatric screeners collected patients‟
responses to the Short Blessed Test (SBT). Consenting subjects were
English-speaking adults > 65 years who lived within 30 miles of
Saint Louis, MO. Subjects were excluded if they were deemed too ill
to participate by the attending physician, institutionalized, and for
those with cognitive impairment, lacked caregiver consent.
Abnormally scoring subjects were referred to MAPS, a free
community resource that offers an in- home safety assessment,
memory testing, caregiver counseling, and physician referrals. An
abnormal result was defined as a score> 4 on the SBT. Followup
phone calls to patients were made at a 1-month interval. Costs of ED
visits, hospitalization, and institutionalization were found using the
Medicare Expenditure Panel Survey, Healthcare Cost and Utilization
Project, and National Health Expenditure Database. A decision
analytic approach was used to analyze the data. One dimensional
microsimulation and sensitivity analysis were used to test the
robustness of the model and to identify critical uncertainties in the
parameters.
Results: The prevalence of cognitive dysfunction in adults>65 in the
ED was 52.8%. Assuming a 20% improvement in patient outcomes,
screening and MAPS referral were shown to reduce the cost of
patient care by $410, on average. A 40% improvement in outcomes
would reduce the cost by $714, and a 10% improvement by $105.
Conclusion: Preliminary analysis indicates that screening and MAPS
referral reduces cost of patient care. This study has several
limitations. First, this study was conducted at a single urban academic
medical center; results may not be generalizable to populations that
differ significantly from the one studied. Second, cost data found was
not specific to the hospital where the study was conducted.
29. Ultrasound Simulation Training: Location of Central Venous
Catheter Guide Wire Position
Melissa Thomas1, Charles Schmier2 and Michael Wadman1. 1University of Nebraska Medical Center, Omaha, NE; 2University of
Arizona Medical Center, Tucson, AZ
Background: Placement of a central venous catheter (CVC) is an
important procedure commonly performed by Emergency Physicians
(EPs). The technique of using ultrasound (US) to confirm that a guide
wire is positioned in the internal jugular vein (IJ) prior to dilation and
canulation has been described. To our knowledge however, no study
has used a control group of guide wires incorrectly positioned in the
carotid artery (CA) when assessing the effectiveness of this
technique.
Objectives: Determine the accuracy of EPs in detecting the location
of a CVC guide wire with the use of ultrasound on a CVC training
model.
Methods: Single blinded cross-sectional study. Prior to study
participant engagement, a CVC guide wire was positioned in either
the IJ or CA of a Blue Phantom(TM) head and torso model designed
for US guided CVC simulation training. Subjects were blinded to the
position of the guide wire. Each participant used a high frequency
linear probe with a Sonosite M-Turbo(TM) US system to detect the
location of the guide wire. Study participants were tested twice, once
with the guide wire in the IJ and once with it placed in the CA.
Sensitivity and specificity were summarized using descriptive
statistics with the associated 95% confidence intervals.
Results: A total of 46 US examinations were performed by 23 EPs
with varying levels of experience; 14 first year residents, 4 second
year residents, 4 third year residents, and one attending participated.
The guide wire was positioned in the IJ for 23 examinations and in
the CA for 23 examinations. The guide wire location was correctly
identified in 43 of the 46 examinations. Correctly localizing the guide
wire as positioned in the IJ (occurred 21 of 23 attempts) was
considered as a true positive, correctly localizing the guide wire as
positioned in the CA (occurred 22 of 23 attempts) was considered as
a true negative. EPs use of US yielded a sensitivity of 91% (CI 70,
98), specificity of 96% (CI 76, 99), positive predictive value of 96%
(CI 75, 99), and negative predictive value of 92% (CI 72, 99).
Conclusion: EPs performed well in the use of US to localize guide
wire position on a CVC training model.
30. Application of Lean Principles of the Toyota Production
System Lead to Greatly Improved Door to Needle Times
Matthew Rudy1, Andria L Ford1, Jennifer A. Williams2, Naim
Khoury1, Tomoko Sampson1, Craig McCammon2, Shawn O'Connor1,
Jin-Moo Lee1 and Peter Panagos1. 1Washington University, Saint
Louis, MO; 2Barnes Jewish Hospital, Saint Louis, MO
Background: Recent analysis has shown that less than a third of
patients treated with intravenous tissue plasminogen activator (tPA)
had door-to-needle times (DTN) within the „Golden Hour‟
recommended by current guidelines. It has been suggested that
shorter DTN is associated with improved outcomes and lower in-
hospital mortality.
Objectives: To apply Toyota Lean manufacturing principles to
improve ED DTN in acute ischemic stroke (AIS) patients receiving
IV tPA.
Methods: In March 2011, a prospective analysis of all AIS patients
presenting to the ED were treated employing Lean manufacturing
principles to improve tPA DTN. Lean techniques such as value-
stream mapping, just-in-time delivery, workplace organization,
reduction of systemic wastes, use of workers for quality improvement
and ongoing process refinement formed the basis of modifications.
Since 2004 detailed data has been kept on all patients given tPA,
including times of symptom onset, ED presentation, and tPA therapy,
adverse outcomes and discharge location. Statistical analysis was
performed to evaluate for reduction in DTN, adverse outcomes and
discharge destination. Data was available for four months post VSA.
A control group was selected with all tPA patients that presented
during the four months immediately prior to the process change. In
addition a four-month period exactly one year prior to the process
change was chosen for comparison to account for any seasonal
variation.
Results: In the post intervention group, 37 patients received tPA with
a mean DTN of 37 minutes (95% CI 28-52). Intracerebral
hemorrhage (ICH) was seen in 2/37 patients. In the four months prior
to change, 28 patients were treated with tPA, mean DTN of 64
minutes (95% CI, 51 -77), ICH seen in 4/28 patients. One-year prior,
14 patients were treated with tPA, mean DTN 59 minutes (95% CI,
51 - 67), ICH noted in 2/14 patients. There was a significant
reduction in DTN comparing the post VSA group to both other
groups, p=0.001, p=0.011 respectively. No statistically significant
difference in occurrence of ICH was observed. Discharge location
data was evaluated categorically, with no significant difference
observed.
Conclusion: Lean-manufacturing principles utilized in the treatment
of AIS can significantly improve DTN without significantly
compromising safety or favorable discharge location.
Lightning Oral Presentation Session 2
1:40pm-3:00pm
31. Impact Of Teaching Life Saving Procedures To First Year
Medical Students
Michael Ybarra, Ryan Murray, David Weiner and David
Milzman. Georgetown University School of Medicine, Bethesda, MD
Background: : A fear of first year medical students involves a
scenario where they are looked to for help in a medical emergency.
\While students may have learned about the life saving effects of
epinephrine in anaphylaxis, they may be unaware of how to
administer an epinephrine auto injector.
Objectives: The purpose of our “Introduction to Life Saving
Procedures” course for the first year medical students is to provide
basic knowledge and practical skills such as taking a pulse, assessing
respirations, caring for a choking victim, using an automatic
defibrillator, and an epinephrine auto injector.
Methods: A core curriculum was developed for first year medical
students and offered electively for one three hour session. A pre-
session survey was given to students to assess for prior medical
experience and knowledge of these potentially life saving sills. The
same survey was given one week after the session.
Results: The pre-session survey confirmed our suspicion that most
students had little knowledge of important, potentially life saving
skills. Only 20% of respondents correctly stated how to assess a
patient‟s respirations and 24% could correctly state the number of
chest compressions needed in cardiac arrest. Sixty-two percent of
respondents listed one or more appropriate critical actions items if
witness to a motor vehicle collision. None of the respondents
correctly stated the three-step method for using an epinephrine auto
injector.
The post-session survey showed significant improvement. There was
a statistically significant improvement in the number of students able
to describe the method for using an epinephrine auto injector (91% of
respondents, p < 0.001). There was also significant improvement in
the correct responses to the number of chest compressions needed in
cardiac arrest and critical action items if witness to a motor vehicle
collision (p values < 0.001 and = 0.007).
Conclusion: First year medical students had a low level of
knowledge and skills required of healthcare providers prior to a
course “Introduction to Life Saving Procedures.” There was
statistically significant improvement in nearly all categories.
Although there was no documented use in life=saving situation future
studies will track the actual value of this course.
32. Association of Falls with Sarcopenia and Frailty in Older
Adults Presenting to The Emergency Department
Denis T.K. Balaban, Steven Abboud, BS, Stephanie Chang, BS, Dan
Feng, BS, Grant M. Fischer, BS, Jessie Hu, BS, Charlene Lai, BA,
Sophia Li, BS, Owais Nadeem, Ross Passo, Taylor Real, Kanika
Taylor, BS, Lila Wahidi, Christopher R. Carpenter, MD, MS.
Washington University in St. Louis, St. Louis, MO
Objectives: Falls are an increasing and preventable source of injury
in older adults presenting to the emergency department (ED). There
exists a scarcity of independent ED-validated falls risk factors.
Identification of risk factors may lead to effective and resource-
efficient falls prevention programs. This study‟s objective is to
investigate the association of falls one month after an ED visit with
grip strength and Deficit Accumulation Index (DAI) score.
Methods: In a prospective observational study at one urban
academic, university-affiliated medical center, trained geriatric
technicians (GTs) measured grip strength, administered the DAI, and
obtained patients‟ falls history as part of a larger study examining
cognitive dysfunction in ED patients 65 or older. One month
following an ED visit, GTs contacted participants by phone to
identify subsequent falls. Association of grip strength and DAI with
one-month fall incidence was measured using Spearman‟s rho for
non-parametric data.
Results: The prevalence of low grip strength, defined as below age,
sex, and height norms, among 38 participants with complete follow-
up was 24%; falls were self-reported in 11%. Using Spearman‟s rho,
no significant correlation was identified between 1-month falls and
grip strength (females: rs = -0.142, p>0.4; males: rs = 0.000, p>0.90)
or between 1-month falls and DAI score (females: rs = 0.107, p>0.60;
males: rs = 0.336, p>0.10).
Conclusions: There exists a minimal association of 1-month falls
with grip strength and sarcopenia. However, due to follow-up
limitations in determining one-month falls, the number of reported
falls was most likely underestimated. The study can be improved by
giving participants a falls calendar, as used in other falls studies,
which would improve follow-up and recollection of falls.
33. Impact Of Airline Flight On Professional Athletes Following
Minor Traumatic Brain Injury (mtbi) In Terms Of Total Games
Missed Due To Injury
David Milzman1, Jeremy Altman2, Matt Milzman2, Chris Fleury2 and
Carla Tilchin3. 1Georgetown University School of Medicine,
Bethesda, MD; 2Georgetown University, Bethesda, DC; 3Bates
College, Bethesda, ME
Background: Air travel may be associated with unmeasured
neurophysiological changes in an injured brain that may impact post-
concussion recovery.
Objectives: To determine if air travel within 6-12 hours of
concussion is associated with increased recovery time in professional
ice hockey players (NHL)
Methods: Prospective cohort study of all active-roster National
Hockey League players during the 2010-2011 seasons
Review of all NHL injuries and games missed based on team website
and confirmed with NHL accounts via website.
Results: : During the 2010-2011 hockey season, 101 players
experienced a concussion. Of these, 39 (39%) flew within 12 hours of
the incident injury. The average distance flown was 1060 miles and
all were in a pressurized cabin. However, the median number of
games missed for head-injured NHL players who traveled by air
immediately after concussion, 6.5 (IQR 3-18), was significantly
higher than the median number missed for those who did not travel
by air (5: IQR 3-12; p <0.01); a 30% increased missed number of
games.
Conclusion: While other confounding factors must also be
considered, early air travel post concussion is associated with
significantly longer recovery times in professional ice hockey
players.
34. Can Ambulances Be Triaged To Urgent Care Centers Based
On Chief Complaint?
Tina Khosla, Joseph Delucia, Ting Zhang and William Terrin. St.
Louis University Hospital, St. Louis, MO
Background: Overcrowding and long waits are well known to the
emergency department. This study was designed to help create a
more efficient practice where people can be served their health care
needs in a faster fashion and help reduce the patient load in the
emergency department.
Objectives: This study focused on developing a system for
Emergency Medical Services (EMS) to take patients to an
appropriate place, whether it is to an emergency department (ED) or
an urgent care center based on their chief complaint.
Methods: This study was a retrospective study looking at medical
records acquired in the ED at St. Louis University Hospital. We used
the records of patients that were brought in by ground EMS. We
excluded all special populations, including pediatric, incarcerated,
pregnant, patients older than 90, and patients with cognitive
impairment. We looked at the chief complaint and the disposition of
the patient to see if the chief complaint can be safely triaged to urgent
care centers. We determined that a chief complaint can be considered
safe if there was a 95% discharge rate with minimal intervention
which is defined as history and physical, lab work and plain films.
Results: We analyzed 9,620 records after exclusions and grouped
them by chief complaint. We included chief complaints if there were
greater than 7 of the same chief complaint. We found 10 chief
complaints that were discharged with a rate greater than 95%. We
then took those 10 chief complaints and investigated what treatment
was completed in the emergency department. Patients with the chief
complaint of toothache, insect bite, and needle stick exposure were
discharged 97%, 95%, 100% respectively with minimal intervention.
Conclusion: EMS can likely safely triage patients to urgent care
centers if they have a chief complaint of toothache, insect bite and
needle stick exposure. This study was intended to be the beginning of
an investigation to start the triage system of EMS to urgent care
centers instead of coming straight to an ED to help provide patients
with faster more appropriate care and secondarily decreasing
overcrowding in the ED. Further studies can break down EMS
gestalt, age, sex, vital signs for triaging purposes.
35. A Cost Benefit Analysis Of Ultrasound Programs For
Central Venous Cannulation
Daniel L Theodoro. Washington University School of Medicine in St.
Louis, St. Louis, MO
Background: Ultrasound (US) guidance for assistance of central
venous cannulation (CVC) has widespread acceptance in teaching
hospitals. Survey data suggests that penetration of US technology
may lag in other hospitals. Barriers might include cost, re-
imbursement and physician acceptance.
Objectives: To perform a cost-benefit analysis comparing
Emergency Departments (ED) with US programs to those without US
programs (ED LM) from the perspective of the provider. The
provider perspective was chosen to inform purchasers who may cite
cost and re-imbursement issues as primary barriers.
Methods: We created a Markov decision model (TreeAge Pro 2009
Healthcare Suite, Williamstown, MA) to estimate the cost benefit of
an ED US program compared to ED LM. Through literature review
adverse event data was obtained on pneumothorax, central line
associate blood stream infections (CLABSI), and catheter related
thrombosis. Vascular complications (e.g. hematoma) were not
included since little evidence suggests they have clinical
consequences. Cost data regarding equipment, time-savings, and
complications were obtained from the literature. Deterministic
sensitivity analyses and Monte Carlo simulation for 10,000 samples
were conducted to account for the uncertainty in our model.
Results: The expected cost benefit to the ED US program was $455
compared to the ED LM program with a cost of $886. There was a
cost benefit to the ED US program until a threshold value of $1223
meaning that if the cost per ultrasound guided central line exceeded
this, a non-ultrasound guided program would be more beneficial.
There was greater cost benefit with the ED US program across all
probabilities of adverse events. The ED US program dominated the
ED LM program across all costs of CLABSI. The cost benefit of the
ED US was more sensitive to changes in the cost of thrombosis and
pneumothorax than CLABSI. Probabilistic sensitivity analysis also
confirmed a cost benefit to the ED US program ($515 compared to
$952). Tracker variables in our Monte Carlo model suggested that
while a greater proportion of CLABSI may occur in the ED US
program, the cost is offset by fewer thrombotic complications.
Conclusion: From the perspective of the provider, an US assisted
program has more cost-benefit than a LM program. Greater cost
savings may be realized avoiding thrombotic complications than
infectious complications.
36. Airway Management at a Regional Trauma Center: An
Analysis of Resident Experience
Jordan Sullivan and James McClay. University of Nebraska
Medical Center, Omaha, NE
Background: Competency in emergency airway management is
essential to the practice of emergency medicine.
Objectives: To determine emergency medicine resident airway
management methods and success rates at a regional trauma center by
post-graduate year (PGY) to compare to published benchmarks.
Methods: The Nebraska Medical Center (NMC) ED is a level I
regional trauma center treating 50,000 patients annually. The data
repository was queried to identify patients with emergency airway
management from 2006 through 2010. Record for patients with
emergency airway management (intubation) seen during the months
of October, November, and December were manually reviewed to
determine the operator, number of attempts, success or failure, and
devices used. These months were chosen to represent mid-year
resident skill levels. This was an IRB approved study.
Results: The NMC ED encountered a monthly average of 18.25
cases requiring emergency airway management during the study
period. Emergency medicine residents performed 72% of all initial
intubation attempts. The first operator was successful in 90% of cases
overall with 80% (± 4.5% over the years studied) on the first attempt.
Success rates on the first attempt were as follows: PGY 1 = 50%,
PGY 2 = 76%, PGY 3 = 84%, and attending physician = 84%.
Success rates by the first operator were as follows: PGY 1 = 50%,
PGY 2 = 87%, PGY 3 = 95%, and attending physician = 97%. There
was a 100% increase in the use of Video Laryngoscopes from 2006-
2010. Success rates with Video Laryngoscope were the same as with
standard laryngoscope.
Conclusion: Published benchmarks indicate that NMC resident
success rates are slightly below the North American benchmarks
(Sagarin et al. 2005). Success rates on initial intubation attempts
increased significantly over the 3 years of residency. Senior residents
(PGY3) obtained success rates nearly identical with attending
physicians. The increased use of video laryngoscopes did not have an
impact on intubation success rates. Intubation success was
determined most directly by experience level, not device. This single
center study demonstrates the success of airway management by
emergency medicine residents at the NMC. Sagarin MJ, et al.,
Airway management by US and Canadian emergency medicine
residents: a multicenter analysis of more than 6,000 endotracheal
intubation attempts, Ann Emerg Med, 2005, 46(4):328-336.
37. A Comparison of 3 Forms of Procedural Sedation for the
Reduction of Dislocated Total Hip Arthroplasty
Scott Burdette, Jonathan dela Cruz, Donald Sullivan, Eric
Varboncouer, Daniel O'Keefe, Joe Milbrandt, Myto Duong, Steven
Scaife, David Griffen and Khaled Saleh. Southern Illinois
University School of Medicine, Springfield, IL
Background: Hip dislocations post total hip arthroplasty (TAH) are
a common complaint seen in the emergency department (ED).
Patients who present to the ED most often require closed reduction
under procedural sedation as their initial form of treatment.
Procedural sedation for prosthetic hip reduction commonly involves
the use of an opiate/benzodiazepine combination (O/BZD),
etomidate, or propofol. All three forms of procedural sedation have
been documented as safe to be utilized in an ED setting, however
little has been studied comparing the effectiveness of these agents in
the reduction of dislocated hip prostheses.
Objectives: A retrospective review comparing TAH reduction
outcomes and complications with the use of O/BZD, etomidate, or
propofol as sedation agents.
Methods: A retrospective chart review was performed on 198
patients presenting to 2 academic EDs identified by CPT codes for
THA dislocations. They were subsequently grouped by sedation
modality. Primary outcomes measured included reduction
complications with skin injury, failure of reduction, neurovascular
injury, or fracture. Secondary outcomes measured included sedation
complications regarding airway compromise, utilization of a reversal
agent, inability to achieve sedation, and time to recover. These
outcomes were than analyzed using chi-square and ANOVA.
Results: 8.7% of propofol sedated patients (n=70) had reduction
complications, with 7.3% having sedation complications. 24.7% of
etomidate sedated patients (n=77) had reduction complications with
11.7% having sedation complications. 28.9% of O/BZD sedated
patients (n=55) had reduction complications, with 21.2% having
sedation complications. There were significantly less reduction
complications with propofol compared to the other agents (p=0.011).
Propofol, etomidate, and O/BZD had mean recovery times of 25.1,
30.8, and 44.4 minutes. Propofol had a significantly decreased
recovery time when compared to O/BZD (p=0.05).
Conclusion: Propofol, etomidate, and O/BZD are commonly used
agents in the sedation of TAH reductions in the emergency
department. In this small study, patients who received propofol had a
trend towards reduced complication rates and improved recovery
times. The use of propofol may lead to improved patient outcomes
and throughput given these results.
38. Knowledge of Alcohol Impairment in Boaters
Maria L Scarbrough and Preeti Dalawari. St. Louis University, St.
Louis, MO
Background: Alcohol is a factor in at least 60% of boating related
fatalities. Prior literature has shown that 30-40% of the participants
drank alcohol while boating, and they seldom knew the laws or
dangers associated with alcohol ingestion while boating.
Objectives: To our knowledge, this is the first study to directly
approach boaters at the dock to assess participants‟ knowledge
regarding alcohol impairment while boating.
Methods: This was a cross sectional survey of a convenience sample
of boaters aged 21 and older at 4 lakes in Illinois during July 2011.
Participants were asked to fill out an 8-question survey covering
knowledge about alcohol use and boating. Chi square analysis was
used to assess knowledge differences by demographic variables, as
well as boat ownership and seating position. Kruskal-Wallis assessed
differences by education level.
Results: 210 people participated. The majority of participants
correctly answered 4 of the 5 knowledge questions, including
84%correctly reporting the watercraft blood alcohol legal limit. 76%
admitted drinking alcohol while boating. 81% erroneously believed
that it was more dangerous for the driver to be intoxicated than the
passenger (N=194). There were no differences in knowledge by
gender, education, boat ownership or seating position. Participants
older than 40 years of age were more likely to know that being
intoxicated makes one 10 times more likely to drown (p<0.05).
Younger participants (age 21-40) were significantly more likely to
report drinking while boating compared to older participants
(p<0.05). Older participants were also more likely to own a boat and
be drivers (p<0.05).
Conclusion: A majority of participants imbibe while boating despite
a basic understanding of the dangers in doing so. Public health
officials may benefit from focusing education on the younger age
group of boaters to help decrease alcohol related morbidity and
mortality.
39. Got Wheels?--Adolescent Exposure to ATVs and Their
Driving Practices
Charles A Jennissen1, Denning Gerene1, Hoogerwerf Pam1, Peck
Jeffrey2 and Wetgen Kristel1. 1University of Iowa Hospitals and
Clinics, Iowa City, IA; 2U.S. Army Corps of Engineers, Iowa City,
IA
Background: All-terrain vehicle (ATV)-related injuries have almost
tripled in the past decade and residents in rural communities suffer
the brunt of this problem. More children die each year in the United
States from ATVs than from bicycle crashes. However, the degree of
adolescent exposure to ATVs is currently unknown. Education is
considered an essential element of improving ATV safety, but many
children receive little or no instruction.
Objectives: (1) Determine adolescent exposure to ATVs and their
operating practices. (2) Educate and help adolescents understand the
key principles for safely operating ATVs.
Methods: A community-based multi-disciplinary ATV task force
was formed and an educational program was developed highlighting
our ten “Safety Tips for ATV Riders” (STARS). The program was
presented at schools targeting 12-15 year olds. An audience response
system was utilized to obtain demographic information, determine
ATV exposure and safety knowledge, and assess knowledge
acquisition.
Results: A total of 2,200 students in 13 Eastern Iowa schools
received the ATV safety educational intervention. 78% reported
riding on an ATV at least a few times a year and nearly 30% stated
they ride an ATV at least once a week. Of those who reported having
been on an ATV in the past, 92% had ridden with more than one
person and 77% had been on a public road with an ATV. Nearly two-
thirds of those riding ATVs reported they never or almost never wear
a helmet. 57% of those with riding exposure had been in an ATV
crash (rolled over, fallen off, or hit something). On the three
knowledge questions, pre-intervention percent correct were 52%,
27% and 46%. This increased to 93%, 80% and 79% correct post-
intervention. 44% said that they were likely or very likely to use the
ATV safety tips they had learned during the intervention, while 36%
said they were unlikely or very unlikely to do so.
Conclusion: Adolescents in Eastern Iowa have a high exposure to
ATV riding. Most practice unsafe behaviors while riding ATVs and
the majority of adolescents exposed to ATVs have experienced a
crash. Most youth in the study demonstrated a deficiency in some
ATV safety knowledge. However, our classroom educational
intervention was able to increase short-term ATV safety knowledge
and a significant proportion of participants felt they would use the
safety information presented.
40. Feasibility of Using Health Literacy Screening Tools in an
Urban Emergency Department
Andrew Melson, Christopher Carpenter and Richard Griffey.
Washington University in St. Louis School of Medicine, Saint Louis,
MO
Background: Health literacy is an important determinant of health
outcomes. Deficits have been linked to poor medication adherence
and greater emergency department (ED) utilization. Validated
screening tools have been developed for general use, but health care
providers do not routinely perform such screening. One possible
reason is the amount of time and effort such assessments can require,
especially in the ED, where significant time pressures are the norm.
Lengthy screening tests not only take more time to administer but
also increase the potential for confounding interruptions.
Objectives: In a separate analysis of health literacy screening tools
we found the short versions of the Test of Functional Health Literacy
in Adults (S-TOHFLA), the Rapid Estimation of Adult Literacy in
Medicine (REALM-R), and the Newest Vital Sign (NVS) to identify
20%, 50% and 76% of ED patients as having low health literacy
respectively. In the present analysis, we aimed to assess the
feasibility of using these health literacy screening tools in the ED,
focusing on relative time burden and test interruptions.
Methods: We performed a prospective observational study of a
convenience sample of adult patients presenting during March and
April 2011 to an urban, academic ED with 97,000 annual visits.
Exclusion criteria included: patients with aphasia, known dementia,
mental retardation, non-English speaking or too ill to interview. We
screened participants using the S-TOHFLA, the REALM-R and the
NVS while documenting start and stop times as well as whether any
interruptions took place during test administration.
Results: In total, 249 patients were enrolled. Among participants,
54% were female, 31% white, 67% black and 2% other race, with an
average age of 43.5 years. On average, the S-TOHFLA took 5.84 (+/-
0.17) minutes to administer, while the NVS and REALM-R took 2.82
(+/- 0.17) and 0.64 (+/- 0.08) minutes, respectively. The S-TOHFLA,
NVS and REALM-R tests were interrupted 10.4%, 6.4% and 0% of
the time respectively.
Conclusion: The S-TOFHLA took on average, 3.02 minutes and 5.2
minutes longer than the NVS and REALM-R respectively. The S-
TOFHLA and the NVS were interrupted 10.4% and 6.4% of the time
respectively, with no interruptions of REALM-R. The S-TOFHLA,
often used as a criterion standard, identifies a lower proportion of ED
patients as having low health literacy but is lengthier and subject to
interruption.
41. Frequency and Mortality of Non-Contiguous Spine Fractures
with CT Scan Use
Vijai Chauhan1, Neelaysh Vukkadala2, Howard Place1, Laura
Sicking1, Lauren Segelhorst1, Eric Armbrecht2, Camelia Guild2 and
Preeti Dalawari1. 1Saint Louis University SOM, Saint Louis, MO; 2Saint Louis University, Saint Louis, MO
Background: : Spine fractures are common in trauma patients. Non-
contiguous spine fracture frequency in published studies is variable
(1.6%-16.7%). The published data on the diagnosis of spine fractures
commonly uses plain radiography as the imaging tool, but there are
limited studies using computed tomography (CT) scan.
Objectives: The purpose of this study was to assess the incidence of
non-contiguous spine fractures and the location pattern of these
fractures in trauma patients who underwent CT scan imaging and, to
assess the relationship between non-contiguous fractures and
mortality.
Methods: : This was a retrospective chart review of trauma patients
admitted between 2005-2010 at a Level 1 trauma center. All patients
with spinal fractures were identified through the trauma registry.
Demographics, vertebral injury, mortality, and time to diagnosis were
recorded. Delay in diagnosis, defined as greater than 60 minutes, was
based upon the time delay between the first and second spine
fractures being reported to the emergency department physician. Chi-
square analysis was used to determine a difference in mortality
between contiguous and non-contiguous fractures. Logistic
regression analysis was used to examine the association between non-
contiguous spine fractures and mortality after adjusting for potential
confounders.
Results: There were 2,222 cases of spine fractures of which 381
(17%) were non-contiguous; while our annual incidence ranged from
16% to 19% for the time period studied. The mortality rate for non-
contiguous spine fracture cases was 8.9% versus 5.5% for contiguous
cases (p= .011). Compared with contiguous spine fractures, patients
with a non-contiguous spine fracture had significantly higher odds for
mortality (aOR= 1.73, 95% CI 1.15-2.62). Of the 364 patients who
had a complete scan, the distribution of regional spine fracture
patterns were, cervical and thoracic (27.6%), thoracic and lumbar
(25.4.%), cervical, thoracic and lumbar (14.0 %), and cervical and
lumbar (12.2%). Neither fracture pattern nor a delay in diagnosis was
significantly associated with mortality.
Conclusion: According to our regional data, of those trauma patients
with spine fractures, approximately 1 in 5 will have non-contiguous
fractures. Non-contiguous spine fractures are associated with a higher
mortality rate.
42. Self-rated Health As A Predictor Of Emergency Department
Recidivism And Functional Decline Among Geriatric Patients
Stephanie K Chang1 and Christopher R Carpenter2. 1St. Louis
University, St. Louis, MO; 2Washington University in St. Louis, St.
Louis, MO
Background: Numerous cohort studies have found poor self-rated
health (SRH) to be a significant risk factor for mortality and
healthcare utilization. SRH assesses self-perceived health status
through a single, categorical question, and is associated with
mortality after adjustment for co-morbidities and functional status.
Objectives: To assess the prognostic accuracy of SRH for functional
decline and ED recidivism among geriatric patients, and to examine
how cognitive impairment influences the predictive value of SRH.
Methods: This study was a secondary analysis of data from a
randomized controlled trial, conducted within one urban academic
medical center in St. Louis, Missouri. Eligible patients were
community-dwelling individuals 65 years of age and older, who
presented to the study site ED between June 1, 2011 and July 31,
2011. Enrollment occurred through a consecutive sampling, with the
following exclusion criteria: residence outside of a 30-mile radius
from the study site, inability to speak English, physician judgment of
critical illness, and subject or caregiver refusal. SRH was assessed
through a single question from the Quality of Life in Alzheimer‟s
Disease subject report, and the Short Blessed Test was utilized for
cognitive screening. Information concerning ED recidivism and
functional decline was collected by telephone, at 1 and 3 months
following the index visit.
Results: As of July 14, 2011, 168 subjects have been enrolled, and
52 have provided 1-month follow-up data. 25 of these subjects were
cognitively normal, and 27 were cognitively impaired. For the
outcome of ED recidivism, sensitivity and specificity of poor/fair
SRH was 65% (95% CI 53-77) and 33% (24-43) for cognitively
normal patients, and 83% (42-99) and 33% (22-38) for cognitively
impaired patients. For the outcome of functional decline, sensitivity
and specificity of poor/fair SRH was 67% (45-87) and 42% (20-62)
for cognitively normal patients, and 83% (60-97) and 40% (22-51)
for cognitively impaired patients.
Conclusion: Preliminary analyses show that poor/fair SRH does not
significantly predict ED recidivism or functional decline, among
cognitively impaired or cognitively normal subjects. Thus, SRH
would not be a useful triaging tool for the ED. Significant limitations
include a lack of external validity, and reliance on patient self-report
during follow-up.
43. Stroke Volume Changes in ED Patients with Shock
Undergoing Serial Passive Leg Raising and Fluid Challenges
Stephanie Charshafian1, Ashley Janssen1, Christopher Holthaus1,
Brian Fuller1, Kevin Williams1, Enyo Ablordeppey1, Brian
Wessman1, Daniel Theodoro1, Ronald Chang1, Jennifer Williams2,
Thomas Ahrens2 and Richard Hotchkiss1. 1Washington University in
St Louis, St Louis, MO; 2Barnes-Jewish Hospital, St Louis, MO
Background: Stroke volume index changes with passive leg raising
have been shown to predict volume responsiveness.
Objectives: To estimate the positive predictive value (PPV) of
Passive Leg Raising (PLR) compared to 500ml saline boluses in ED
patients with shock.
Methods: This is a subset analysis of adult ED patients prospectively
randomized to fluid optimization (FO) in the ED between Aug 2010-
Aug 2011(ClinTrials ID: NCT01128413). The study is IRB approved
with informed consent and being conducted at an academic ED with
90,000 visits/yr. Inclusion criteria are vasopressor use, or SBP ≤90 or
MAP ≤65 after ≥20ml/kg IV fluids, or lactate ≥2.5 mmol/L.
Exclusion criteria are pulse oximetry <90% or inability to do PLR.
FO consists of non-invasive bioreactance monitoring of stroke
volume (Cheetah NICOM®) and PLR testing. Patients deemed
volume responsive (VR) receive a 500ml saline bolus if the PLR
percent change (%Δ) in stroke volume index (SVI) or cardiac index is
≥15%. PLR is repeated immediately after each bolus with repeat
boluses if ≥15%. If <15%, fluids are saline locked and PLR done
every 30 minutes. SVI changes are calculated as:
%ΔSVI=(Maximum challenge SVI-Average baseline SVI)/Average
baseline SVI. Paired Students t-Test and descriptive analysis were
performed (Microsoft® Excel).
Results: 7 patients (4 male) with a median age of 60 yrs (range 42-
87) underwent 69 PLRs. 40 of 69 (58%) PLRs were VR and received
fluid boluses. The median %ΔSVI are as follows: bolus 10% (IQR 1-
22), pre-bolus PLR 32% (IQR 24-39), and post-bolus 26% (IQR 11-
36). The pre-& post PLR %ΔSVI were statistically different when
compared to the bolus %ΔSVI (both p ≤ 0.01). The PPV of pre-&
post bolus %ΔSVI were 38% and 22% respectively. 10/40 (25%)
bolus events resulted in a negative bolus %ΔSVI.
Conclusion: In this small subset analysis, pre-& post PLR SVI
changes demonstrated suboptimal PPV when compared to fluid
challenges. More study is needed in ED patients and quantitative
incorporation of SVI changes with fluid boluses may be additionally
useful in guiding fluid administration.
44. Seeking a Functional Definition of Drug-Seeking Behavior
Benjamin Scallon, Mark Graber, Azeemuddin Ahmed, Kari Harland
and Gerene Denning. University of Iowa, Iowa City, IA.
Background. The 2005 National Institute on Drug Abuse (NIDA)
Research Report on prescription drug abuse and addiction estimated
that a startling 48 million Americans have used prescription
medication for illicit, nonmedical purposes. Approximately 80-90%
of misused prescription drugs are legally obtained through the
healthcare system, most often via emergency departments (ED).
Using an open-ended question, the top five drug-seeking criteria
listed by EM physicians were “multiple visits,” “multiple allergies,”
“asking for a drug by name,” “abnormal behavior” and “high-risk
complaint.”
Objective. The goal of this study was to determine whether top
criteria were consistent using a different survey method and if these
criteria or foils impacted decision-making.
Methods. ED physicians (n = 56) were randomized into three groups.
Each group was asked to evaluate three patient scenarios. Scenarios
between groups varied in detail. Participants scored the likelihood
that the patient was drug-seeking (10 pt scale) and indicated the
amount of drugs they would prescribe. Physicians also ranked their
top 5 out of 25 listed characteristics of drug-seeking behavior.
Results. Patient 1 mean scores for baseline history, history plus
multiple drug allergies, and history plus allergies and requesting a
specific drug were 4.3, 5.2, and 6.5 (overall p = 0.0023). Patient 2
mean scores for baseline history, history plus smoking/bad dentition,
and history plus smoking/bad dentition and prison tattoos were 5.8,
6.5, and 5.2 (overall p = 0.0949). Patient 3 mean scores for baseline
history, history plus stating Vicodin is ineffective, and history plus
Vicodin comment and white-collar occupation were 3.8, 5.1, and 4.9
(overall p = 0.2379). For patient 1, the length of the drug
prescription (days) exhibited a weak negative correlation with the
score given for the likelihood of being a drug seeker (r = -0.24). The
top five criteria chosen were “lying,” “multiple prescribers,” “history
of drug abuse,” “acting” and “the Iowa Prescription Monitoring
Program.”
Conclusions. The scenario portion suggests that ED physicians make
judgments based on commonly accepted drug-seeking criteria and
are, generally, unbiased against potential foils. Both survey methods
provide insights into physician decision-making, however, prompting
them with a list results in different selections.
45. Disposition Variability For Patients with Chest Pain Among
Emergency Department Physicians
David J Gresback and Michael D Zwank. Regions Hospital, Saint
Paul, MN
Background: Chest pain is a common presenting complaint to the
emergency department (ED) with high rates of hospitalization. There
is a high degree of variability in the management of these patients
including ultimate disposition.
Objectives: As a quality measure, we sought to examine the
variability of disposition among different emergency department
physicians in an effort to understand differences between practicing
pattern and as a baseline for further quality improvement initiatives.
Methods: In this retrospective chart review at an urban academic
emergency department, all visits with chief complaint of chest pain
from March 2011 to June 2011 were reviewed (n=1168). The charts
were examined with a one month follow-up looking at: disposition,
repeat visits, repeat hospitalizations and outcomes of interest. All
providers with less than 10 chest pain visits were excluded from
review. Outcomes of interest were defined as: unstable angina,
STEMI or NSTEMI, coronary artery bypass graft, percutaneous
coronary intervention or death. Acuity rate was calculated as
outcomes of interest divided by total chest pain patient visits. Acuity
admission index was calculated as acuity rate over admission rate.
Results: 31 out of 36 physician met inclusion criteria of at least 10
chest pain patient visits (mean=38). Mean admission rate was 0.55
(range 0.31-0.79). Outcomes of interest were seen in 77 patient visits
(7%) with 2 missed outcomes (one cardiac, one non-cardiac). No
provider had more than one missed outcome. Mean acuity admission
index was 0.15 (SD 0.10; range 0.0-0.37). No providers with lower
than the mean acuity admission index had a missed outcome. Five
providers had an acuity admission index more than one standard
deviation below the mean. Among these providers, 128 patients were
admitted with no outcomes of interest.
Conclusion: The acuity admission index may be a way to stratify
providers practice patterns in regards to disposition while accounting
for the acuity of patients seen. Only 1 cardiac outcome was missed
among 1168 patient visits. Our hospital will be instituting a low-risk
chest pain protocol which likely will lead to fewer admissions of low-
risk patients. This data set suggests that several providers and many
patients may benefit from such a protocol. The data set only included
three months of patient visits and may be limited by
this.
Poster Presentations
3:00pm-4:20pm
46. Characterization Of On-road ATV Crashes In Iowa From
2002-2009
Kevin Kremer, Gerene Denning, PhD and Christopher Buresh,
MD. University of Iowa, Iowa City, IA
Background: All-terrain vehicle (ATV) crashes result in over 500
fatalities each year and produce similar mortality rates and higher
rates of head and neck trauma as compared to motorcycles. A study
in Ohio showed worse outcomes for individuals involved in on-road
ATV crashes relative to crash victims at recreational parks. Iowa law
allows counties and cities to designate roads for ATV use; however,
the potential impact of increased on-road ATV use has not been
investigated.
Objectives: To determine demographics and crash mechanisms for
Iowa‟s on-road ATV crashes, and to develop public policy
recommendations based on these results.
Methods: The Iowa Department of Transportation (DOT) records
data for all ATV crashes on Iowa roads and highways including GPS
Coordinates of the location of the crash. GPS coordinates were
mapped in ArcGIS 10.0 using the Universal Transverse Mercator
coordinate system in zone 15N. Qualitative analysis of Iowa DOT
crash data was performed to characterize on-road crashes.
Results: There were 246 on-road ATV crashes reported by the Iowa
DOT from 2002 to 2009. Of these crashes, 78% of victims were male
(20% female, 2% unknown), 66% were 16 years old or older (22%
<16 years old, 13% unknown), and 13% involved passengers. 57% of
on-road crashes were collisions; 65% of those collisions involved
another vehicle. Mapping showed that on-road crashes happen in
both urban and rural areas.
Conclusion: Although it is illegal to carry passengers on ATVs in
Iowa, over 1 in 10 on-road crashes involved a passenger. It is also
illegal to ride ATVs on public roads; however, there were 246 on-
road crashes during the study period. Over 33% of these crashes
involved a collision with another vehicle, thus posing a general traffic
hazard. The number of on-road crashes in Iowa is alarming and some
occur at a significant distance from trauma centers. Based on our
findings, we would strongly recommend against counties and cities
designating roads and streets for ATV recreational use. Future
projects will include continuing crash surveillance and educational
efforts to inform the public about the dangers of on-road ATV use.
47. Differences In Perception About Access To Care Between
Patients Who Choose An Urban Academic Emergency
Department Over A Community-based Student-run Free Clinic
For Non-urgent Care
Matthew Dettmer1, Cerrone Cohen2, Edward Jauch3, Kit N Simpson3,
Brenda Walker3, Wanda Gonsalves3, Kathryn Koval3, Joshua Gray3
and Steven Saef3. 1Washington University Medical Center/Barnes-
Jewish Hospital, St. Louis, MO; 2UC Davis Health System,
Sacramento, CA; 3Medical University of South Carolina, Charleston,
SC
Background: Uninsured patients often choose the Emergency
Department (ED) over other suitable venues for non-urgent care.
Understanding patient preferences and obstacles to non-urgent care
can improve access to care.
Objectives: Characterize differences in perception about access to
non-urgent care by uninsured patients who present to an urban
academic ED vs. a community-based student-run free clinic (FC).
Methods: We compared responses of uninsured patients with non-
urgent complaints presenting to an urban academic level I
trauma/tertiary care ED with those of a FC using a prospective,
anonymous survey. Survey items evaluated patients' perceptions
about access to care which might explain their choice of venue. ED
patients with Emergency Severity Index (ESI) categories 4 or 5 and
selected category 3 patients (ambulatory, normal mental status, skin
warm and dry, no signs or symptoms of vital organ compromise)
were deemed non-urgent. All patients presenting to the FC were
deemed non-urgent. The study instrument was a 10 item survey
addressing Desirability of a FC over the ED (DFE); Transportation
Status (Access to a Car); Perceived Quality of Care; Usual Place of
Care; Importance of Cost; Self-Perceived Level of Illness (SPLOI);
distance to ED or FC, and patient demographics. All items were
answered on a 5-point Likert Scale. Scores from like items
addressing similar concerns were combined. A convenience sample
of 100 patients was obtained from each site. Comparisons were made
using Student‟s t-Test. Logistic regression was used to adjust for the
effect of significant variables, demographics, and distance on the
response to the item about DFE.
Results: Differences were noted between the ED and FC patients for
items regarding Cost (ED mean 4.31, FC mean 3.68; p=0.03) with
ED patients showing less concern about cost; Transportation (ED
mean 7.00, FC mean 8.01; p=0.003) with ED patients showing
greater concern about access to a car; and SPLOI (ED mean 2.87, FC
mean 3.40; p=0.01) with ED patients perceiving themselves as more
ill. No difference was noted between the groups regarding DFE after
adjustment (p=0.68)
Conclusion: Non-urgent, uninsured patients presenting to the ED
showed less concern about the cost of care, greater concern about
transportation, and felt themselves to be more ill than those
presenting to a FC. No difference was noted between the groups
regarding DFE after adjustment.
48. Preliminary Report On Factors Associated With Inadequate
Or Uninterpretable Cervical Spine Radiographs And Need For
Ct In Cervical Spine Trauma.
Richard Griffey, Betty Chen and Steven Katz. Barnes-
Jewish/Washington University in St. Louis, Saint Louis, MO
Background: Though cervical spine CT (CSCT) comprises an
increasing proportion of initial cervical spine (c-spine) imaging in
trauma, patients at low to moderate risk of injury often undergo
radiography (xrays) as the initial imaging modality. Initial screening
with CSCT in trauma has been demonstrated only to be cost-effective
for patients meeting specific high-risk criteria who are undergoing
concomitant head CT. For patients not meeting these criteria,
identification of patients likely to have inadequate or uninterpretable
c-spine xrays, requiring subsequent CT would aid in an evidence-
based approach in determining initial imaging modality and improve
upon imaging efficiency.
Objectives: To identify risk factors associated with inadequate
evaluation with xrays as a first step in further distinguishing which
patients would benefit from primary CT.
Methods: Setting: Academic, urban, level 1 trauma center with
87,000 visits. Participants: Trauma patients >18 years old with c-
spine xrays followed by CSCT in the ED. Design: Retrospective
observational study from March 2008-2010. We performed explicit
chart review of an electronic medical record for comorbidities,
medications and other features likely to result in inadequate xrays,
and noted the reasons for performing CT.
Results: Among 8752 visits with c-spine imaging, there were 4838
with CT, and 616 with xrays and CT. The latter had a mean age of 46
were 55% male and 52% black. Common mechanisms were motor
vehicle collision (282) and fall (177) and assault (50) with
Emergency Severity Index scores of 3 (358) and 2 (195). Arrival was
by ambulance in 405(65%). 5.7% of patients had chronic neck pain
or prior c-spine surgery. 5.7% of patients also had arthritis or bone
disease. 10% of patients were taking a steroid or a medication for
osteoporosis, and 9.4% were either unable to cooperate or had an
upper extremity injury. CT after xray was most often performed for
inadequate xrays (53%), degenerative disease (36%), and
malalignment (25%).
Conclusion: This preliminary review identifies chronic neck pain,
prior c-spine surgery, arthritis, osteoporosis, steroid use, and
behavioral issues as potential risk factors for inadequate or
uninterpretable c-spine xrays. Further study in a larger cohort of
control patients is underway to determine whether significant
differences warrant development of a clinical decision rule.
49. All Terrain Vehicle (ATV) Crash Fatality Surveillance
through Press Clippings
Gretchen McCall and Charles Jennissen, MD. University of Iowa,
Iowa City, IA
Background: ATV crashes are a growing source of injuries and
deaths, particularly in rural communities. Every year, ATV crashes
result in over 700 deaths and more than 130,000 ED visits. ATV
injury surveillance is extremely challenging and crash data must be
collected from many sources. Newspaper reports are an untapped
resource to investigate the factors and variables surrounding ATV
crashes.
Objective: The objective of this study was to use press clippings for
nine states (IA, IL, KS, MN, MO, ND, NE, and SD) as a source for
studying fatal ATV crashes.
Methods: A retrospective study of 2009 and 2010 ATV press
clippings was performed and clippings for fatal crashes were
identified. Descriptive analyses were done for demographics and
crash mechanisms. The number of press clippings for fatal and non-
fatal crashes was compared using the Mann-Whitney test.
Results: Press clippings captured over 90% of state fatalities as
reported by the Consumer Product Safety Commission (CPSC); and
the number of press clippings for fatal crashes was significantly
higher than for non-fatal crashes (median 2.0 vs. 1.0). Demographic
variables (e.g., gender) were well documented (93-100%). ATV-
related fatalities were 84% males and 16% of victims were children
under 16 years of age. Approximately 1 in 4 victims (24%) were
wearing a helmet. Documentation of crash circumstances (e.g.,
surface type) was variable (20-97%). The majority of crashes
occurred at dusk/dark (52%). More than 1 in 10 fatal crashes
involved vehicle-vehicle collisions (15%) or being pinned by the
vehicle (11%). Vehicle-related parameters (e.g., vehicle model) were
poorly documented (12-30%). Annual fatality rates were higher than
the overall average of 1.0 deaths/100,000 rural population for MN
(1.2), MO (1.3), NE (1.4), and ND (1.4). Rates for IL (1.0) and WI
(0.9) were at or near the average, and IA (0.6), KS (0.8), and SD (0.6)
were below average. There did not appear to be an association
between mortality rate and number of ATV laws.
Conclusions: Press clippings are a valuable resource for ATV
fatality surveillance because they comprehensively capture fatalities
in multiple states and they provide information not readily available
from other sources. They also contribute additional insights as part of
our integrated ATV surveillance database.
50. A Quality Curriculum: A Novel Approach To Addressing
The ACGME Core Competencies
Jonathan dela Cruz, Antonio Cummings, James Waymack, David
Griffen and Christopher McDowell. Southern Illinois University
School of Medicine, Springfield, IL
Background: Of the ACGME core competencies, application of
practice-based learning and improvement, and systems-based practice
have been difficult to assess in emergency medicine (EM) residency
curriculum. ABEM has now required attestation to a quality
improvement (QI) activity for continued certification. It is important
that EM residents are fluent in their core competencies and are
exposed to QI principles.
Objectives: We present here a formalized curriculum in quality to
assess resident understanding of ACGME core competencies while
providing them with a skill set in QI.
Methods: A class of 6 EM residents participated in a 3 part lecture
series on QI principles during core didactics. Using a previous
hospital QI project as a model, the residents learned the application of
statistical process control. Residents then became members of an
interdisciplinary QI project team intervening on the reversal of
coagulopathic ICH. Each resident was required to advance different
areas of the project. Their progress was tracked through periodic
meetings with the QI project leader and time was allotted during core
conferences for them to present their tasks. Presentations included
basic science didactics on the coagulation cascade, literature reviews
on current treatments, and a focused audit of the year‟s previous ICH
data. Understanding of the ACGME core competencies was
evaluated by core faculty during resident presentations and during
their meetings with the QI project team leader who also was a core
faculty member.
Results: All residents engaged in the process and showed an
improved understanding of the ACGME core competencies and QI
principles. This knowledge was demonstrated through their
presentation of didactic lectures, integration with an interdisciplinary
QI project team, and successful implementation of a new treatment
protocol. The QI project continues to be monitored and the outcomes
of the process changes are to be followed longitudinally.
Conclusion: A quality curriculum surrounding resident involvement
in a QI project seems feasible and promising. Involvement in a QI
project enhanced understanding of ACGME core competencies.
Further observation of resident project involvement and data
collection of QI project outcomes need to be performed to fully
assess the potential this curriculum has on resident education.
51. Emergency Department Interruptions in the Age of
Electronic Health Records
Matthew Albrecht, Jonathan dela Cruz and John Shabosky.
Southern Illinois University School of Medicine, Springfield, IL
Background: Interruptions of clinical care in the emergency
department (ED) have been correlated with increased medical errors
and decreased patient satisfaction. Studies have also shown that most
interruptions happen during physician documentation. With the
advent of the electronic health record and computerized
documentation, ED physicians now spend much of their clinical time
in front of computers and are more susceptible to interruptions. Voice
recognition dictation adjuncts to computerized charting boast
increased provider efficiency, however, little is known about how
data input of computerized documentation affects physician
interruptions.
Objectives: We present here observational interruptions data
comparing two separate ED sites, one that uses computerized
charting by conventional techniques and one assisted by voice
recognition dictation technology.
Methods: A prospective observational quality initiative was
conducted at two teaching hospital EDs located less than 1 mile from
each other. One site primarily uses conventional computerized
charting while the other uses voice recognition dictation
computerized charting. Four trained observers followed ED
physicians for 180 minutes during shifts. The tasks each ED
physician performed were noted and logged in 30 second intervals.
Tasks listed were selected from a predetermined standardized list
presented at observer training. Tasks were also noted as either
completed or placed in queue after a change in task occurred. A total
of 4140 minutes were logged. Interruptions were noted when a
change in task occurred with the previous task being placed in queue.
Data was then compared between sites.
Results: ED physicians averaged 5.33 interruptions/hour with
conventional computerized charting compared to 3.47
interruptions/hour with assisted voice recognition dictation
(p=0.0165).
Conclusion: Computerized charting assisted with voice recognition
dictation significantly decreased total per hour interruptions when
compared to conventional techniques. Charting with voice
recognition dictation has the potential to decrease interruptions in the
ED allowing for more efficient workflow and improved patient care.
52. Ct Scanning Practice In Minor Pediatric Head Injury At A
Community Emergency Department
Myto Duong, Varshita Pande and Joseph Milbrandt. Southern
Illinois University, Springfield, IL
Background: Pediatric head injury (HI) is responsible for >7400
deaths, 60,000 admissions and 600,000 emergency department (ED)
visits annually. Over 50% of minor pediatric HI will get a head CT
scan. Head CT scans has doubled between 1995 and 2005.
Objectives: The objective of our study was to determine the overall
rate of head CT use in children with minor HI and to evaluate the
appropriateness of head CT use based on Kuppermann et al
recommendations in 2009.
Methods: A retrospective chart review was performed for patients
<18 years old presenting to the ED with a HI in 2008 and 2009.
Patients were identified using ICD codes. Information collected
included age, gender, mechanism of injury, clinical findings, imaging
studies on initial presentation, any clinically significant HI finding on
head CT, number of repeat head CT related to initial injury with a
limit of 1 month post-injury.
Results: A total of 654 charts were reviewed. 383 (59%) patients had
a head CT scan. Out of 654 HI, 352 were minor and 165 (47%) had a
CT scan. Of these 165 head CT scans, 123 met criteria for a scan.
Only 10 of the 123 (8%) had abnormalities. 42 of the 352 (12%)
minor HI had a scan when they did not meet criteria (all were
negative except 2 -neither required any intervention). We identified
62 (18%) HI with no scan but did meet criteria for a head CT scan.
Conclusion: Even before head CT scanning guidelines for minor
pediatric HI were available, the overall rate of head CT use in
children with minor HI (47%) in our community ED was below the
national average for adult ED but high compared to pediatric EDs in
the United States. The percentage of pediatric patients with minor HI
who met criterias for the head CT scan was 53% but only 35% of the
minor HI who met criteria had a CT scan. Eighteen percent of
patients with minor HI met criteria for a head CT scan but did not
have one. Although there are other urgent cares and ED in our
community, our hospital is the only children‟s hospital in the
community who would admit patients with HI complications. Based
on return visits data to our hospital, none of these patients required
further evaluation or hospitalization. Although the algorithm
previously suggested for CT scan utilization was designed to
decrease pediatric head CT scanning, the algorithm identified a large
number of patients who had negative CT findings. In addition, we
identified overutilization of head CT scans in 12% of minor pediatric
HI in our ED.
53. Comparison Of Interpreters In Emergency Medicine: Video
Conference Vs. In-person
Yanika Wolfe1, Leslie Zun2, LaVonne Downey3 and Trena Burke4. 1Rosalind Franklin University/Chicago Medical School, North
Chicago, IL; 2Mount Sinai Hospital Emergency Department,
Chicago, IL; 3Roosevelt University, Chicago, IL; 4Mount Sinai
Hospital Emergency Medicine, Chicago, IL
Background: Many studies have shown the benefits of using
professional interpreters for patients with limited English proficiency.
Despite this, interpreters are still underutilized within the ED. This
fact is attributable to the lack of available interpreters, cost and time
constraints. Only a few studies have examined the impact of using
videoconference interpretation method in the ED.
Objectives: The purpose of this study is to compare the effectiveness
of video conference (IVIN-Illinois Video Interpreter Network) and
in-person (LIVE) interpretation methods in ED setting with regards
to patient and staff satisfaction, cost, and throughput times.
Methods: This was an IRB approved, prospective cohort study
consisting of a convenience sample of 100 medically stable Spanish
speaking patients, 18 years and older, presenting to the level 1 trauma
ED of an urban teaching hospital. Each patient was assigned to
receive either IVIN or LIVE interpreter. At the end of treatment,
patient was given a survey which assessed the patient‟s satisfaction of
the communication quality with staff and patient‟s level of
understanding of what was explained. A survey was also given to the
health care provider to assess whether or not language barrier issues
were addressed.
Results: 25 patients were enrolled, 15 in LIVE interpreter and 7 in
IVIN group. Majority of both cohorts listed elementary school as
their highest level of education and was currently unemployed. In
regards to patient‟s satisfaction of the quality of communication with
hospital staff, 93% LIVE interpreter users reported that they were
either very satisfied or somewhat satisfied, compared to 100% of
IVIN users. 80% LIVE interpreter users reported that they could
understand very or mostly easily things that were explained to them,
compared to 71% of IVIN users. Most healthcare providers felt that
language issues were adequately addressed by using the LIVE
interpreter (87%) or IVIN (85%).
Conclusion: This preliminary data suggests that video-conference
interpreters performs as well as in-person interpreters in ED setting
with regards to the patient and provider‟s satisfactions. This
preliminary result warrants further data collection. Potential
differences in throughput times between these two interpretation
methods will also be considered and further analyzed as part of the
second phase of the study.
54. Impact Of The Use Of A Standardized Order Set For
Asthma Patients In The Emergency Department
Daniel D Ofori1, Leslie Zun1 and LaVonne Downey2. 1Rosalind
Franklin University of Medicine and Sciences, North Chicago, IL; 2Roosevelt University, Chicago, IL
Background: Order set use is on the rise. Order sets combine
evidence-based orders for specific diagnosis into concise, easy to use
formats. How beneficial is this in the E.D for asthma patients?
Objectives: To investigate the impact of the use of a standardized
order set list for patients presenting to the E.D with asthma
exacerbation, on treatment throughput time, outcome, length of stay,
cost and patient return to the E.D.
Methods: An IRB-approved randomized chart review was conducted
on patients presenting to the E.D. of a Midwest, inner city, level 1
trauma hospital between December 2003 and June 2011. The study
compared patients for whom an asthma order set was used (users) to
those for whom an asthma order was not used (non-users). The data
was analyzed using SPSS frequency descriptive, one-way anova and
crosstabulations.
Results: 101 patients were enrolled: 52 male and 49 female.
Ethnicities included 91 African-American, 8 Hispanic and 2
unknown. 28 patients were 17 years old or younger, with 73 older
than 17 years. Most patients were brought in by the fire department.
E.D priority ratings were 55 urgent, 23 non-urgent, 20 acute and 1
critical. 62 patients were on publicaid, 28 uninsured/self-pay and 8 on
private insurance. Asthma order sets were used for 34 patients; order
sets were not used for 55 patients; order set use/non-use could not be
verified for 12 patients. 49 patients returned to the E.D within 30
days of discharge. Significant difference between order set users and
non-users were found for: 1) Length of stay: sig value of 0.015 and F
value of 6.164 for 37 patients (13 users vs. 24 non-users) staying for
1 day; 2) Total treatment time: sig value of 0.010 and F value 7.028
for 18 patients (6 users vs. 12 non-users) with 2.5-4 hours, 18 patients
(6 users vs. 12 non-users) with 5-7 hours; 3) Total throughput time:
sig value of 0.014 and F value of 6.342 for 12 patients (3 users vs. 9
non-users) with 2.5-3.5 hours, 19 patients (6 users vs. 13 non-users)
with 5-7 hours; 4)E.D. charges: sig value of 0.001 and F value of
12.948 for 19 patients (all non-users) with $0-$1,000, 16 patients (6
users vs. 10 non-users) with $2,000-$5,000.
Conclusion: The study showed that using a standardized order set for
asthma patients in the E.D. resulted in fewer patients with long
treatment and throughput times, thus expediting patient care delivery.
55. Same Patient. Same Overdose. Different Treatment.
Different Outcome.
Jon B Cole1, Heather Ellsworth2 and Samuel J Stellpflug2. 1Hennepin
Regional Poison Center, Minneapolis, MN; 2Regions Hospital, St.
Paul, MN
Background: Intravenous Fat Emulsion (IFE) is a promising therapy
for Poison-Induced Cardiogenic Shock (PICS). An American College
of Medical Toxicology position statement asserts that IFE is “a
reasonable consideration for therapy, even if the patient is not in
cardiac arrest.”
Objectives: We present a case series of a single patient who
overdosed on two separate occasions with diltiazem (D), metoprolol
(M), and amiodarone (A). She received IFE both times with different
outcomes.
Methods: This is a retrospective review of a 2-case series; the same
patient was the subject in both cases.
Results: Case 1: A 30 yo woman with hypertrophic cardiomyopathy
and an AICD presented with an overdose (OD) of D, M, and A.
Initial vital signs showed BP 89/46 and HR 73. Over 3 hrs the BP and
HR dropped to 64/41 and 70, and she was confused. ECG showed
paced rhythm. Normal saline (NS) 4L IV and 27 mEq IV Ca2+ were
given, and a high dose insulin (HDI) infusion escalated to 10U/kg/hr.
She remained hypotensive and confused. The CVP was 20 and an
Echo showed low EF. IFE (20%) was given as a 100mL bolus and an
infusion of 1.5L over 1 hr. Within 15 min of the bolus the BP was
110/60 and confusion improved. She had no negative sequelae.
Serum levels from the ED were D: 1449 ng/mL (nl 130-190), M: 388
ng/mL (30-300), A: 2.7 mg/L (0.5-2).
Case 2: The same patient presented with an OD of D, M, and A 4
months later. She was treated with NS, but became hypotensive and
suffered a cardiac arrest treated with glucagon and pressors
unsuccessfully. IFE was given with return of spontaneous circulation.
She received HDI at 1U/kg/hr, a Ca2+ infusion, dopamine,
phenylephrine and vasopressin. She improved clinically and was
noted to be alert and following commands. Shortly thereafter she
suffered a second cardiac arrest and died. Post-mortem drug levels
were D: 4,500 ng/mL, M 162 ng/mL, and A: 1.9 mg/L.
Conclusion: Early IFE in the setting of refractory Poison-Induced
Cardiogenic Shock may be preferable to waiting for cardiac arrest. In
case 1 the patient got IFE while declining clinically but had a pulse;
she had rapid improvement and a good outcome. In case 2 IFE was
delayed; though she clearly responded, she ultimately died. In this
patient it appears early IFE was associated with a better outcome. We
recognize that in case 2 the concentration of D was higher than case
1, and pressors were included in the treatment of case 2; both factors
may have affected the outcome.
56. Effect of Protocol Implementation on Emergency
Department Observation Unit Length of Stay and Charges
Adam E Stenger, Robert Poirier and Jennifer Wiler. Washington
University, St. Louis, MO
Background: Emergency Department-based observation units are
becoming increasingly used for the assessment and treatment of
patients who may not require inpatient management or monitoring.
Objectives: To determine if implementation of Emergency
Department Observation Unit (EDOU) care pathways (CP) impacted
EDOU patient length of stay (LOS) and total ED (professional plus
facility) charges.
Methods: In June of 2009, 21 CP were implemented in a 12 bed
EDOU. Data from a 2 week period (12/1-14/2008) 6 months pre-
implementation were retrospectively compared to a 2 week period
(12/1-14/2009) 6 months post-implementation. EDOU LOS and total
charges were compared for all EDOU patients, those admitted to the
hospital, and those discharged from the EDOU. Boarding patients
(ED patients admitted to the hospital waiting in the EDOU for an
inpatient bed) were excluded from the analysis. EDOU LOS and total
charges were analyzed using medians and interquartile ranges (IQ)
(25th and 75th %tiles). Statistical significance was analyzed using
Wilcoxon Rank Sum.
Results: 171 pre-implementation and 192 post-implementation
patient visits met inclusion criteria with 3 visits excluded because of
incomplete billing data. The overall median EDOU patient LOS was
15 minutes shorter after the implementation of CP (658 vs 643 mins;
P=0.89). The LOS of EDOU patients who required inpatient
hospitalization decreased 287 minutes post-implementation (1027 vs
740 mins; P=0.10); whereas those discharged from the EDOU only
decreased 9 minutes (620 vs 611 mins; P=0.74). Median overall
charges for the entire cohort were $755 higher post-CP
implementation ($4,863 vs $5,618; P=0.13); and were $53 higher for
EDOU patients who required inpatient hospitalization ($10,857 vs
$10,910; P=0.74). Total charges decreased $179 for patients who
were discharged from the EDOU ($4,173 vs $4,352; P=0.13).
Conclusion: Implementation of EDOU CP decreased the overall
LOS for EDOU patients. LOS was also decreased for patients those
who required inpatient hospitalization or were discharged from the
EDOU. EDOU CP also increased total ED billing. Future multicenter
research is needed to validate these findings.
57. Retrospective Study of Underage Drinking and Emergency
Department (ED) Visits: Before and After the 21 Ordinance
Christopher R Peterson and Michael Takacs. University of Iowa,
Iowa City, IA
Background: Excessive consumption of alcohol and dangerous
drinking behaviors continue to be a growing concern in Iowa City. A
2009 study reported that 70% of UI students had engaged in high-risk
drinking in the last two weeks as compared to 44% nationally. The
Iowa City Council sought to curtail underage alcohol consumption by
passing the 21-Only Ordinance on 6/1/2010, banning people under 21
from bars after 10:00 pm. There has been much debate in the
community as to the effectiveness of this measure - whether it would
reduce dangerous drinking, or simply shift drinking to house parties
where supervision and police presence would be minimal.
Objectives: The objective of our study was to determine whether the
rate of alcohol-related ED visits among 18-20 year olds decreased
following implementation of the 21-Only Ordinance.
Methods: A retrospective study of 18-20 year olds presenting to the
ED for alcohol-related reasons from 6/1/2009 to 5/31/2011 was
performed. Medical record data were compiled, including age, blood
alcohol content (BAC), date and time of visit, complaint and
diagnosis. Data were analyzed using Pearson‟s chi-square test.
Results: In the year prior to the 21-Only Ordinance, there were 1685
visits to the ED by 18-20 year old patients; 272 of these visits were
for alcohol related reason (16.3/100 patients). In the year following,
there were 206 alcohol visits out of 1608 total visits (12.4/100
patients), suggesting overall decline (23.8%) in alcohol-related visits
among the study population (p<.01).
Alcohol-related ED visits by 18-20 year old UI students decreased
from 8.72% to 6.16% (p<.01).
Alcohol-related visits involving violence decreased from 2.85% of
total visits in the year prior to 1.43% after (p<.01). Similarly, the
proportion of visits involving a mental or emotional condition, such
as depression or suicidal ideations, decreased from 2.20% to 1.06%
(p=.01).
Conclusion: Retrospective studies can reveal trends within a given
population over time, but are unable to provide causation for these
trends. Thus, while this study suggests a significant decline in 18-20
year old alcohol-related visits to the ED in the year after the 21-Only
Ordinance, additional studies are needed to determine the
sustainability of these changes.
58. A Retrospective Review of the Use and Safety of Sedation for
Agitated Patients with Hepatic Encephalopathy in the
Emergency Department
Jason West1 and Vijai Chauhan2. 1Albert Einstein School of
Medicine, Jacobi/Montefiore Hospitals, Bronx, NY; 2Saint Louis
University School of Medicine, St. Louis, MO
Background: Patients with hepatic encephalopathy may present with
a wide range of alterations in mental status including delirium,
agitation, and aggression. There are no consensus guidelines to
recommend a standard agent for sedation in patients with hepatic
encephalopathy or hepatic failure in the emergency department (ED).
Objectives: We intended to compare and characterize the use of
intravenous midazolam, lorazepam, and haloperidol for the sedation
of agitated patients with hepatic encephalopathy and end-stage liver
disease (ESLD) in the ED.
Methods: This was a retrospective chart review set in a university
hospital ED. The ED database was queried to identify patients
admitted with hepatic encephalopathy 2005-2009, and further chart
review was performed if the patient received sedation for agitation.
We analyzed the adequacy of sedation, adverse events, and
disposition.
Results: Of the 401 patients presenting with hepatic encephalopathy
or ESLD, 8 received sedation for agitation in the ED. 7 patients
recieved lorazepam, and 1 patient received both haloperidol and
lorazepam. One patient recieving both drugs required active airway
management and intubation for respiratory depression. No patients
were reported to have post-sedation hypotension, arrhythmia,
vomiting, or significant Glasgow Coma Scale changes. All patients
were adequately sedated at the time of disposition and were more
likely to require admission to intensive care units.
Conclusion: Agitated patients with hepatic encephalopathy given
lorazepam were adequately sedated but may be at increased risk of
requiring active airway management.
59. A Cost Comparison of Fomepizole and Hemodialysis in the
Treatment of Methanol and Ethylene Glycol Toxicity
Heather Ellsworth, Kristin M Engebretsen, Lisa M Hlavenka, Andy
K Kim, Jon B Cole, Carson R Harris and Samuel J Stellpflug.
Regions Hospital, St. Paul, MN
Background: Fomepizole (F), alone or in combination with
hemodialysis (HD), may be used in the treatment of toxic alcohol
exposures such as methanol (M) and ethylene glycol (EG). There is a
paucity of data regarding the financial cost of each treatment.
Objectives: Using patient charge estimates specific to our institution,
we present an analysis comparing cost effectiveness of F and HD for
treatment of M and EG levels of 50 mg/dL.
Methods: Patient charges associated with treatment of EG and M
exposures in 2010 at our institution were reviewed and averaged with
respect to the cost of the following: F dose, HD session, and daily
rates of a general care (GC) and intensive care unit (ICU) beds. All
other costs were assumed comparable irrespective of treatment
received. Based on available pharmacokinetic (PK) data for M and
EG in the presence of F, the duration of treatment was projected.
Results: The average patient charge for a dose of F was $1,267, HD
session $765, GC bed (daily rate) $915, and ICU bed (daily rate)
$1,524. For an EG or M level of 50 mg/dL treated with HD, the
patient charge would approximate $4,823 (2 doses of F, 1 HD
session, 1 day of hospitalization in the ICU). In contrast, the
estimated cost associated with treatment of an EG level of 50 mg/dL
with F only, based on a t½ of 12.9 h, to an endpoint of <20 mg/dL
was $5,631 (based on a treatment duration of 25.8 h, 3 doses of F, 2
days of hospitalization in a GC bed). Similarly, for a M level of 50
mg/dL treated with F only, with an estimated t½ of 54 h, the
estimated cost was $17,245 (administration of 10 doses of F and 5
days of hospitalization in a GC bed).
Conclusion: Hemodialysis is a more cost effective approach to the
management of methanol and ethylene glycol toxicity than alone if
levels exceed 50 mg/dL. This is especially true for M, which has a
significantly longer t½ than EG. Limitations include not accounting
for the cost of complications related to HD such as vascular injury,
infection, and thrombosis (data suggest these complications are rare).
Another limitation is the failure to account for individual variability
with respect to PK as well as patient weight, which may influence the
number and volume of F doses required. Accounting for these
parameters could make the cost difference between F and HD even
more favorable for HD, considering reports of extremely long EG
and M t½'s treated with F alone.
60. Equestrian Helmet Use in Horse Organization Promotional
Material
Charles A Jennissen1 and Suleimaan Waheed2. 1University of Iowa
Hospitals and Clinics, Iowa City, IA; 2University of Iowa, Iowa City,
IA
Background: Equestrian helmet use is an effective method to
prevent head injuries in horse-related events. However, rates of
protective head gear use while riding or working around horses is still
low. The media can have a great impact on injury prevention both
positively and negatively by their portrayal of protective safety
equipment or lack thereof.
Objectives: To determine the equestrian helmet use by individuals
pictured in horse organization promotional materials.
Methods: Literature was requested from horse organizations through
email and/or mail, with the inquiring investigator posing as a horse
enthusiast. Organizations contacted included national horse agencies,
breed registries and all state equine councils. Photographs in
materials received were reviewed for equestrian helmet use along
with the age and activity of individuals depicted in photographs.
Results: 113 of 335 organizations responded and 95 organizations
sent published material. A total of 2,004 photos with 2,738 people
were evaluated. The highest equestrian helmet use was by children,
and teen helmet use was generally portrayed more frequently than in
adults. The lowest rate were in those that appeared elderly (14.6%).
Helmet use was highest in photos that depicted competition-jumping
(87.9%). Competition-riding and pleasure-riding helmet use was only
30.0% and 34.5%, respectively. Equestrian helmet use was low in all
portrait categories--photos where pictured individuals were formally
posing for the camera. No one who was pictured while working on,
with or while on a horse was shown with an equestrian helmet; nor
was anyone in a parade. Adults riding with children did have a
significantly higher rate of wearing an equestrian helmet than adults
who were pleasure-riding in general (44.2% vs. 23.2%).
Conclusion: Photographs in horse organization literature often show
people not wearing helmets during equine-related activities. Horse
organizations have an excellent opportunity to define injury
prevention practices as normative behavior. One way this may be
accomplished is by portraying people always wearing equestrian
helmets in the photos they use in their published material.
Developing a culture of safe equestrian practices including helmet
use will decrease the number of serious head injuries experienced by
horse enthusiasts.
61. Facilitators of Evidence-Based Pediatric Pain Management
in Emergency Departments: Similarities and Differences Between
Rural and Urban Hospitals
Charles A Jennissen1, Sarah Wente2, Charmaine Kleiber2 and Ryoko
Furukawa2. 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2University of Iowa College of Nursing, Iowa City, IA
Background: Children‟s pain management in the Emergency
Department (ED) remains inadequate. Available evidence-based
practice (EBP) guidelines for pediatric pain management exist, but
are currently under utilized in managing pediatric pain in EDs.
Objectives: To determine the factors that nurses identify as
facilitating the use of EBP in the management and prevention of
pediatric pain in the ED and whether these factors are different for
rural versus urban hospitals.
Methods: All nurses working in hospital EDs in the state of Iowa
were invited to participate in a confidential survey regarding EBP of
pediatric pain treatment and included the question “What would
facilitate the use of EBP pediatric pain management in your ED?”
Qualitative responses were analyzed using Nvivo software to identify
patterns and themes. Researchers reviewed the responses
independently and then discussed the coding, resolving any
discrepancies.
Results: Of 1171 returned surveys, 735 contained responses to the
study question. Data fell into five nodes: knowledge, staff aspects,
hospital system, treatment, and patient/family issues. Knowledge and
staff aspects appear to be key facilitators for EBP in EDs. The
knowledge node revealed several themes including the desire for
specific types of training and education, information sharing, and for
examples of guidelines and policies. Staff aspects included the need
for more collaboration with physicians, and more openness and
motivation to change. Critical access hospital ED nurses more
frequently reported a need for education and guidelines/standing
orders than nurses from larger hospital EDs. Nurses from rural
facilities also reported wanting more exposure to pediatric patients
and asked for processes for the sharing of information from other
facilities, including larger hospitals with pediatric expertise. Nurses
from all hospital sizes reported the need for “proof” of effectiveness
of pain management practices.
Conclusion: Most strategies to increase evidence-based pediatric
pain management in EDs can be utilized in hospitals of all sizes.
However, rural hospitals may benefit more from networking and
information sharing with other hospitals, including examples of
guidelines and standing orders. It will be important all strategies
stress effectiveness and positive impact on the patient.
62. Characterization of Clinical Rotations in Three and Four
Year Emergency Medicine Residency Training Programs
Kenneth D Grosz, Robert Muelleman, Lance Hoffman and Michael
Wadman. University of Nebraska Medical Center, Omaha, NE
Background: Emergency medicine (EM) currently recognizes 3
training formats: PGY 1-3, 2-4, and 1-4. EM program requirements
proscribe that „no less than 50% of the clinical experience take place
under the supervision of emergency medicine faculty‟, that there
must be „at least two months of critical care rotations,‟ and if less
than 16% of all ED encounters are pediatric patients, some pediatric
rotations are required. Little is known about the content of the
remaining rotations in EM programs.
Objectives: To describe the similarities and differences in clinical
rotations between three and four year EM residency programs.
Methods: EM residency programs were identified on the SAEM
website during November, 2010. Information was abstracted from
individual program websites regarding the types and duration of
rotations during residency. Rotations were grouped into EM, critical
care (CC), surgery (surg), medicine (IM), pediatrics (peds), other or
(s)elective clinical categories. The median/interquartile range for the
number of blocks in each category were calculated for PGY 1-3 and
PGY 1-4 programs and compared by Mann-Whitney Rank Sum Test.
Results: We identified 152 programs: 113 PGY 1-3, 35 PGY 1-4 and
4 PGY 2-4. Within the PGY 1-3 programs there were 44 with 39 four
week blocks and 69 with 36 month blocks. Within the 35 PGY 1-4
programs there were 25 with 52 four week blocks and 10 with 48
month blocks. In comparing 52 and 39 block programs, there were
significant differences in EM: 34(32.2, 36) vs 26(24.5, 27.1)
p<0.001, other: 7(5.4,7.8) vs 4(3, 5.4) P<0.001 and (s)elective
4(2,4.5) vs 2(1,2) p<0.001. There were no differences in CC: 4(3,5)
vs 4 (3,4.4) p=0.653, surg: 2.5(1.4,3) vs 2(1.25,3) p=0.389, IM:
1(0.75,2) vs 1(0,1) p=0.115, and peds 0(0,1) vs 0(0,0) p=0.081. In
comparing 48 and 36 block programs, there were significant
differences in EM: 29.5(28, 30) vs 23(22, 24.6) p<0.001, other:
5.4(4,7) vs 3.5(3,4)p<0.001, and (s)elective: 4.25(3,6.5) vs 2(1,2)
p<0.001. There were no differences in CC: 4(3,5) vs 4 (3,4) p=0.988,
surg: 3(2,4.5) vs 2(1.4,3) p=0.054, IM: 2(1,3) vs 1(0,2) p=0.051, and
peds 0(0,1) vs 0(0,1) p=0.685.
Conclusion: Of the additional 13 or 12 blocks in four year programs,
there are an additional 8 or 6.5 EM blocks, 3 or 1.9 other blocks, and
2 or 2.25 elective blocks respectively.
63. Let The Good Times Roll: Computer Modeling to Investigate
Risk of ATV Rollover While Turning
Charles A Jennissen1, Gerene Denning1, John Steffen2, Jonathon
Marsico2, Thomas Schnell2 and Daniel McGehee2. 1University of
Iowa Hospitals and Clinics, Iowa City, IA; 2University of Iowa
College of Engineering, Iowa City, IA
Background: Rollovers are the most common all-terrain vehicle
(ATV) crash mechanism. Most field research of ATV rollovers is
limited due to the risk of subject injury. Computer modeling is a
potential tool to safely investigate ATV crash mechanisms and risk
factors.
Objectives: To explore how various factors might affect the
likelihood of an ATV rollover while turning including velocity,
surface friction, turning radius, passenger and ATV center of gravity,
and wheelbase dimensions
Methods: Vehicle specifications for a convenience sampling of
utility ATVs were compiled. A computerized free body diagram was
constructed of an ATV with passenger(s), and the risk of sliding or
rollover with turning was assessed for multiple parameters while
keeping ATV size specifications constant. The relative rollover risk
of various ATV models was also determined.
Results: Surfaces with higher friction coefficients (i.e. dry pavement)
increase the likelihood of a rollover while turning. Even a typical dirt
trail (friction coefficient of 0.3) would require a 16.4 mph limit to
avoid a slide with an average adult male driver making a 60 ft. radius
turn. A slide may not result in a rollover but will reduce the operators
control over the ATV. The risk of rollover increases significantly
with tighter turns. If the operator simply takes more gradual turns at
higher speeds, roll-overs can be avoided entirely. The minimum
turning radius for most ATVs was around 8 ft. which only allows a
maximum speed of around 10 mph to avoid a rollover on high
friction surfaces. As the combined operator/passenger weight
increases from 85 lbs to 365 lbs, the vehicle speed needs to be
reduced approximately 4 mph in order to prevent a rollover at the
same turning radius. There was a difference, albeit relatively small, in
the speed at which ATVs from different manufacturers will rollover.
Conclusion: Surface friction, total rider mass, velocity and turning
radius are rollover determinants that are terrain and rider decision
dependent. Education of operators, enforcement of strict no passenger
rules, and speed limiters for younger drivers may be important to
affect these factors and prevent rollover crashes. Manufacturers could
engineer better rollover protection by optimizing ATV width and
lowering its center of gravity, and/or producing ATVs with roll bars
and safety belts.
64. A Picture’s Worth a Thousand Words: Utilizing Social
Media to Better Understand ATV Crash Mechanisms
Morgan Price1, Gerene Denning2 and Charles A Jennissen2. 1University of Iowa Emergency Department, Iowa City, IA; 2University of Iowa Hospitals and Clinics, Iowa City, IA
Background: Over the last decade, all terrain vehicle (ATV) crashes,
injuries and deaths have risen more than 400%, with over 800 deaths
and 130,000 ED visits every year. Rollovers have been reported as
the most common mechanism. However, most injury surveillance
sources provide limited data on the sequence of events during an
ATV crash. This limitation provides the rationale to investigate less
traditional sources such as social media sites like YouTube.
Objectives: The study‟s objective was to compile a video library of
ATV crashes and to review these videos in order to achieve insights
regarding the crash mechanisms and contributing factors of ATV
crashes on uphill inclines.
Methods: A retrospective search of videos posted on YouTube
between April 2006 and July 2011 was performed. Videos were
compiled and coded according to occupant, crash, vehicle, and video
parameters. Uphill incline crashes were identified and reviewed
creating a highly detailed account of the crash sequence, moment by
moment, for every vehicle and person involved.
Results: One hundred eighty three ATV crash videos have been
downloaded to date and 52 uphill incline crashes were reviewed.
Almost all ATV operators in the videos were males and 81% were
adults. Helmet use was 73%. All crashes involving adolescents
occurred on adult-sized vehicles. 75% of vehicles were sports ATVs
and 25% were single-person utility ATVs. Major surface types shown
in the videos were dirt (72%), mud (10%), and solid rock (6%).
Overall, forty-three of the uphill crashes (83%) resulted in rollovers,
68% of these rollovers were backwards. A major contributor in the
majority of these crashes was loss of momentum followed by
inappropriate acceleration. A difference between sports and utility
ATVs was noted in which utility ATVs during a slower velocity
backward rollover would veer to the side once the metal rack on the
back hit the ground.
Conclusion: Videos from social media sites are a rich source of ATV
crash mechanism information. Analysis of these videos yields
significant details that are not available through any other data
source. Our ATV crash video library will serve as both an important
educational and research tool.
65. Complications of Extremity Computed Tomography
Angiogram Completed in Emergency Department
Emily Tilzer and Vijai Chauhan. Saint Louis University Hospital,
Saint Louis, MO
Background: Computed Tomography Angiography (CTA) is
increasingly used as a imaging modality for extremity vascular
pathology in patients presenting to the Emergency Department. From
limb trauma to acute arterial blockage, CTA is noninvasive and
frequently immediately available (1). However, the procedure still
requires intravenous contrast, which can cause adverse events, such
as anaphylactoid reactions or acute kidney injury.
Objectives: The objective of this study was to analyze the frequency
of adverse reactions related to CTA studies ordered for Emergency
Department patients.
Methods: This was a retrospective chart review of patients age 18-90
who received a CTA from July 2009 to August 2010 at an academic
medical center. A list of all CTA studies ordered from the Emergency
Department was cross referenced with patient‟s creatinine, admission
status, documented reactions, and time-to and type-of intervention.
Results: This is preliminary study data on 20 of approximately 60
subjects. These 20 patients had no documented adverse reaction to
the intravenous contrast or increase in creatinine.
Conclusion: As a modality that is becoming more common for
evaluation of extremity vascular pathology, CTA did not have an
increase in complications when ordered from the Emergency
Department. Further studies are needed to with larger number of
patient‟s who receive a CTA to detect any possible complications.
66. Safety Depictions on Primetime TV: Lack of Seat belts and
Helmets
David Milzman. Georgetown University School of Medicine,
Bethesda, MD
Background: A 1998 Mich St. U study recorded prime time TV
portrayal of 25% seatbelt usage when actual national usage was 65%
that year.. in 13 years, since the US national usage had inc. to 85%.
Objectives: Compare Primetime TV traffic/safety exposures with
USDOT NHTSA figures and Compare to Past TV representations.
Methods: Researchers watched a total of 53 non-news, non reality-
TV totaling 53 programs across 10 weeks of Spring 2011 primetime
(8-11 PM EST)from the following networks: ABC, CBS, NBC, FOX
and CW. Commercials were excluded. All instances of seat belt
usage (driver and passenger) , helmets (bikes and motorcycle) and
miscellaneous pedestrian and vehicular traffic infractions were also
recorded.
Results: total of 273 of prime time tV was viewed with an overall
rate for proper seat belt usage in 37.6% (95% CI: 32.4-42.9) of
drivers, 22.3% (95% CI:18.5-26.0) passengers. Proper seating and
childseat usage , not noted in original 1998 study was only 14%.
Helmet were used by 15.9% of bicyclists, 70.3%of motorcyclists.
There was 17% rate of Pedestrian and 22% vehicular traffic
violations, also. Overall proper 2011 restraint use was 30.1%
(95%CI: 25.4- 34.6). This figure represent only a 4.2% rise and NS
increase since the prior study. Portrayal of Primetime TV seatbelt
usage rose a 4.8% (p ≤ 0.11) from 1998 to 2011 while actual US
seatbelt use increased a significant 20%.(p ≤ 0.03) helmet use did
increase for both bike by 32% to 15.9% and motorcycle by 20% to
70.3%.
Conclusion: Recent studies have found traffic safety behaviors
continue to increase in Us population; however, major TV network
programs have not incorporated such simple safety changes into
current programming despite prior study into these deficiencies. A
poor example continues to be set.
67. Agreement Between Physician and CT Scan in High Energy
Mechanism Stable Trauma Patients
Michael D Zwank1, Eric A Gross2, Mary J Hughes3, David J Castle3,
Amanda C Miller3, William P Hughes3 and Christopher P Anderson4. 1Regions Hospital, Saint Paul, MN; 2Hennepin County Medical
Center, Minneapolis, MN; 3Michigan State University, East Lansing,
MI; 4Healthpartners Research Foundation, Bloomington, MN
Background: Computed tomography (CT) is a vital adjunct in the
evaluation and care of trauma patients. While its usefulness is
undisputable, this benefit comes with radiation related risk given the
relatively high doses of ionizing radiation that are used. This concern
has generated a debate over the proper role of CT in stable trauma
patients. While several studies have promoted liberal CT use, to date
there has been no well designed prospective study to examine this
practice in this patient population.
Objectives: This study assessed how closely physician assessment
and CT scan results agree in the alert stable patient who has
experienced high energy trauma. Can physicians reliably detect
severe injuries in this select patient population?
Methods: This is a prospective cohort study conducted at three Level
I trauma centers. A convenience sample was enrolled when study
personnel were available. Patients were included if they met the
inclusion criteria: blunt trauma, trauma team activation, Glasgow
Coma Score 15, systolic blood pressure on arrival > 100, age between
18 and 65. Trauma team leaders completed a survey regarding the
reliability of the patient and suspicion of any injury and severe injury
in various body regions (head, neck, chest, abdomen, pelvis and
extremities). The patient‟s chart was later abstracted for outcome and
injuries detected on x-ray or CT. Major injuries were defined a priori.
Results: 150 patients were enrolled. Mean age was 43 (SD=17.6).
Mechanisms of injury were primarily motor vehicle accident and fall.
46% of patients were deemed unreliable mostly because of
intoxication or distracting injury. Among the reliable patients (n=81),
there were 4 major injuries that were not detected by the provider.
The negative predictive value of physician assessment ranged from
0.97 to 1 (CI 0.85 to 1). Sensitivity of physician assessment to the
presence of major injury ranged from 0.67 to 1 (CI 0.09-1).
Conclusion: Clinicians can reliably detect major injuries in alert
stable trauma patients who are deemed reliable. There were only four
major injuries that were missed. None of these injuries required
intervention beyond observation. Attention needs to be given to
patients who are intoxicated or otherwise deemed unreliable and to
patients with significant distracting injuries. These patients may
benefit from increased CT scan utilization.
68. Padding the Slider Transfer Board and Patient Comfort in
the Emergency Department
Jerome R Walker1, Christopher P Anderson2 and Michael D Zwank1. 1Regions Hospital, Saint Paul, MN; 2Healthpartners Research
Foundation, Bloomington, MN
Background: A slider board (SB) is a rigid thin plastic board that
facilitates the movement of a patient from an emergency department
(ED) gurney to a radiology imaging table such as CT scan or x-ray.
Often patients who have experienced trauma are placed on a SB
immediately on arrival in the ED with the anticipation of needs for
imaging.
Objectives: The primary objective of this study is to compare patient
comfort when using a padded versus an unpadded SB. Secondary
objectives including number of imaging tests ordered and dose of
analgesics.
Methods: This was a randomized controlled trial involving adults
age 18-65 arriving to the ED on pre-hospital EMS backboard who
were expected to be on a SB for greater than 30 minutes. Patients
were excluded if: trauma team activation, pregnant,
hemodynamically unstable, GCS < 14. Patients were randomized to
standard care of slider board versus slider board padded by 3 inch egg
crate overlay foam. Pain scores were measured using visual analog
scale (VAS) measured in centimeters at 0, 30, 60, 90, 120 minutes.
Frequency/dosage of analgesics and number/type of imaging tests
ordered were recorded. Variables were analyzed descriptively with
means, medians, standard deviations and ranges. The outcome of pain
(as measured by VAS) was evaluated for normality using the
Kolmogorov-Smirnov test. The association between pain time and
the use of a padded board was quantified using linear mixed-effects
regression.
Results: 39 patients were enrolled (16 women, 23 men; 18 assigned
to control, 21 padded). Mean age was 42. Mean time on the slider
board was 107 minutes and mean number of imaging studies was 1.7.
Mean pain score in the control group was 6.73 and in the padded
group was 5.45 (p=0.047). Pain ratings diminished in both groups
over time. The time on the slider board, total amount of analgesics
and number of imaging studies ordered was similar in both groups.
Conclusion: Padding the slider board led to decreased discomfort but
not decreased amount of analgesics or number of imaging studies.
The difference in VAS scores is not likely to be clinically significant.
Since the conclusion of this study, our hospital has instituted a policy
of only using the slider board when needed - not placing any patient
on a slider board in anticipation of imaging studies.
69. The Utility of Computed Tomography in the Diagnosis of
Renal Colic in the Emergency Department
Michael D Zwank1, David J Gresback1 and Benjamin M Ho2. 1Regions Hospital, Saint Paul, MN; 2University of Wisconsin,
Madison, WI
Background: Patients with renal colic commonly present to the
emergency department and are usually treated with analgesics,
antiemetics and rehydration. Rarely to these patients require more
acute care or hospitalization. A very common approach to evaluating
patients with suspected renal colic in 2011 is to use computed
tomography (CT) scan which carries a heavy burden in both radiation
exposure and expense.
Objectives: Does CT scan change management, diagnosis or
disposition in patients with suspected renal colic?
Methods: In this observational study, a convenience sample of 35
(ongoing enrollment, goal=100) clinically stable patients between the
age of 18 and 50 with chief complaint of abdominal/back/flank pain
and renal colic as the most likely diagnosis were enrolled. Exclusion
criteria were: history of previous kidney stone, history of chronic
kidney disease (CR >2.0), urinary tract infection, recent CT (<6 mo)
or history of nephrectomy or renal transplant. Pre-CT and Post-CT
surveys were completed by the treating provider. Descriptive
statistics were used.
Results: 35 patients were enrolled in the study to date. The discharge
diagnosis was renal colic in 24 patients (69%). 10 cases had change
of diagnosis from renal colic: 4 muscular back pain, 3 abdominal
pain, 1 ovarian cyst seen on CT, 1 ovarian mass seen on CT, 1
testicular torsion not seen on CT. 4 cases had changed disposition
after CT-scan: 3 were diagnosed with renal colic/ureterolithiasis and
admitted for further care and 1 was taken to the operating room for
surgical management of testicular torsion. 10 patients were given
tamsulosin only after confirmation of ureterolithiasis. In the pre-CT
survey, providers thought that CT scan would/might be useful in 15
cases. In this group, 8/15 cases (53%) resulted in either changed
diagnosis or disposition. Conversely, in cases where no perceived
value would come from CT scan, 0/6 cases (0%) resulted in changed
diagnosis or disposition.
Conclusion: CT scans with high perceived value prior to completion
changed diagnosis or disposition in 53% of these patients while CT
scans with no perceived value did not change diagnosis or
disposition. There were a significant number of diagnosis and
disposition changes after completion of CT. These results are limited
by small patient numbers to date.
70. The True Impact Of A Left Vs. A Right Shift In Assessing A
White Blood Cell Count: Bacterial Viral And The True
Infectious Source
David Milzman1, Anchal Ghai1, Jenika Ferritti-gallon2 and Stephan
Chang1. 1Georgetown University School of Medicine, Bethesda, DC; 2Georgetown University, Washington, DC
Background: The complete blood cell count and differential, have
been used f as a diagnostic tool for acute bacterial infections. it has
always been taught that an increase in WBC accompanied by a
specific increase in neutrophils especially immature neutrophils,
referred to as a left shift, are associated with a bacterial infection. In
contrast an increase in WBC, specifically lymphocytes, referred to as
a right shift, is associated with a viral disease.
Objectives: This study will compare proven viral and bacterial
infections and the finding of right and left WBC shifts with the
respective infectious causation.
Methods: The study was completed at a level 1 trauma center urban
teaching ED with 87,000 annual visits. A retrospective cohort study
of all ED patients presenting between Jan 1 2009 and Jan 1 2011with
a full white blood cell count and differential performed on admission
with necessary supporting medical record info obtained through the
Azyxxi( Smith, M and Microsoft, Redmond, WA) EMR. Viral
disease was confirmed with a positive viral swab and bacterial
infection was confirmed with positive blood culture.
Results: a total of 107 viral infections and 205 bacterial infections
meeting strict criteria were discovered. There was a difference for
age and gender between the two groups with mean age for viral 44.5
and bacterial 62.2 with viral having 65% female and bacterial : 51%
female P 10000 neutrophils was 79% accurate compared to accuracy
for a right shift finding a viral infection was 34%.
Conclusion: Although the total WBC was greater in bacterial VS
viral infection the finding of the "classic" shifts in lymphocyte
predominance for viral infections was not accurate and that of
bacterial infection was found to be a better marker.
71. Pre-Arrest Characteristics and Use of Advance Directives
among Out-of-Hospital Cardiac Arrest Victims
David Milzman1, Erwin Wang2 and Han Huang3. 1Georgetown
University School of Medicine, Bethesda, MD; 2Georgetown
University School of Medicine, Bethesda, DC; 3Georgetown
University School of Medicine, Washington, DC
Background: Several factors have Early recognition of an arrest
improves survival, as every delay in initiating treatment reduces
likelihood of survival (Larsen, 1993) demonstrated to improve CA
survival rates.
Objectives: to determine the true survival to hospital discharge in a
major urban city with a documented less than 5% survival rate from
out-of hospital cardiac arrest and to evaluate the value of
implementing advanced directives from the prehospital side.
Methods: A two year prospective data collection and scene
investigation study of all cardiac arrest victims who presented to a 87,
000 Annual ED visit urban teaching hospital was completed b/w
2009-2010. Utstein criteria and Demographic information including
age, gender, and ethnicity
Medical information:
Location of cardiac arrest
Incidence of pre-existing disease
EMS response time
Presenting cardiac rhythm
Interventions by EMS, family m
Results: Initially, 199 cases were identified and 53 were excluded
according to Utstein criteria: of the 146 included study patients there
was an overall 6/6 % survival to hospital discharge. CA was most
frequently reported from home with a 8.6% survival rate vs. skilled
nursing facility 1.8% survival. P < 0.03. SNF patients were older,
had lower SF-36 scores for independent living and actually had only
2/ 66 with Advanced directives in place.
Conclusion: Advanced directives do not coincide with low
independent functionality in this urban city with very low cardiac
arrest survival even from V Fib. Improvements in education and
acceptance of not only DNR orders but bystander CPR are needed to
improve outcomes and correct expectations.
72. Comparison of Data Collection Using Real Time Observers
to Subsequent Review of Video Data for Airway Management
Research
James Miner, Megan Terrebonne, Robert Reardon and John
McGill. Hennepin County Medical Center, Minneapolis, MN
Background: The optimal method of data collection for clinical
airway research is unknown.
Objectives: To compare data collected by a real-time observer to
data obtained by subsequent review of video of the same procedure
by a different observer.
Methods: This was a prospective observational study of patients
undergoing endotracheal intubation at an urban level one trauma
center where all emergency intubations are recorded using video
devices from three distinct angles with the cardiac monitor
information recorded alongside these images. Observers at the
bedside collected information regarding vital signs, airway
maneuvers, method of intubation, number of breaths delivered by
bag-valve-mask, number of intubation attempts, the duration of each
maneuver and attempt, and any adverse events including oxygen
saturations <93%. The same procedure was subsequently reviewed
for the same data using the video recordings of the procedure using a
different observer. Data describing the occurrence of hypoxia, the
number of bag-valve-mask breaths given, the number of intubation
attempts, and the time to successful intubation recorded for each
procedure were compared between the real time assessment and the
video assessment. Data were compared using descriptive statistics.
Results: Twenty patients were included. The number of breaths
given by bag-valve mask prior to intubation was different between
the two groups in 8 cases. More breaths were detected by video than
by real time in 6 cases (median difference 6, range 1 to 17). The
device used was recorded the same in both groups (13 laryngoscope,
7 CMAC). The drugs given and the doses were recorded the same in
both groups. The lowest oxygen saturation was recorded the same in
both groups. The number of attempts was the same in both groups.
The time to intubation was recorded the same in 14 cases. In one case
the time to intubation could not be determined from the video. In 4
cases it was longer in the video group (median difference 45 seconds,
range 22 to 95); in 1 case it was longer in the real-time group
(difference 2 minutes).
Conclusion: There were significant discrepancies between the data
collected from real-time observers and from review of video. It is
possible that a combination of video and real-time data collection
may improve research accuracy.
73. Correlation Between Exercise Levels and Medical School
Board Scores
Vijai Chauhan and Sean Cavanaugh. Saint Louis University SOM,
Saint Louis, MO
Background: Medical education is recognized as a stressful
undertaking and coping strategies of students impact their
performance and wellbeing. It is accepted that the demanding
workload often prevents students from a steady exercise schedule,
and as they progress through their medical training, good health
habits and health status decline. A few studies with adolescents have
strongly suggested a positive relationship between physical fitness
and academic achievement, although the causation may be unclear.
However none have examined a relationship between levels of
exercise and academic performance in medical students.
Objectives: This study sought to find a correlation between exercise
levels and academic performance as indicated by student US Medical
Licensing Examination (USMLE) Step 1 test scores.
Methods: This IRB-approved study involved two anonymous
surveys of a midwestern medical school class of 2012. The first
survey was administered at the beginning of 2nd year and the second
survey at beginning of the 3rd year of medical school. Surveys asked
height, weight & exercise practices. The second survey included
specific questions about weekly exercise practices over the preceding
year, and also a 10-digit range of USMLE Step 1 score.
Results: A total of 28 students responded to the second survey, 46%
male, with a mean age of 24.8 and mean BMI of 22.6. Two groups
were designated according to USMLE score range of 226-265 or 186-
225. Those in the lower score group had a higher BMI of 23.5 versus
the higher score group with BMI of 21 (p=0.110). Exercise practices
of these two groups were examined by comparing the self-reported
average number of hours of exercise per week over the previous year,
3.42 for the 186-225 group versus 4.13 for the 226-265 group
(p=0.431). The group that exercised more had a higher incidence of
reporting running/jogging and weight training as their preferred
modes of exercise.
Conclusion: This small study suggests an association between a
higher USMLE Step 1 score with increased exercise activity and
lower BMI, although calculated p-values did not indicate statistical
significance. Both factors suggest a motivated individual. Further
study involving more respondents is necessary to better characterize
the validity of this association.
74. Pain Medication Delivery In The Ed For Extremity
Fractures: Correlation Of Prescribers' And Patients' Gender
And Ethnicity
David Milzman1, Valerie Huckabee1, bill dirkes1, Julie Vieth2 and
collier Wright1. 1Georgetown University School of Medicine,
Washington, DC; 2Georgetown U / Georgetown WHC EM
Residency, Washington, DC
Background: There is great debate on timing of pain medication in
the ED and especially if there may be bias based on patient selection
factors such as age, gender and ethnicity. No study has really
investigated the role of the physician prescriber own demographic
factors in relation to that of the patient.
Objectives: Primary: To determine if bias exists in analgesic
prescribing practices based solely on patients' gender and ethnicity
Secondary: To determine if the gender and ethnicity of the physician
relative to that of the patient influenced pain management
Methods: A 5 year review of patients presenting to an Urban,
Teaching Hospital ED with 80,000 annual visits.
Inclusion criteria: Adult patients with long-bone fractures but without
other distracting diagnoses
Caucasian, African American, Latino or American Indian
Primary Outcome: Administration of analgesia in the ED based on
patient gender and ethnicity.
Secondary Outcome: Gender/ethnicity of prescribing physician and
type of medication
Results: 782 patients met inclusion criteria. Mean age was 50.9
years, 60.7% were female, 191 identified as Caucasian, 562 as
African-American, 95 as Latino/Hispanic
Physician prescriber incidents: 79% male and 55% White, 29%
African American and 14% Asian.
There was no outlier group with regard to physician and patients
when looking at timing of pain medication delivery and narcotic VS
non narcotic medication selection. Although overall ED physician
performance was delayed with mean time to medication > 30 min in
68% of cases without bias and overall, all groups tended to
administer less medication to women VS men and Older > 65 yrs
received less mediation than younger patients without bias based on
physician prescribing.
Conclusion: No observed bias based on patient gender nor ethnicity
No observed bias based on physician gender nor ethnicity
Type of pain medication prescribed and delay to medication delivery
in minutes were independent of the race and gender of patients and
physicians
75. Protein Expression Of M2 Receptor In Atria And Ventricles
Of Sham Rats
Elizabeth M Spartz, Huiyin Tu, T. Paul Tran and Yu-Long Li.
University of Nebraska Medical Center, Omaha, NE
Background: Autonomic dysfunction is being recognized as an
important pathogenic cause of increased morbidity and mortality in
many disease states, including chronic heart failure (CHF) and
diabetes mellitus (DM). The dysfunction is caused by an imbalance
between the sympathetic tone, which of left ventricle, right ventricle,
left atria, and right atria were harvested, homogenized, and protein
levels for M2 receptors were measured using western blotting.
Results: See graph (attached).
Conclusion: Cardiac function is profoundly affected by neural
activation. While activation of the sympathetic system increases heart
rate, contractility and conduction velocity, activation of the
parasympathetic system (PNS) has the opposite effects; PNS is
concerned with rest, conservation, and restoration of energy via
reduction of heart rate and blood pressure. Of the five muscarinic
subtypes, only M2 receptors appear to be clinically relevant in
mammalian cardiac physiology. Although a body of data established
that PNS outflow is reduced in disease states such as CHF and DM, it
is not clear whether the reduction in PNS outflow occurs at the ICG
level or the PNS terminal level. This preliminary study is part of our
larger study to answer the question if the reduction in PNS outflow in
CHF/DM is caused by a dysfunction in ICG or a reduction in M2
receptor at the cardiac tissue. Consistent with data obtained through
other methods, our data suggest that most of the M2 receptors localize
in the cardiac atria in this rodent model.
76. Rates of Selected Procedures and High-Acuity Diagnoses in
Urban and Rural Emergency Departments
James Waymack, Steve Markwell and Ted Clark. Southern Illinois
University, Springfield, IL.
Background: EM workforce studies show relatively low rates of
board certified/residency-trained emergency physicians practicing in
rural EDs. Rural ED rotations for EM residents may lead to increased
numbers of residency-trained EM providers in rural areas, as well as
provide unique training experience. There is concern, however, that
residents trained in rural environments will not get sufficient
procedural experience or patient acuity.
Objectives: To compare the rates of selected procedures and high-
acuity diagnoses at rural and urban EDs in the US.
Methods: Procedures and high-acuity diagnoses were selected based
on ACGME guidelines and were identified in the Nationwide
Emergency Department Sample (NEDS) database by ICD9 Code.
The rates of procedures and diagnoses, reported as a percentage of all
visits, are compared between two categories. The urban category (U)
includes hospitals that are in counties defined as large or small
metropolitan; the rural category (R) includes hospitals that are in
counties defined as metropolitan or non-metropolitan.
Results: Procedure rates are lower for rural EDs. (R%, U%) Fracture
reduction - 0.25, 0.46; chest tube - 0.06, 0.13; cricothyrotomy - 0.01,
0.07; intubation - 0.27, 0.55; lumbar puncture - 0.13, 0.33;
pericardiocentesis - 0.002, 0.007; thoracotomy - 0.002, 0.006. High-
acuity diagnosis rates are lower for rural EDs. (R%, U%) Acute MI -
0.53, 0.68; cardiac arrest - 0.19, 0.24; cardiac dysrhythmia - 3.50,
4.36; pneumothorax - 0.04, 0.05, intracranial bleeding - 0.10, 0.15;
ischemic CVA - 0.73, 0.88; acute appendicitis - 0.19, 0.29; ectopic
pregnancy - 0.02, 0.05; pulmonary embolism - 0.12, 0.19; aortic
aneurysm - 0.13, 0.17; aortic dissection - 0.01, 0.02; testicular torsion
- 0.01, 0.02.
Conclusion: The lower rates of procedures and high-acuity diagnoses
in rural EDs confirms the concern that residents receiving a
substantial portion of their training in rural EDs may not get
sufficient experience in certain procedures or diagnoses. The benefits
of a rural ED rotation must be weighed against the risk of lower
procedure and high-acuity diagnosis rates. The impact of a 1-3 month
rotation in a rural ED on overall procedural competency and clinical
experience cannot, however, be extrapolated, and further study is
required to quantify this effect.
77. Do Alcohol-Related Emergency Department (ED) Visits
Mirror Police Data? A Retrospective Study
Greg Pelc, Michael Takacs and Hans House. University of Iowa,
Iowa City, IA
Background: A 2011 self-reported survey at the University of Iowa
(UI) indicates that 64.5% of UI students engaged in binge drinking in
the past two weeks, exceeding the national average of 44%. The UI
has recently supported a number of programs to address this problem,
including AlcoholEdu, more Friday classes, Red Watch Band
Program, the under 21-Ordinance, and increased late-night
programming. Measures to identify the effectiveness of these
interventions are needed to determine their worth. Police data and
alcohol-related ED visits are two measures for adverse consequences
of alcohol use.
Objectives: The study was designed to examine the relationship
between alcohol-related visits at the UI ED with Iowa City Police
Department (ICPD) and University of Iowa Police Department
(UIPD) records. Does the level of alcohol-related ED visits reflect the
number of alcohol-related incidents documented by police?
Methods: ED medical records for patients 18-22 years of age
presenting between 6:00 pm and 6:00 am were retrospectively
examined from June 2008 to May 2011. Patient data (including age,
date and time of visit, and diagnosis) was compiled for any subject
with an alcohol-related illness or injury. ICPD and UIPD records
were obtained and compiled into categories for common offenses.
Monthly totals for alcohol-related ED visits were then compared to
police data using correlation tests.
Results: From June 2008 to May 2011, there were 1,258 alcohol-
related ED visits. In the same period, the aggregate police data
indicated the following number of charges: 3,335 Public Intoxication
(PI), 2,937 Possession of Alcohol Under Legal Age (PAULA), 1,572
Operating While Intoxicated (OWI), 1,143 Disorderly Conduct (DC),
and 784 Interference with Official Acts (IOA). A weak positive
correlation exists between alcohol-related ED visits and alcohol-
related police charges, with correlation coefficients for ED visits
versus PI, PAULA, and IOA charges of 0.61, 0.55, and 0.51,
respectively.
Conclusion: The weak positive correlation between alcohol-related
ED visits and police charges tracks the general trends of college-age
alcohol abuse, with rises and falls cyclically based on student life in
Iowa City. Both ED and police data are worthwhile measures of
college-age alcohol abuse in Iowa City, as they are not mutually
dependent upon one another.
78. Acute Disaster Response: Lessons Learned from a Small-
scale Event
Kathy Lehman-Huskamp and Anthony Scalzo. Southern Illinois
University, Springfield, IL; Saint Louis University, Saint Louis, MO
Background: In August 2008, the St. Louis area experienced an
incident involving nine individuals who were illegally entering a
waste dumpster at a repackaging facility in East St. Louis, IL. The
men were inadvertently exposed to nitroaniline. Within hours, the
individuals began having symptoms and presented by either private
car or ambulance to hospitals in St. Louis, MO. This event ultimately
resulted in the temporary closing of two Emergency Departments and
one Intensive Care Unit.
Objectives: To illustrate critical lessons learned with disaster
response involving a small-scale event.
Methods: A retrospective analysis was performed on publicly
available records of a real-time event. This project was determined to
be exempt from review of the Institutional Review Board.
Results: Eight significant lessons regarding disaster response were
derived from this experience.
Conclusion: Disaster response plans cannot solely be based on mass
casualty events. Small scale events such as this case study have a
higher probability of occurrence in any given response area.
Consequently, disaster planning must be flexible in its response scale
at both the emergency responder and hospital level.
Medical Student SimWars Competition
Kansas University Medical Center
Jeremy Cook, MS2
Patrick Harper, MS2
Elspeth Pearce, MS2
Julianne Schwerdtfager, MS2
St. Louis University, School of Medicine Team 1
Stephen Gregory, MS4
Sarah Kuehnle, MS3
Stefan Law, MS3
Andrew Jung, MS2
Neil Kalsi, MS3 (alternate)
St. Louis University, School of Medicine Team 2
Cory Cheatham, MS3
Matthew Fellin, MS3
Jeff Scott, MS3
Kamran Hussaini, MS2
Jacinta Robenstine, MS3 (alternate)
Southern Illinois University, School of Medicine
Jennifer Carroll, MS3
Loren Reed, MS3
Matt Albrecht, MS4
Dan O‟Keefe, MS4
Mike O‟Keefe, MS4 (alternate)
Washington University in St. Louis, School of Medicine Team 1
Rob Klemisch, MS2
Akshay Ganju, MS2
Clark Smith, MS4
Sara Manning, MS4
Washington University in St. Louis, School of Medicine Team 2
Austin Wesevich, MS1
Dylan Kluck, MS1
Amelia Lucisano, MS1
Shelley Forbes, MS1
Notes
Notes
Notes
Notes