Supplement to Annals of Emergency Medicine An International Journal пќ¶пќЇпќ¬пќµпќпќҐ пњµпњґ пќ®пќµпќпќўпќҐпќІ пњі пќіпќҐпќ°пќґпќҐпќпќўпќҐпќІ пњІпњ°пњ°пњ№ ACEP RESEARCH FORUM October 5-6, 2009 Boston Convention and Exhibition Center Hall B2 Boston, MA 3A 19A S1 S4 Schedule of Presentations Index of Presenters Oral Presentations Poster Presentations www.annemergmed.com SEPTEMBER 2009 VOLUME 54 NUMBER 3 Supplement to Annals of Emergency Medicine Journal of the American College of Emergency Physicians ACEP RESEARCH FORUM October 5-6, 2009 Boston Convention and Exhibition Center Hall B2 Boston, MA Annals of Emergency Medicine is owned by the American College of Emergency Physicians (www.acep.org). Manuscript submissions and editorial correspondence should be sent to the Editorial Office. Annals ACEP PO Box 619911 Dallas, TX 75261-9911 1125 Executive Circle Irving, TX 75038-2522 800-803-1403 Fax 972-580-0051 The Manuscript Submission Agreement is published in every issue. Business correspondence (subscriptions, permission, and reprint requests, advertising sales and production) should be sent to Elsevier Inc., 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2888, telephone 800-523-4069. Copyright В© 2009 by the American College of Emergency Physicians. All rights reserved: No part of this publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the Publisher. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers. Acceptance of an advertisement for placement in Annals in no way represents endorsement of a particular product or service by Annals of Emergency Medicine, the American College of Emergency Physicians, or rhe Publisher. 2009 Research Committee/Research Forum Steering Subcommittee Charles B. Cairns, MD, FACEP, Research Committee Chair Debra E. Houry, MD, MPH, Research Forum Co-Director; Research Committee/Research Forum Subcommittee Chair Brian J. OвЂ™Neil, MD, FACEP, Research Forum Co-Director Steven B. Bird, MD, FACEP Deborah B. Diercks, MD, FACEP 2009 Research Forum Abstract Reviewers Vikhyat S. Bebarta, MD Michelle Blanda, MD, FACEP Keith Borg, MD, PhD Edward Boyer, MD, PhD Carlos Camargo, Jr, MD, DrPH Brendan Carr, MD Shu B. Chan, MD, MS, FACEP D. Mark Courtney, MD, FACEP Francis M. Fesmire, MD, FACEP Michelle Garcia, MD, FACEP Robert T. Gerhardt, MD, MPH, FACEP Seth W. Glickman, MD Edward C. Jauch, MD, FACEP Alan E. Jones, MD, FACEP Amy H. Kaji, MD, MPH, PhD Phillip D. Levy, MD, FACEP Roger J. Lewis, MD, PhD, FACEP Matthew Lyon, MD, FACEP Lawrence A. Melniker, MD, MS, FACEP David Morgan, MD, FACEP James E. Olson, PhD Peter R. Panagos, MD, FACEP Jesse H. Pines, MD, MDA Eileen C. Quintana, MD, FACEP Maria R. Ramos Fernandez, MD Michael Roshon, MD, PhD, FACEP Luis A. Serrano, MD Anand Shah, MD Adam J. Singer, MD, FACEP Jonathon M. Sullivan, MD, PhD Richard L. Summers, MD Selim Suner, MD, FACEP RESEARCH FORUM EDUCATIONAL PROGRAM 2009 MONDAY, OCTOBER 5, 2009 MONDAY, OCTOBER 5, 2009 1:00 - 1:30 PM State of the Art Presentation 8:00 - 9:00 AM Poster Session 1 Administration CardiologyвЂ”Judd E. Hollander, MD, FACEPвЂ” Room TBA, Boston Exhibition and Convention Center 9 Does a Clinical Productivity Incentive Plan Work for Emergency Medicine Faculty? Richerson PJ, Texas A&M University Health Science Center, Temple, TX 1:30 - 2:30 PM Oral Presentations 10 Does a Team Triage Service Affect Patient Satisfaction in an Urban Academic Emergency Department? Saef SH, Medical University of South Carolina, Charleston, SC 11 Impact of Triage Physician and Clinical Operation Management Consultant Implementation on Emergency Department Throughput at a Tertiary Care Center AlDarrab A, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia 12 When the Emergency Department Is Packed Can Physician Assistants Pick Up the Pace? An Analysis of Physician Assistant Productivity Related to Patient Volume Brook C, Albany Medical College, Albany, NY 13 Utilizing Time-Driven Activity-Based Costing in the Emergency Department Bank DE, Phoenix ChildrenвЂ™s Hospital, Phoenix, AZ 14вЂ«ШЎвЂ¬ An Analysis of Emergency Department Flow, Severity and Congestion Factors That Are Associated With Decreases in the Left Without Being Seen Rate Sattarian M, George Washington University, Washington, DC 15 Satisfaction of Emergency Department Hallway Patients Stiffler KA, Summa Health System/NEOUCOMP, Akron, OH 16вЂ Emergency Department Consultation Practices and Documentation Vary Widely Across Hospitals Schuur J, Brigham and WomenвЂ™s Hospital, Boston, MA 17 Emergency Department Rapid Assessment Unit at the Cambridge Hospital: Why and How? Lobon LF, The Cambridge Hospital/Cambridge Health Alliance, Cambridge, MA CardiologyвЂ”Moderator: Judd E. Hollander, MD, FACEPвЂ” Room TBA, Boston Exhibition and Convention Center 1вЂ«ШЎвЂ¬ вЂ A Clinical Prediction Model to Estimate Risk for 30-Day Adverse Events in Emergency Department Patients With Symptomatic Atrial Fibrillation Barrett TW, Vanderbilt University Medical Center, Nashville, TN 2 Early Objective Identification of Chest Pain Patients at Very Low Risk of 30-Day Adverse Outcomes Peacock W, The Cleveland Clinic, Cleveland, OH 3 Quality of Care for Acute Myocardial Infarction in 58 US Emergency Departments Tsai C, Massachusetts General Hospital, Harvard Medical School, Boston, MA 4 The Impact of a Statewide ST-segment Myocardial Infarction Regionalization Program on Treatment Times for Women, Minorities, and Elderly Patients at Hospitals Without Percutaneous Coronary Intervention Capability Glickman S, University of North Carolina, Chapel Hill, NC TUESDAY, OCTOBER 6, 2009 8:00 - 8:30 AM State of the Art Presentation Infectious DiseasesвЂ”Gregory J. Moran, MD, FACEPвЂ” Room TBA, Boston Exhibition and Convention Center Cardiology 8:30 - 9:30 AM Oral Presentations Infectious DiseasesвЂ”Moderator: Gregory J. Moran, MD, FACEPвЂ”Room TBA, Boston Exhibition and Convention Center 18 Fibrinolytics for Acute Myocardial Infarction in Emergency Departments Niska RW, Centers for Disease Control, Hyattsville, MD 19 Prescription of Non-Steroid Anti-Inflammatory Drugs in Emergency Department Patients With Acute Coronary Syndrome/ Myocardial Infarction Zito JA, Stony Brook University, Stony Brook, NY 5 Mass Screening of Children During a Pandemic Influenza Drill Fertel BS, University of Cincinnati, Cincinnati, OH 20вЂ Can Point-of-Care Assays Deliver Lab Quality Accuracy? Peacock W, The Cleveland Clinic, Cleveland, OH 6вЂ«ШЎвЂ¬ Effect of Hyperlactatemia on the Likelihood of In-Patient Mortality for Patients With a Normal and Abnormal Anion Gap Green J, New York Hospital Medical Center of Queens, Flushing, NY 21 Oral Anticoagulation Quality Index as a Predictor for Bleeding Pazin-Filho A, Medical School of Ribeirao Preto - University of Sao Paulo, Ribeirao Preto, Brazil 22 Error in Body Weight Estimation Leads to Inadequate Parenteral Anticoagulation Pazin-Filho A, Medical School of Ribeirao Preto - University of Sao Paulo, Ribeirao Preto, Brazil 23 Typical Angina Is Not Predictive of the Presence of Inducible Cardiac Ischemia in Emergency Department Chest Pain Patients Hermann LK, Mt Sinai School of Medicine, New York, NY 7 How Reliable Is Urinalysis to Predict Urinary Tract Infections? Waseem M, Lincoln Hospital, Bronx, NY 8EMF The Effect of Etomidate on Hospital Length of Stay of Patients With Sepsis: A Prospective, Randomized Study Tekwani K, Advocate Christ Medical Center, Oak Lawn, IL Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Annals of Emergency Medicine 3A Research Forum Educational Program 2009 MONDAY, OCTOBER 5вЂ”contвЂ™d 24 Initiating Medical Therapies in the Cardiac Catheterization Lab Decreases Door-To-Balloon Time for Acute ST Elevation Myocardial Infarction Bastani A, William Beaumont Hospital, Troy, MI 39 25 Additional Diagnostic Utility of Upright T-Wave in V1 and TWave V1 Vs. T-Wave in V6 in Differentiating Acute Anterior STSegment Elevation Myocardial Infarction From Benign Early Repolarization Smith SW, Hennepin County Medical Center, Minneapolis, MN Pain Management 26 When вЂњGoodвЂќ Is Below Average Kiefer CS, Mayo Clinic, Rochester, MN 27 An Assessment of Resident Training in Emergency Department Administration Farley HL, Christiana Care Health Systems, Newark, DE 40 Comparison of Analgesic Practices in Pregnant and Non-Pregnant Emergency Department Patients Bloch RB, Maine Medical Center, Portland, ME 41вЂ A Qualitative Study Assessing the Information Needed to Manage Adults in the Emergency Department With Sickle Cell Disease Tanabe P, Northwestern University, Chicago, IL 42вЂ The Emergency Department Pain Experience for Adults With Sickle Cell Disease Tanabe P, Northwestern University, Chicago, IL 43 How Does Use of a Statewide Prescription Monitoring Program Affect Emergency Department Prescribing Behaviors? Sinha S, University of Toledo College of Medicine, Toledo, OH 44 Risk Factors for Delayed Analgesia in Patients Presenting to the Emergency Department With Long Bone Fractures Mejia J, New York Hospital Queens, Flushing, NY 45 A Clinical Study to Evaluate the Efficacy of 4% Liposomal Lidocaine as Compared to Placebo for Pain Reduction of Nonemergent Venipuncture in Adults Rusczyk G, New York Hospital Queens, Flushing, NY Education 28вЂ«ШЎвЂ¬ The Use of Video Laryngoscopy in Massachusetts Emergency Departments Raja AS, Brigham and WomenвЂ™s Hospital, Boston, MA 29 Evaluating Applicants to a New Emergency Medicine Residency Program: Characteristics of Applicants Who Used the Electronic Residency Application Service Versus Applicants Who Did Not Groke S, University of Utah School of Medicine, Salt Lake City, UT 30вЂ«ШЎвЂ¬ Characteristics of Emergency Medicine Residency Curricula That Affect Board Performance Babcock C, University of Chicago, Chicago, IL 31 Evaluation of Different Teaching Modalities for EKG Interpretation Among Emergency Medicine Residents Das D, New York Hospital Queens, Flushing, NY 32 The Perceived Impact of Precepting Medical Students on ResidentsвЂ™ Clinical Work and Education Barcomb T, Albany Medical College, Albany, NY 33 Direct Observation Evaluations by Emergency Medicine Faculty Do Not Provide Unique Information Over That Provided by Summative Quarterly Evaluations by the Same Faculty Barlas D, New York Hospital Queens, Flushing, NY Imaging 2 (Other Imaging) 34 35вЂ«ШЎвЂ¬ Assessing Inter-Rater Reliability and Agreement Between Two Methods of Noninvasive Hemodynamic Monitoring in Clinically Stable Emergency Department Patients Napoli A, Rhode Island Hospital/Brown University, Providence, RI Value of Noninvasive Measurement of Contractility to Predict Mortality in Emergency Department Patients Undergoing Early Goal-Directed Therapy for Severe Sepsis Napoli A, Rhode Island Hospital/Brown University, Providence, RI 36 Ionizing Radiation From Computed Tomography During Evaluation of Intermediate-Risk Trauma Patients Thompson K, Mayo Clinic, Rochester, MN 37вЂ«ШЎвЂ¬ New Generation CT Scanners Demonstrate Higher Sensitivity for Subarachnoid Hemorrhage Phanthavady T, University of Utah, Salt Lake City, UT 38 The вЂњTriple Rule-OutвЂќ 64-Section Coronary Computed Tomographic Angiography Protocol: Coronary and Extra-Coronary Findings of Emergency Department Patients Takakuwa KM, Thomas Jefferson University Hospital, Philadelphia, PA 4A Annals of Emergency Medicine Intussusception in Adults: A 148-Patient Experience Lindor RA, Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN Pediatrics 46 The Pediatric Experience in the Emergency Department, 2000-2006 Thode HC, Stony Brook University, Stony Brook, NY 47 Delayed Repeat Enema Management of Failed Initial EnemaReduction Intussusception Losek JD, Medical University of South Carolina, Charleston, SC 48вЂ«ШЎвЂ¬ Anaphylaxis Management in the Pediatric Emergency Department: Opportunities for Improvement Russell S, Medical University of South Carolina, Charleston, SC 49вЂ Recombinant Human Hyaluronidase-Facilitated Subcutaneous vs Intravenous Hydration Therapy in Infants and Children Hahn B, Staten Island University Hospital, Staten Island, NY 50вЂ«ШЎвЂ¬ Emergency Department Prescriptions for Long-Term Inhaled Corticosteroids for Children With Asthma: Are We Following Recommendations? Garro A, Rhode Island Hospital and Alpert School of Medicine at Brown University, Providence, RI 51 Spontaneous Pneumomediastinum in Children: A 10-Year Experience van Tonder RJ, Mayo Clinic, Rochester, MN 52 Endotracheal Tube Cuff Pressures in Pediatric Patients Intubated Prior to Aeromedical Transport Tollefsen WW, Harvard University, Boston, MA 53вЂ«ШЎвЂ¬ Does Sex Delay the Diagnosis of Appendicitis in Female Patients With Abdominal Pain? Baquero A, Lincoln Medical Center, Bronx, NY Public Health 54 Characteristics and Risk Factors of Patients Who Refuse Routine HIV Testing in an Urban Emergency Department Calderon Y, Jacobi Medical Center, Bronx, NY Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Educational Program 2009 MONDAY, OCTOBER 5вЂ”contвЂ™d 55 STEP-DC: Stop Emergency Department Visits for Hyperglycemia Project -DC Dubin J, Washington Hospital Center, Washington, DC 70 A Regional Study of Emergency Department Visits for Acute Exacerbation of Chronic Obstructive Pulmonary Disease Faig O, Morristown Memorial Hospital, Morristown, NJ 56 A Performance Improvement Audit to Assess Airway Documentation: How Well Do Emergency Physicians Document Confirmation of Endotracheal Tube Placement? Phelan MP, Cleveland Clinic, Cleveland, OH 71 Does the Pulmonary Embolism Severity Index Identify Patients at Risk for Short Term Clinical Deterioration? Hariharan P, Massachusetts General Hospital, Boston, MA 57 Copperhead (Agkistrodon Contortrix) Snakebites in the United States: 2000-2007 Bhakta NS, Scott and White Memorial Hospital, Temple, TX Resuscitation 58 Epidemiology of Prolonged Emergency Department Length of Stay Heins A, University of South Alabama College of Medicine, Loxley, AL 59 Multicenter Study of Internet Use by Emergency Department Patients in Boston Sullivan AF, Massachusetts General Hospital, Boston, MA 60 The Prevalence of Tobacco and Alcohol Use in Immigrant Emergency Department Patients in Queens, NY Gupta S, New York Hospital Queens, Flushing, NY 61 National Survey of Preventive Health Services in United States Emergency Departments Delgado MK, Stanford-Kaiser Emergency Medicine Residency, Palo Alto, CA 369вЂЎ A Randomized Controlled Trial of the Effect of Energy Drinks on Exercise Performance, Dexterity, Reaction Time and Vital Signs Before and After Exercise OвЂ™Neil BD, Everest Academy, Clarkston, MI 72 Outcome of Cardiac Arrest After Accidental Hypothermia and Indication for Cardiopulmonary Bypass Mori K, Sapporo Medical University, Sapporo, Japan 73 Effects of the Low Dose Radiation on Nerve Cells as a Method to Increase the Survival Rate of Emergency Patients Kim S, Chungnam National University Hospital, Daejeon, Republic of Korea 74 Heat Loss From IV Fluids During the Administration of PreWarmed Normal Saline Lyng J, SUNY Upstate Medical University, Syracuse, NY 75EMF Time to Invasive Airway Placement and Resuscitation Outcomes After Inhospital Cardiopulmonary Arrest Wong ML, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 76 Early Goal-Directed Therapy for Severe Sepsis/Septic Shock: Which Components of Treatment Are More Difficult to Implement in a Community-Based Emergency Department? OвЂ™Neill R, Genesys Regional Medical Center, Grand Blanc, MI 77вЂ Rebound Hyperthermia After Cessation of Mild Therapeutic Hypothermia in Patients With Successful Resuscitation From Cardiac Arrest Park E, Ajou University School of Medicine, Suwon, KyoungGi Do, Republic of Korea Respiratory 1 (Airway) 62 Comparison of the AirtraqВ® to Direct Laryngoscopy by Flight Nurses and Respiratory Therapists in the Simulated Airway Suozzi JC, Hartford Hospital, Hartford, CT 63 Respiratory Isolation Rooms in the Emergency Department Pazin-Filho A, Medical School of Ribeirao Preto - University of Sao Paulo, Ribeirao Preto, Brazil 78 Risk of Death in Emergency Department Patients Needing Intubation Irvin MM, St. John Hospital and Medical Center, Detroit, MI 64 Intubator Recall of Hypoxia and Number of Attempts Is Often Inaccurate Compared to Video Review Hill CH, Hennepin County Medical Center, Minneapolis, MN EMF-2вЂЎ 65 Emergency Physician Ability to Predict Difficult Endotracheal Intubations Shum L, University of Pittsburgh Medical Center, Pittsburgh, PA Induced Mild Hypothermia Modulates Akt Phosphorylation and Hsp27 Expression in Mouse Hemorrhagic Shock Das A, University of Chicago, Chicago, IL See page S28 66 Airway Characteristics of Patients With Difficult Airways Wong E, Singapore General Hospital, Singapore, Singapore EMF-1вЂЎ Characteristics of Patients Undergoing Mechanical Ventilation in US Emergency Departments Easter B, Harvard Medical School, Boston, MA See page S28 Trauma 79 Establishment of a Prospective Burn Registry Taira BR, Stony Brook University, Stony Brook, NY 80вЂ«ШЎвЂ¬ Epidemiology of Trampoline-Related Injuries in Children Attending the Emergency Department Dhillon RJ, Mayo Clinic, Rochester, MN 81вЂ«ШЎвЂ¬ Use of a Clinical Sobriety Assessment Tool With the NEXUS LowRisk Cervical Spine Criteria to Reduce Cervical Spine Imaging in Blunt Trauma Patients With Acute Alcohol or Drug Use: A Pilot Study Mahler SA, LSUHSC-Shreveport, Shreveport, LA Respiratory 3 (Pulmonary) 67 Pulmonary Effects of Atropine in Humans Ly S, University of Massachusetts, Worcester, MA 82 68вЂ«ШЎвЂ¬ Spontaneous Pneumomediastinum: A Ten-Year Experience Beatty N, Mayo Medical School, Rochester, MN Beyond BoxerвЂ™s: Bony Injuries Sustained From Punching Jeanmonod R, Albany Medical College, Albany, NY 83 69 Patient Outcomes and Resource Utilization for Emergency Department Patients With Suspected Pulmonary Embolism and Initial Chest Computed Tomography Angiography Studies Deemed Suboptimal for Interpretation Burton J, Albany Medical Center, Albany, NY Utility of Additional Radiographs in Emergency Department Patients With Extremity Injuries Mirhadi M, UC Irvine, Orange, CA 84 Alcohol-Related Sexual Assault Victimization Among Adolescents Oostema A, MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Annals of Emergency Medicine 5A Research Forum Educational Program 2009 MONDAY, OCTOBER 5вЂ”contвЂ™d 85 Penile Fracture: Evaluation and Management Hawkins D, Michigan State University College of Human Medicine, Grand Rapids, MI 10:45 - 11:45 AM Poster Session 2 Cardiology Education 102 Does Correlation of Faculty Assessment of Emergency Medicine ResidentsвЂ™ Medical Knowledge Competency with Performance on the In-Training Examination Improve With Advancement Through the Program? Barlas D, New York Hospital Queens, Flushing, NY 103 Is There a Doctor in the House? The Experience of Medical Students as Responders to Out-of-Hospital Emergency Medical Situations Greene T, Mount Sinai School of Medicine, New York, NY 104вЂ Performance of an Ultrasound-Guided Thoracentesis Teaching Model Nomura JT, Christiana Care Health System, New Castle, DE 105вЂ«ШЎвЂ¬ Evaluation of Quantity-Based Credentialing: The Need for Competency Metrics Wu TS, Orlando Health, Orlando, FL 106 Improved Resident Knowledge and Adherence to Care Guidelines Using an Algorithm for Ectopic Pregnancy Evaluation Nelson BP, Mount Sinai School of Medicine, New York, NY 86 Use of New Cardiac Biomarkers as Diagnostic Tools in the Emergency Department Battista S, San Giovanni Battista Hospital of Turin, Turin, Italy 87 Prognostic Significance of an Estimated Glomerular Filtration Rate for Long-Term Mortality in Patients With Syncope Suzuki M, Keio University, Tokyo, Japan 88вЂ Acute Heart Failure Mortality Prediction Using Copeptin: Results of the Biomarkers in ACute Heart Failure Trial Peacock W, The Cleveland Clinic, Cleveland, OH 89 Abstract Withdrawn 90 A Randomized Comparison of Continuous IV Infusion of Furosemide Versus Repeated IV Bolus Furosemide in Acutely Decompensated Congestive Heart Failure Cienki JJ, Jackson Memorial Hospital, Miami, FL 107 Continuous Non-Invasive Hemodynamic Monitoring Using Novel Finger-Cuff Technology in Emergency Department Patients: A Pilot Study Sen A, Henry Ford Hospital, Detroit, MI Assessing Reaction Time Among Emergency Medicine Residents Working Different Shift Hours Berios I, Christus Spohn Memorial Hospital, Texas A&M University, Corpus Christi, TX 108 The Effect of Video Demonstration to Improve the Quality of Dispatcher-Assisted Chest Compression-Only Cardiopulmonary Resuscitation Amongst Middle-Aged Persons You Y, Ajou University, Suwon, Republic of Korea 91вЂ 92вЂ«ШЎвЂ¬ Out-of-Hospital Electrocardiogram Interpretation and Early Activation for ST-Segment Elevation Myocardial Infarction Patients Reduces Door-to-Balloon Times and Hospital Length of Stay Miller A, Lehigh Valley Hospital, Allentown, PA 93вЂ«ШЎвЂ¬ Cost-Effectiveness Analysis of Out-of-Hospital 12-Lead Electrocardiogram Programs Gross T, University of Pennsylvania, Philadelphia, PA Emergency Medical Services Diagnosis/Treatment 109 Airway Management by Critical Care Teams Is Not Associated With Physiologic Decompensation Starr GA, University of Oklahoma School of Community Medicine, Tulsa, OK Diagnostic Accuracy of Non-Contrast Computed Tomography for Appendicitis in Adults: A Systematic Review Hlibczuk V, New York Presbyterian Hospital, New York, NY 110 The Impact of Unit Hour Utilization on Out-of-Hospital Interventions Myers LA, Mayo Clinic Medical Transport, Rochester, MN 96 Comparison of Traditional Pediatric-Age, Nontraditional PediatricAge and Adult-Age Patients With Intussusception: A Case Series Cochran AM, Maine Medical Center, Portland, ME 111 Insurance Status as a Predictor of Mode of Arrival for Patients Who Present to the Emergency Department With Chest Pain Weiner SG, Tufts Medical Center, Boston, MA 97 An Analysis of Emergency Department Utilization by Intellectually Disabled Adults Venkat A, Allegheny General Hospital, Pittsburgh, PA 112 98 Management of the Bariatric Surgery Patient in the Emergency Department Kiebel W, Michigan State University College of Human Medicine, Grand Rapids, MI Knowledge of Self-Injectable Epinephrine Technique Among Emergency Medical Services Providers Davis JE, Georgetown University Hospital & Washington Hospital Center, Washington, DC 113 Clinical Features of Acute Diverticulitis in Very Young Patients Oosterhouse T, Michigan State University College of Human Medicine, Grand Rapids, MI The Treatment of Motion Sickness in the Out-of-Hospital Setting: A Comparison of Metoclopramide and Diphenhydramine to Placebo Weichenthal LA, UCSF-Fresno, Fresno, CA 114 Fecal Occult Blood Testing Does Not Predict Major Gastrointestinal Bleeding in Heparinized Patients Bennett CJ, University of Maryland, Baltimore, MD A Comparison of Out-of-Hospital Rapid Sequence Intubation Success to Non-Paralyzed Patients Felderman H, Morristown Memorial Hospital, Morristown, NJ 115 The Predictive Value of Arrival With EMS Felderman H, Morristown Memorial Hospital, Morristown, NJ 116 Postural Hypotension in the Elderly: Predictors for Intervention Chan W, Tan Tock Seng Hospital, Singapore, Singapore, Singapore 94 Spontaneous Retroperitoneal Hematoma: Etiology, Characteristics, Management, and Outcome Sunga KL, Mayo Clinic, Rochester, MN 95 99 100 101 The Utility of Routine Reticulocyte Count in Uncomplicated VasoOcclusive Crisis Due to Sickle Cell Disease Garman A, Medical College of Georgia, Augusta, GA 6A Annals of Emergency Medicine Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Educational Program 2009 MONDAY, OCTOBER 5вЂ”contвЂ™d Infectious Diseases 117вЂ«ШЎвЂ¬ Do HIV-Positive Patients With Severe Sepsis Receive Adequate Initial Antibiotics in the Emergency Department When Compared With HIV-Negative Patients? McGrath ME, Boston Medical Center, Boston, MA 118 External Site Testing of an Instrument to Predict Endocarditis in Injection Drug Users With Fever Romero K, University of California, San Francisco, San Francisco, CA 119 Diagnostic Testing and Site-of-Care Assigned to 608 Pneumonia Patients Admitted to the Hospital After Evaluation at the Emergency Department Ferre C, Bellvitge Universitary Hospital, LвЂ™Hospitalet de Llobregat, Spain 120 How Many Methicillin-Resistant Staphylococcus aureus Infections Are Missed Upon Admission to the Emergency Department? Akpunonu P, University of Toledo College of Medicine, Toledo, OH 121 Prognosis of Urosepsis Patients Who Are Treated by Inappropriate Initial Antimicrobial Therapy in the Emergency Department Imamura T, Shonan Kamakura General Hospital, Kamakura, Japan 122 Vancomycin Minimum Inhibitory Concentration Values Пѕ1.0 вђ®g/mL Do Not Predict a Worse Clinical Outcome in Non-ICU, Adult, Methicillin-Resistant Staphylococcus aureus-Positive Patients Virk PS, University of Nevada School of Medicine, Las Vegas, NV 123 124 134вЂ«ШЎвЂ¬ Does a Novel Abscess Drainage Technique Differ in Procedural Times and Times to Discharge From Traditional Incision and Drainage at a Level I Pediatric Trauma Center? Ladde J, Orlando Regional Medical Center, Orlando, FL 135 Provider Compliance With the Food and Drug Administration Recommendation to Avoid the Use of Over the Counter (Nonprescription) Cough and Cold Medications in Children Under Two Years Old Goo R, Tripler Army Medical Center, Honolulu, HI 136вЂ«ШЎвЂ¬ Fever in Children Less Than 60 Days Old: What Are Current Cerebrospinal Fluid, Blood, and Urine Culture Positive Rates in the Vaccination Era? Morley EJ, SUNY Upstate Medical University, Syracuse, NY 137 Frequency of Preschoolers Positive for Drugs or Alcohol After Suffering Traumatic Injuries Eadeh H, St. John Hospital and Medical Center, Detroit, MI Practice Management Nausea and Vomiting: Are We Treating the Patients or Ourselves? Garra G, Stony Brook University, Stony Brook, NY 139 The Significance of Lactate Clearance Rate as a Predictor of Organ Failure Cho YD, Korea University Medical Center, Seoul, Republic of Korea Comparison in the Management of Inhalational Injuries Presenting to a Tertiary Hospital Emergency Department Ngo AS, Singapore General Hospital, Singapore, Singapore 140вЂ A Prospective Observational Study of Medication Errors in a Tertiary Care Academic Emergency Department Patanwala A, University of Arizona, Tucson, AZ Rapid HIV Testing in a Large Urban Emergency Department Harper JB, Rush University, Chicago, IL 141EMF Patient Satisfaction of Emergency Department Boarders With Inpatient Hallway Admission Zito JA, Stony Brook University, Stony Brook, NY 142 Medication Errors Recovered by Emergency Department Pharmacists Rothschild JM, Brigham and WomenвЂ™s Hospital, Boston, MA 143 Materials Management of a Busy Emergency Department Richardson D, Lehigh Valley Hospital, Allentown, PA 144 Evaluating Predictors of Door-to-EKG Times Borquez EA, Los Angeles County/University of Southern California, Los Angeles, CA 125 Trauma Care Access for Road Traffic Injuries in Hanoi City Nagata T, Himeno Hospital, Hirokawa-city, Japan 126 Road Traffic Injury Hot Spots in Yerevan, Armenia Lynch CA, Yale School of Medicine, New Haven, CT 127вЂ Comparison of Acidosis Markers Associated With Law Enforcement Applications of Force Ho JD, Hennepin County Medical Center, Minneapolis, MN 128 Radiation Exposure in Emergency Physicians Working in an Urban Emergency Department: A Prospective Cohort Study Gottesman B, University of Cincinnati College of Medicine, Cincinnati, OH 129вЂ«ШЎвЂ¬ Emergency Department Blood Cultures Have Limited Usefulness in the Management of Children Hospitalized for CommunityAcquired Pneumonia Davis V, University of Alabama at Birmingham, Birmingham, AL 138 Injury Prevention 2 (Unintentional) вЂ«ШЎвЂ¬ 133 Industrial Accidents: An Epidemiological Profile of 866 Emergency Admissions in a Tertiary Care Teaching Hospital, S. India Banala SR, Sri Ramchandra Medical College & Research Institute, Chennai, India Psychiatry 145 Content Validity Testing for the Agitation Severity Scale: Development of a Measure for Use With Acute Presentation Behavioral Management Patients Strout TD, Maine Medical Center, Portland, ME 146 Punch Injuries and Psychiatric Comorbidity in Men and Women Damewood S, Albany Medical College, Albany, NY 147 Psychiatric Clearance in the Pediatric Emergency Department Waseem M, Lincoln Hospital, Bronx, NY 148 Factors Predicting Return Visits Among Emergency Department Patients With Psychiatric Complaints Groke S, University of Utah School of Medicine, N Salt Lake, UT 149 Psychiatric Transfers From the Emergency Department: Factors Associated With Length of Stay Klope JL, Resurrection Medical Center, Chicago, IL Pediatrics 130 Abstract Withdrawn 131вЂ«ШЎвЂ¬ Impact of Rapid Streptococcal Test on Antibiotic Use in a Pediatric Emergency Department Waseem M, Lincoln Hospital, Bronx, NY 132 Obesity in Children Chohan JK, Stony Brook University, Stony Brook, NY Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Annals of Emergency Medicine 7A Research Forum Educational Program 2009 MONDAY, OCTOBER 5вЂ”contвЂ™d Public Health The Effect of Access to Health Care and Socioeconomic Status on the Availability and Effectiveness of Medical Treatment for Asthma and Hypertension Among Patients Presenting to the Emergency Department Miner JR, Hennepin County Medical Center, Minneapolis, MN 150 Emergency Department Patient Acceptance of Rapid HIV Testing Practices, Revisited: The 2006 CDC Recommendations for NonTargeted, Opt-Out HIV Screening Prekker ME, Hennepin County Medical Center, Minneapolis, MN 151 152 Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department Wall JJ, The Ohio State University, Columbus, OH 153 Do Attitudes About Homosexuality Affect Emergency Medicine Practice? Results of a Survey Shearer P, Mount Sinai School of Medicine, New York, NY 154 Impact of Care Management on the Highest Utilizers of Camden NJвЂ™s Emergency Departments Sciorra D, University of Medicine and Dentistry of New Jersey, Camden, NJ 155 Preliminary Results of the Survivors of Torture Presenting to an Urban Emergency Department Prevalence Study Hexom B, Mount Sinai School of Medicine, New York, NY 156 Large Increase in Emergency Department Visits for Head Trauma After Natasha RichardsonвЂ™s Death Campo C, Morristown Memorial Hospital, Morristown, NJ 157 Patient Perceived Alcohol and Substance Abuse Treatment Needs: An Urban Emergency Department Pilot Study Scott S, The University of Medicine and Dentistry of New Jersey, Newark, NJ 165вЂ«ШЎвЂ¬ 2:30 - 4:00 PM Poster Session 3 Administration 166 Emergency Department Operational ImprovementsвЂ™ Impact on Volume, Quality Core Measures, Patient Stay and Satisfaction Sayah A, Cambridge Health Alliance, Cambridge, MA 167 Implementation of Crowding Solutions from the American College of Emergency Physicians Task Force Report on Boarding Handel DA, Oregon Health & Science University, Portland, OR 168 Utilization of the Situation-Background-Assessment-Request, Companion Phones, and Cell Phones Improves Communication With Consultants in the Emergency Department Farley H, Christiana Care Health System, Newark, DE 169 A Protocol to Improve Door-to-EKG Times in the Emergency Department Mostofi M, Tufts Medical Center, Boston, MA 170 Managing Patient Expectations at Emergency Department Triage Rumoro D, Rush University Medical Center, Chicago, IL 171 Characteristics of an Emergency Medicine-Led Rapid Response Team at an Academic Tertiary Care Hospital in the United States Mace SE, Cleveland Clinic, Cleveland, OH 172 An Analysis of Patients Treated by a Rapid Response Team: A High Acuity, Critically Ill Patient Population Requiring Multiple Procedures and Transfer to a Higher Level of Care Mace SE, Cleveland Clinic, Cleveland, OH 173 Effect of an Attending Physician Float Shift to Care for Boarding Patients in a Crowded Emergency Department Holt S, Advocate Christ Medical Center, Chicago, IL 174 Emergency Severity Index Triage System Correlation With Emergency Department Evaluation and Management Billing Codes Hendry D, Washington University St. Louis, St. Louis, MO 175вЂ«ШЎвЂ¬ Emergency Department Inpatient Bed Management Inventory System Shah S, Rush University Medical Center, Chicago, IL Research Issues 158 Interobserver Reliability of a Novel Scar Evaluation Scale Singer AJ, Stony Brook University, Stony Brook, NY 159 Use of the Descriptive Term вЂњExperimentвЂќ Does Not Significantly Influence a Potential SubjectвЂ™s Decision to Participate in Research Schroeder JW, Philadelphia College of Osteopathic Medicine, Philadelphia, PA Survey of Medical Decisionmaking: Ability of the Public to SelfTriage and Recognize Symptoms of Emergency Conditions Plonk T, East Carolina University, Greenville, NC 160 вЂ«ШЎвЂ¬ 161 Cardiology 176 Evolution of Door to Electrocardiogram Times After an Educational Strategy in Patients Presenting With Chest Pain to the Emergency Department in a Chilean Academic Center Aguilera P, Pontificia Universidad CatoВґlica de Chile, Santiago, Chile 177вЂ A Comparative Analysis of Screening Hypertensive Patients for Left Ventricular Abnormality With Electrocardiograph and NT-proBNP Chandra A, Duke University Medical Center, Durham, NC 178 The Percent of Total Emergency Department Visits for Congestive Heart Failure Declined From 1996 to 2008 Allegra JR, Morristown Memorial Hospital, Morristown, NJ 179 Disposition and Final Diagnosis of Patients Presenting With Chest Pain to an Academic Emergency Department in Chile Aguilera P, Pontificia Universidad CatoВґlica de Chile, Santiago, Chile 180вЂ«ШЎвЂ¬ Epidemiology of Elevated Blood Pressure in Emergency Department Adhikari S, University of Nebraska Medical Center, Omaha, NE Do Prolonged Emergency Department Waiting Times Reduce Emergency Research Consent Rates? Limkakeng AT, Duke University, Durham, NC Respiratory 2 (Asthma) 162 Trends and Disparities in Emergency Department Asthma Care, 1992-2006 Heins A, University of South Alabama College of Medicine, Loxley, AL 163 Educational Intervention in Adult Asthma: A Randomized Clinical Trial to Determine If Adult Patients With Asthma Can Learn How to Use a Metered Dose Inhaler Acosta JF, Yakima Regional Medical & Cardiac Center, Yakima, WA 164вЂ Percutaneous Vagal Electrical Stimulation for Severe Asthma Lewis L, Washington University, St. Louis, MO 8A Annals of Emergency Medicine Initial Out-of-Hospital End-Tidal Carbon Dioxide Measurements in Adult Asthmatic Patients Lamba S, The University of Medicine and Dentistry of New Jersey, Newark, NJ Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Educational Program 2009 MONDAY, OCTOBER 5вЂ”contвЂ™d 181вЂ вЂ«ШЎвЂ¬ Describing Global and Tissue Level Perfusion in Congestive Heart Failure Patients Presenting to an Urban Emergency Department: A Pilot Study Sherwin R, Wayne State University, Detroit, MI 197 Endotracheal Tube and Laryngeal Mask Airway Cuff Pressures Can Exceed Critical Values During Air Transport Miyashiro R, University of Hawaii John A. Burns School of Medicine, Honolulu, HI 182 Performance of a Novel Spanish-Language Chest Pain Tool for Evaluation, Risk Stratification, and Dissection/Fibrinolysis Screening in Spanish-Speaking Emergency Department Patients Slattery DE, University of Nevada School of Medicine, Las Vegas, NV 198 Injury Incidence and Predictors on a Mass Bicycle Ride Boeke P, University of Iowa, Iowa City, IA 199 Does вЂњOff-HourвЂќ Presentation Contribute to Out-of-Hospital Process Delays Among Patients With ST-Elevation Myocardial Infarction? Agarwal A, Southern Illinois University, Springfield, IL 200 The Impact of 24-Hour Shifts on Paramedics Providing Out-ofHospital Analgesia in Patient-Reported Pain Scales Myers LA, Mayo Clinic Medical Transport, Rochester, MN 201 Safety and Efficacy of a Novel Abdominal Aortic Tourniquet Device for the Control of Pelvic and Lower Extremity Hemorrhage Greenfield EM, Medical College of Georgia, Augusta, GA 202 Improvement in Bag-Mask Ventilation Performance After Training With a Novel Terminal Feedback Manikin System Salvucci AA, Ventura County Medical Center, Ventura, CA 203 Hospital Processes, Not EMS Transport Times, Are Crucial Predictors of Rapid Reperfusion for ST-Segment Elevation Myocardial Infarction Patients Swor R, William Beaumont Hospital, Royal Oak, MI 204 Endotracheal Intubation Success in an Ambulance by Emergency Medical Out-of-Hospital Personnel Using Direct and GlidescopeВ® Laryngoscopes Toofan M, Scott & White Memorial Hospital, Temple, TX 183 Effects of Body Mass Index and B-type Natriuretic Peptide Level in Chronic Heart Failure Patients Phelan T, LSUHSC-Shreveport, Shreveport, LA 184 Quantitative Meaning of Common Terms Like вЂњVery Low RiskвЂќ and вЂњLow RiskвЂќ for Chest Pain Patients Menchine M, University of California, Irvine, Irvine, CA Diagnosis/Treatment 185 Asymptomatic Bacteriuria: Is the Presence of Microscopic Bacteriuria Without Pyuria in Asymptomatic Pregnant Females Associated With Positive Urine Culture? A Retrospective CrossSectional Study Hile D, Madigan Army Medical Center, Tacoma, WA 186 Tamsulosin Does Not Increase One-Week Rate of Passage of Ureteral Stones in Emergency Department Patients Lipe KM, William Beaumont Hospital, Royal Oak, MI 187 Value of Head CT in Syncope Patients in the Emergency Department VeВґlez I, University of Puerto Rico School of Medicine, Carolina, PR 188 Evaluation of a Non-Contact Infrared Thermometer in an Adult Emergency Department Patyrak S, UT Southwestern, Dallas, TX 189 Accuracy of Point-of-Care Finger Stick Hemoglobin Compared to Laboratory Value Morris DF, UCSD, San Diego, CA 190вЂ«ШЎвЂ¬ Fear of Brain Herniation From Lumbar Puncture: Do History and Physical Exam Indicate Abnormalities on Head Computed Tomography? OвЂ™Laughlin KN, Harvard Medical School, Boston, MA Health Care Policy 205 Accountability, Transparency, and Interoperability: Developing a Database of Federal Efforts in Emergency Medical Care Johnson KA, Dept. of Health and Human Services, Washington, DC 206 Poor and Sick: Do Low-Income Areas Have Fewer Emergency Departments? Ravikumar D, University of California, San Francisco, San Francisco, CA 207 Penetration of Board Certified Emergency Physicians Into Rural Emergency Departments in Iowa House H, University of Iowa, Iowa City, IA 208 Does Having and Using a Usual Source of Care Decrease Emergency Department Use? Gabayan GZ, VA Greater Los Angeles Health System, Los Angeles, CA 191вЂ«ШЎвЂ¬ Disease and Non-Battle Traumatic Injuries Evaluated by Emergency Physicians in a US Tertiary Combat Hospital Bebarta VS, Wilford Hall Medical Center, San Antonio, TX 192вЂ«ШЎвЂ¬ The Utility of HbA1C Screening in Low-Risk Chest Pain Patients in the Emergency Department Observation Unit Wiederhold H, William Beaumont Hospital, Royal Oak, MI 209 A New Study of Intraosseous Blood for CBC and Chemistry Profile Philbeck T, Vidacare Corporation, San Antonio, TX Determinants of Health Care Access on the US-Mexico Border Watts S, Texas Tech University Health Sciences Center, El Paso, TX 210 The Use of a Subcutaneous Insulin Aspart Protocol for the Treatment of Hyperglycemia in the Emergency Department: A Randomized Clinical Trial Harper JB, Rush University, Chicago, IL Severity of Illness Does Not Differ Based on Insurance Status in Two Urban Emergency Departments Shukla KT, University of Illinois, Chicago, IL 211 Does Pay for Performance Lead to Potential Misuse of Antibiotics Among Patients With Congestive Heart Failure? Duseja R, Wharton School, University of Pennsylvania, Philadelphia, PA 212вЂ Resident Alertness, Stress, and Self-Reported Medical Errors in an Urban Teaching Hospital Emergency Department Hansen KN, University of Maryland School of Medicine, Baltimore, MD 213 Major Barriers to Follow-Up of Emergency Department Patients at Federally Funded Clinics: Metropolitan-Wide Survey Pilot Data Lewis L, Washington University, St. Louis, MO 193вЂ 194 Emergency Medical Services 195 Refusals of Medical Aid in the Out-of-Hospital Setting Waldron R, New York Hospital Queens, Flushing, NY 196 Intubation Success Rates in Helicopter Emergency Medical Services: A Prospective Multicenter Analysis Howard Z, Harvard Affiliated Emergency Medicine Residency, Boston, MA Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Annals of Emergency Medicine 9A Research Forum Educational Program 2009 MONDAY, OCTOBER 5вЂ”contвЂ™d 214вЂ«ШЎвЂ¬ Emergency Department Boarding Is Associated With Higher Medication-Related Errors but Fewer Laboratory Errors During the Early Admission Period Liu SW, Massachusetts General Hospital, Boston, MA 229 A Survey of Emergency Physician and Stroke Specialist Beliefs and Expectations Regarding Telestroke Moskowitz A, Mount Sinai School of Medicine, New York, NY 230 A Comparison of Inferior Vena Cava Measurements in Emergency Department Patients With Acute Systolic Versus Diastolic Heart Failure Sen A, Henry Ford Hospital, Detroit, MI Out-of-Hospital Normobaric Oxygen Therapy in Presumptive Acute Stroke Patients: A Preliminary Study Chan Y, Mount Sinai School of Medicine, New York, NY 231вЂ«ШЎвЂ¬ Comparison of Bedside Ultrasound and Panorex Radiography in the Diagnosis of a Dental Abscess in the Emergency Department Adhikari S, University of Nebraska Medical Center, Omaha, NE Predictors of Mortality in Patients Presenting to the Emergency Department With Stroke: A Developing Nation Scenario Chandra S, All India Institute of Medical Sciences, New Delhi, India 232 Emergency Department Hyperglycemia as a Predictor of Mortality and Functional Outcome After Intracerebral Hemorrhage by Diabetes Mellitus Status Bellolio M, Mayo Medical School, Rochester, MN 233 Screening Electroencephalograms Are Feasible and Identify Potential Subclinical Seizure Activity in Emergency Department Patients Bastani A, Troy Beaumont Hospital, Troy, MI 234вЂ«ШЎвЂ¬ Comparison of Blunt Versus Sharp Spinal Needles Used in the Emergency Department in Rates of Post-Lumbar Puncture Headache Torbati S, Cedars-Sinai Medical Center, Los Angeles, CA Imaging 1 (Ultrasound) 215 216вЂ«ШЎвЂ¬ 217вЂ«ШЎвЂ¬ INSPIRED: Instruction of Sonographic Placement of IVs by RNs in the Emergency Department Liteplo AS, Massachusetts General Hospital, Boston, MA 218вЂ«ШЎвЂ¬ Bedside Ultrasound Evaluation of Tendon Injuries Wu TS, Orlando Regional Medical Center, Orlando, FL 219 Time to Identify Needle Tip Location Is Independent of Ultrasound Transducer Orientation and Physician Level of Training Cook D, Christiana Care Health Services, Newark, DE 220вЂ«ШЎвЂ¬ How Accurate Is the Last Menstrual Period in Dating a First Trimester Pregnancy? Saul T, St. LukeвЂ™s Roosevelt Hospital, New York, NY TUESDAY, OCTOBER 6, 2009 221 Evaluation of Ectopic Pregnancy With Bedside Ultrasound by Emergency Physicians: A Meta-Analysis Stein JC, University of California, San Francisco, CA 9:30 - 11:30 AM Poster Session 4 Administration 222 Nurse Utilization of Ultrasound Guidance for Peripheral IV Placement in the Emergency Department: Does It Change Over Time? Lyon M, Medical College of Georgia, Augusta, GA 235 Can We Defer a Type and Screen for Pregnant Patients With Vaginal Bleeding Who вЂњKnowвЂќ Their Blood Type? Shah K, St. LukeвЂ™s-Roosevelt Hospital, New York, NY 236 223 Emergency Department Bedside Ultrasound Measurement of Caval Index as Non-Invasive Determination of Low Central Venous Pressure: A Multi-Center Validation of an Emergency Department Protocol Hansen AV, University of California - San Diego, San Diego, CA An Analysis of Prolonged Length of Stay in a Pediatric Emergency Department Place R, Inova Fairfax Hospital, Falls Church, VA 237вЂ«ШЎвЂ¬ Supplemented Triage and Rapid Treatment in the Emergency Department White BA, Massachusetts General Hospital, Boston, MA 238 An Analysis of Emergency Department Observation Units Impact on Patient Satisfaction Scores Chandra A, Duke University Medical Center, Durham, NC 239вЂ«ШЎвЂ¬EMF The Impact of Emergency Department Boarding on Hospital Revenues Pines JM, University of Pennsylvania, Philadelphia, PA 240вЂ«ШЎвЂ¬ Primary and Specialty Care Follow-Up for Uninsured Emergency Department Patients Ginde AA, University of Colorado Denver School of Medicine, Aurora, CO 241 A Multifaceted Quality Improvement Program Improves Hand Hygiene Compliance in the Emergency Department Schuur J, Brigham and WomenвЂ™s Hospital, Boston, MA 242 Validating an Emergency Medicine-Specific Tool to Estimate Cognitive Impairment Birkhahn R, New York Methodist Hospital, Brooklyn, NY 243вЂ«ШЎвЂ¬ The Use of an Expeditor and Its Impact on Emergency Department Length of Stay Handel DA, Oregon Health & Science University, Portland, OR 244 Environmental Predictors of Hand Hygiene Compliance in the Emergency Department Venkatesh A, Brigham and WomenвЂ™s Hospital, Boston, MA 224 Teaching the Focused Assessment With Sonography in Trauma Exam: Is an Ultrasound Mannequin Simulator as Good as or Better Than Using Live Models for Practical Training? Damewood S, Albany Medical Center, Albany, NY Neurology 225 Should This Stroke Patient Be Transferred? Computed Tomographic Angiography Predicts Use of Tertiary Interventional Services Thomas LE, Massachusetts General Hospital, Boston, MA 226 Nonaneurysmal Subarachnoid Hemorrhage: Clinical Course and Outcome in Two Distinct Hemorrhage Patterns Gilmer M, Michigan State University College of Human Medicine, Grand Rapids, MI 227 Examination of Adherence to Evidence-Based Practices and 30-Day Outcomes for Emergency Department Patients Treated for Transient Ischemic Attack Baumann MR, Maine Medical Center, Portland, ME 228вЂ«ШЎвЂ¬ Cephalgia in Emergency Department Patients Responds to Oxygen, Decreasing Time to Relief, Length of Stay, Computed Tomographic Utilization, and Need for Pharmacotherapy Veysman BD, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 10A Annals of Emergency Medicine Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Educational Program 2009 TUESDAY, OCTOBER 6вЂ”contвЂ™d Emergency Medical Services 245 246 247 Should the Deeply Comatose Trauma Patient Be Intubated by EMS? Walters J, St. John Hospital and Medical Center, Detroit, MI Admission Rates for Walk-In Patients Differ Between Suburban and Urban Emergency Departments While Admission Rates for Emergency Medical Services Arrivals Show No Significant Difference Matthews P, Christiana Care Health Services, Newark, DE Baseline Carboxyhemoglobin Levels in Firefighters Using the Masimo Rainbow SET Rad-57 Pulse CO-Oximeter Black A, University of Texas Southwestern Medical Center, Dallas, TX 248вЂ«ШЎвЂ¬ Predictors of Ambulance Use for Emergency Department Patients Over 45 With Chest Pain Meisel ZF, University of Pennsylvania, Philadelphia, PA 249вЂ«ШЎвЂ¬ Type of Insurance Is Associated With Ambulance Use for Transport to Emergency Departments in the United States Meisel ZF, University of Pennsylvania, Philadelphia, PA 250 Collaborative to Decrease Ambulance Diversion: The California Emergency Department Diversion Project Castillo EM, University of California, San Diego, San Diego, CA 261 Restraint Use in the Elderly Emergency Department Patient Swickhamer C, Resurrection Medical Center, Chicago, IL 262 Yield of Head Computed Tomography in the Alcohol-Intoxicated Patient Shah K, St. LukeвЂ™s-Roosevelt Hospital, New York, NY 263 Assessing Three-Month Fall Risk for Geriatric Emergency Department Patients Carpenter CR, Washington University in St. Louis, St. Louis, MO 264 Has Grandma Been Drinking? Kott I, St. John Hospital and Medical Center, Detroit, MI 265 Guided Medication Dosing for Elderly Emergency Department Patients Using a Real-Time, Computerized Decision Support Tool Griffey RT, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO Health Care Policy 266 Do Non-English-Speaking Patients With an Admitting Diagnosis of Pneumonia Experience a Systematic Delay in Time to Antibiotics? Green JP, New York Hospital Queens, Flushing, NY 267вЂ«ШЎвЂ¬ Emergency Department Nurse Workloads and Their Contributors Rabin E, Mount Sinai School of Medicine, New York, NY 268вЂ«ШЎвЂ¬ Change in Acuity of Emergency Department Visits After Massachusetts Health Care Reform Smulowitz PB, Beth Israel Deaconess Medical Center, Boston, MA 251вЂ«ШЎвЂ¬ Pharmacist Implementation in the Emergency Department Hong AL, Memorial Hermann Katy Hospital, Katy, TX 252 Provider Impression of Cervical Spine Injury and Its Effects on Quality of Out-of-Hospital Immobilization Techniques Dailey M, Albany Medical Center, Albany, NY 269вЂ«ШЎвЂ¬ The C.I.N. Study: Is Contrast-Induced Nephropathy a Problem in High-Risk Emergency Department Patients? Su M, North Shore University Hospital, Manhasset, NY The Impact of Declining Emergency Department Subspecialty Availability Ladde J, Orlando Regional Medical Center, Orlando, FL 270вЂ«ШЎвЂ¬ Epidemiology of Out-of-Hospital Emergencies in Andhra Pradesh, India, 2007 Mahadevan SV, Stanford University School of Medicine, Palo Alto, CA The Impact of Health Care Reform in Massachusetts on Emergency Department Use by Uninsured and Publicly Subsidized Individuals Smulowitz PB, Beth Israel Deaconess Medical Center, Boston, MA 271вЂ«ШЎвЂ¬ Accidents Waiting to Happen: Decreasing Access to Emergency Departments in Rural Areas in the US, 2001-2005 Hsia RY, University of California at San Francisco, San Francisco, CA 272 Are Public Hospitals More Efficient in Providing Health Care? Roberts RR, Stroger Hospital of Cook County, Chicago, IL 273 Hospitalizations of Older Human Immunodeficiency Virus Patients in the United States from 2000-2006 Tadros A, West Virginia University, Morgantown, WV Association Between Emergency Department Crowding on the Appropriateness of Resuscitation Room Utilization: An Expert Panel Study in a Single Emergency Center Kim J, Seoul National University Hospital, Seoul, Republic of Korea 274 Cognitive Impairment and Comprehension of Emergency Department Discharge Instructions in Older Patients Bryce SN, Vanderbilt University School of Medicine, Nashville, TN Multi-Center Study of Left Without Treatment Rates From Emergency Departments Serving a Large Metropolitan Region Lev R, Scripps Mercy Hospital, San Diego, CA 275 A Classification System for Emergency Departments: Massachusetts, 2008 Camargo CA, Massachusetts General Hospital, Boston, MA 258вЂ«ШЎвЂ¬ Preliminary Results of a Multidisciplinary Falls Evaluation Program for Elderly Fallers Presenting to the Emergency Department Wong EM, Tan Tock Seng Hospital, Singapore, Singapore Imaging 1 (Ultrasound) 259 Occult Cognitive Impairment in Admitted Older Emergency Department Patients Is Not Identified by Admitting Services Heidt JW, Washington University in St. Louis, St. Louis, MO 253 254 Geriatrics 255 256 257EMF 260 The Outcome of Out-of-Hospital Cardiopulmonary Arrest in the Over 85-Year-Old Japanese Population Taken to the Emergency Department Umezawa K, Shounan Kamakura General Hospital, Kamakura, Japan Geriatric Syndrome Screening in Emergency Medicine: A Geriatric Technician Acceptability Analysis Carpenter CR, Washington University in St. Louis, St. Louis, MO Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 276 Nurse-Operated Ultrasound for Difficult Intravenous Access: A Randomized Trial River G, UCSF School of Medicine, San Francisco, CA 277вЂ«ШЎвЂ¬ Teaching Focused Obstetric Ultrasound to Midwives in Rural Zambia Kimberly H, Massachusetts General Hospital, Boston, MA 278вЂ«ШЎвЂ¬ Comparative Extravasation Rates of 1.75-Inch and 2.5-Inch Ultrasound-Guided Peripheral Vascular Catheters Bauman MJ, Christiana Care Health System, Newark, DE Annals of Emergency Medicine 11A Research Forum Educational Program 2009 TUESDAY, OCTOBER 6вЂ”contвЂ™d 279вЂ«ШЎвЂ¬ Optic Nerve Sheath Ultrasound for the Evaluation of Children With Suspected Ventriculo-Peritoneal Shunt Failure Hall MK, Oregon Health & Science University, Portland, OR 280вЂ«ШЎвЂ¬ Comparison of Web- Versus Classroom-Based Basic Ultrasound and Extended Focused Assessment With Sonography for Trauma Training in Two European Hospitals Platz E, Brigham and WomenвЂ™s Hospital, Boston, MA 281 Impact of Image Processing on the Pleural Sliding Sign Holm M, Hennepin County Medical Center, Minneapolis, MN 282 Correlation of Bedside Ultrasound Measurement of the Respiratory Variation of Internal Jugular Venous Diameter With Invasive Central Venous Pressure Measurement in Patients With Severe Sepsis Bigler JB, University of Nevada School of Medicine, Las Vegas, NV 283вЂ«ШЎвЂ¬ 284 Utility of Bedside Biliary Ultrasound in the Evaluation of Emergency Department Patients With Isolated Epigastric Pain Adhikari S, University of Nebraska Medical Center, Omaha, NE Intra-Articular Foreign Body Evaluation: Ultrasound Versus Fluoroscopy Lyon M, Medical College of Georgia, Augusta, GA Pediatrics 285 The Significance of Peripheral White Blood Cell Count in Cases of Acute Otitis Media in Children Between 2 to 17 Years of Age Nibhanipudi KV, NY Medical College Metropolitan Hospital Center, New York, NY 286 Evaluation of Emergency Medicine Discharge Instructions in Pediatric Head Injury Sarsfield MJ, SUNY Upstate Medical University, Syracuse, NY 287 288 289вЂ«ШЎвЂ¬ 295 What Happens at the 72-Hour Mark? Physical Findings in Sexual Assault Cases When Victims Delay Reporting Burger C, Michigan State University College of Human Medicine, Grand Rapids, MI 296 Early Treatment of Hypertonic Saline and Arginine Is Important in Restoration of T Cell Dysfunction Choi S, Korea University Guro Hispital, Seoul, Republic of Korea 297 Injury Patterns Are Different for Older and Younger Patients in Equestrian Accidents Allegra JR, Morristown Memorial Hospital, Morristown, NJ 298вЂ«ШЎвЂ¬ Admission Fibrin Degradation Product Level Predicts the Need for Massive Transfusion and Mortality in Adult Blunt Trauma Patients MAEKAWA K, Sapporo Medical University, Sapporo, Japan 299 Can Coagulation Markers on Arrival Predict Neurological Outcome in Patients With Traumatic Brain Injury? Shimizu T, Teine Keijinkai Hospital, Sapporo, Japan 300 Fishing-Related Infections in the United States Krieg C, Resurrection Medical Center, Chicago, IL 301 The Effect of the Repeal of the Pennsylvania Helmet Law on the Severity of Head and Neck Injuries Sustained in Motorcycle Accidents Eberhardt M, St. LukeвЂ™s Hospital, Bethelehem, PA 302 Characteristics of Fragment Wounds in a Combat Setting Givens ML, Carl R Darnall Army Medical Center, Fort Hood, TX 1:00 - 2:30 PM Poster Session 5 Administration 303 Does Insurance Status Make a Difference in Pediatric Trauma Patients? Hakmeh W, St. John Hospital and Medical Center, Detroit, MI An Analysis of Emergency Department Revisit Rates Based on Patient Satisfaction Scores Yang A, UMDNJ-Robert Wood Johnson, New Brunswick, NJ 304вЂ«ШЎвЂ¬ A Rise in Emergency Department Visits of Pediatric Patients for Renal Colic From 1999-2008 Kairam N, Morristown Memorial Hospital, Morristown, NJ The Use of Scripting at Triage and Its Impact on Elopements Handel DA, Oregon Health & Science University, Portland, OR 305 Ultrasound Assessment of Dehydration in Children With Gastroenteritis Levine AC, Brigham and WomenвЂ™s Hospital, Boston, MA Reliability of Emergency Severity Index Version 4 Choi M, Seoul National University Hospital, Seoul, Republic of Korea 306 Video Technologies in Emergency Health Research in Assessing Quality of Care: A Study of Trauma Resuscitation Milestones Sen A, Henry Ford Hospital, Detroit, MI 307 Customer Service and Communication Training Initiative for Emergency Physicians Improves Patient Satisfaction Despite Crowding in the Emergency Department Katz GR, The Ohio State University, Columbus, OH 308 A Lean-Based Triage Redesign Process Improves Door-to-Room Times and Decreases Number of Patients at Triage Farley H, Christiana Care Health Systems, Newark, DE 309 Validation of Modified Emergency Severity Index Version 4 Lee J, Seoul National University Hospital, Seoul, Republic of Korea 310EMF Impact of Mandated Nurse-Patient Ratios on Time to Antibiotic Administration in the Emergency Department Chan TC, University of California, San Diego, San Diego, CA 311 Care Plan Program Reduces the Number of Visits for HighUtilizing Psychiatric Patients in the Emergency Department Abello A, University Medical Center at Brackenridge, Austin, TX 290 A Teaspoon of Medication: How Much Is Really in It? Mir M, Wycoff Heights Hospital, Brooklyn, NY 291 Spectrum of Bacterial Pathogens Seen in a Community Pediatric Emergency Department Kondamudi N, The Brooklyn Hospital Center, Brooklyn, NY 292 Perceptions and Practices of Fever: Survey for Parents With Febrile Child Visiting Pediatric Emergency Department Kim D, Seoul National University Hospital, Seoul, Republic of Korea 293вЂ«ШЎвЂ¬ Respiratory Distress Assessment Instrument as a Predictor of Hospital Admission and Severity in Children With Bronchiolitis Dhillon RK, Mayo Clinic, Rochester, MN Trauma 294 The Effects of Skin Pigmentation on the Detection of Genital Injury From Sexual Assault: A Population-Based Study Rechtin C, MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI 12A Annals of Emergency Medicine Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Educational Program 2009 TUESDAY, OCTOBER 6вЂ”contвЂ™d 312 Patient Satisfaction Is Associated With Clinical Quality and Hospital Outcomes in Acute Myocardial Infarction Glickman S, University of North Carolina, Chapel Hill, NC Basic Science 313 Effect of IV Deferoxamine on Burn Wound Progression Lim T, Stony Brook University, Stony Brook, NY 314вЂ Effect of IV Pentoxifylline on Burn Wound Progression Lim T, Stony Brook University, Stony Brook, NY 315 Catecholamines in Simulated Arrest Scenarios Lundin EJ, University of Louisville, Louisville, KY 316 Visualization of Intraosseous Flow Paths by Angiography, Computed Tomography and Vital Dye Techniques De Lorenzo RA, Brooke Army Medical Center, Fort Sam Houston, TX 317 A Manometric Method for Evaluating Flow Dynamics and Thrombus Burden of Intraosseous Devices: Theory and Application Rubal BJ, Brooke Army Medical Center, Fort Sam Houston, TX 318вЂ Fetuin Protects Mice Against Lethal Sepsis by Modulating Bacterial Endotoxin-Induced HMGB1 Release and Autophagy Wang H, North Shore University Hospital, Manhasset, NY 319 Intracranial Constructive Interference of Low Frequency Ultrasound: An In-Vitro Pilot Study of Parameter Dependence Shaw GJ, University of Cincinnati, Cincinnati, OH EMF-3вЂЎ Inhibition of Trx Nitrative Modification as a Means of Attenuating Myocardial Ischemia/Reperfusion Injury in a Diabetic Model Lau WB, Thomas Jefferson University, Lansdale, PA See page S116 327вЂ«ШЎвЂ¬ Correlation of вђ¤-hCG and Ultrasound Diagnosis of Ectopic Pregnancy in the Emergency Department Bloch AJ, MCG, Augusta, GA 328вЂ«ШЎвЂ¬ Thromboembolic Events During Venous Compression Ultrasound of the Lower Extremity in Patients With Deep Venous Thrombosis Adhikari S, University of Nebraska Medical Center, Omaha, NE 329 Bedside Urinary Bladder Duplex Ultrasonography for the Detection of Obstructing Ureteral Calculi in the Emergency Department Chin E, University of California, Irvine Medical Center, Orange, CA Infectious Diseases 330 Antibiotic Prescription by Emergency and ICU Physicians in Patients Admitted to the Intensive Care Unit With the Diagnosis of Septic Shock Capp R, Massachusetts General Hospital, Boston, MA 331вЂ вЂ«ШЎвЂ¬EMF Prospective Randomized Trial of Trimethoprim-Sulfamethoxazole vs Placebo on 30-Day Recurrence Rates for Uncomplicated Skin Abscesses in Patients at Risk for Community-Acquired MethicillinResistant Staphylococcus aureus Infection: An Interim Analysis Schmitz GR, Wilford Hall Medical Center, San Antonio, TX 332вЂ«ШЎвЂ¬ A Survey of Provider Opinions Regarding Implementing Rapid HIV Testing in the Emergency Department of a Safety Net Hospital Schechter-Perkins E, Boston University School of Medicine, Boston, MA 333 Screening Strategies for Early Identification of Spine Infections in Patients Presenting to Emergency Departments With Severe Back or Neck Pain Shroyer SR, Greater San Antonio Emergency Physicians, San Antonio, TX EMF-4вЂЎ Regulation of the Neuronal Taurine Transporter Protein Reese A, Wright State University, Dayton, OH See page S117 334 EMF-5вЂЎ Combination Therapy for Ischemic Brain Injury After Cardiac Arrest Lagina A, Wayne State University, Detroit, MI See page S117 A Two-Year Experience of Patients Receiving Non-Occupational Post-Exposure Prophylaxis Against HIV in a NYC Emergency Department Egan D, St. LukeвЂ™s Roosevelt Hospital Center, New York, NY 335EMF Double-Blind, Randomized, Controlled Multi-Center Trial of Antibiotic Treatment for Uncomplicated Skin Abscesses in Patients at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection: An Interim Analysis Olderog CK, Brooke Army Medical Center, San Antonio, TX 336 Respiratory Syncytial Virus Is Not Protective of Urinary Tract Infections in Febrile Infants Less Than 90 Days Old Mun Лњiz AE, The University of Texas Health Sciences Center at Houston, Houston, TX 337 Significant Bacterial Infections in Febrile Children Less Than 2 Years of Age With Influenza A Mun Лњiz AE, The University of Texas Health Science Center at Houston, Houston, TX Imaging 1 (Ultrasound) 320вЂ«ШЎвЂ¬ Asepsis in Ultrasound-Guided Central Venous Access: A New Technique Jain A, University of Rochester, Rochester, NY 321 Out-of-Hospital Critical Care ProvidersвЂ™ Retention of Ultrasound Skills for Diagnosis of Pneumothoraces: A Nine-Month Follow-Up Walton P, Medical College of Georgia, Augusta, GA 322вЂ«ШЎвЂ¬ Rate and Outcome of First Trimester Indeterminate Pelvic Ultrasounds in an Urban Emergency Department Phillips C, Washington Hospital Center, Washington, DC 323вЂ«ШЎвЂ¬ Technical and Interpretive Error Rates for the Focused Assessment With Sonography in Trauma Exam Montoya AM, University of Massachusetts Medical School, Worcester, MA 338 The Significance of the Wall Echo Shadow Triad on Ultrasonography in Emergency Department Patients Singla A, New York Hospital Queens, Flushing, NY Emergency Medicine Versus Pediatric Emergency Medicine Physicians in the Management of Febrile Infants ПЅ 1 Month of Age Mun Лњiz AE, The University of Texas Health Science Center at Houston, Houston, TX 339 Characteristics of Patients Undergoing Rapid HIV Testing in a NYC Emergency Department Egan D, St. LukeвЂ™s Roosevelt Hospital Center, New York, NY 324вЂ«ШЎвЂ¬ 325 Access to Immediate Bedside Ultrasound in the Emergency Department Talley B, Denver Health Medical Center, Denver, CO 326 Ultrasound of the Inferior Vena Cava Can Assess Volume Status in Pediatric Patients Ayvazyan S, Maimonides Medical Center, Brooklyn, NY Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Informatics 340 Automated Referral for Elevated Blood Pressure Has No Impact on Patient Knowledge of Referral Robinson JA, Wilford Hall Medical Center, San Antonio, TX Annals of Emergency Medicine 13A Research Forum Educational Program 2009 TUESDAY, OCTOBER 6вЂ”contвЂ™d 341 Change in Staff Opinions After Initiation of Emergency Department Full Electronic Health Record Norton RL, Oregon Health & Science University, Portland, OR 342 Two Troponins: Defining and Characterizing a Resource-Intensive Emergency Department Cohort Using a Clinical Datamart Genes N, Mount Sinai School of Medicine, New York, NY 343вЂ«ШЎвЂ¬ Emergency Department Information System Adoption in the United States Landman AB, Yale University, New Haven, CT 344 Impact of the Implementation of an Electronic Hand-Off Tool on Patient Safety and Clinician Satisfaction in an Academic Emergency Department Little JH, Maine Medical Center, Portland, ME 345вЂ Development of a Technology for the Estimation of ScVO2 in Individual Patients Summers RL, University of Mississippi Medical Center, Jackson, MS 346 Usability Comparison of 9 Methods of Preparing Patient Discharge Instructions and Prescriptions Nielson JA, Summa Health System, Akron, OH 347 Performance of a Chief Complaint Classifier for Syndromic Surveillance for Three Gastrointestinal Sub-Syndromes Cochrane DG, Morristown Memorial Hospital, Kinnelon, NJ 348вЂ Assessing the Satisfaction of Emergency Department Patients Who Used PatientTouchв„ў to Provide a Medical History Prior to Physician Contact Arora S, Keck School of Medicine of USC, Los Angeles, CA 358вЂ«ШЎвЂ¬ Electrocardiographic Changes in Spontaneous Intracerebral Hemorrhage Jain A, University of Rochester, Rochester, NY Toxicology & Pharmacology 359 Stonefish Envenomation Presenting to a Singapore Hospital Ngo AS, Singapore General Hospital, Singapore, Singapore 360 A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial to Evaluate 4% Liposomal Lidocaine Cream on Pain and Anxiety During Venipuncture in Pediatric Patients Who Present to the Emergency Department Boucher J, Lehigh Valley Hospital, Allentown, PA 361 Medication Errors Occurring in Fomepizole Administration Wong S, University of Texas Southwestern Medical Center, Dallas, TX 362 Coagulopathy in Pediatric Copperhead Snakebites Anderson BW, Washington University School of Medicine, St. Louis, MO 363 Obese Dosing Adjustments for Selected Antimicrobials in the Emergency Department Fuentes JM, Washington University School of Medicine in St. Louis, St. Louis, MO 364 Acid Base Status as a Predictor of Severity in Salicylate Toxicity Levine M, Banner Good Samaritan Medical Center, Phoenix, AZ 365 Fatal Toxicity from Nucleoside Reverse Transcriptase Inhibitor Use: Factors Implicated With Symptomatic Hyperlactemia Emergencies Leung L, Mount Sinai School of Medicine, New York, NY 366вЂ Clinical Experience of Continuous Renal Replacement Therapy as an Extracorporeal Elimination Performed by Emergency Physicians in Patients With Poisoning Park E, Ajou University Medical Center, Suwon, Kyoung-Gi Do, Republic of Korea Neurology 349 Serum Interleukin-6 as a Marker of Functional Outcome After Acute Ischemic Stroke Stead LG, University of Rochester, Rochester, NY 350 Circulating Levels of Pro-Inflammatory Cytokines After Acute Ischemic Stroke as Markers of Stroke Severity Stead LG, University of Rochester, Rochester, NY 367 Are Venous Carboxyhemoglobin Levels Being Utilized by Physicians? Fiesseler F, Morristown Memorial Hospital, Morristown, NJ 351 Association of Interleukin 1b and Volume of Acute Ischemic Infarct on Magnetic Resonance Imaging Stead LG, University of Rochester, Rochester, NY 368 Diphenhydramine Increases Lethality in a Porcine Model of Intravenous Rattlesnake Envenomation Sekhon N, Brody School of Medicine, Greenville, NC 352 Relationship Between Early Blood Pressure Parameters and Intraventricular Extension After Emergency Department Presentation for Intracranial Hemorrhage Stead LG, University of Rochester, Rochester, NY 369 See page 5A 353 354 355вЂ«ШЎвЂ¬ Number of Headache Patients/Day in New York City Public Hospitals: Relation to Time, Weather, Air Pollution and Economic Variables Low RB, New York City Health and Hospitals, New York, NY Relationship Between Ambient Temperature and Emergency Department Visits for Headaches Gee SW, Morristown Memorial Hospital, Morristown, NJ Anti-Coagulant, Anti-Platelet Use in Intra-Cerebral Hemorrhage Patients: Does Reversal of International Normalized Ratio Translate to Improved Outcome? Jain A, University of Rochester, Rochester, NY 2:30 - 3:30 PM Poster Session 6 Cardiology 370 Coronary CT Angiography Versus Stress Testing in Predicting Long-Term Adverse Events: Two-Year Follow-Up of a Randomized Controlled Trial OвЂ™Neil BJ, Wayne State University, Detroit, MI 371 Prognostic Importance of Elevated Cardiac Troponin-t in Patients With Acute Supraventricular Tachycardia Marinsek M, Celje General Hospital, Celje, Slovenia 372вЂ«ШЎвЂ¬ Initial Troponin as a Predictor of Adverse Outcome in Patients With Syncope Serrano LA, Mayo Clinic, Rochester, MN 356вЂ«ШЎвЂ¬ Do Not Resuscitate Orders in Spontaneous Non-Traumatic IntraCerebral Hemorrhage: What Is the Difference? Jain A, University of Rochester, Rochester, NY 373вЂ«ШЎвЂ¬ Electrocardiographic Intervals and One-Year Cardiovascular Outcomes in Syncope Serrano LA, Mayo Clinic, Rochester, MN 357вЂ«ШЎвЂ¬ The Mayo ICH Score: Evaluating Patients With Non-Traumatic Intra-Cerebral Hemorrhage Jain A, University of Rochester, Rochester, NY 374вЂ«ШЎвЂ¬ Prospective Observational Trial of Carotid Intima-Media Thickness in the Evaluation of Patients With Acute Chest Pain Khan T, NY Methodist Hospital, Brooklyn, NY 14A Annals of Emergency Medicine Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Educational Program 2009 TUESDAY, OCTOBER 6вЂ”contвЂ™d 375вЂ Using a Rapid Cardiac Disposition Protocol to Improve Patient Flow Birkhahn R, New York Methodist Hospital, Brooklyn, NY 376вЂ EMF Evaluation of a Heart Failure Mortality Prediction Model for PostDischarge Outcomes Hiestand BC, The Ohio State University, Columbus, OH 392 Can Total and Motor Glasgow Coma Scale Predict Mortality in Penetrating Trauma? Duemling KE, St. John Hospital and Medical Center, Detroit, MI Education Diagnosis/Treatment вЂ«ШЎвЂ¬ 377 Characteristics of Waiting Patients With Abrupt Deterioration in the Emergency Department Ode Y, Juntendo University Urayasu Hospital, Urayasu City, Japan 378 Diverticulitis in Taiwan: A Different Story to Western Countries Liu C, Chia-Yi Christian Hospital, Chia-Yi, Taiwan 379вЂ«ШЎвЂ¬ OB/GYN Emergencies in the Emergency Department: Ovarian Torsion Walker TN, New York Presbyterian Hospital, New York, NY 380 381 Blatchford Clinical Risk Stratification Score May Be Used in an Observation Unit Setting to Risk Stratify Patients With Gastrointestinal Bleeding Chandra A, Duke University Medical Center, Durham, NC Erythrocyte Sedimentation Rate Compared to C-Reactive Protein as a Screening Marker of Inflammation in the Emergency Department Vilke GM, University of California, San Diego, San Diego, CA 382 Glycemic Control Is Improved in Emergency Department Patients With an Identifiable Primary Care Provider Horwitz D, Washington University, St. Louis, MO 383 To Scan or Not to Scan: Predicting Appendicitis in Adult and Pediatric Patients Melville LD, New York Methodist Hospital, Brooklyn, NY 384вЂ«ШЎвЂ¬ Symptom Recurrence and Biphasic Reactions in Patients Presenting to the Emergency Department With Anaphylaxis Manivannan V, Mayo Clinic, Rochester, MN 393 Objective Structured Clinical Examination Performance Versus Faculty Evaluation of Resident Performance Shih RD, Morristown Memorial Hospital, Morristown, NJ 394 A Prospective Study of Cardiopulmonary Resuscitation Training in 7th Grade Students Using a Take-Home Self-Instruction Cardiopulmonary Resuscitation Kit Faccio K, Lehigh Valley Hospital, Allentown, PA 395 Bedside Teaching in an Academic Emergency Department Beckmann B, Brooke Army Medical Center, San Antonio, TX 396 Repetitive Questions in the Emergency Department: PatientsвЂ™ Perspectives Ha J, University of Toledo College of Medicine, Toledo, OH 397 Code-Blue as a Teaching Moment: Re-Evaluation of Medical Student Experiences Following Curriculum Changes Milzman DP, Georgetown University School of Medicine/ Georgetown WHC EM Residency, Washington, MD 398 Sports Medicine Fellowship Training for Emergency Medicine Residency Graduates: Interest, Availability and Practice: A Niche Not Being Filled Milzman DP, Georgetown University School of Medicine, Washington, DC EMF-6вЂЎ The EMCAPs Training Method for Procedural Competency Among Emergency Medicine Residents Van Roo J, Northwestern University, Chicago, IL See page S144 EMF-7вЂЎ The Northwestern University Rotating Resident Curriculum: A Novel Web-Based Didactic Program for Rotating Residents in the Emergency Department Branzetti J, Northwestern University, Chicago, IL See page S144 Disaster/Nuclear, Biological, or Chemical Event 385 Implementing an Electronic Point-of-Care Medical Record at an Organized Athletic Event: Challenges, Pitfalls and Lessons Learned Wells HJ, Maine Medical Center, Portland, ME 386 Accuracy of EMS Identification of ST-Elevation Myocardial Infarctions and Its Effect on Door-to-Balloon Time Ardolic B, Staten Island University Hospital, Staten Island, NY 387вЂ Evaluation of Time Required for Water-Only Topical Decontamination of an Oil-Based Agent Moffett P, Madigan Army Medical Center, Tacoma, WA 388вЂ«ШЎвЂ¬ Imaging Utilization During Explosive Multiple Casualty Incidents Raja AS, The 445th Aeromedical Staging Squadron, WrightPatterson Air Force Base, Dayton, OH 389 A Mass Medication Distribution Emergency Response Exercise Using Vaccination, Not Simulation Martens KA, Loyola Medicine, Maywood, IL 390 In a Major Disaster, How Do You Allocate Hospital Resources? Messman A, St. John Hospital and Medical Center, Detroit, MI 391 The Impact of Emergency Department Size on Pandemic Influenza Preparedness in US Emergency Departments Morton MJ, Johns Hopkins University School of Medicine, Baltimore, MD Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Injury Prevention 1 (Intentional) 399 Improving Coordinated Responses for Victims of Intimate Partner Violence: Law Enforcement Compliance With State Mandated Intimate Partner Violence Documentation Edwardsen EA, University of Rochester, Rochester, NY 400вЂ«ШЎвЂ¬ Predictors of Being Unsafe to Answer Intimate Partner Violence Screening Questions: Findings From the Behavioral Risk Factor Surveillance System 2006 Ranney M, Rhode Island Hospital/Brown University, Providence, RI 401вЂ«ШЎвЂ¬ The Correlation Between Adolescent-Reported Parental Driving Behaviors and Observed Adult Driving Behaviors Murphy S, Lehigh Valley Hospital, Allentown, PA 402 TXT Rx: Using Health Information Technology to Safely Discharge Suicidal Patients From the Emergency Department Larkin G, Yale University, New Haven, CT 403 College Student Alcohol Screening and Outcome From AlcoholRelated Injury and Illness: Longitudinal Study of Campus Alcohol Problem Ybarra MP, Georgetown University School of Medicine/ Georgetown WHC EM Residency, Washington, DC Annals of Emergency Medicine 15A Research Forum Educational Program 2009 TUESDAY, OCTOBER 6вЂ”contвЂ™d Pain Management 404 Hyaluronidase-Enhanced Subcutaneous Hydration and Opioid Administration for Sickle Cell Disease Acute Pain Episodes Sandoval M, Beth Israel Medical Center, NY 405вЂ Prophylactic Etoricoxib Prevents Yom Kippur Headache: A PlaceboControlled Double Blind Trial Drescher MJ, Hartford Hospital/University of Connecticut, Hartford, CT 406 Transbuccal Fentanyl for Rapid Relief of Orthopedic Pain in the Emergency Department Nelson SW, Brigham and WomenвЂ™s and Massachusetts General Hospital, Boston, MA 420вЂ«ШЎвЂ¬ Clinical Features of Fitz-Hugh-Curtis Syndrome and Length of the Emergency Department Stay Moon S, Korea University, Ansan City, Kyunggido, Republic of Korea 421 Self-Removal of Sutures by Emergency Department Patients Albert M, Michigan State University College of Human Medicine, Grand Rapids, MI 422вЂ«ШЎвЂ¬ A Comparison of Rates of Emergency Department and Observation Unit Adverse Drug Events Chandra A, Duke University Medical Center, Durham, NC 423 Variation in the Practice of Emergency Department Handoffs Cheung DS, Carepoint, Denver, CO 407вЂ Pain Management during Intraosseous Infusion Through the Proximal Humerus Philbeck T, Vidacare Corporation, San Antonio, TX 424EMF Association Between Length of Emergency Department Boarding, Mortality and Length of Hospital Stay Singer AJ, Stony Brook University, Stony Brook, NY 408вЂ«ШЎвЂ¬ Randomized Double-Blind Placebo-Controlled Trial Comparing Room Temperature and Heated Lidocaine for Local Anesthesia and Digital Nerve Block Papa MK, Sri Ramchandra Medical College & Research Institute, Chennai, India 425 Physican Sex Bias in Evaluating Emergency Department Patients With Chest Pain: A Pilot Study Wilkie L, Stony Brook University, Stony Brook, NY 426 Strangulation in Sexual Assault Sun M, UCLA Emergency Medicine, Los Angeles, CA 409вЂ«ШЎвЂ¬ 410 The Efficacy and Adverse Events of Morphine Versus Fentanyl on a Physician-Staffed Helicopter Smith MD, MetroHealth Medical Center, Cleveland, OH Public Health 427вЂ An Emergency Department Intervention for Tobacco Cessation Among Patients and Visitors Utilizing Pre-Health Professional Students as Research Associates Bradley K, St. VincentвЂ™s Medical Center, Bridgeport, CT 428 Child Car Seat Safety Knowledge Among Caregivers in Puerto Rico: Is More Education Needed? Martinez Martinez CJ, University of Puerto Rico Emergency Medicine Residency, Carolina, PR The Routine Use of Local Anesthetics in Pediatric Lumbar Punctures: Are We There Yet? Gorchynski JA, JPS Health Network, Fort Worth, TX Pediatrics 411вЂ«ШЎвЂ¬ Correlation of Pediatric Asthma Severity Score and End Tidal CO2 Values With Asthma Severity in the Pediatric Population Dhillon RK, Mayo Clinic, Rochester, MN 429 412 An Observational Study of Cutaneous Abscess Management in a Pediatric Emergency Department Setting Ramirez J, Orlando Health: Arnold Palmer Hospital for Children, Orlando, FL Demographic and Clinical Variables Associated With Follow-Up of Emergency Department Patients at Federally Funded Clinics: Metropolitan-Wide Survey Pilot Data Dziuba D, Washington University, St. Louis, MO 430 413вЂ«ШЎвЂ¬ Assessing Competency of the Broselow-Luten Pediatric Resuscitation Tape: A Prospective, Cross Sectional, Analytical Study of 15,000 South Indian School Children Cattamanchi S, Sri Ramchandra Medical College & Research Institute, Chennai, India The SAVED Study: A Six-Year Consecutive Review of Factors Associated With Loss of Consciousness Among Sexual Assault Survivors in the Emergency Department OвЂ™Donnell MB, North Shore University Hospital, Manhasset, NY 431вЂ«ШЎвЂ¬ 414 Pacifier Use for SIDS Prevention: Extent of Caregiver Awareness and an Educational Intervention Vieth TL, Kern Medical Center, Bakersfield, CA Describing the Characteristics of Non-Border Patient Populations That Utilize Cross Border Health Services Arora S, Keck School of Medicine of USC, Los Angeles, CA 432вЂ«ШЎвЂ¬ 415 Does Inferior Vena Cava/Aorta Ratio Correlate With Fluid Therapy in Clinically Dehydrated Children? Barata I, North Shore University Hospital, Manhasset, NY Comparison of the Health Care Utilization of Resettled Hurricane Katrina Victims Okafor N, University of Texas - Health Science Center at Houston, Houston, TX 416 Ambulatory Prescription Errors in a Pediatric Emergency Department Place R, Inova Fairfax Hospital, Falls Church, VA 433 417 Cardiovascular Abnormalities Among Children Presenting With Chest Pain to a Community Hospital and Compliance to Follow-Up Kondamudi N, The Brooklyn Hospital Center, Brooklyn, NY A Health Needs Assessment Conducted at the Kausay Wasi Clinic in Coya, Peru Arora S, Keck School of Medicine of USC, Los Angeles, CA 434 Parental Expectation to Receive Anti-Tussive Medications for Their Coughing Children Presenting to the Emergency Department: Impact on Satisfaction Kondamudi N, The Brooklyn Hospital Center, Brooklyn, NY Describing Prevalence, Health and Demographics of Emergency Department Patients With Diabetes Arora S, Keck School of Medicine of USC, Los Angeles, CA Respiratory 1 (Airway) 418 435 Changes in Emergency Department Airway Management Over the Last 12 Years Sakles JC, University of Arizona, Tucson, AZ 436 Time to Successful Intubation Has a Similar Correlation to Hypoxia as Number of Attempts in Rapid Sequence Intubation Hill C, Hennepin County Medical Center, Minneapolis, MN Practice Management 419 Work-Induced Memory Decline in Emergency Medicine Attending Physicians Machi MS, University of Pittsburgh, Pittsburgh, PA 16A Annals of Emergency Medicine Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Educational Program 2009 TUESDAY, OCTOBER 6вЂ”contвЂ™d 437вЂ«ШЎвЂ¬ Glottic View Using Direct and GlidescopeВ® Laryngoscopes in the Hands of Emergency Physicians Drigalla D, Scott & White Memorial Hospital, Temple, TX 450 Factors Affecting Time to Head CT in Trauma Patients With Intracerebral Hemorrhage Owen K, University of California Davis, Sacramento, CA 438вЂ«ШЎвЂ¬ Successful Endotracheal Intubation by Experienced Emergency Physicians Using Direct and GlidescopeВ® Laryngoscopes Drigalla D, Scott & White Memorial Hospital, Temple, TX 451 Beta-adrenergic Blockade Prevents Myocardial Oxidative Stress Due to Traumatic Brain Injury Larson B, University of Vermont, Burlington, VT 439 Effects of Emergent Intubation on Heart Rate Using Three Different Medication Regimens for Rapid Sequence Intubation: A Retrospective Video Review Hill C, Hennepin County Medical Center, Minneapolis, MN 452 Continuous Out-of-Hospital Vital Signs Acquisition Improves Trauma Triage Sen A, Henry Ford Hospital, Detroit, MI 453вЂ«ШЎвЂ¬ The Efficacy of Factor VIIa in Emergency Department Patients With Warfarin Use and Traumatic Intracranial Hemorrhage Nishijima DK, UC Davis Medical Center, Sacramento, CA 454 Serum Lactate Is Not Predictive of Major Injuries in Pediatric Blunt Trauma Mun Лњiz AE, The University of Texas Health Science Center at Houston, Houston, TX 455 The Prevalence and Prognostic Value of Hyperglycemia and APACHE II Scores Among Adult Sepsis Patients in the Emergency Department DвЂ™Amore J, North Shore University Hospital, Manhasset, NY 440 Out-of-Hospital Intubations: Are Patients Well Ventilated on Emergency Department Arrival? Peng JS, UC Davis Medical Center, Sacramento, CA Resuscitation 441вЂ«ШЎвЂ¬ 442 443 Comparison of Chest Compression Quality Between the Floor and the Bed Using Backboard Jang J, Chung-Ang University Hospital, Seoul, Republic of Korea Alpha (2B)-Adrenergic Receptor Gene Polymorphism and the Response to Epinephrine in Cardiopulmonary Resuscitation Rivas F, Instituto Mexicano del Seguro Social, Guadalajara, Mexico Feasibility of Intraosseous Infusion of Iced Saline to Induce Therapeutic Hypothermia After Cardiac Resuscitation Walterscheid JK, Baystate Medical Center/Tufts University School of Medicine, Springfield, MA 444 Intraosseous Infusion of Crystalloid Fluid Immediately After Intraosseous Infusion of Nitroglycerin in the Proximal Tibia of a Swine (Sus Scrofa) Model Miller J, Wilford Hall Medical Center, San Antonio, TX 445вЂ«ШЎвЂ¬ Out-of-Hospital Cardiac Arrest: Are We Getting Our MoneyвЂ™s Worth? Sasson C, University of Michigan, Ann Arbor, MI 446 ECG Analysis in Accidental Urban Hypothermia Urdang MS, Los Angeles County П© USC Medical Center, Los Angeles, CA 447 Metabolic Profiles, Coagulopathy and Survivorship in Accidental Urban Hypothermia Shoenberger JM, Los Angeles County П© USC Medical Center, Los Angeles, CA Trauma 448 Utility of Computed Tomography of the Thorax, Abdomen and Pelvis in Patients Presenting After Ground-Level Falls Marynowski M, Allegheny General Hospital, Pittsburgh, PA 449вЂ«ШЎвЂ¬ Identification of Occult Shock Using Out-of-Hospital Lactate Guyette F, University of Pittsburgh, Pittsburgh, PA Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ TUESDAY, OCTOBER 6, 2009 4:00 - 5:30 PM Cutting Edge: Highlights of Emergency Medicine Research Moderator: Brian J. OвЂ™Neil, MD, FACEP Panelists: Charles B. Cairns, MD, FACEP; Debra E. Houry, MD, MPH, FACEP; Ian G. Stiell, MD; and Donald M. Yealy, MD, FACEP A panel of experts will focus on the most interesting abstracts of Research Forum and the take-home message for practitioners and researchers alike. No badge or ticket is required to attend this event. вЂ In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and the policy of the American College of Emergency Physicians, the presenters noted with an (вЂ ) have indicated they have a relationship which, in the context of their presentation, could be perceived by some as a real or apparent conflict of interest (eg, ownership of stock, honoraria, or consulting fees), but these presenters do not consider that it will influence their presentations. EMF Supported by an Emergency Medicine Foundation grant. *Young Investigator. вЂЎ These abstracts were recategorized after acceptance. Annals of Emergency Medicine 17A INDEX OF PRESENTERS Abello A, 311 Acosta JF, 163 Adhikari S, 180, 216, 283, 328 Aguilera P, 176, 179 Akpunonu P, 120 Albert M, 421 AlDarrab A, 11 Allegra JR, 178, 297 Anderson BW, 362 Ardolic B, 386 Arora S, 348, 431, 433, 434 Ayvazyan S, 326 Babcock C, 30 Banala SR, 129 Bank DE, 13 Baquero A, 53 Barata I, 415 Barcomb T, 32 Barlas D, 33, 102 Barrett TW, 1 Bastani A, 24, 233 Battista S, 86 Bauman MJ, 278 Baumann MR, 227 Beatty N, 68 Bebarta VS, 191 Beckmann B, 395 Bellolio M, 232 Bennett CJ, 100 Berios I, 107 Bhakta NS, 57 Bigler JB, 282 Birkhahn R, 242, 375 Black A, 247 Bloch AJ, 327 Bloch RB, 40 Boeke P, 198 Borquez EA, 144 Boucher J, 360 Bradley K, 427 Branzetti J, EMF-7 Brook C, 12 Bryce SN, 257 Burger C, 295 Burton J, 69 Calderon Y, 54 Camargo CA, 275 Campo C, 156 Capp R, 330 Carpenter CR, 260, 263 Castillo EM, 250 Cattamanchi S, 413 Chan TC, 310 Chan W, 116 Chan Y, 230 Chandra A, 177, 238, 380, 422 Chandra S, 231 Cheung DS, 423 Chin E, 329 Cho YD, 123 Chohan JK, 132 Choi M, 305 Choi S, 296 Cienki JJ, 90 Cochran AM, 96 Cochrane DG, 347 Cook D, 219 DвЂ™Amore J, 455 Dailey M, 252 Damewood S, 146, 224 Das A, EMF-2 Das D, 31 Davis JE, 112 Davis V, 133 De Lorenzo RA, 316 Delgado MK, 61 Dhillon RK, 293, 411 Dhillon RJ, 80 Drescher MJ, 405 Drigalla D, 437, 438 Dubin J, 55 Duemling KE, 392 Duseja R, 211 Dziuba D, 429 Eadeh H, 137 Easter B, EMF-1 Eberhardt M, 301 Edwardsen EA, 399 Egan D, 334, 339 Faccio K, 394 Faig O, 70 Farley HL, 27, 168, 308 Felderman H, 114, 115 Ferre C, 119 Fertel BS, 5 Fiesseler F, 367 Fuentes JM, 363 Gabayan GZ, 208 Garman A, 101 Garra G, 138 Garro A, 50 Gee SW, 354 Genes N, 342 Gilmer M, 226 Ginde AA, 240 Givens ML, 302 Glickman S, 4, 312 Goo R, 135 Gorchynski JA, 410 Gottesman B, 128 Green J, 6, 266 Greene T, 103 Greenfield EM, 201 Griffey RT, 265 Groke S, 29, 148 Gross T, 93 Gupta S, 60 Guyette F, 449 Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Ha J, 396 Hahn B, 49 Hakmeh W, 287 Hall MK, 279 Handel DA, 167, 243, 304 Hansen AV, 223 Hansen KN, 212 Hariharan P, 71 Harper JB, 124, 194 Hawkins D, 85 Heidt JW, 259 Heins A, 58, 162 Hendry D, 174 Hermann LK, 23 Hexom B, 155 Hiestand BC, 376 Hile D, 185 Hill CH, 64, 436, 439 Hlibczuk V, 95 Ho JD, 127 Holm M, 281 Holt S, 173 Hong AL, 251 Horwitz D, 382 House H, 207 Howard Z, 196 Hsia RY, 271 Imamura T, 121 Irvin MM, 78 Jain A, 320, 355, 356, 357, 358 Jang J, 441 Jeanmonod R, 82 Johnson KA, 205 Kairam N, 288 Katz GR, 307 Khan T, 374 Kiebel W, 98 Kiefer CS, 26 Kim D, 292 Kim J, 273 Kim S, 73 Kimberly H, 277 Klope JL, 149 Kondamudi N, 291, 417, 418 Kott I, 264 Krieg C, 300 Ladde J, 134, 269 Lagina A, EMF-5 Lamba S, 165 Landman AB, 343 Larkin G, 402 Larson B, 451 Lau WB, EMF-3 Lee J, 309 Leung L, 365 Lev R, 274 Levine AC, 289 Levine M, 364 Lewis L, 164, 213 Lim T, 313, 314 Limkakeng AT, 161 Lindor RA, 39 Lipe KM, 186 Liteplo AS, 217 Little JH, 344 Liu C, 378 Liu SW, 214 Lobon LF, 17 Losek JD, 47 Low RB, 353 Lundin EJ, 315 Ly S, 67 Lynch CA, 126 Lyng J, 74 Lyon M, 222, 284 Mace SE, 171, 172 Machi MS, 419 Maekawa K, 298 Mahadevan SV, 254 Mahler SA, 81 Manivannan V, 384 Marinsek M, 371 Martens KA, 389 Martinez Martinez CJ, 428 Marynowski M, 448 Matthews P, 246 McGrath ME, 117 Meisel ZF, 248, 249 Mejia J, 44 Melville LD, 383 Menchine M, 184 Messman A, 390 Miller A, 92 Miller J, 444 Milzman DP, 397, 398 Miner JR, 150 Mir M, 290 Mirhadi M, 83 Miyashiro R, 197 Moffett P, 387 Montoya AM, 323 Moon S, 420 Mori K, 72 Morley EJ, 136 Morris DF, 189 Morton MJ, 391 Moskowitz A, 229 Mostofi M, 169 MunЛњiz AE, 336, 337, 338, 454 Murphy S, 401 Myers LA, 110, 200 Nagata T, 125 Napoli A, 34, 35 Nelson BP, 106 Nelson SW, 406 Ngo AS, 139, 359 Nibhanipudi KV, 285 Nielson JA, 346 Annals of Emergency Medicine 19A Index of Presenters Nishijima DK, 453 Niska RW, 18 Nomura JT, 104 Norton RL, 341 OвЂ™Donnell MB, 430 OвЂ™Laughlin KN, 190 OвЂ™Neil BD, 369 OвЂ™Neil BJ, 370 OвЂ™Neill R, 76 Ode Y, 377 Okafor N, 432 Olderog CK, 335 Oostema A, 84 Oosterhouse T, 99 Owen K, 450 Papa MK, 408 Park E, 77, 366 Patanwala A, 140 Patyrak S, 188 Pazin-Filho A, 21, 22, 63 Peacock W, 2, 20, 88 Peng JS, 440 Phanthavady T, 37 Phelan MP, 56 Phelan T, 183 Philbeck T, 193, 407 Phillips C, 322 Pines JM, 239 Place R, 236, 416 Platz E, 280 Plonk T, 160 Prekker ME, 151 Rabin E, 267 Raja AS, 28, 388 Ramirez J, 412 Ranney M, 400 Ravikumar D, 206 Rechtin C, 294 Reese A, EMF-4 Richardson D, 143 Richerson PJ, 9 Rivas F, 442 River G, 276 Roberts RR, 272 Robinson JA, 340 Romero K, 118 Rothschild JM, 142 Rubal BJ, 317 Rumoro D, 170 Rusczyk G, 45 Russell S, 48 Saef SH, 10 Sakles JC, 435 Salvucci AA, 202 Sandoval M, 404 Sarsfield MJ, 286 Sasson C, 445 Sattarian M, 14 Saul T, 220 Sayah A, 166 Schechter-Perkins E, 332 Schmitz GR, 331 Schroeder JW, 159 Schuur J, 16, 241 Sciorra D, 154 Scott S, 157 Sekhon N, 368 Sen A, 91, 215, 306, 452 Serrano LA, 372, 373 Shah K, 235, 262 Shah S, 175 Shaw GJ, 319 Shearer P, 153 Sherwin R, 181 Shih RD, 393 Shimizu T, 299 20A Annals of Emergency Medicine Shoenberger JM, 447 Shroyer SR, 333 Shukla KT, 210 Shum L, 65 Singer AJ, 158, 424 Singla A, 324 Sinha S, 43 Slattery DE, 182 Smith MD, 409 Smith SW, 25 Smulowitz PB, 268, 270 Starr GA, 109 Stead LG, 349, 350, 351, 352 Stein JC, 221 Stiffler KA, 15 Strout TD, 145 Su M, 253 Sullivan AF, 59 Summers RL, 345 Sun M, 426 Sunga KL, 94 Suozzi JC, 62 Suzuki M, 87 Swickhamer C, 261 Swor R, 203 Tadros A, 256 Taira BR, 79 Takakuwa KM, 38 Talley B, 325 Tanabe P, 41, 42 Tekwani K, 8 Thode HC, 46 Thomas LE, 225 Thompson K, 36 Tollefsen WW, 52 Toofan M, 204 Torbati S, 234 Tsai C, 3 Umezawa K, 255 Urdang MS, 446 Van Roo J, EMF-6 Van Tonder RJ, 51 VeВґlez I, 187 Venkat A, 97 Venkatesh A, 244 Veysman BD, 228 Vieth TL, 414 Vilke GM, 381 Virk PS, 122 Waldron R, 195 Walker TN, 379 Wall JJ, 152 Walters J, 245 Walterscheid JK, 443 Walton P, 321 Wang H, 318 Waseem M, 7, 131, 147 Watts S, 209 Weichenthal LA, 113 Weiner SG, 111 Wells HJ, 385 White BA, 237 Wiederhold H, 192 Wilkie L, 425 Wong EM, 258 Wong E, 66 Wong ML, 75 Wong S, 361 Wu TS, 105, 218 Yang A, 303 Ybarra MP, 403 You Y, 108 Zito JA, 19, 141 Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts From the American College of Emergency Physicians 2009 Research Forum October 5-6, 2009 Boston Exhibition and Convention Center, Hall B2 The presenting authorвЂ™s name is listed in italic type. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 1 A Clinical Prediction Model to Estimate Risk for 30-Day Adverse Events in Emergency Department Patients With Symptomatic Atrial Fibrillation Barrett TW, Martin AR, Storrow AB, Jenkins CA, Russ S, Darbar D/Vanderbilt University Medical Center, Nashville, TN Study Objectives: One percent of all emergency department (ED) visits are related to atrial fibrillation and 70% of these patients are admitted. Our objective was to develop a clinical prediction model that would predict 30-day adverse outcomes in patients presenting to the ED with symptomatic atrial fibrillation. We hypothesized that data available within the first 2 hours of ED management can assess a patientвЂ™s risk of experiencing an adverse event within 30 days of their ED visit. Methods: In this retrospective cohort study, we systematically reviewed the electronic medical records of all ED patients presenting with atrial fibrillation between August 2005 and July 2008 at an urban academic medical center. We defined symptomatic atrial fibrillation as patients with a new or established diagnosis of atrial fibrillation or atrial flutter that required ED evaluation for a complaint thought related to their rhythm disturbance. The predetermined adverse outcome measures included failing to achieve successful ventricular rate control (pulse less than 100 bpm) at time of ED disposition; 30-day ED return visit for an atrial fibrillationrelated complaint; 30-day hospital admission for an atrial fibrillation-related complaint; 30-day cardiovascular complication, and patient death secondary to an atrial fibrillation-related problem. We selected 12 predictor variables for inclusion in the model based on clinical relevance and review of baseline descriptive statistics. We performed a proportional odds logistic regression analysis and validated the model using 150 bootstrap replications. We calculated the c index, which generalizes area under the receiver operator curve, to test the modelвЂ™s predictive ability. Results: During the 3-year study period, 914 patients accounted for 1228 ED visits. We included only the patientвЂ™s first ED visit in the analysis and 80 patients were excluded for non-atrial fibrillation related complaints. The median age was 68 years, 46% were male and 77% were admitted. New atrial fibrillation was diagnosed in 36%; 43% had paroxysmal atrial fibrillation and 21% had permanent atrial fibrillation. Twenty-seven percent of patients had at least one of the 30-day atrial fibrillation-related adverse events. The odds ratios and 95% confidence intervals for the selected predictors impact on risk of 30-day adverse event in ED patients with symptomatic atrial fibrillation are presented in the Table. The prediction model showed that increasing age, higher ED maximum pulse rate, ED complaint of dyspnea, cigarette smokers, and patients not taking outpatient digoxin were independently associated with increased odds of higher risk for 30-day adverse events. The modelвЂ™s c-index was 0.75. Conclusion: In patients presenting to the ED with symptomatic atrial fibrillation, this study suggests that patients with increased age, smoking history, complaint of dyspnea, higher maximum pulse rates in the ED and no home treatment with digoxin are more likely to experience an atrial fibrillation-related adverse event within 30 days. Annals of Emergency Medicine S1 Research Forum Abstracts 2 Early Objective Identification of Chest Pain Patients at Very Low Risk of 30-Day Adverse Outcomes Peacock IV W, Hoekstra J, Krucoff M, Diercks D, Fermann G, Clark C, Grines C, Jois-Bilowich P/The Cleveland Clinic, Cleveland, OH; Wake Forest School of Medicine, Winston-Salem, NC; Duke University, Durham, NC; University of California, Davis, Sacramento, CA; University of Cincinnati, Cincinnati, OH; William Beaumont Hospital, Royal Oak, MI; University of Florida, Gainsville, FL Study Objectives: There are no objective early emergency department (ED) measures that identify chest pain patients at sufficient low risk so that immediate discharge is clinically reasonable. Our purpose was to determine if the combination of a normal creatinine, negative troponin, and negative 80 lead ECG (PRIME ECG, Heartscape, Inc., Columbia, MD) could identify patients at very low risk for 30-day adverse events. Methods: The Optimal Cardiovascular Diagnostic Evaluation Enabling Faster Treatment of Myocardial Infarction (OCCULT-MI) trial was a multicenter prospective observational study of moderate-to-high risk patients, Пѕ39 years old, presenting to the ED with chest pain or symptoms suspicious for acute coronary syndrome. Moderate-tohigh risk for adverse cardiovascular outcomes was defined as chest pain and either 1) ischemic 12 lead ECG abnormalities, 2) known coronary artery disease, or 3) 3 or more cardiac risk factors (diabetes, hypertension, current smoking, family history of coronary artery disease, or hypercholesterolemia). Patients received simultaneous 12 lead and 80 lead ECGs as part of their initial evaluation, and were treated according to the standard of care, with clinicians blinded to the 80 lead ECG results. For this analysis patients were included if both troponin and creatinine levels were measured, and they received an 80 lead ECG in the ED. Endpoints were defined as death, myocardial infarction, or rehospitalization within 30 days of the index visit. Results: OCCULT enrolled 1816 patients meeting all inclusion criteria. Patients were excluded for elevated Tn (nП217, 11.9%) or a creatinine Пѕ 2.0 mg/dL (nП52, 2.9%), leaving 1288 with evaluable 80 lead ECGs. Patients with abnormal 80 lead ECGs were excluded for ST elevation (nП72, 5.6%), ST depression (nП19, 1.5%), and T wave inversion (nП65, 5.0%). The remaining 1132 (87.9%) patients make up the analysis cohort and had an 80 lead ECG without ST deviation or T wave inversion, an initial troponin below the institutional myocardial infarction cutpoint, and a creatinine ПЅ 2.0 mg/dL. Overall, 36 (3.2%) of patients were lost to follow-up. The 30-day outcomes included death in 5 (0.4%, 95% CI П 0.1 to 1.0), myocardial infarction in 9 (0.8%, 95% CI П 0.3 to 1.5%), and re-hospitalization in 27 (2.4%, 95% CI П1.6 to 3.4). Conclusion: In patients at moderate to high risk of acute coronary syndromes, the combination of a single initial negative troponin, the absence of renal dysfunction, and a negative 80 lead ECG, identifies those for whom 30-day death and myocardial infarction occur at very low rates. A prospective study is warranted. 3 Quality of Care for Acute Myocardial Infarction in 58 US Emergency Departments Tsai C, Magid DJ, Sullivan AF, Gordon JA, Kaushal R, Blumenthal D, Camargo Jr CA/Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Institute for Health Research, Kaiser Permanente Colorado and the Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Science Center, Aurora, CO; Weill Medical College of Cornell University and New YorkPresbyterian Hospital, New York, NY; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA Study Objectives: Little is known about quality of emergency department (ED) care for patients with acute myocardial infarction (AMI). The objectives of the study S2 Annals of Emergency Medicine were (1) to determine concordance of ED management of AMI with 1996 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, and (2) to identify ED characteristics predictive of higher guideline concordance. Methods: We conducted a chart review study of AMI as part of the National Emergency Department Safety Study. Using a primary hospital discharge diagnosis of AMI (ICD-9 code 410.XX), we identified ED visits for AMI in 58 urban EDs across 20 US states between 2003 and 2006. Concordance with guideline recommendations was evaluated using five individual quality measures (electrocardiogram within 10 minutes of ED arrival, aspirin use in the ED, вђ¤-blocker use in the ED, fibrinolytic therapy within 30 minutes of ED arrival, and ED disposition for cardiac catheterization or transfer within 60 minutes of ED arrival) and a composite concordance score. Concordance scores were calculated as the percentage of eligible patients with AMI who received guidelines-recommended care. Clinically indicated deviations from guideline-recommended care were not counted as discordant (eg, beta-blockers withheld for hypotension; aspirin withheld for bleeding). These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance. Results: The cohort consisted of 3,819 subjects; their median age was 65 years and 62% were men. The mean ED composite concordance score was 60 (standard deviation, 8), with a broad range of values (40 to 81). Except for aspirin use in the ED (mean concordance, 82), ED concordance scores of other quality measures were low (вђ¤-blocker use, 54; timely electrocardiogram, 41; timely fibrinolytic therapy, 26; timely ED disposition for cardiac catheterization or transfer, 43). A factor analysis revealed two distinct clusters of AMI processes of care (use of medications [aspirin, вђ¤-blocker] vs. the 3 timeliness-related care processes). In a multivariable analysis adjusting for aggregate patient mix (age, sex, race/ethnicity, prior myocardial infarction, rales Пѕ50% of lung fields at ED presentation), and several hospital characteristics (number of beds in the ED, region, and affiliation with an emergency medicine residency program), southern EDs were independently associated with lower ED composite concordance scores (вђ¤ coefficient, ПЄ10; 95% confidence interval, ПЄ20 to ПЄ1), compared to northeastern EDs. Conclusion: Overall ED concordance with treatment recommendations in the ACC/AHA guidelines was low. We identified substantial variations in ED quality of care for AMI, with lower guideline concordance in the South. Future quality improvement efforts should continue to focus on AMI management in the ED. 4 The Impact of a Statewide ST-segment Myocardial Infarction Regionalization Program on Treatment Times for Women, Minorities, and Elderly Patients at Hospitals Without Percutaneous Coronary Intervention Capability Glickman S, Cairns C, OвЂ™Brien S, Ou F, Lytle B, Granger C, Jollis J/University of North Carolina, Chapel Hill, NC; Duke University, Durham, NC Background: Disparities in time to reperfusion for ST-segment myocardial infarction has been shown for women and elderly patients who receive primary fibrinolysis and those who are transferred for primary percutaneous intervention (PCI). Regionalization has been shown to improve overall ST-segment myocardial infarction treatment times, although the impact on disparities in care in non-PCI centers has not been evaluated. Study Objective: To assess the impact of a statewide system of care for STsegment myocardial infarction (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments [RACE]) on reperfusion times and change in baseline treatment disparities according to sex and age at non-PCI hospitals. Methods: ST-segment myocardial infarction treatment times were determined before (7/05вЂ“9/05) and after (1/07вЂ“3/07) a year-long implementation of RACE. RACE implemented tailored reperfusion plans and quality interventions at 65 hospitals, including 55 non-PCI and 10-PCI centers. Treatment times in the pre- and post- intervention periods at non-PCI hospitals were compared using Wilcoxon tests and disparities were analyzed using a linear mixed effects model which adjusted for patient demographics and co-morbidities. Results: Six hundred thirteen patients at non-PCI hospitals were analyzed. At baseline, older patients and women had longer delays in door-to-needle, door-toEKG, and door-in-door-out times among patients transferred for primary PCI. Doorto-needle, door-to-EKG, and door-in-door-out times all decreased among the elderly (ageПѕ70) and women (113 to 78, 15 to 9, and 48 to 36 minutes respectively for the elderly, and 114 to 65, 13 to 8, and 42 to 30 minutes respectively for women, pПЅ0.05 for all subgroups). Yet, elderly patients still had relatively longer treatment times than younger patients after implementation of the RACE program. While there were no changes in baseline treatment disparities in the elderly, the baseline disparity Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts in door-in-door-out times between women and men was reduced at non-PCI hospitals (pre: 36 min, post: 10 min, pП0.07). Hospital and EMS RACE factors associated improvement in treatment times included: use of out-of-hospital electrocardiography, emergency physicians having the authority to implement reperfusion without consulting cardiology, and stocking/reconstituting thrombolytics in the ED versus the pharmacy. Conclusion: A statewide STEMI regionalization program was associated with overall improvements in treatment times for women and elderly patients. Disparities remained in elderly patients, suggesting the need for further study and intervention. 5 Mass Screening of Children During a Pandemic Influenza Drill Fertel BS, Kohlhoff SA, Roblin PM, Parker CE, Augenbraun MH, Arquilla B/ University of Cincinnati, Cincinnati, OH; SUNY Downstate Medical Center, Brooklyn, NY Study Objectives: Tools for mass screening have been developed to separate symptomatic from asymptomatic patients during outbreaks of contagious infectious illnesses, such as pandemic influenza, in emergency departments (EDs). We sought to evaluate the effectiveness of one such tool in identifying symptomatic children, to assess the impact of such screening on children and family units and to identify pitfalls in the screening and quarantine of pediatric patients during a pandemic. Methods: In a prospective, observational, multicenter, pandemic influenza simulation exercise, we assessed the disposition of patients (actors) who self-presented for treatment at 3 hospital EDs (a tertiary care university hospital, a community hospital and an academic, urban, municipal, level 1 trauma center). Eight sequential public health alerts identifying the outbreak and case definition were issued over a number of weeks by the local health department and sent to hospital clinicians. Each patient was randomly assigned to a pre-identified influenza or non-outbreak-related case scenario and screened at the hospital entrance. Mass screening officers used a Mass Screening, Triage and Isolation (MSTI) tool based on clinical signs and symptoms of influenza for adults and children and CDC interim guidance documents on pandemic influenza. Victims meeting the case definition for influenza were isolated in a separate area of the hospital. Actual disposition of participants was recorded by trained observers using standardized forms and compared with intended outcomes. Descriptive statistics and chi square test were performed. Results: A total of 171 adults and 113 children (ages 0 вЂ“5, nП15; ages 6 вЂ“12, nП40; and ages 13вЂ“17, nП58 ) were screened by ED physicians and nurses using the MSTI. Of victims whose assigned scenario met the influenza case definition, 20%, 23%, 33%, and 46% of adults, children 13вЂ“17y, children 6 вЂ“12y, and children 0 вЂ“5y, respectively, were incorrectly identified as not having influenza. There was a significant correlation between decreasing age and difficulty recognizing influenza symptoms (p П 0.005). There were 45 families that consisted of at least one adult and one or more children. Of these, 26 families (58%) had a child with symptoms that differed from those of their parent resulting in one individual meeting the case definition and the other not. Fourteen of these family units (54%) received discordant dispositions that resulted in the separation of children from parents despite existing recommendations to the contrary. Conclusion: This drill identified the challenge of correctly applying pandemic influenza case definitions to young children receiving ED-based care, which is consistent with clinical studies during current influenza season. As the clinical case definition of infectious diseases often varies with age, just-in-time-training of ED personnel should incorporate and highlight the different age-specific presentations of the identified outbreak. Mass screening protocols, tools and disaster plans should pay careful attention to younger children, account for the challenge of treating family units with discordant symptoms and identify strategies to minimize the impact on affected children. 6 Effect of Hyperlactatemia on the Likelihood of In-Patient Mortality for Patients With a Normal and Abnormal Anion Gap Green J/New York Hospital Medical Center of Queens, Flushing, NY Study Objective: Hyperlactatemia (serum lactateХ†4.0 mmol/L) is a marker of increased short-term mortality in adult septic patients and is an enrollment criterion for early goal-directed therapy (EGDT). Prior studies have shown that lactic acidosis (serum lactateХ†4.0 mmol/L, blood pHПЅ7.35) is predictive of short-term mortality, but that hyperlactatemia with a normal blood pH (7.35вЂ“7.45) is less predictive. We Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ sought to determine whether hyperlactatemia is predictive of short-term mortality both in patients with a normal corrected anion gap and in patients with an abnormal corrected anion gap (Пѕ12 mEq/L). Methods: This was a prospective observational cohort. Setting: Urban tertiary care teaching hospital (90,000 annual ED visits) with an active severe sepsis screening protocol (serum lactate checked when clinician suspects infection likely to require admission). Inclusion criteria: Patients Х† 21 years of age with an admitting diagnosis of suspected or confirmed infection that were screened for severe sepsis during a 1year period (2/1/2007вЂ“1/30/2008) Exclusion criteria: Repeat patient visits during the study period were excluded. Statistical Analysis: The calculated anion gap was corrected for hypoalbuminemia via the Figge equation. The primary outcome was in-patient 28-day mortality stratified by anion gap and serum lactate. Chi-square was used for categorical data, t-test for continuous parametric data. Results: One thousand eight hundred thirty-eight patients were screened for severe sepsis during the study period, of which 1430 (77.8%) were admitted with an infectious diagnosis. Complete records were available for 1308 patients (91.5%). The most common admitting diagnosis was lower respiratory infection (nП667, 51%), followed by urogenital tract infection (nП262, 20%). Mean age was 73.3 years, 52% were female. In-patient 28-day mortality was 12.5% (95%CI 10.1 to 13.4%). One hundred seventy four patients had a serum lactateХ†4.0 mmol/L (13%, 95%CI 11.3 to 14.9%); 361 patients had a corrected anion gapПѕ12 mEq/L (27.6%, 95%CI 25.2 to 30.0%). 28-day in-patient mortality for patients with a normal vs. elevated corrected anion gap was 9.8% vs. 18.9% (OR 2.16, 95%CI 1.53 to 3.05). Twenty eight-day in-patient mortality for patients with a serum lactateПЅ4 mmol/L vs. lactateХ†4 mmol/L was 9.4% vs. 28.7% (OR 3.90, 95%CI 2.66 to 5.71). Among patients with a normal corrected anion gap, 28-day in-patient mortality for lactateПЅ4 mmol/L vs. lactateХ†4.0 mmol/L was 8.8% vs. 23.3%, (OR 3.16, 95%CI 1.50 to 6.65). Among patients with a corrected anion gap Пѕ12 mEq/L, 28-day in-patient mortality for lactateПЅ4 mmol/L vs. lactateХ†4.0 mmol/L was 12.9% vs. 30.8% (OR 3.01, 95%CI 1.76 to 5.13). Hyperlactatemia had a similar effect on the likelihood of 28-day in-patient mortality for patients with a normal corrected anion gap vs. patients with an elevated anion gap (pП0.917). Conclusion: In this cohort of adult ED patients with suspected infection requiring admission, both an elevated corrected anion gap and hyperlactatemia significantly increased the likelihood of 28-day in-patient mortality. Hyperlactatemia had a similar effect on the likelihood of 28-day in-patient mortality for patients with a normal corrected anion gap and patients with an abnormal corrected anion gap. Hyperlactatemia can be used to risk stratify patients for 28-day in-patient mortality regardless of the anion gap. 7 How Reliable Is Urinalysis to Predict Urinary Tract Infections? Waseem M, Paudel G, Sharma N/Lincoln Hospital, Bronx, NY; Lincoln Medical & Mental Health Center, Bronx, NY Background: Urinary tract infection (UTI) has a prevalence of up to 5.3% among febrile infants and young children. In the emergency department, results of urinalysis are often used to guide management of febrile patients with suspected UTI. Specific attention is paid to the leukocyte esterase (LE) and nitrite tests in order to determine the likelihood of UTI, and thus begin antibiotic treatment pending urine culture results. It has, however, been noted that UTI may be confirmed by urine culture even in the presence of a negative urinalysis. Study Objective: To determine whether a negative urinalysis is predictive of a negative urine culture in febrile children. Methods: A retrospective review of all patients under 2 years of age with cultureproven UTI was performed from January 2004 to December 2007 in an inner city teaching hospital. For study purposes, urinalysis results were reviewed by two independent emergency physicians, blinded to urine culture results, and to the patientвЂ™s clinical presentation. Physicians were asked to predict UTI based on urinalysis results. Based on the physicianвЂ™s prediction, the results of urinalysis were classified into three groups; high, intermediate and low probability. Urine cultures were obtained for a definite diagnosis of UTI. A chi-square analysis was performed. Results: Over the study period, 749 patients were identified with culture-proven UTI. Of these, 206 (27.5%) had urinalysis with less than 5 WBCs, negative LE & nitrite, and were therefore classified in low probability group. 478/749 (63.8%) had Пѕ15 WBCs and positive LE & nitrite, and were determined to be in the high probability group. 65 (8.7%) were in the intermediate probability group (5вЂ“15 WBCs with minimal/or trace LE or nitrite) (P ПЅ .001). Annals of Emergency Medicine S3 Research Forum Abstracts Conclusion: Urinalysis is a poor predictor for UTI, especially if negative. Almost one in four urinalysis with culture proven UTI was classified in the low probability group. A negative urinalysis therefore does not rule out UTI and should be interpreted with caution in the young febrile children. Urine cultures should be obtained to evaluate the possibility of UTI. 8 The Effect of Etomidate on Hospital Length of Stay of Patients With Sepsis: A Prospective, Randomized Study Tekwani K, Watts H, Sweis R, Rzechula K, Kulstad E/Advocate Christ Medical Center, Oak Lawn, IL Study Objectives: Etomidate is a widely used induction agent for rapid sequence intubation in the emergency department (ED) that has been demonstrated to cause measurable adrenal suppression after a single bolus dose. The clinical significance of this adrenal suppression in septic patients remains controversial. We sought to determine the difference in hospital length of stay (LOS) of septic patients intubated in our ED given etomidate compared to patients given midazolam, hypothesizing at least a 4-day increase in LOS in patients given etomidate. Methods: We performed a prospective, double blind, randomized study of septic patients intubated in our ED over a 16-month period. Eligible patients who were critically ill and suspected to be septic were randomized to either etomidate or midazolam prior to intubation. We recorded times of patient presentation, intubation/extubation, administration of first antibiotic, intensive care unit (ICU) LOS, discharge and/or death, as well as the presence of sepsis criteria and the use of corticosteroids. We also recorded relevant laboratory and demographic variables to determine severity of illness using the Mortality in Emergency Department Sepsis (MEDS) score in addition to vital signs and lactate levels. Results: A total of 116 patients were enrolled over the study period, of which 92 (79%) completely fulfilled sepsis criteria, while 24 initially thought to be septic were found to have alternative etiologies for their illness. Of the 92 patients with confirmed sepsis, 49 received midazolam and 43 received etomidate. Age in years (mean 71, SD П® 14), sex (56% male), MEDS score (mean 12.1, SD П® 4.6), need for vasopressors (48%), need for blood transfusion (6.5%), mean arterial pressure (mean 75, SD П® 25), pulse rate (mean 111, SD П® 28), respiratory rate (mean 26, SD П® 9), lactate (median 2.8, IQR 1.7 to 4.1) and receipt of supplemental corticosteroids (46%) were statistically similar between the two groups. In-hospital mortality of patients given etomidate (42%, 95% CI 28% to 57%) was similar to those receiving midazolam (35%, 95% CI 23% to 49%). There were no significant differences in median hospital LOS (9.2 vs. 10.8 days), median ICU LOS (3.1 vs 4.2 days), or median ventilator days (2.2 vs. 2.8) between patients who received etomidate and patients who received midazolam. Conclusions: Our results do not support the contention of significant effects on outcome from the use of etomidate for the intubation of patients with sepsis. Suggestions to discontinue the use of etomidate for intubation in the ED may not be warranted. 9 Does a Clinical Productivity Incentive Plan Work for Emergency Medicine Faculty? Richerson PJ, Morgan DL, Burr MF, Stone CK/Texas A&M University Health Science Center, Temple, TX; Scott and White, Temple, TX Study Objectives: There is growing financial pressure to maximize clinical productivity for academic physicians. Although incentive plans based on relative value unit (RVU) productivity have been studied in other academic departments, their use in emergency medicine departments have not been widely studied for effectiveness. Our goal was to determine if the implementation of an RVU-based incentive plan significantly increased the productivity of the emergency medicine faculty at a teaching hospital. Methods: Design: Retrospective analysis for the 6-month control period (1 year prior to implementation of the incentive plan) and the 6-month study period immediately after the incentive plan began. The incentive plan was a вЂњbase П© incentiveвЂќ model with the incentive payment to be distributed every 6 months to those faculty members who achieved the targeted RVUs/hour. This study analyzed total RVUs, patients seen, and hours worked for each faculty member. Setting: Academic teaching hospital and a Level I Trauma Center affiliated with a medical school located in a small city. The ED treats over 75,000 patients annually and has 30 emergency medicine residents. Type of Participants: 14 EM board-certified faculty S4 Annals of Emergency Medicine members with 1вЂ“25 years experience. Part-time faculty and full-time faculty who left the department during the study were excluded. Results: The emergency medicine faculty saw 30,263 patients during the control period and 33,474 (П© 10.6%) for the study period. The fraction of patients who left without being seen decreased from 2.6% to 2.0%. The total faculty time increased from 8,925 hours to 9,185 (П©2.9 %) due to decreases in part-time faculty coverage. The total RVUs increased from 62,654 to 66,199 (П©5.7%), but the total charges increased by 15.3%. The RVUs/patient decreased from 2.1 to 2.0 (ПЄ4.5%), but there was an increase in RVUs/hour from 7.02 to 7.2 (П©2.7%). Conclusion: There was a large increase in patients seen by the faculty. This may have been due to factors other than the incentive plan. Although the RVUs/patient decreased (probably due to seeing more patients with less acuity), the RVUs/hour increased. The significant increase in total charges indicates this incentive plan may increase clinical productivity in an academic emergency department. 10 Does a Team Triage Service Affect Patient Satisfaction in an Urban Academic Emergency Department? Saef SH, Gist A, Carr CM, Headden G, Lukasavage JN/Medical University of South Carolina, Charleston, SC Study Objectives: Compare patient perceptions of emergency care delivered by a team triage service in the hallway of a busy emergency department (ED) with the care provided in the regular treatment rooms of the same ED. Methods: The study setting was an urban level I trauma and tertiary care center at a southeastern academic medical center. The study design was a prospective, selfadministered, anonymous survey. The study site offers a вЂњteam triageвЂќ (TT) service in which patients receive expedited care by an expert emergency physician (EEP) working independently with an experienced emergency nurse and ED technician. TT patients were selected by the EEP or triage nurse and were seen separately from regular ED patients in a wide central hallway within the ED. Patient satisfaction surveys consisted of 4 questions which were validated prior to the study and addressed patient perceptions regarding (1) excellence of care, (2) MD hurriedness, (3) empathy of staff, and (4) waiting time. Survey forms were placed in wall files in the TT and regular treatment areas and were easily accessible to all patients. Surveys were submitted anonymously into drop-boxes at exit points from the ED. All questions were answered using a 5 point Likert scale. Results were compared using StudentвЂ™s t-test. Results: 274 patients submitted surveys; 197 regular ED and 77 TT. No significant differences were noted in excellence of care (pП0.64), MD hurriedness (pП0.69), staff empathy (pП0.87), or waiting time (pП0.57). Conclusion: Patients perceived equivalent quality of care, hurriedness of physicians, empathy of staff, and waiting times between TT and the regular ED. In this data, being seen quickly in the hall did not impact the studied measures of patient satisfaction. A team triage service, even when run in a busy ED hallway, appears to be a valid mechanism to provide expedited care in an urban academic ED. 11 Impact of Triage Physician and Clinical Operation Management Consultant Implementation on Emergency Department Throughput at a Tertiary Care Center AlDarrab A, Abuhaimed K, Alabdullah T, Alshabanah H, Almogbil M, Gletsu S/ King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia Study Objectives: Emergency department (ED) crowding is recognized to be a major, international concern that affects patients and providers. ED crowding causes are multifactorial and divided into 3 ED functions: input, throughput and output. In February 2008; 2 interventions were implemented in our ED: 1- Triage physician from 0800 вЂ“1600, to assist triage nurses and to initiate treatment for low acuity patients in a separate designated area. 2- Clinical operation management consultant on duty from 0800 вЂ“1400, to manage ED flow and administration, answer medical calls, assist charge nurses and act as a liaison with admitting services to ensure optimal care and expedite in-patient flow for boarded patients in the ED. We seek to evaluate the effect of implementing these 2 interventions on throughput at an ED of a tertiary care center. Methods: A before-after intervention administrative database review was completed for 6 months (MarchвЂ“August 2007) and same 6 months (MarchвЂ“August 2008). Outcome of interest was average monthly length of stay (LOS) (П©/ПЄ SD) for all patients presenting to our ED from arrival until disposition (discharge home for discharged patient and decision to admit for admitted patient). Results: During the study periods, 22987 were seen in 2007 compared to 24314 Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts in 2008. 2008 patients were admitted in 2007 compared to 2522 patients in 2008. LOS of admitted patients from decision to admit until they leave the department increased from 551 minutes (П©/ПЄ105) in 2007 to 979 minutes (П©/ПЄ 89) in 2008. LOS of patients from arrival till disposition reduced from 279 minutes (П©/ПЄ 28) in 2007 to 270 minutes (П©/ПЄ 22) in 2008. Conclusion: Despite the significant increase in input and output, implementation of triage physician and clinical operation management consultant provided benefits to throughput of crowded ED. The results strongly suggest that the implementation of this intervention could provide significant improvement to the delivery of emergency medical care in a tertiary care ED. 12 When the Emergency Department Is Packed Can Physician Assistants Pick Up the Pace? An Analysis of Physician Assistant Productivity Related to Patient Volume Brook C, Chomut A, Jeanmonod R/Albany Medical College, Albany, NY; St. LukeвЂ™s Hospital, Bethlehem, PA Background: The volume of patients seen in an emergency department (ED) is highly variable. It has been determined that resident productivity is not highly correlated with volume, but the relationship between physician assistant (PA) productivity and volume has not been studied. Study Objective: To determine whether PA productivity varies with ED census. Methods: A retrospective review was conducted of all ED visits at a level one trauma center during June and July 2007. The PA who first signed up for the patient and dictated the patientвЂ™s chart was considered to be the primary caregiver. All patients seen by PAs were included in the study. The hour during which care was initiated was defined as the hour that a PA electronically signed up for a patient. Productivity was calculated as the number of patients upon which care was initiated each hour. Data was collected regarding the total number of patients registered in the ED from 0700 to 2359 each day of the study period, as PAs do not work overnights at our institution. This was then broken down to patients registered per hour to determine ED volume per hour. Regression analysis was used to determine the relationship that hourly and daily volume had on PA productivity. Monthly Relative Value Units (RVUs) were also collected for the PAs during the study period. Results: During June and July 2007, there were 160 PA shifts. The number of patients seen in the ED per hour ranged from 0 вЂ“22 patients (Mean: 9.4 Standard Deviation: 3.9). Anywhere from 133вЂ“198 patients were seen daily (Mean: 160.4, Standard Deviation: 14.8). Regression analysis examining shift productivity related to daily volume showed a R2 of 0.01. Regression analysis of productivity per hour plotted against volume per hour yielded a R2 of 0.02. Productivity in terms of mean RVUs per hour during the study period was calculated as 2.35 RVUs/hour (95% CI П 1.98 вЂ“2.72). Conclusion: PA productivity does not correlate with the total or hourly volume of patients seen in the ED. 13 Utilizing Time-Driven Activity-Based Costing in the Emergency Department Bank DE, McIlrath T/Phoenix ChildrenвЂ™s Hospital, Phoenix, AZ Study Objectives: Traditionally employed health care costing methods may not accurately reflect actual costs of emergency department (ED) service. The introduction of a practical costing tool using a time driven activity-based costing (TDABC) model allows ED directors to understand the costs of ED service and make decisions on the allocation of resources. Methods: This study was conducted using data from a high volume pediatric ED in a free-standing childrenвЂ™s hospital. The TDABC model was utilized to estimate costs of provider resources and apply them to three specific clinical scenarios common to any ED service: a simple laceration repair of an extremity (ПЅ2.5cm), a mild asthma exacerbation requiring respiratory therapy, and acute gastroenteritis with mild dehydration requiring intravenous fluid therapy. We compared our calculated costs for each of these three clinical scenarios with the standard Medicaid Outpatient Prospective Payment System (OPPS) and physician fee reimbursement schedules for 2008. The total direct and indirect costs to the ED were obtained from 2008 hospital accounting. Costs of medications and supplies were obtained from hospital materials management and pharmacy accounting and were treated as separate entities. Results: In each of the 3 clinical scenarios, combined 2008 OPPS and physician reimbursement was greater than the total ED costs derived using TDABC. In Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Scenario 1: a simple laceration repair of an extremity (ПЅ2.5cm), the Medicaid reimbursement was $581.77 and the estimated actual cost was $365.53 (profit margin 37%). In Scenario 2: a child with mild asthma exacerbation requiring respiratory therapy, the Medicaid reimbursement was $501.87 versus the estimated actual cost of $491.61 (profit margin 2%). In Scenario 3: a child with acute gastroenteritis and mild dehydration requiring intravenous fluid therapy, the Medicaid reimbursement was $523.00 versus the estimated actual cost of $491.43 (profit margin 6%). Conclusion: TDABC may be utilized as an effective and accurate tool to estimate the true cost of ED service. For any given patient encounter, the costs of service vary greatly based on the proportion and time of resources utilized. TDABC analysis can be used by ED directors to help determine the allocation of ED clinical resources. TDABC analysis of service can be used as a tool to help development professional and facility reimbursement strategies with commercial payers. 14 An Analysis of Emergency Department Flow, Severity and Congestion Factors That Are Associated With Decreases in the Left Without Being Seen Rate Sattarian M, Shesser R/George Washington University, Washington, DC Study Objective: During the last 3 years, the overall left without being seen (LWBS) rate in our academic, urban emergency department (ED) decreased from 4.6% (2006) to 3.2 % (2008) despite an increase in ED census and the absence of specific process change that focused on LWBS rate reduction. This analysis examines the strengths of association between the LWBS rate and a group of standard ED flow, congestion, and severity parameters. Methods: Data on all visits during calendar years 2006 вЂ“ 8 to the GW Hospital ED were tracked with an EMR application that required assignment of a specific discharge category for every arrival. The LWBS category included all registrants who left either before or after nursing triage, but before being seen by a physician. Data were analyzed by hour for each of the 26,304 hours in the study period. The LWBS patient number for each hour during this period was compared to the mean arrivalbed (waiting) times for ambulatory patients arriving that same hour who successfully completed their evaluation, their mean Emergency Severity Index scores, the number of patient arrivals during that hour, and the total number of patients in the ED treatment area and lobby at each hourвЂ™s end. Results: During the analysis period, 187,663 patients were registered; 128,430 walk-ins (68.4%) and 59,233 ambulance arrivals (31.6%). 7,543 patients LWBS, 6,705 (88.9%) of whom were walk-ins and 838 (11.1%) arrived by EMS. LWBS rates for the three year analysis period were 4.0% overall, 5.2% for walk-ins and 1.4% for ambulance arrivals. The LWBS rate for walk-ins decreased by 36% from 5.5% (JulyвЂ“December, 2006) to 3.5% (JulyвЂ“December 2008) (P ПЅ 0.001). During the analysis period, mean waiting times for ambulatory arrivals decreased from 61.4 minutes (2006) to 52.6 minutes (2008); mean total hourly arrival volume increased from 6.9 patients (2006) to 7.5 patients (2008); and mean, total end-hourly ED census increased from 36.5 patients (2006) to 39.5 patients (2008). Measuring the strength of association between the hourly LWBS patients and that same hourвЂ™s waiting times, arrival volume, Emergency Severity Index acuity, and total end-hourly ED census demonstrated highly significant relationships between LWBS and waiting times (P ПЅ 0.001, r: 0.48) and total ED census (P ПЅ 0.001, r: 0.34). There was a weaker relationship with arrival intensity (P ПЅ 0.001, r: 0.26), and no relationship with mean patient acuity. Conclusion: ED process improvements that lead to a modest decrease in patient waiting time, may achieve larger, proportional decreases in the EDвЂ™s LWBS rate. Although decreased waiting time in our setting was achieved by вЂњfront-endвЂќ process improvement, вЂњback-endвЂќ strategies that reduce total ED census may have a greater effect on reducing the LWBS rate due to the strong association between LWBS and total ED census. It is still possible to lower LWBS rates during periods of increasing ED census and congestion. 15 Satisfaction of Emergency Department Hallway Patients Stiffler KA, Wilber ST, Blanda M, Nielson J, Winot S, Kline J/ Summa Health System/NEOUCOMP, Akron, OH Study Objectives: Emergency department (ED) crowding is recognized as a national problem and has reached epidemic proportions. During times of acute ED crowding, patients experience their most significant delay while waiting for an ED bed. Many EDs attempt to ameliorate this problem by treating non-urgent conditions in hallway treatment areas instead of regular treatment rooms. Many studies are Annals of Emergency Medicine S5 Research Forum Abstracts available on patient satisfaction, but none specifically address the satisfaction of patients who are assigned hallway beds in the ED. We conducted a study to evaluate patientsвЂ™ opinions, concerns, and satisfaction about being placed in hallway treatment spaces for their ED care. Methods: A cross-sectional study of patients assigned to a hallway treatment space at Akron City Hospital ED, a 72,500 adult visit urban community teaching hospital, was performed. Sequential patients who were placed in hallway treatment spaces during peak volume hours were asked to complete a confidential, self-administered survey regarding hallway treatment issues. The initial questions asked how patients felt about various issues pertaining to being treated in the hallway using a 5-point Likert scale. The second portion of the survey used 100mm visual analog scale questions (0Пnot satisfied, 100Пsatisfied) to determine satisfaction levels with regard to treatment location, medical care, and overall satisfaction. Data are reported as means and proportions with 95% confidence intervals (mean 95% CI). Results: A total of 100 patients with a mean age of 41.6П®16.4 years completed the survey. Fifty nine percent were female. Areas of greatest concern for patients included feeling in the way (60%, 95% CI 49.7вЂ“ 69.7), having no room for visitors (57%, 95% CI 46.7вЂ“ 66.9), and a lack of privacy (56%, 95% CI 45.7вЂ“ 65.9). Forty two percent (95% CI 32.2вЂ“52.3) identified safety as a concern. Overall visit satisfaction scores were 52.77 (95% CI 46.9 вЂ“58.6), while satisfaction with regard to medical care revealed 70.27 (95% CI 65.0 вЂ“75.5). Satisfaction with regard to hallway treatment location scored 46.31 (95% CI 39.7вЂ“52.9). Thirty-four percent of patients (95% CI 24.8 вЂ“ 44.1) surveyed were less likely to recommend our ED to others based on treatment location, while 26% (95% CI 17.7вЂ“35.7) were less likely to recommend this hospital system. When questioned about willingness to wait any longer for a treatment room, 75% (95% CI 65.3вЂ“ 83.1) preferred to be treated in the hallway immediately. The most common Emergency Severity Index score of surveyed hallway patients was 3 (72%, 95% CI 62.1вЂ“ 80.5). Emergency Severity Index category 4 patients represented 25% (95% CI 16.9 вЂ“34.7) of the population. The remaining 3 patients had an Emergency Severity Index of 5 (95% CI 0.62вЂ“ 8.5). Conclusion: Overall satisfaction and satisfaction with treatment area are low for patients treated in the hallway. Patients feel as if they are in the way, and cite lack of visitor space, lack of privacy, and a fear for safety. Despite these issues, most patients would prefer to be treated in the hallway as opposed to waiting any longer in the waiting room. 16 Emergency Department Consultation Practices and Documentation Vary Widely Across Hospitals Schuur J, Moreau J, Bohan J, Fauchet G, Lobon L, Lyn E, Nathanson L, Stack A, Temin E, Tibbles C/Brigham and WomenвЂ™s Hospital, Boston, MA; Cambridge Health Alliance, Cambridge, MA; North Shore Medical Center, Salem, MA; Beth Israel Deaconess Medical Center, Boston, MA; ChildrenвЂ™s Hospital Boston, Boston, MA; Massachusetts General Hospital, Boston, MA Study Objectives: Emergency department (ED) specialty consultation carries significant patient safety and medico-legal risk, as it involves information transfer between multiple providers. We aimed to determine the frequency that information considered critical to consultations is documented and the prevalence of informal consults. Methods: We conducted retrospective chart review at 6 hospitals (2 community teaching hospitals [CHs] and 4 academic/urban Level 1 trauma centers [AHs]) in a Northeastern metro area. At each hospital, we consulted with ED and consultant service leaders to determine critical elements of consults. We identified the following time points: consult called, consult acknowledged, and consult completed. Other elements identified as critical to document included: reason for consult, supervision of trainees, and real-time вЂњclosed-loopвЂќ communication between the consultant and the emergency physician at the beginning and completion of the consultation. Each ED reviewed 20 charts from each of 4 commonly consulted services for documentation of the critical elements of consultation (80 вЂ“ 87 charts at each AH and 10 and 75 charts at CHs). To determine the prevalence of informal (ie, вЂњcurbsideвЂќ) consults, we reviewed 100 вЂ“200 consecutive ED charts at each hospital (nП737). We identified documented mentions of specialty consults within emergency physician documentation and matching consultant documentation. We determined the percent of informal consults from all services by calculating the ratio between explicit consult mentions and written consult notes. Results: Documentation of critical elements varied widely across services and hospitals (Table). Time consult requested was logged 100% of the time at one ED with a dashboard that logged consults, and two other hospitals had high percentages of documented consult request time due to formal recording policies (55% and 100% S6 Annals of Emergency Medicine compliance). Time consult acknowledged was rarely recorded (8% across all hospitals), except at the ED with the electronic dashboard (25%). Documentation of other critical communication elements also varied across hospitals: reason for consult: 37вЂ“96%; role of supervising MD: 38 вЂ“78%; and real-time closed loop communication at consult completion: 19 вЂ“ 88%. Evidence of informal consultation in ED documentation was common, with 17вЂ“ 43% of consult mentions unaccompanied by consultant documentation. There was significant variation in all measures between services at each hospital (see table). Conclusion: Consultation practice varied significantly across 6 hospitals in a metropolitan area and within each hospital by service. Timeliness, supervision and communication between emergency physicians and consultants is not routinely documented in the medical record, and informal ED consults (вЂњcurbsidesвЂќ) are common. There is an opportunity to standardize communication and documentation, which may improve patient safety and reduce medico-legal risk. 17 Emergency Department Rapid Assessment Unit at the Cambridge Hospital: Why and How? Lobon LF, Sayah AJ, Rivard L, Brady M, Skura S/The Cambridge Hospital/Cambridge Health Alliance, Cambridge, MA Background: Before having contact with a provider and receiving medical treatment the majority of emergency department (ED) patients in the US are screened by clinical and non-clinical staff. This screening follows a sequential process including triage, registration and initial assessment which requires patients to move through different areas of the ED. Our model at The Cambridge Hospital ED (TCH ED) followed that operational structure until 4/2/08. We believe that delays in patient care were caused by the factors described above and contributed to: в—Џ Increase in time for provider evaluation and management в—Џ Increase total length of stay with long вЂњwaiting roomвЂќ times в—Џ Crowding/ambulance diversion situations в—Џ Very low patient satisfaction scores Study Objectives: Rapid Assessment Unit (RAU) implementation on 4/2/08 impact on time-to-provider (TTP), turn-around-times (TAT) and ED quality indicators: Press Ganey scores (PG) and left without been seeing (LWBS). RAU has 5 dedicated front-end multipurpose treatment areas and is staffed 10am-10pm by 1 PA (supervised by an ED attending), 2 RNs, 1 ED tech and 1 patient partner (PP). Immediately upon arrival to the ED reception area patients are greeted by our PP and entered into our electronic record system. Subsequently they are escorted into the RAU where the clinical team assesses their condition and determines based on the Emergency Scale Index (ESI) if: 1. the patient can stay in RAU for treatment and release 2. the patient needs to be evaluated immediately in the acute care area due to the severity of the presentation 3. management will start in RAU and will continue in the acute care area when appropriate. Registration and triage are brought to the patientвЂ™s bedside avoiding delays and uncomfortable transfers. Methods: Retrospective data analysis includes ED visits pre-implementation of a RAU in Jan 08 and post-implementation in Jan 09, during the hours that RAU is operational, 10am-10pm. We will compare mean values for time -to-provider and turn-around-times. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts A comparison of quality indicators such as PG scores and LWBS will also be evaluated around the time periods selected. Results: 1. Time Indicators: TTP down from 37 minutes in Jan 08 to 23 minutes in Jan 09 TAT down from 160 minutes in Jan 08 to 137 minutes in Jan 09 2. Quality Indicators: PG scores up 80.9 Q2FY08 to 85.6 Q2FY09 LWBS down from 61 Q2FY08 to 28 Q2FY09 Conclusion: Budget neutral operational changes such as implementation of the RAU at TCH ED can have significant impact on the efficiency of the department. Reduction in key time intervals in emergency medicine such as time-to-provider and turn-around-time seems to correlate with improved scores in patient satisfaction surveys and other quality indicators such as LWBS. The improvement in efficiency indicators provided by the implementation of the RAU at TCH ED has increased our competiveness in a demanding health care market where patients choose their providers based on quality of care and expeditious service. 18 Fibrinolytics for Acute Myocardial Infarction in Emergency Departments Niska RW/Centers for Disease Control, Hyattsville, MD Study Objectives: In 2006, the American College of Emergency Physicians proposed measures to improve quality of emergency medical care, including the use of fibrinolytics in acute myocardial infarction. This investigation is important because it studies the extent of emergency department use of fibrinolytic agents for myocardial infarction in response to recent clinical guidelines, and the factors associated with using fibrinolytics. Methods: The National Hospital Ambulatory Medical Care Survey (NHAMCS) is an annual nationally representative cross-sectional survey of hospitals with emergency and outpatient departments. This study examines fibrinolytic use in the treatment of acute myocardial infarction in emergency departments, using data from the NHAMCS for 2000 вЂ“2006. From 2000 to 2006, there were 661 unweighted visits from patients with acute myocardial infarction (weighted national estimate of 297 thousand annual visits) without contraindications to fibrinolytics. The prevalence of fibrinolytic therapy was determined and cross-tabulated against independent variables that might influence compliance with fibrinolytic guidelines, including age, sex, ethnicity, triage acuity, ambulance arrival, transfer to another facility, primary payment source, metropolitan statistical area, and annual visit volume. Bivariate associations were analyzed with chi-square test of significance at alpha less than 0.05. Odds ratios with 95 percent confidence intervals were derived for each independent variable from logistic regression, adjusting for other independent variables. Results: Fibrinolytic agents were given at 7.6 percent of visits. Adjusting for all independent variables in a logistic regression model, fibrinolytic therapy was about seven times more likely to be given to patients who were then transferred to another facility, and about four times more likely to be to patients triaged as needing to be seen in less than 15 minutes. Fibrinolytics were less than a tenth as likely to be given to non-white, non-Hispanic patients, and about a tenth as likely to be given to Medicaid patients as to those who were privately insured. Conclusion: Relatively few acute myocardial infarction patients are receiving fibrinolytics when indicated, and there is evidence of socioeconomic disparities in their use. This analysis is timely as a reminder to clinicians to understand and implement fibrinolytic guidelines. More research is needed to define disparities in fibrinolytic use more precisely, as well as to determine whether other interventions are being used as an alternative to fibrinolytics. 19 Prescription of Non-Steroid Anti-Inflammatory Drugs in Emergency Department Patients With Acute Coronary Syndrome/Myocardial Infarction Zito JA, Garra G, Thode Jr HC, Singer AJ/Stony Brook University, Stony Brook, NY Study Objectives: There is mounting evidence that use of non-steroid antiinflammatory drugs (NSAID) is associated with increased cardiovascular risk. Recent American Heart Association guidelines discourage the use of NSAIDs in Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ patients with acute coronary syndrome/myocardial infarction. We determined trends in NSAID prescriptions for ED patients with acute coronary syndrome/ myocardial infarction who presented to US emergency departments over the last decade. Study Design: Retrospective analysis of National Hospital Ambulatory Medical Care Survey for the years 1998 вЂ“2005. Subjects: Primary diagnosis of acute coronary syndrome/myocardial infarction based on ICD-9-CM codes. Methods: Demographic and clinical characteristics and prescription of NSAIDs in ED based on medication codes. Analysis: PatientsвЂ™ weights were used to obtain estimated national values. Univariate and multivariate analyses used to determine association between predictor variables and NSAID prescriptions and trends over time. Results: The number of acute coronary syndrome/myocardial infarction patients decreased from 320,000 and 360,000 in 1998 to 177,000 and 264,000 in 2005 respectively, while the number of ED visits increased from 100 to 115 million. Acute coronary syndrome/myocardial infarction patients were similar in mean age (65 vs 63) and sex (55% vs 53% male). There was a significant but nonlinear increase in NSAIDs prescribing in acute coronary syndrome patients over time (PП0.003): 17% from 1998 to 2000, then increasing from 17% in 2000 to 37% in 2005. The rate of NSAID prescribing in myocardial infarction patients varied widely from year to year (min 20% in 1999, max 31% in 2002) but there was no trend over time. By comparison, there was an increasing linear trend (PПЅ0.001) in NSAIDs usage over time in patients without acute coronary syndrome/myocardial infarction from 15% in 1998 to 20% in 2005. Multivariate analysis indicated there was no relation between NSAIDs use and age, sex or geographic region for either acute coronary syndrome or myocardial infarction patients. Conclusion: The rates of NSAID prescription in acute coronary syndrome but not myocardial infarction patients increased over time. Education of emergency physicians regarding the risks of NSAIDs in acute coronary syndrome may be required. 20 Can Point-of-Care Assays Deliver Lab Quality Accuracy? Peacock IV W, Diercks D, Hollander J, Singer A, Birkhahn R, Shapiro N, Lewandrowski E, Nagurney J/The Cleveland Clinic, Cleveland, OH; University of California, Davis, Sacramento, CA; University of Pennsylvania, Philadelphia, PA; Stony Brook University and Medical Center, Stony Brook, NY; New York Methodist Hospital, Brooklyn, NY; Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts General Hospital, Boston, MA Study Objectives: Troponin I (TnI) point-of-care (POC) assays historically suffer greater inaccuracy than lab-based assays. Our purpose was to compare the diagnostic accuracy of a contemporary POC TnI assay to a lab-based platform. Methods: From healthy normal banked samples, we determined the 99th%ile TnI reference value with the POC Cardio3 TnI (Biosite, Inc, San Diego, CA) and the lab-based DxI TnI (Beckman Coulter, Inc, Fullerton, CA), termed the вЂњderivation cohort.вЂќ The Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS) was a multicenter study that collected plasma from patients presenting to the emergency department with suspected acute coronary syndromes in whom the emergency physician planned an objective cardiac ischemia evaluation (eg, exercise stress testing, myocardial perfusion imaging, etc). In the MIDAS study, gold standard diagnoses were adjudicated by the site principal investigator at the end of hospitalization, using all available data. Applying the reference ranges from the derivation cohort, we determined assay performance to diagnose non-ST segment myocardial infarction (NSTEMI) in a validation cohort from the MIDAS study, enriched to provide a 50% acute coronary syndrome rate. Results: The derivation cohort (nП997) provided TnI reference ranges of 0.05ng/mL for both the lab and POC platforms. The final diagnosis distribution of the validation cohort was non-cardiac chest pain (nП176, 50.7%), unstable angina (nП74, 21.3%), NSTEMI (nП72, 20.7%), and STEMI (nП25, 7.2%). In the validation cohort, after exclusion of STEMI patients, there were no performance differences between the lab or POC tests when comparing patients with and without NSTEMI (see table). Conclusion: In ED suspected ACS patients, the Cardio3 TnI POC platform provides similar diagnostic performance for the outcome of NSTEMI as a contemporary laboratory-based Troponin I assay. Annals of Emergency Medicine S7 Research Forum Abstracts 23 Typical Angina Is Not Predictive of the Presence of Inducible Cardiac Ischemia in Emergency Department Chest Pain Patients Hermann LK, Weingart S, Yoon Y, Shearer P, Henzlova M, Duvall WL/Mt Sinai School of Medicine, New York, NY; Elmhurst Hospital, New York, NY; Mt Sinai, New York, NY 21 Oral Anticoagulation Quality Index as a Predictor for Bleeding Franciscon A, Machado J, Schmidt A, Pazin-Filho A/Medical School of Ribeirao Preto - University of Sao Paulo, Ribeirao Preto, Brazil Study Objectives: To evaluate the impact of the oral anticoagulation quality index over the emergency department visits for patients regular taking warfarin in a tertiary reference hospital. Methods: Two groups of patients taking warfarin on a regular basis were identified - Group I (57,4П®10,4 years; 30% male) constituted by patients with atrial fibralation and a RNI target 2вЂ“3 and Group II (41,3П®13,7 years; 37% male) of patients anticoagulated due to methalic valve prosthesis and a RNI target 2.5вЂ“3.5. Both groups were free of bleeding events prior enrollment and were followed through a median of 11 years (interquartil range 2.5 вЂ“ 15 years). Outcome was defined as a bleeding event over moderate severity or those in need of blood transfusion, fresh frozen plasm or vitamin K administration. Exposure was defined as the oral anticoagulation quality index, determined by the percentage of the RNI values in the target range devided by the total RNI values obtained. Survival analysis techniques were employed to calculate events rate and Cox proportional analysis for adjusting for potential confounders. To exclude the erratious RNI levels during anticoagulation start, we used a lag time analysis. Results: Group I quality index did not differ from the Group II (0,60П®0,20 x 0,62П®0,10 ПЄ p 0,54) in univariate analysis. Group I (23 events) showed an incidence rate of 86.7 per 100.000 patients/year (48.5 вЂ“ 143.0 95% CI) while Group II (28 events), an incidence rate of 58.2 per 100.000 patients/year (38.0 вЂ“ 85.2 95% CI) ПЄ Log Rank test 0.1518. In multivariate analysis, only the quality index was associated with a hazard ratio for Group II ПЄ 15.5 (1.31 вЂ“ 181.8 95% CI). Conclusion: Keeping the RNI in the recommended range is of extreme importance to avoid significant bleeding events. In our study, the intensity of the RNI range was not associated with greater hazard ratio for bleeding, while a significant difference was shown for the quality of the anticoagulation. 22 Error in Body Weight Estimation Leads to Inadequate Parenteral Anticoagulation Macedo LG, Pazin-Filho A/Medical School of Ribeirao Preto - University of Sao Paulo, Ribeirao Preto, Brazil Study Objectives: To evaluate the adequacy of parenteral anticoagulation with enoxaparin, mensurated by anti-Xa (Пѕ 0.5 and Х… 0.5 UI/ml), according to body weight estimation error (Пѕ 10% and Х… 10 %). Methods: 28 patients (13 men; age 59.3П®13.9 years) initiating enoxaparin due to cardiovascular emergency conditions (acute coronary syndromes, pulmonary embolism or intracardiac thrombus) were prospectively enrolled. The initial enoxaparin dose was based on subjective estimation by the attending physician or on information provided by the patient. Objective measured body weight was obtained 24 hours after admission and the patients were classified in group 1 (body weight error Пѕ 10%) or 2 (Х… 10 %). The activity of anti-Xa factor was measured before and after the first dose of enoxaparin and after the second dose for every patient and the values compared between the groups. Results: Group 1 (21 patients; 59.3П®14.2 years) had anti-Xa levels within the therapeutic range for all the patients, while 4 patients (14.3%) of Group 2 (7 patients; 59.2П®14.2 years) had anti-Xa levels ПЅ 0.5 Ul/mL. Anti-Xa levels were normal before starting enoxaparin for both groups and there was no difference referring to creatinine levels between the groups. Group 1 had an estimated weight of 63.3П®12.0 kg and a mensurated of 76.2П®10.3 kg (p non-significant), while Group 2 had an estimated weight of 75.0П®5.0 kg and a mensurated of 95.6П®4.6 kg. Conclusion: Body weight estimation error greater than 10% is frequent, associated to patients with greater measured body weight and leads to undertherapeutic anti-Xa levels. S8 Annals of Emergency Medicine Study Objectives: To assess the value of the presenting symptom of typical anginal pain, atypical/non-anginal pain, or lack of chest pain in predicting the presence of inducible myocardial ischemia via cardiac stress testing in emergency department (ED) patients being evaluated for possible acute coronary syndrome (ACS). Methods: This was a retrospective observational study of adult patients who were evaluated for ACS in an ED chest pain unit from March 2004 to May 2008. Patient presenting symptom was categorized based on the presence of: 1) substernal chest pain or discomfort that is 2) provoked by exertion or emotional stress and 3) relieved by rest and/or nitroglycein. Chest pain was classified as вЂњtypicalвЂќ angina if all three descriptors were present and atypical or non-anginal if less than three descriptors were present. All patients underwent serial biomarker and cardiac stress testing prior to discharge. Results: 2525 patients, aged 22вЂ“97, met eligibility criteria. Inducible ischemia on stress testing was found in 33 (14%) of the 231 patients who had typical anginal pain, 238 (11%) of the 2,140 patients presenting with atypical/non-anginal chest pain; and 25 (16%) of the 153 patients who had no complaint of chest pain at presentation. The presence of typical chest pain had a likelihood ratio positive of 1.25 (95% CI 0.89 вЂ“1.78) and negative 0.98 (95% CI 0.94 вЂ“1.02). The presence of any form of chest pain when compared to the absence of pain had a likelihood ratio positive of 0.97 (95% CI 0.94 вЂ“1.01). Conclusion: In our study, patients who presented with typical angina were no more likely to have inducible myocardial ischemia by stress testing than other presenting symptoms. Our data suggests that presenting symptoms are not helpful in identifying which patients have a high probability of obstructive coronary artery disease and therefore should be used with caution to determine disposition and the need for further testing. 24 Initiating Medical Therapies in the Cardiac Catheterization Lab Decreases Door-To-Balloon Time for Acute ST Elevation Myocardial Infarction Bastani A, Anderson W, Rocchini A, Newman S, Lazarus J, Ishioka N, Cholette K, Hercula J, Hunt-Walch R, Kraft P/William Beaumont Hospital, Troy, MI Study Objective: The national standard for door-to-balloon time (DBT) is 90 minutes as recommended by the American Heart Association/American College of Cardiology guidelines for ST-elevation myocardial infarction (STEMI). In 2007 39% of STEMI patients at our institution did not meet this recommendation. A STEMI multidisciplinary team consisting of emergency physicians, cardiologists, cardiac catheterization lab (CCL) and emergency department (ED) personnel was assembled to identify areas of delay in our DBTs. This team identified that the timeframe between STEMI team notification by the emergency physician and transfer to the CCL accounted for a significant portion of the delay. This time period consisted of the 2 main procedures: 1) the initiation of all anti-platelet, anti-thrombotic and vasoactive therapies and 2) the preparation of the patient for transport to the CCL. Our objective was to shorten this time period by prioritizing the ED personnel to prepare and transfer the patient to the CCL rather than focusing on the initiation of medical therapies. By focusing the ED personnel to immediately transfer the patient to the CCL after STEMI team notification, the patient would be able to simultaneously receive medical therapies and prepare for angiography, thus decreasing our DBTs. Methods: To evaluate the outcome of our new protocol on DBTs, we conducted a before and after study from January 2007 to Feb 2009. In Feb 2008, the acute STEMI protocol at our institution was revised to focus on immediate transport of the patient to the CCL before all medical therapies had been initiated. No other significant changes were made to the protocol during the study period. Our primary outcome was the mean DBT for the 13 months prior to our intervention, compared to the mean DBT for the following 13 months. DBT was then subdivided to elucidate the effect of our protocol modification on the time between STEMI team notification and time of transfer to the CCL. Means were reported with standard deviations and significance was analyzed by an unpaired two-tailed t-test (вђЈП 0.05). Results: During the 13-month period prior to protocol revision, the mean DBT was 91.70 minutes (П©/ПЄSD П 32.57). After the protocol was revised, the mean Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts DBT decreased to 66.84 minutes (П©/ПЄSD П 19.76). By implementing this protocol change DBT was decreased an average of 25 minutes (pПЅ0.0001). Furthermore, the mean CCL transfer time was 38.17 minutes (П©/ПЄ SD 12.49). After the protocol was revised, the mean CCL transfer time was 26.73 minutes (П©/ПЄ SD 9.04); with an absolute reduction of 11.44 minutes (pПЅ0.0001). Conclusions: Immediate transport of the patient to the CCL prior to initiation of all medical therapies in the ED significantly decreases DBTs for acute STEMI. 25 Additional Diagnostic Utility of Upright T-Wave in V1 and T-Wave V1 Vs. T-Wave in V6 in Differentiating Acute Anterior ST-Elevation Myocardial Infarction From Benign Early Repolarization Smith SW/Hennepin County Medical Center, Minneapolis, MN Background: Using logistic regression, we previously derived, then later validated, a predictive rule to differentiate benign early repolarization (BER) from subtle acute anterior ST elevation myocardial infarction (STEMI) due to acute left anterior descending (LAD) coronary artery occlusion. The logistic regression rule (LRR) uses the mean R wave (RA) amplitude in V2-V4, mean ST elevation at the J-point (STEJ) in V2-V4, and Bazett corrected QT interval (QTc-B) in milliseconds (ms) such that if (1.553 x mean STEJ) П© (.0546 x mean QTc-B in ms) вЂ“ (0.3813 x mean RA) Пѕ 21, vs. ПЅ/П 21, then anterior STEMI was predicted. It has been suggested that an upright T-wave (TW) in lead V1 (TV1) is predictive of acute myocardial infarction, especially when the amplitude of TV1 Пѕ TV6. Study Objective: We sought to determine how the addition of this latter TW rule to the LRR would improve the utility of the LRR alone in the diagnosis of anterior STEMI. Methods: Retrospective study combining the derivation and validation sets for the previous study. The study group comprised consecutive anterior STEMI sent for primary percutaneous coronary intervention who had proven LAD occlusion. The control group comprised consecutive ED chest pain patients whose ECGs were coded as BER and who had 3 negative serial troponins. ECGs were excluded if MI was obvious: this was defined if there was inferior ST depression, STE Пѕ 5mm, anterior TW inversion, terminal QRS distortion, or a single straight or convex ST segment in any of leads V2-V6. Computerized QTc-B, and hand measured RA and STEJ in leads V2-V4 were measured to the nearest 0.5mm relative to the PR interval. In addition, TV1 was scrutinized and deemed inverted if either the entire T, or just the terminal portion of it, was inverted. It was coded as upright if there was no inversion. An upright TV1 was Пѕ TV6 if it was at least 1.0 mm greater in amplitude. Statistics were by two-tailed Chi square and Fisher exact test. Results: There were 292 ECGs; 125 with anterior STEMI and 167 with BER. 78/167 BER (47%) and 88/125 anterior STEMI (70%) had an upright TW in V1 (pПЅ .0001). 24/167 (14%) BER and 51/125 (41%) anterior STEMI had TV1ПѕTV6 (pПЅ.0001). Sensitivity (Sens), specificity (Spec), and accuracy (Acc) of upright TV1, and TV1 Пѕ TV6 for MI were, respectively, 70%, 47%, and 61%, and 41%, 86%, and 66%. Sens, Spec, and Acc of the LRR value Пѕ 21 was 91%, 83%, and 87%. Sens, Spec, and Acc of the LRR value Пѕ 21 or upright TW in V1, vs. neither, was 97% (pП0.11 vs. LRR alone), 42% (pПЅ.0001), and 65% (pПЅ.0001). Sens, Spec, and Acc of the LRR value Пѕ 21 or TV1 Пѕ TV6, vs. neither, was 96% (pП0.20 vs. LRR alone), 72% (pП.01), and 82% (pП0.17). Conclusion: An upright TW in V1, and TV1ПѕTV6, are both significantly more common in anterior STEMI than BER. Neither rule performed as well as the LRR which uses RA, STEJ, and QTc-B. The addition of upright TW in V1, or TV1ПѕTV6, minimally and nonsignificantly improved sensitivity of the LRR for LAD occlusion at the expense of significant decrement in specificity and accuracy. 26 When вЂњGoodвЂќ Is Below Average Kiefer CS, Colletti JE, Bellolio M, Thomas KB, Woolridge DP/Mayo Clinic, Rochester, MN; University of Arizona, Tucson, AZ Study Objectives: The Medical Student Performance Evaluation (MSPE) is a summarative evaluation composed by a studentвЂ™s medical school dean that takes into account the studentвЂ™s performance during pre clinical and clinical years. The aim of this study was to determine if there was a relationship between usage of the term вЂњgoodвЂќ in the descriptive paragraph of the MSPE and academic performance in medical school as described by the ranking within the class. Methods: The final paragraph of the MSPE contains a summary statement in which the writer of the evaluation often uses a descriptive term such as вЂњgood,вЂќ Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ вЂњoutstanding,вЂќ or вЂњexcellentвЂќ in order to summarize a studentвЂ™s overall performance. All MSPEs submitted to 3 different residency programs were reviewed. Each MSPE was examined to determine the presence or absence of the descriptive term вЂњgoodвЂќ in either the summary statement or the appendices accompanying the MSPE. For institutions using the term вЂњgood,вЂќ the percentile ranking of students in the class receiving вЂњgoodвЂќ as a descriptive term was noted. Following tabulation, the data was dichotomized in вЂњbadвЂќ for institutions describing students in the bottom 25% and вЂњintermediateвЂќ for the rest of the institutions, and analyzed with Wilcoxon test according to its non-normal distribution. Results: MSPEs were collected from122/125 accredited medical schools. Overall, 34 (27.9%) of institutions sampled used the term вЂњgood,вЂќ 86 (70.5%) of schools had no mention or category of students that was classified as вЂњgood,вЂќ and the use of the term вЂњgoodвЂќ was unclear in 2 institutions. Of the 34 institutions utilizing вЂњgoodвЂќ to describe students, all used the term to classify students in either the bottom 50%. Specifically, 25 schools used the term to classify students in the bottom quartile (0 вЂ“25%), 4 schools to students in the bottom 33%, 4 schools to students ranked between the 20 and 40th percentile, and in 1 institution вЂњgoodвЂќ was applied to students in the bottom half of the class (0 вЂ“50%). There was a significant difference in the use of the term вЂњgoodвЂќ among different medical schools when comparing those in the bottom 25% versus those with intermediate scores (pПЅ0.0001). Students described by вЂњgoodвЂќ could be anywhere between the 1st and 50th percentile. Conclusion: In the MSPE, the term вЂњgoodвЂќ was utilized to describe students in the bottom 50% of the class. This makes a вЂњgoodвЂќ medical student, a code for a below average medical school performance. 27 An Assessment of Resident Training in Emergency Department Administration Farley HL, Buehler G/Christiana Care Health Systems, Newark, DE; Christiana Care Health Systems, Newark, DE Background: Emergency department (ED) administration encompasses a wide range of topics which residents spend a variable amount of time learning during training. Study Objective: To examine the curricula of emergency medicine (EM) residency programs with regards to ED administration. Methods: An electronic survey was sent to all U.S. EM residency coordinators to evaluate resident training in ED administration. Data included which post-graduate year (PGY) residents completed the rotation, the amount of time dedicated to ED administration, and administrative topics covered. Possible administrative topics covered included ED operations, billing/coding, quality assurance/performance improvement, risk management/medical-legal, EMTALA, contracts, budget planning/financing, scheduling, marketing, public policy/political advocacy, and an option to specify other topics. Results: 55/140(39.3%) of coordinators completed the survey. Of programs that completed the survey, 73.6% reported having ED administration as part of the curriculum, and 57.7% had a dedicated rotation block for ED administration. Of those with dedicated administration rotations, 77.4% occurred during the PGY-3 year. The most common length of an administration rotation was 4 weeks (41.9%). However, about half (51.6%) reported having ED administration combined with another rotation, such as EMS, research, or toxicology. The most common topics covered included ED operations (93.8%), quality assurance/performance improvement (84.4%), and risk management(87.5%). Other topics covered included billing/coding (62.5%), EMTALA (56.3%), contracts (34.4%), budget planning/ financing (46.9%), scheduling (28.1%), marketing (9.4%), and public policy/political advocacy (43.8%). Conclusions: The amount of time dedicated to ED administration and the administrative topics covered vary widely among training programs. 28 The Use of Video Laryngoscopy in Massachusetts Emergency Departments Raja AS, Sullivan AF, Pallin DJ, Bohan J, Camargo Jr CA/Brigham and WomenвЂ™s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA Study Objectives: Video laryngoscopy decreases time to intubation, diminishes cervical spine motion, and increases the chance of first pass success during difficult intubations when compared to direct laryngoscopy. We sought to determine how many emergency departments (EDs) in Massachusetts were using video laryngoscopy, the characteristics of user and non-user EDs, and the reasons why non-users do not use video laryngoscopy. Annals of Emergency Medicine S9 Research Forum Abstracts Methods: Surveys were mailed to the medical directors of all non-federal EDs in Massachusetts (nП74). Non-responders received repeat mailings, and then ED clinical directors or nurse managers were contacted via telephone or email. Data regarding annual ED visit volume was obtained from the National Emergency Department Inventory - USA (www.emnet-usa.org). Results: 63 (85%) of 74 EDs responded. 43% (27/63) had video laryngoscopy available in the ED. EDs with video laryngoscopy had a higher mean annual visit volume than EDs without video laryngoscopy (49,043 vs. 38,093, respectively; PП0.04). EDs with and without video laryngoscopy reported similar percentages of American Board of Emergency Medicine, American Osteopathic Board of Emergency Medicine, or American Board of Pediatrics certified intubating physicians (93% vs 92%, PП0.89), mean intubations per week (4.5 vs. 4.4, PП0.97), and mean surgical airways per year (0.7 vs 1.1, PП0.19). 50% (5/10) of EDs affiliated with emergency medicine residency programs had video laryngoscopy available. Amongst all EDs with video laryngoscopy, the technology had been available for ПЅ 1 year in 52% (14/27), between 1 and 5 years in 48% (12/27), and for Пѕ5 years in 4% (1/27). EDs without video laryngoscopy felt that it was too expensive [69% (25/36)], believed that it showed no improvement over standard direct laryngoscopy [17% (6/36)], or were unwilling to invest in technology that might soon become outdated [14% (5/36)]. None of the EDs without video laryngoscopy believed that it was too difficult to use. Conclusion: At present, 57% of Massachusetts EDs, including 50% of emergency medicine residency-affiliated EDs, do not have video laryngoscopy available. EDs with and without video laryngoscopy perform the same number of intubations per week. In addition, while 69% of ED directors not using video laryngoscopy do not do so because of its cost, an additional 17% of directors believed that it showed no improvement over direct laryngoscopy, despite peer-reviewed evidence to the contrary. Nevertheless, the tide appears to be turning; while available since 2001, video laryngoscopy was adopted by 52% of users only within the past year. Efforts to further disseminate this proven technology should focus on incorporating it into residency training, evaluating its cost-effectiveness, and educating providers regarding its proven clinical benefits over direct laryngoscopy. 29 Evaluating Applicants to a New Emergency Medicine Residency Program: Characteristics of Applicants Who Used the Electronic Residency Application Service Vs. Applicants Who Did Not Groke S, Knapp S, Dawson M, Strate L, Stroud S, Davis V, Hartsell S, Madsen T/University of Utah School of Medicine, Salt Lake City, UT Study Objectives: One previous study has compared differences in applicants between years in which the Electronic Residency Application Service (ERAS) was used and years in which ERAS was not used. To date, no study has compared applicant characteristics in the first two years of a new residency program. Because of the Accreditation Council for Graduate Medical Education (ACGME) approval timelines, new residency programs cannot use ERAS during their first year of applicants. We compared applicant characteristics in an emergency medicine (EM) residency programвЂ™s first year (in which ERAS was not used) vs. applicant characteristics in year two (using ERAS). Methods: The University of Utah Emergency Medicine Residency Program received approval from the ACGME in 2004 and began accepting applicants for its first class, to begin in 2005. We retrospectively reviewed the applications to the residency program for the entering classes of 2005 (year one) and 2006 (year two). Because of the ACGME residency approval timeline, applicants in year one did not use ERAS and were required to complete a separate application for the University of Utah residency program, while those in year two used ERAS for the application. Applicant characteristics, board scores, previous residency application history, and characteristics from the medical school record were recorded. Chi square and t-test statistics were used to compare groups, with pПЅ0.05 considered statistically significant. Results: A total of 130 and 458 applications were received in year one and year two, respectively. Applicants were similar in age (30.9 yrs vs. 30.3 yrs; pП0.225), while year one had a higher percentage of male applicants (77.3% vs. 67.2%; pП0.028). Applicants in year one and year two were similar in average Step 1 score (211.8 vs. 212.4; pП0.791), previously failed Step 1 or Step 2 attempt (12.1% vs. 11.0%; pП0.729), previous failure to match in a residency program (8.6% vs. 4.6%; pП0.083), previous residency training (18.8% vs. 14.9%; pП0.288), and the percent who had completed an EM clerkship (95.3% vs. 93.0%; pП0.342). Applicants in year one were more likely to have been remediated in medical school (13.2% vs. 4.2%; pПЅ0.001) and to have a standardized letter of recommendation (SLOR) (87% S10 Annals of Emergency Medicine vs. 78%; pП0.024). Applicants in year two were more likely to have a SLOR match estimate of вЂњvery competitiveвЂќ (38.2% vs. 54.1%; pП0.004). Conclusion: In addition to an increased number of applicants once ERAS use was initiated, the applicant pool in year two of a new emergency medicine residency program had a higher percentage of applicants who were estimated as вЂњvery competitiveвЂќ on the SLOR and a lower percentage of applicants who had been remediated during medical school. These results may provide a guide to new emergency medicine residency programs in terms of applicant numbers and potential characteristics. 30 Characteristics of Emergency Medicine Residency Curricula That Affect Board Performance Ahn J, Christian MR, Patel SR, Allen NG, Theodosis C, Babcock C/University of Chicago, Chicago, IL Study Objectives: With emergency medicine (EM) maturing as a specialty, there is no consensus regarding the best model for training competent emergency physicians. There is a paucity of validated research regarding how to appropriately structure EM curricula. This study aimed to identify whether certain characteristics of residency program curricula correlate with improved first-time pass rates on written and oral emergency medicine boards after residency completion. Methods: A survey tool was developed and disseminated to all EM residency program directors (PDs) using the Council of Residency Directors listserv. Personal emails were then sent to PDs who did not initially participate in the survey. 149 programs were contacted and 115 partially completed the survey (77.2%). 69 completed the entire survey (46.3%). PDs were asked questions regarding the format of their residency program and curricula, as well as historical written and oral board exam first-time passage rate (Пѕ95% vs ПЅ95%). Correlations between program characteristics and board pass rates were analyzed using STATAv10. Results: As expected, written board pass rates correlate strongly with oral board pass rates (pП0.000). In addition, programs with greater than one half of residents honored by Alpha Omega Alpha score higher on written (pП0.001) and oral boards (pП0.023). Higher oral board pass rates were demonstrated if greater than 4 faculty members routinely attend weekly conferences (pП0.054). No relationship was noted for written boards (pП0.145). Lack of a required reading curriculum trended toward a higher written board pass rate (pП0.063), but did not influence oral board performance (pП0.34). Finally, semi-annual mock oral board simulations trended toward higher written (pП0.053) and oral board pass rates (pП0.063). No correlation was identified between board performance and other factors studied including; length of training program (PGY1-3, 1-4, 2-4), frequency of curriculum repetition, percent of conference lectures given by residents versus faculty, resident attendance requirements, frequency of written quizzing, and curriculum format. Conclusion: In summary, factors that improve board pass rates were those that encourage verbal communication between faculty and residents including increased faculty conference attendance and semi-annual mock oral boards. Medical school Alpha Omega Alpha recipients continued to excel after residency. Interestingly, no correlation existed between board performance and program structure, curriculum structure, readings, quizzing, or resident lecture attendance. This study is limited by an incomplete survey completion rate and PD opinion bias. Clearly, additional research regarding optimal EM education components is necessary. 31 Evaluation of Different Teaching Modalities for EKG Interpretation Among Emergency Medicine Residents Das D, Garg N, Green JP, Gupta S, Suarez AE/New York Hospital Queens, Flushing, NY Study Objectives: To determine whether a Web-based teaching module is more effective in teaching residents to identify and manage wide-complex tachycardic rhythms as compared to a traditional didactic lecture format. Background: Accurate EKG interpretation is a vital component in the management of patients. Previous research reveals that traditional forms of teaching fail to adequately enforce the ability to interpret critical EKG diagnoses in emergency medicine residents. Further, independent Web-based resources can be an effective method of education. The demands of the resident work schedule coupled with the abundance of medical knowledge to be acquired in the short years of residency make it necessary to incorporate newer, more innovative means of individualized education. Methods: Prospective, observational study conducted in an urban Level I emergency department with over 100,000 visits per year. The subjects were 14 emergency medicine residents. The participants were randomly assigned to two Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts groups: a didactic session or a Web-based interactive learning module. Each group was composed of nearly equal number of residents with a comparable level of training. Each group was administered a 30-minute pretest that included 25 multiple choice questions regarding the recognition and management of wide complex tachycardic rhythms. The duration of each session was 30 minutes and both covered the recognition and management of wide complex tachycardic rhythms. The participants were then administered a 30-minute test composed of the same 25 questions they were initially given on the pretest. Analysis of test results was performed utilizing the paired T test and ANOVA. Results: There is no difference in the mean pretest scores between the Web-based (55%) and lecture groups (62%), pП0.063. There is a significant improvement in mean test scores for all subjects, 59% pretest and 71% test, pП0.002. There is a trend for improvement in mean test scores in the lecture group, 62% pretest to 72% test, pП0.118. There is a statistically significant improvement in test scores in the Webbased group, 55% pretest and 69% test, pП0.005. The difference in the mean pretest scores stratified according to postgraduate year (PGY) level was significant, PGY-1 49%, PGY-2 66%, PGY-3 64%, pП0.042. The difference in the mean test scores stratified according to PGY level did not achieve significance, PGY-1 67%, PGY-2 69%, PGY-3 81%, pП0.133. The change in the residentsвЂ™ scores stratified by PGY level did not achieve significance, pП0.153. Conclusion: Web-based resources may be used effectively for teaching EKG interpretation for emergency medicine residencies. 32 The Perceived Impact of Precepting Medical Students on ResidentsвЂ™ Clinical Work and Education Barcomb T, Jeanmonod R, Pattee J/St. LukeвЂ™s Hospital, Bethlehem, PA; Albany Medical College, Albany, NY Study Objectives: This study aims to evaluate the impact precepting medical students has on both resident education and clinical work as perceived by the residents. We hypothesized that precepting students would have a larger negative impact on second year residents (PGY2s) compared to third year residents (PGY3s), as PGY3s have more experience with teaching and prioritizing tasks. We also hypothesized that the perceived impact of precepting students on PGY2s would diminish over the study period as they became more comfortable in their roles as teachers and physicians. Methods: This is a prospective study of PGY2 and PGY3 emergency medicine (EM) residents during 6 months beginning July 1st, 2008. The study was performed at a tertiary care emergency department with a census of 70,000. The hospital is affiliated with a medical school, and EM is a mandatory rotation for all 4th year students. While in the ED, students are assigned to residents for day and evening shifts. Residents involved in precepting turned in monthly surveys evaluating the impact teaching medical students had on their education and clinical work. The questions were designed by drawing on previously validated educational surveys given to medical students and residents in inpatient settings to evaluate clinical educators. In addition, these surveys are based on educational research from the EM literature regarding specific goals of EM education. Responses were scored on a 10 cm visual analog scale (VAS). PGY3s had a previous year of precepting students prior to the start of the study. PGY2s first precepted students in August 2008. Changes in answers over time for all residents were analyzed using FriedmanвЂ™s test. PGY2 and PGY3 data were compared on a month-by-month basis using Mann Whitney, with particular attention paid to comparisons of the first month and the last month. The study protocol was approved by the IRB. Results: In the first month of the study, PGY2s and PGY3s had similar attitudes toward precepting students. They had similar enthusiasm for teaching (7.29 П® 1.01 vs. 6.73 П® 1.32, pП0.5) and rated their ability to teach as similar (6.62 П® 1.12 vs 5.39 П® 1.68, pП0.18). All other survey items were not significantly different between the two classes with the exception that PGY2s were significantly less likely to think that students appreciated their teaching (6.9 П® 1.21 vs. 5.06 П® 1.35, pП0.046). At the end of the 6-month study period, however, survey items showed differences between the 2 classes as PGY2 VAS scores fell and PGY3 VAS scores remained stable or increased. Specifically, there were differences in PGY3 vs. PGY2 scores on the statement вЂњTeaching medical students is an important role of the resident physicianвЂќ (8.01 П® 0.93 vs. 5.24 П® 2.22, p П 0.029), вЂњIf busy, I still find time to teachвЂќ (6.6 П® 0.81 vs. 4.5 П® 1.77, p П 0.023), вЂњStudents do not interfere with my ability to effectively see patientsвЂќ (5.67 П® 1.55 vs. 2.8 П® 1.63, p П 0.015), вЂњThere is adequate time for teaching during a shiftвЂќ (6.1 П® 1.62 vs. 2.63 П® 1.53, p П 0.006), and вЂњI feel well qualified to teachвЂќ (6.87 П® 0.92 vs. 4.44 П® 1.87, p П 0.033). Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Conclusion: In the first 6 months of the PGY2 year, residents find precepting students interferes with their ability to effectively perform clinical work. They are also less likely than PGY3s to think teaching students is an important role of the resident physician. PGY3s feel better able to handle the time constraints of clinical practice while precepting students. 33 Direct Observation Evaluations by Emergency Medicine Faculty Do Not Provide Unique Information Over That Provided by Summative Quarterly Evaluations by the Same Faculty Barlas D, Ryan JG/New York Hospital Queens, Flushing, NY Study Objectives: Shift-based direct observation evaluations (DOE) are used by many emergency medicine residency programs for faculty evaluations of residents on the 6 core competencies, but it is unclear if these provide any unique data over that provided by summative quarterly evaluations (QE). The purpose of this study is to determine if and how well DOE correlates with QE submitted by the same faculty during the same evaluation period. Methods: This observational, cohort study was performed at a 3-year emergency medicine residency with 10 residents/year. QE and DOE with 8 identical corecompetency based questions and identical discrete, 1вЂ“9 rating scales (1ПLevel of a medical student and 9ПLevel of an attending) were completed by emergency medicine attending physicians over 4 years for 39 emergency medicine residents. We collected 1) All direct observation evaluations completed by the faculty pertaining to performance on specific shifts and patient encounters, and 2) Quarterly summative evaluations that were submitted by faculty members who had also submitted direct observation evaluations for the same residents. Pearson correlation coefficients were performed across these groups of evaluations. Results: 297 complete data sets were available for analysis. When there were greater than 4 DOE, there was excellent correlation between scores on DOE and QE by faculty who completed both (rП0.973, pПѕ.001). When there were less than 3 DOE per QE, the correlation dropped to (rП0.739; pПѕ.001). Conclusion: Direct observation evaluations of EM residents are highly correlated with paired quarterly summative evaluations when there are more than 4 observations available, but the correlation drops significantly when the number of direct observations is below 3. Hence, as the number of DOE increases per resident and faculty pair, the data that is gained becaomes more and more similar to that which appears in the QE. 34 Assessing Inter-Rater Reliability and Agreement Between Two Methods of Noninvasive Hemodynamic Monitoring in Clinically Stable Emergency Department Patients Napoli A, Forcada A, Corl K, Machan J/Rhode Island Hospital/Brown University, Providence, RI; Rhode Island Hospital, Providence, RI Study Objectives: Noninvasive hemodynamic monitoring is becoming more frequent. Transcutaneous doppler ultrasonagraphy (TCDU) and impedance cardiography (IC) are two technologies available for use in the emergency department setting. Limited studies have indicated some operator variability, particularly with novice users of TCDU. We sought to evaluate the inter-rater reliability of two devices based on these technologies and compare them in clinically and hemodynamically stable ED patients. We hypothesized a high inter-rater reliability for each device, as well as a high level of agreement between the devices. Methods: We enrolled 30 low acuity ED patients over a 2-day period. Patients had 3 consecutive simultaneously blinded measurements recorded by TCDU (USCOM, Sydney, Australia) and IC (Cardiodynamics, San Diego, CA). 2 physicians, with basic familiarity and no clinical experience with either device, made 3 measurements of pulse rate (HR) and stroke volume (SV) with each device within 1 minute of each other. After 3 minutes, operators switched devices and 3 more measurements were recorded. Inter-rater reliability was assessed using intra-class correlation coefficients (ICC). Mixed linear models for repeated measures were used to estimate the relationship between measures using a compound symmetry variancecovariance structure, with different parameters for each device operator. In addition, Bland-Altman plots were used for further assessing instruments for bias and nonlinearity. Results: Both devices had excellent inter-rater reliability as assessed by ICC. The ICC for TCDU was 0.96 for HR and 0.95 for SV. The ICC for IC was 0.93 for HR Annals of Emergency Medicine S11 Research Forum Abstracts and 0.98 for SV. Measures of HR from the two devices were significantly related (pПЅ.0001 for all slopes), but biased in the first 50 trials, with both slope and intercept differing from ideal: slope 0.48 (0.27вЂ“ 0.68) and intercept 35.80 (21.56 вЂ“50.04). However, by the final 26 trials, both slope and intercept were not statistically different from their ideals: slope 1.02 (0.71вЂ“1.33) and intercept ПЄ0.35 (ПЄ22.37вЂ“ 21.67). In contrast, the relationship between device measures of SV failed to reach statistical significance except in the first 50 trials (t(94.2)П2.72, pП0.0077), where there were several points of high leverage that may have created that effect. There was fair agreement of individual measures of HR (bias ПЄ0.9, limits of agreement ПЄ16.9 вЂ“ 15.1) but poor agreement in SV (bias ПЄ3.8, limits of agreement (ПЄ57.6 вЂ“ 50). Conclusion: Both TCDU and IC have very good inter-rater reliability and this reliability appears not to be limited by clinical experience. A statistically significant relationship exists between the two devices but this does not appear to produce predictable values. Over time comparative results become less biased but are still limited by a great degree of variability. Further study in patients with a larger range of HR and SV may clarify this relationship further. 35 Value of Noninvasive Measurement of Contractility to Predict Mortality in Emergency Department Patients Undergoing Early Goal-Directed Therapy for Severe Sepsis Napoli A, Corl K, Forcada A, Gardiner F/Rhode Island Hospital/Brown University, Providence, RI Study Objectives: Research on severe sepsis and septic shock has demonstrated that increases in cardiac output and decreases in systemic vascular resistance are often accompanied by a depression of myocardial contractility. Prior ICU-based studies of ejection fraction (EF), a commonly used surrogate for contractility, have shown a significantly depressed EF in septic patients vs. controls as well as in survivors vs. nonsurvivors. The prognostic significance of assessing this myocardial depression and decreased inotropic state in emergency department patients remains ill-defined. The severity of myocardial depression and contractility is difficult to measure in the ED. Impedance cardiography (Bio-Zв„ў, Cardiodynamics, San Diego, CA), utilizing the accelerated cardiac index (ACI) or an estimated EF (by the modified Capan equation), represents a technology with the potential to noninvasively measure myocardial contractility in the ED. Previous research has shown that the modified Capan equation and the ACI index are strong measures of cardiac contractility. We hypothesized that reduced cardiac contractility, as defined by the ACI index and a refined Capan mathematical model of ejection fraction, will predict mortality in ED patients undergoing early goal-directed therapy for severe sepsis and septic shock. Methods: This is a prospective observational cohort study of 49 patients ageПѕ 18 who met criteria for early goal-directed therapy (lactate Пѕ4, SBPПЅ90 after 2L normal saline); none were lost to follow-up. 43 patients were screened but excluded due to inability to consent. Continuous measurements of left cardiac work index (LCWI) and ACI, as well as measures required for calculation of the Capan EF, were obtained. APACHE scores and MEDS scores were calculated on each patient. Prior studies demonstrated a greater than 30% difference in EF in nonsurvivors vs. survivors. To detect a 15% difference (вђЈП0.05, вђ¤П0.2, 2 tailed) a sample size of 17 in each group is necessary. AUROC was calculated using the Wilcoxon method. Results: The average age was 66 П® 18.7 years. APACHE II and MEDS scores were 18П®7.9 and 10П®4.3, respectively. The mortality rate was 29%. None of the study variables (LCWI, modified Capan, APACHE, MEDS score) predicted mortality with the exception of the ACI. The ACI had the highest and only statistically significant AUROCП0.67 (CI 0.51вЂ“ 0.83). The mean ACI for survivors and nonsurvivors was 124.8 and 84.3, respectively. An ACI of Пѕ50 was 75% sensitive and 45% specific for predicting survival. Conclusion: Noninvasive measurement of cardiac contractility using ACI significantly predicted mortality in ED patients undergoing early goal-directed therapy. A larger sample size and further studies are necessary to examine the clinical significance of this relationship particularly as it pertains to its role in ongoing resuscitation. 36 Ionizing Radiation From Computerized Tomography During Evaluation of Intermediate-Risk Trauma Patients Thompson K, Laack N, Kofler J, Bellolio M, Sawyer M, Laack T/Mayo Clinic, Rochester, MN Study Objectives: Computerized tomography (CT) is used extensively in the initial evaluation of trauma patients. CT studies are responsible for the majority of S12 Annals of Emergency Medicine ionizing radiation exposure in medical populations. Because ionizing radiation exposure is associated with long-term risks of cancer mortality, much attention has been given to reducing unnecessary CT scans. In severely injured trauma patients, the risk of radiation exposure is negligible in comparison to that of the acute injuries. However, the balance of risk versus benefit in trauma patients with less severe injury is unknown. To our knowledge, this is the first study to compare mortality from trauma with estimated mortality from CT ionizing radiation in intermediate-risk trauma patients. Methods: This observational cohort study included patients over a one-year period with blunt trauma who presented to a trauma center and were prospectively triaged to an intermediate risk group (level II). Patients were triaged based on criteria that included the initial EMS report, mechanism of injury, and patient risk factors. Level 1 (high risk) patients were excluded from the study. The number and type of CT scans performed during the initial evaluation (first 24 hours) were recorded. Individual and median cumulative radiation doses were calculated using an average dosage for each type of CT received based on International Commission on Radiological Protection (ICRP) 60 weighting factors for typical size patients. Attributable radiation risk was calculated using Biologic Effects of Ionizing Radiation (BEIR) VII data. Results: A total of 642 eligible patients presented to the emergency department between August 2006 and September 2007. The mean age was 43.8 years with 64% males. The median Injury Severity Score (ISS) was 8 {interquartile range (IQR) 4 to 12}. The median radiation effective dose from CT was 24.7 (IQR 6.2 to 26.6) milliSieverts (mSv). Dose by age is shown in Table 1. Higher ISS was associated with greater total radiation dose (pПЅ0.0001). There were 4 deaths secondary to trauma (0.6%); patients who died were older (median 90 vs. 41 years, pПЅ0.001), and all had intracranial injuries. The cumulative estimated risk of cancer death attributable to CT exposure in the ED for all patients was 0.00106 (IQR 0.00043 to 0.00139) or 0.1%, with the risk by age shown in Table 2. Conclusion: In our study population of intermediate severity trauma patients, the risk of mortality from trauma is 6 times higher than the estimated risk of radiationinduced cancer mortality. The mortality due to trauma is greatest in older patients, suggesting lower clinical suspicion is needed to warrant CT studies in this population. Clearly, the risk of death from trauma outweighs the long-term risk of mortality from radiation-induced neoplasia in older patients, but this gap narrows with younger patient age and less serious trauma. Further investigation to evaluate the benefits of CT in preventing mortality may help determine a possible crossing point between these two mortality risks. 37 New Generation CT Scanners Demonstrate Higher Sensitivity for Subarachnoid Hemorrhage Gee CA, Phanthavady T, McGuire T, Madsen T/University of Utah, Salt Lake City, UT Study Objective: Previous studies have reported inadequate sensitivity of computed tomography (CT) to rule out subarachnoid hemorrhage (SAH). These studies have typically been performed using 4-slice or lower CT scanners. We aimed Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts to evaluate the sensitivity of CT scan for subarachnoid hemorrhage using highergeneration CT scanners. Methods: We performed a retrospective chart review of all patients who had a non-contrast head CT scan and were diagnosed with subarachnoid hemorrhage between January 1, 2005 and December 31, 2008 at the University of Utah Medical Center. This included patients who were transferred from outside hospitals as well as those who were seen initially in the University of Utah emergency department. CT scanner type from outside hospitals was not known, but the University of Utah CT scanner was upgraded from a 16-slice CT scanner to a 64-slice scanner in early 2005. Patients were included only if they presented with a non-traumatic mechanism. We calculated the sensitivity of CT for SAH based on those diagnosed by CT vs. those with a negative head CT and positive lumbar puncture (LP). Results: 134 patients were diagnosed with SAH during the study period. Average age was 53.6 years old, and 62.2% of patients were female. 130 patients (97%) had a non-contrast head CT demonstrating SAH. 4 patients (3%) who had a negative head CT were diagnosed with SAH by LP. Of these 4 patients, two were diagnosed with aneurismal SAH, while the other two patients had no aneurysm and were discharged without intervention. Sensitivity of CT for SAH was 97% (95% CI: 92.1%вЂ“99%). Including only those patients who had a negative head CT with later diagnosis of aneurismal SAH, sensitivity of CT was 98.5% (94.1%вЂ“99.7%). One of these two patients had an initial CT scan done at an outside hospital, where the generation of scanner was not known. Conclusion: Our results demonstrate a higher sensitivity of CT for SAH than has been previously reported. Still, the sensitivity of CT may not be high enough to warrant the use of CT scanning as the sole modality for diagnosis of SAH. Further study of newer generation CT scanner sensitivity and patient stratification by presentation is warranted. 38 The вЂњTriple Rule-OutвЂќ 64-Section Coronary Computed Tomographic Angiography Protocol: Coronary and ExtraCoronary Findings of Emergency Department Patients Takakuwa KM, Estepa AT, Halpern EJ/Thomas Jefferson University Hospital, Philadelphia, PA Study Objectives: To determine the frequency of coronary and extra-coronary diagnoses that explain the patient presentation among emergency department (ED) patients with acute chest pain or symptoms suggestive of acute coronary syndrome (ACS) evaluated with a coronary CT angiography (CCTA) вЂњtriple rule-outвЂќ (TRO) protocol. Methods: This was a prospective cohort study (10/06 вЂ“3/09) at a single academic ED. Patients judged to be at low to intermediate risk of having ACS based on nonacute ECGs, initial normal myoglobin and troponin I, and TIMI risk scores were studied with a CCTA TRO protocol that evaluated for coronary disease, aortic dissection and pulmonary embolism. We performed our study with a 64-slice scanner (Brilliance Pro, Philips Medical Systems) using 100ml of iodinated contrast material. Structured data collection included demographics, laboratory test data, treatment provided, CCTA findings and 30-day clinical outcomes. Results: 466 patients were studied. Mean age was 49.6 П© 11 years. 44% were men; 50% were black, 44% were white. Of 168 patients with detectable coronary lesions, 113 (24%) had minimal-mild coronary artery disease (CAD with ПЅ50% diameter reduction), 36 (8%) had moderate CAD (50 вЂ“70%) and 19 (4%) had severe CAD (Пѕ70%). ACS was ultimately diagnosed in 11 (2.4%) of patients: 9 had severe CAD, 1 had moderate CAD and 1 had minimal CAD. There were 74 patients (16%) with extra-coronary findings that explained their symptoms. These diagnoses included pneumonia (nП15), pulmonary embolis (nП11), cardiomyopathy (nП10), chronic obstructive pulmonary disease (nП8), hiatal hernia (nП6), metastatic cancer (nП4), congestive heart failure (nП3), anomalous coronary artery (nП3), aortic aneurysm (nП2), Barretts esophagitis (nП2), aortic dissection (nП1), breast cancer (nП1), lung cancer (nП1), lymphoma (nП1), myocarditis (nП1), pancreatitis (nП1), pneumomediastinum (nП1), sarcoidosis (nП1), thyroid cancer (nП1) and thyroid mass (nП1). Conclusion: A majority of patients were safely discharged based upon normal coronary arteries or CAD ПЅ 50% with no extra-coronary findings. Many more Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ patients with ACS symptoms had extra-coronary findings that explained their symptoms than actual ACS. Only 9 of 11 patients with ACS had severe CAD. 39 Intussusception in Adults: A 148-Patient Experience Lindor RA, Bellolio M, Sadosty AT, Earnest IV F, Cabrera D/Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN; Mayo Clinic College of Medicine, Rochester, MN; Mayo Clinic College of Medicine, Rochester, MN Study Objective: Intussusception is a predominantly pediatric diagnosis that is not well characterized in adults. Undiagnosed cases can result in significant morbidity, making early recognition important for clinicians. We describe the clinical characteristics, management, and outcome of adult patients diagnosed with intussusception during a 12-year period. Methods: Observational cohort study of consecutive adult patients diagnosed with intussusception at a tertiary academic center from 1996 to 2008. Cases were identified using ICD-9 codes. Data was abstracted in duplicate by 2 independent authors. Parametric and non-parametric tests were used according to the data type and distribution. Results are presented as percentages and relative risks (RR) with confidence intervals (CI). Results: Of 196 identified patients, 148 were eligible for inclusion; the most common reason for exclusion was diagnosis at an outside facility or prior to the study period. The mean age at diagnosis was 48 years (SD 16.6) with females making up the slight majority (56.8%). The most common symptoms at diagnosis were abdominal pain (71.6%), nausea (48.7%), vomiting (35.8%), diarrhea (18.9%), and bloody stools (11.5%); 20.3% were asymptomatic. The causes of intussusception included malignancy (14.9%), benign neoplasm (12.8%), adhesions (9.5%), inflammation (8.1%), and other identifiable causes (15.5%); an unknown etiology accounted for 39.9%. Symptomatic patients were more likely to have a determined cause for the intussusception (RR 2.57, pПЅ.0001). The most common method of diagnosis was computed tomography which was positive for intussusception in 128/138 patients (92.8%). The majority of cases were enteroenteric (80.4%), followed by ileocolonic (10.8%). A total of 88 patients (59.5%) were admitted to the hospital. Seventy-seven (52.0%) underwent surgery within 1 month while 71 (48%) were either managed conservatively or received no specific treatment. Predictors of surgery included the presence of abdominal pain (RR 1.46), nausea (RR 1.73), vomiting (RR 1.65), or bloody stool (RR 6.91) and cases that were ileocolonic location (RR 6.45). A total of 46 patients (31.1%) presented to the emergency department (ED). There was no difference in age (pП0.62) or sex (pП0.29) between patients presenting to the ED and those diagnosed elsewhere. Those presenting to the ED were more likely to have abdominal pain (RR 1.51, pПЅ0.0001), nausea (RR 2.1, pПЅ0.0001), vomiting (RR 2.9, pПЅ0.0001), and diarrhea (RR 2.2, pП0.016); those presenting outside the ED were 13 times more likely to be asymptomatic (pПЅ0.0001). Patients presenting to the ED were more likely to have intussusceptions caused by malignancy (RR 2.66) or inflammation (RR 4.43) and to be admitted to the hospital (RR 2.32) and require surgical intervention (RR 1.75). There were 10 cases of recurrent intussusception within 1 year, with a median time to recurrence of 2 months. There were no clinical predictors of recurrence. Conclusions: The majority of adult intussusceptions present with abdominal pain, are enteroenteric in nature, have an unknown etiology, and require surgical management. Predictors for surgery include the presence of abdominal pain, nausea, vomiting, or bloody stool and an ileocolonic location. Patients presenting to the ED are more likely to be symptomatic, have an underlying malignancy, and be admitted for surgery than patients diagnosed elsewhere. 40 Comparison of Analgesic Practices in Pregnant and Non-Pregnant Emergency Department Patients Bloch RB, Strout TD, Pierson EA/Maine Medical Center, Portland, ME; University of Vermont College of Medicine, Burlington, VT Study Objective: Disparities in the treatment of pain exist for vulnerable groups such as the elderly, minorities, and indigent populations. It is generally recognized that the use of medication in pregnancy requires careful consideration as not all agents are safe. We sought to determine whether pregnancy status affects prescribing practices for the treatment of pain. Methods: This IRB-approved study is a retrospective health records survey of female patients treated for acutely painful conditions: dental pain, minor burns, Annals of Emergency Medicine S13 Research Forum Abstracts extremity fractures, and renal colic in the emergency department over a 5-year period. Records were systematically reviewed, and data pertaining to pregnancy, pain, and treatment were abstracted. Data were analyzed to compare pain treatment in pregnant vs. non-pregnant patients. Results: 1419 records were reviewed. Mean age was 29.3 yrs П©/ПЄ 9.4 yrs and 63 subjects (4.4%) were pregnant. The mean self-reported pain score was 8.04 П©/ПЄ 2.23, 95% CI: 7.93вЂ“ 8.16. 802 subjects (56.5 %) received narcotics in the ED. 1019 subjects (71.8%) were prescribed narcotics for home. 780 subjects (55.0%) received non-narcotic medication in the ED and 853 (60.1%) were prescribed non-narcotic analgesics for home. In comparing the use of narcotics in the ED for pregnant and non-pregnant subjects, a significant difference was not noted (pП0.919); however, pregnant subjects were significantly less likely to be prescribed a narcotic for home (pП0.038). When examining the use of non-narcotic analgesics in the ED or when prescribed for home, no significant differences were noted (pП0.374 and pП0.450, respectively). Conclusions: Narcotic medications can be used safely during pregnancy, and our data suggest that practitioners are equally likely to use them to treat pain in the ED for pregnant and non-pregnant patients. However, we demonstrate that pregnant patients are less likely to be prescribed narcotics for home use, suggesting that pregnant women may face a health disparity when confronting pain at home. 41 A Qualitative Study Assessing the Information Needed to Manage Adults in the Emergency Department With Sickle Cell Disease Tanabe P, Lyons JS, Reddin CJ, Thornton VL, Wun T, Todd KH/Northwestern University, Chicago, IL; United States Naval Nurse Corp, Chicago, IL; Duke University, Durham, NC; University of California, Davis, Sacramento, CA; Albert Einstein College of Medicine, New York, NY Study Objectives: A decision support tool may guide emergency clinicians in recognizing assessment, analgesic and overall management and health service delivery needs for patients with sickle cell anemia (SCA) in the emergency department (ED). We aimed to identify data elements and resulting decisions to providing optimal care and analgesic management to adult patients with painful episodes in the ED. Methods: Qualitative methods using a series of focus groups and grounded theory were used. Eligible participants included adult clients with SCA and ED physicians and nurses with a minimum of one year of experience providing care to patients with SCA in emergency medicine. Patients were recruited in conjunction with annual SCA meetings, and providers included clinicians who were and were not affiliated with sickle cell centers. Groups were conducted until saturation was reached and included a total of two client groups, three physician groups, and two nurse groups. Focus groups were held in New York, Durham, Chicago, New Orleans and Denver. Clinician participants were asked the following two questions to guide the discussion: (1) What information do you need to provide care to a patient with SCA and (2) What should you do with the information and what kind of decisions do you need to make? Client participants were asked the same questions with re-wording to reflect what they believed providers should know to provide the best care and what they should do with the information. All focus groups were audiotaped and transcribed. The constant comparative method was used to analyze the data. Two coders independently coded participant responses and identified focal themes based on the key questions. The investigator and assistant independently reviewed the transcripts and later met four times until the final coding structure was determined. Results: 47 individuals participated (14 clients, 16 physicians and 17 nurses) in a total of seven different groups. Two major themes emerged: acute management and health care utilization. Major sub-themes included the following: physiologic findings, diagnostics, assessment and treatment of acute painful episodes, and disposition. The most common minor sub-themes which emerged included: past medical history, presence of a medical home (physician or clinic), individualized analgesic treatment plan for treatment of painful episodes, history of present illness, medical home follow-up available, patient reported analgesic treatment that works, and availability of analgesic prescription at discharge. Additional important elements in treatment of acute pain episodes included the use of a standard analgesic protocol, need for fluids and non-pharmacologic interventions, and the assessment of typicality of pain presentation. The patientsвЂ™ interpretation of the need for hospital admission also ranked high. S14 Annals of Emergency Medicine Conclusion: Participants identified several areas which are important in the assessment, management and disposition decisions which may help guide best practices in SCA patients in the ED setting. 42 The Emergency Department Pain Experience for Adults With Sickle Cell Disease Tanabe P, Hafner JW, Courtney DM, Martinovich Z, Zvirbulis E, Artz N/ Northwestern University, Chicago, IL; University of Illinois, Peoria, IL; University of Chicago, Chicago, IL Study Objectives: To report baseline patient characteristics, health services utilization, and analgesic management practices of emergency department (ED) patients with sickle cell disease. Methods: A multi-center, prospective, longitudinal surveillance study enrolled patients from three academic medical centers (rural and urban). All ED patients Пѕ18 years with a chief complaint of a sickle cell pain episode were eligible for inclusion. All records for all visits with a chief complaint of sickle cell pain were reviewed at all three sites, and at two sites, patients participated in a structured interview within 7 days of emergency department (ED) visit (1 interview per month). The study period was 10 months for Sites 1 & 2 and 3.5 months for Site 3. Outcome variables examined collectively and between sites included the number of patients, number of visits, mean number of visits/patient/month, ED discharge rate, time to initial analgesic (from arrival, controlled for the individual patient due to repeat visits), pain score documented in the medical record within 45 minutes of discharge, compared with discharge pain score desired at discharge as reported by the patient on follow-up interview. Time to analgesic is reported as median with intra-quartile range (ICR). For patients discharged home, the Wilcoxon test with z score analyzed differences between the highest tolerable pain score at ED discharge (reported during a follow-up interview) with the score documented in the medical record (when documented). Results: 703 eligible ED visits were made by 157 different patients [50% male, median age 32 (ICR 24, 40)]. The mean number of ED visits per individual patient per site per month was 0.55, 1.0 and 0.58 respectively. For the entire cohort, 72% of patients had between 1вЂ“3 visits to the ED during the study period, 14% had between 4 вЂ“9 visits, and 14% of patients had greater than 10 visits. The discharge rate to home/site were 47%, 76% & 54% respectively. The median and ICR time to initial analgesic per site was; Site #1 П 90 (62, 141), Site 2 П 70 (49, 84), and Site 3 П 172 (86, 278). On follow-up interview patients reported a significantly lower desired targeted discharge pain score (median П 4, ICR П 3, 5) when compared with the actual documented discharge pain score within 45 minutes of discharge (median П 5, ICR П 3, 7), (z score П ПЄ3.2, p ПЅ.001, nП43). Conclusion: These data show that the range of patient visits per month was as low as 0.5 but only as high as 1.0 visits/patient/month. Baseline data demonstrate individual differences between study sites. Site 2 achieved faster time to analgesia and a higher proportion of discharged patients (primarily accounted for by one patient). Data support the need for individual case management for the few patients at each site for patients with multiple visits and opportunities to improve analgesic management at all sites. 43 How Does Use of a Statewide Prescription Monitoring Program Affect Emergency Department Prescribing Behaviors? Sinha S, Callan EM, Akpunonu P, Baehren D, Marco C/University of Toledo College of Medicine, Toledo, OH Background: Prescription opioid dependence and abuse are public health problems of national importance. The state of Ohio recently instituted an online prescription monitoring program (PMP), The Ohio Automated Rx Reporting System (OARRS) to monitor controlled substance prescriptions within the state of Ohio. Study Objectives: This study was undertaken to identify the influence of OARRS data on clinical management of emergency department patients with painful conditions. Methods: This prospective quasi-experimental study was conducted at the University of Toledo Medical Center Emergency Department during June and July of 2008. Eligible participants included ED patients with painful conditions (including dental, neck, back, head, joint, or abdominal pain). After clinical evaluation, attending physicians answered a set of questions regarding planned opioid prescription for the patient. Following the intervention of presentation of OARRS data, attending physicians again responded to the questions regarding opioid Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts prescription. Outcome measures included changes in opioid prescription, and other potential factors that influenced opioid prescription. Results: Among 174 (90% of eligible) participants, OARRS data revealed high numbers of narcotics prescriptions filled in the most recent 12 months (18.9 mean prescriptions П©/ПЄ 26.6, range 0 вЂ“128). Numerous physicians prescribed narcotics for patients (mean 5.6 physicians per patient П©/ПЄ 7.6, range 0 вЂ“ 40). Patients had filled narcotics prescriptions at numerous pharmacies (mean 3.5 П©/ПЄ4.4). Following review of the OARRS data, physicians changed the clinical management in 41% of cases. In cases of altered management, the majority (63%) resulted in fewer or no opioid medications prescribed than originally planned. The most common reasons for change in management, as cited by physicians, included the number of previous prescriptions filled (41%) and number of physicians writing prescriptions (31%). Other reasons for change in management included number of pharmacies filling prescriptions (26%), number of addresses (16%), physical exam (10%), and patient statements (6%). Conclusion: In our patient population, the use of prescription opioids within the past twelve months was common. The use of data from a statewide narcotic registry frequently altered clinical management of ED patients with complaints of pain. In addition to information from the registry, information from the physical examination and statements by the patients also altered management in some cases. 44 Risk Factors for Delayed Analgesia in Patients Presenting to the Emergency Department With Long Bone Fractures Mejia J, Bautista F, Garg N, Reddy V, Radeos MS, Caligiuri AC/New York Hospital Queens, Flushing, NY Study Objectives: Oligoanalgesia has been identified as a problem area in emergency medicine. We sought to determine the causes for delayed administration of analgesics in adults presenting to the emergency department (ED) with long bone fractures. Methods: Retrospective review of consecutive adult patients presenting to an urban level I Trauma Center ED with a long bone fracture. Patients were excluded if they were age 17 or less or involved in a major trauma. We examined demographic and clinical data, mode of arrival and time to analgesic administration. Data were analyzed using chi-square and Kruskal-Wallis test for non-parametric data as needed. Logistic regression was performed and odds ratios (OR) with 95% confidence intervals (95% CI) were used. Alpha was set at 0.05 by convention. Results: 615 total patients were enrolled between 7/1/06 and 11/30/06. 407 (66.2%) were female, age groups were 18 вЂ“39 (75 [12.2%]), 40 вЂ“ 64 (168 [27.3%]) and 65 and above 372 (60.5%). More than a dozen languages were represented in our patient population, with 393 (63.9%) speaking English as their primary language. 338 (55.1%) were white, 40 (6.5%) were Black, 63 (10.3%) were Latino 123 (20.0%) were Asian or Pacific Islander and 50 (8.1%) were other race. 402 (66.0%) of our patients arrived via ambulance. 301 (65.4%) patients experienced a delay in getting analgesia. Delay was statistically significantly related to age (209 (74.1%) of those 65 and older): OR 1.84 (95% CI [1.35,2.50]) pПЅ0.001. There was no delay associated with either race or English-speaking ability. Neither was delay associated with sex or mode of arrival. The effect remained quite significant even when adjusting for sex, age, race, English language preference and mode of arrival. Conclusion: There does appear to be a delay in older emergency department patients getting timely analgesia when they have suffered a long bone fracture. Future studies should focus on how to overcome barriers to rapid pain relief for all of our patients, especially the elderly. 45 A Clinical Study to Evaluate the Efficacy of 4% Liposomal Lidocaine as Compared to Placebo for Pain Reduction of Nonemergent Venipuncture in Adults Rusczyk G, Bhatt S, Amodeo D, Cregin R, Green JP/New York Hospital Queens, Flushing, NY Study Objectives: There is a multitude of literature describing the benefits of topical anesthetics for pain reduction during venipuncture in children, but no study to date has shown a pain reduction from topical anesthetic use during venipuncture in adults. This study was a randomized, double-blind, placebo-controlled trial to assess the efficacy of an existing topical anesthetic- 4% liposomal lidocaine (LMX-4 В®) already in use for children, for pain relief in adult patients during non-emergent venipuncture procedures. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Methods: This was a randomized, double-blind, placebo-controlled trial. Setting: ED urgent care and outpatient surgery of a 500 bed, urban, tertiary care hospital. Subject Enrollment: During specified enrollment periods consecutive adult patients (Х† 21 years of age) at the 2 sites requiring non-emergent venipuncture were approached, and all consenting patients enrolled. Subjects were randomized via random number generator to LMXВ® or placebo application for 30 minutes prior to venipuncture. Subject allocation was concealed and research staff, clinicians and subjects were blinded to groups. The placebo was a cream with the same color and consistency as the LMXВ® product, but containing no anesthetic. Inclusion criteria: Adult patients Х† 21-years of age requiring non-emergent venipuncture. Exclusion criteria: Inability to obtain IV access, allergy to topical anesthetic or cream. Statistical analysis: Data was analyzed following an intention-to-treat basis. The primary outcome was the patientвЂ™s rating of pain immediately after venipuncture as compared to baseline pain pre-procedure using the visual/verbal analogue pain scale. Chi-square was used to analyze categorical data, t-test for continuous parametric data and MannWhitney-U for continuous non-parametric data. Results: 95 adult patients were enrolled in the study. Complete records were available for 93 patients (98 %). There were no baseline differences between groups in terms of age, sex or baseline pain. The LMXВ® group contained 63% females and had a mean age of 47.1 years. The placebo group was 60% female and had a mean age of 42.3 years. Mean baseline pain score (pre-cannulation) in the placebo group was 2.46 (95% CI 1.48 вЂ“3.44) and 2.05(95% CI 1.06 вЂ“3.03) in the LMXВ® group. Mean post IV cannulation pain in the placebo group was 4.02 (95%CI 3.26 вЂ“ 4.78) and 4.12 (95% CI 3.25вЂ“ 4.98) in the LMXВ® group. The primary outcome (mean change in pain score after IV cannulation), was 1.56 (95%CI 0.38 вЂ“2.74) for the placebo group and 2.07 (95%CI 0.97вЂ“3.12) for the LMXВ® group, PП0.628. Conclusion: This study did not demonstrate statistically significant pain reduction with the use of LMXВ® or placebo in adult subjects. The study was limited by a small sample size, which should be addressed in future studies. 46 The Pediatric Experience in the Emergency Department, 2000 вЂ“2006 Thode Jr HC, Garra G/Stony Brook University, Stony Brook, NY Study Objectives: Determine the characteristics of pediatric visits to emergency departments (EDs) with the purpose of identifying focuses of research needs. Methods: Retrospective analysis of The National Hospital Ambulatory Medical Care Survey (NHAMCS) data for 2000 вЂ“2006. Pediatric patients were defined as ПЅ18 years old. Trends over time were evaluated using linear regression; comparisons to adults were also performed. Results: From 2000 to 2006 pediatric ED visit characteristics were uniform. There were about 28 million visits per year, 25% of all ED visits. Mean age was 7 years, 75% were ПЅ 13 years. More than half were male, 40% were injury related with injury rate increasing with age. More than 50% of visits occurred between 4 PM and midnight. There was a slight increase in pediatric visits on Sundays; no seasonal variation was seen. Thirty percent of patients received antibiotics and 40% received analgesics during their visit. Fewer than 7% arrived by ambulance. 40% of all pediatric patients were located in the southern geographic region, and 25% were in the Midwest. About 4% of patients were admitted, with the admission rate highest for patients ПЅ 2 years old (Пѕ 5%) and lowest for those between 2 and 4 (Пі3%). Some differences between pediatric and adult ED populations included: 15% of adults arrived by ambulance, 15% admitted, and a third were due to injury. Twenty five percent of patients ПЅ 6 years had an imaging study done, with imaging increasing with age to almost 50% for adults. The most common reasons for visits were fever, cough and vomiting (pediatrics) vs abdominal and chest pain (adults). Similarities between older and younger patients included race and geographic distribution. Conclusion: There has been no change in the characteristics of the pediatric ED population over the 7-year study period. The nature of pediatric ED visits is different than that of adults, which requires a different focus on diseases and treatments. Relatively few pediatric cases arrive by ambulance, limiting the availability of subjects to conduct out-of-hospital research in this population. 47 Delayed Repeat Enema Management of Failed Initial Enema-Reduction Intussusception Pazo A, Hill J, Losek JD/Medical University of South Carolina, Charleston, SC Study Objectives: Air enema reduction under fluoroscopic guidance has become the treatment of choice for intussusception. Although surgery is the Annals of Emergency Medicine S15 Research Forum Abstracts recommended management for failed enema patients, successful reduction has been reported with delayed repeat enemas. The purpose of this study is to describe the demographic and clinical characteristics of children managed by delayed repeat enema reduction for failed initial enema attempts and identify predictors of delayed repeat enema success. Methods: This is a retrospective cross-sectional study of children diagnosed with intussusception who received care at an urban 110 bed childrenвЂ™s hospital. Patients with initial failed enema attempts who were managed by delayed repeat enemas made up the study population. The primary outcome variable was success of delayed repeat enema reduction. Predictor variables included duration of presenting symptoms (ПЅ 24 hours vs equal to or greater than 24 hours), gross bloody stools, dehydration, altered mental status, radiographic ileus and lack of partial reduction to the ileocecal valve and clinical improvement with the first enema. Results: Over a 6-year period (March 2003 вЂ“ Feb 2008) 16 patients with 17 intussusception events managed by delayed repeat enemas were identified. Of the 16 patients there were 11 (69%) males. Race was 7 (43%) Caucasians, 5 (31%) African Americans and 4 (25%) Hispanics. The mean age (months) at the time of intussusception was 16.1, SD 13.8, median 8 and range 2 to 43 months. Of the 17 delayed repeat enemas 9 (53%) were successful. Of the 8 unsuccessful attempts 4 had a second delayed repeat enema attempt and 3 were successful. Overall delayed repeat enemas were successful in 12 (71%). Surgical reduction was performed in 5 (29%) patient events. Of these manual reduction was performed in 3 and surgical incision in 2 with one requiring resection of 7 cm of the distal ileum. There were 15 (88%) ileo-colic and 2 (12%) ileo-ileo-colic intussusceptions. There were no pathologic lead points. In comparing the successful vs failed delayed repeat enema groups there was no significant difference in demographic or clinical characteristics or time from initial enema to 1st repeat enema. However, there was a trend towards a significant difference in regard to the failed group having a greater rate of rectal bleeding, dehydration and altered mental status. There was a significant difference for the degree of partial reduction achieved on the initial enema. For the successful vs failed delayed repeat enema groups the location of the lead point of the intussusceptum post the initial enema was at the ileocecal value for 9 (90%) vs 2 (40%) respectively. Although not significantly different the successful delayed repeat enema group had trends for significance in regard to fewer patients with radiographic ileus and more patients with clinical improvement post initial enema. Conclusion: Delayed repeat enemas were successful in 12 (71%) patients thus avoiding the need for standard surgical management. Therefore with the coordinated care of emergency medicine, surgery and radiology services delayed repeat enema appears to be a safe and effective management option for clinically stable children when partial reduction to the ileocecal value on the initial enema attempt is achieved. 48 Anaphylaxis Management in the Pediatric Emergency Department: Opportunities for Improvement Russell S, Monroe K, Losek JD/Medical University of South Carolina, Charleston, SC; University of Alabama-Birmingham, Birmingham, AL Study Objective: To determine the rate of anaphylaxis, review the immediate (out-of-hospital and emergency department (ED)) management of anaphylaxis, and identify opportunities for improving anaphylaxis management of children receiving care in a pediatric emergency department. Methods: Retrospective cross-sectional descriptive study of children (21 years of age or younger) who received care for anaphylaxis over a 5-year period in an urban childrenвЂ™s hospital emergency department with an annual census of 55,000. The diagnostic criteria for anaphylaxis were: symptoms and/or signs involving two or more organ systems (dermatologic, respiratory, gastrointestinal and cardiovascular), hypotension for age, one organ system involvement with admission to the hospital, and/or dermatologic system involvement treated with intramuscular epinephrine. Results: There were 124 patient visits by 103 patients (4.5 events/10,000 ED patient visits) who met the diagnostic criteria for anaphylaxis. This included 114 (92%) who had two or more organ system involvement. There were 66 (64%) males. The most common organ system involvement was dermatologic 121 (98%), followed by respiratory 101 (81%), gastrointestinal 33 (27%) and cardiovascular 11 (9%). Intramuscular epinephrine was administered to 69 (56%) patients. Interventions other than epinephrine included administration of H1 S16 Annals of Emergency Medicine and/or H2 antihistamine 114 (93%), corticosteroids 97 (79%), albuterol nebulization 37 (30%) and intravenous fluid bolus 15 (12%). Food was the most common inciting allergen 45 (36%). Hospitalization occurred in 33 (27%) patient visits and 91 (73%) were managed as outpatients. Compared to the children managed as outpatients, those hospitalized had a significantly greater rate of cardiovascular system involvement and of receiving 3 or more interventions other than epinephrine. When compared to those not treated with intramuscular epinephrine, patients treated with intramuscular epinephrine had a significantly greater rate of hospitalization and of receiving 3 or more interventions other than epinephrine. Of the 91 children managed as outpatients, auto-injection epinephrine was prescribed to 57 (63%) and referral to an allergist was recommended to 30 (33%). There were no patient deaths. Conclusion: This study is the first to describe the management of anaphylaxis in a pediatric emergency department. The results revealed opportunities for improvement. Although our ED treatment and outpatient management of children with anaphylaxis did not meet recommended standards of care in regard to administering intramuscular epinephrine, prescribing auto-injection epinephrine, or referral to allergist for all patients diagnosed with anaphylaxis, we do report higher concordance with published recommendations than those reported in previous studies performed in adults. 49 Recombinant Human Hyaluronidase-Facilitated Subcutaneous vs Intravenous Hydration Therapy in Infants and Children Hahn B, Mace SE, Maher G, Harb G/Staten Island University Hospital, Staten Island, NY; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Memorial Children Hospital/Memorial Medical Group, South Bend, IN; Baxter Health Care Corporation, New Providence, NJ Study Objectives: Clinical trials have demonstrated the safety, efficacy, and tolerability of recombinant human hyaluronidase (rHuPH20)-facilitated subcutaneous (SC) hydration therapy in adults and children. The objective of the Increased Flow Utilizing Subcutaneously Enabled Pediatric Rehydration Study II (INFUSE II) is to evaluate whether rHuPH20-facilitated SC fluid administration can be given safely and effectively in clinically appropriate volumes no less than that delivered via the intravenous (IV) route in infants and children with mild to moderate dehydration. Methods: In this ongoing phase 4, open-label, randomized, stratified study, eligible patients are otherwise healthy children aged 1 month to ПЅ3 years in the emergency department or pediatric inpatient unit with mild to moderate dehydration (Gorelick scores 1 to 6). Patients are stratified based on body weight (ПЅ10 kg and Х†10 kg) and dehydration severity (Gorelick score 1 to 2 [mild] and 3 to 6 [moderate]), then randomly assigned (1:1 ratio) to receive rehydration therapy (20 mL/kg isotonic fluid over 1 hour and additional fluid as needed until deemed clinically rehydrated up to 72 hours) via rHuPH20-facilitated SC or IV administration. One mL of rHuPH20 (150 U) is administered SC through an angiocatheter or needle placed in the upper back or other suitable region, immediately followed by SC isotonic fluid administration. The primary study end point is the total volume of fluids administered at a single infusion site. Secondary end points include the percentage of patients successfully hydrated; time to urine output; total volume infused over all infusion sites; safety evaluations (adverse events [AEs]), and health care provider ease of use assessment. Results: An interim data analysis was conducted on 41 subjects (20 randomized to SC; 21 randomized to IV), mean age (standard deviation [SD]) 1.6 (0.7) years. Baseline Gorelick score indicated mild dehydration in 45% in the SC group vs 71% in the IV group, and moderate dehydration in 55% in the SC group vs 29% in the IV group. The primary efficacy outcome, mean total volume (SD) infused over a single site, was 329.4 (216.7) mL for SC vs 560.2 (799.4) mL for IV (Table 1). The mean total volumes, adjusted for duration of infusion, were 466 mL for SC and 429 mL for IV. Mean volumes per body weight were 28.3 (17.2) mL/kg (SC) and 52.1 (77.2) mL/kg (IV). Secondary end point results are provided in Table 2. Conclusions: Preliminary results reveal that rHuPH20-facilitated SC infusions were safe and resulted in a higher percentage of patients who were successfully Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts hydrated compared with IV. Duration-adjusted mean volume of fluids infused was comparable for both routes of administration. was younger for possible compared to definite asthma patients (6 vs. 8 years; pПЅ0.0001). Long-term ICS were prescribed more frequently at visits for definite vs. possible asthma (5.5 vs. 0.1%; pПЅ0.0001). Patients with a greater odds of being prescribed a long-term ICS in the ED were those with definite vs. possible asthma (OR 49.4; 95% CI: 18.4 вЂ“132.5); those triaged to be seen immediately vs. later (OR 6.1; 95% CI 1.1 вЂ“ 33.6); and those who received a short-acting вђ¤-agonist and oral steroid vs. neither medication while in the ED (OR 4.8; (95% CI: 1.7вЂ“13.7). Conclusion: Long-term ICS are prescribed from EDs, although very infrequently. Children with definite asthma were more likely to receive a long-term ICS, despite presenting complaints similar to those with possible asthma. Our findings suggest that unrecognized asthma in children with presenting complaints consistent with possible asthma contributes to the already low rate of long-term ICS prescribing from EDs. 51 Spontaneous Pneumomediastinum in Children: A 10-Year Experience van Tonder RJ, Beatty NC, Bellolio MF, Colletti JE/Mayo Clinic, Rochester, MN 50 Emergency Department Prescriptions for Long-term Inhaled Corticosteroids for Children With Asthma: Are We Following Recommendations? Garro A, Asnis L, Merchant R, McQuaid E/Rhode Island Hospital and Alpert School of Medicine at Brown University, Providence, RI; Brown University, Providence, RI; Rhode Island Hospital and Alpert School of Medicine at Brown University, Providence, RI; Bradley/Hasbro Research Center, Alpert Medical School at Brown University, Providence, RI Study Objectives: Emergency departments (EDs) are a unique component of the health care system involved in treating childhood asthma. EDs in the US are visited by underserved populations disproportionate to other health care settings. These populations are more likely to have poorly controlled asthma and less likely to be using an appropriate asthma controller medication. National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines recommend that children with persistent asthma be prescribed long-term inhaled corticosteroids (ICS). Our first objective was to determine how frequently US ED providers prescribe long-term ICS to children with definite or possible asthma. Our second objective was to examine clinical and demographic factors associated with children being prescribed these medications. Methods: This study examined data from the 2005 and 2006 National Hospital Ambulatory Medical Care Survey for US ED visits for children between 0 and 21 years old. For this study, ED visits for definite asthma were defined as visits with presenting patient complaints consistent with a potential asthma exacerbation (eg, wheezing, dyspnea/shortness of breath, cough) and ICD-9 code of 493. ED visits for possible asthma were defined as visits with the same presenting complaints, but excluded visits for definite asthma and those with an alternative definitive diagnosis (eg, heart failure). Summary statistics on long-term ICS prescriptions were calculated for definite and possible asthma. Logistic regression modeling was used to identify demographic, clinical, and temporal variables associated with prescriptions for long-term ICS. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated. Results: There were 1,841,551 ED visits for definite asthma, and 5,899,192 for possible asthma for children 0 вЂ“21 years old during the study period. The mean age Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Study Objectives: To examine demographic characteristics, clinical presentation, workup for diagnosis, treatment and outcome of children presenting with spontaneous pneumomediastinum (SPM) to the emergency department. Methods: Observational cohort study of all consecutive patients less than 19, presenting with SPM between 1998 and 2007 to an academic ED. The medical records were reviewed and demographics, risk factors, symptoms, treatment, and outcomes were collected. The statistical analyses were performed according to the distribution and the characteristics of the variables collected. Results: A total of 22 children were seen with SPM over the 10-year period, 90.9% were male. The median age was 15 years (range 6 to 17 years). A total of 16 (72.7%) children had chest pain, 63.6% had neck pain or sore throat, and 5 (22.7%) children complaint of shortness of breath. Nine children (40.9%) had asthma, 14% reported drug use and 13.6% were active smokers. Patients with asthma were as likely to have chest pain as those without asthma (Relative risk 0.87, 95%CI 0.5вЂ“1.5, pП0.655). A trigger for the SPM was identified in 12 children (55%) and the most common trigger was cough in 11 children (50% of the cohort) and Valsalva in one. Overall 15 (68.2%) were admitted to the hospital, with a median length of stay of 1 day (range 1 to 4 days). Age (pП0.75) and asthma (pП0.99) were not predictors of hospital admission. All of the patients had a chest X-ray, 31.8% had a chest CT, and 22.7% had an esophagogram performed. Three SPM were missed on the initial chest X-ray (13.6%). Having a CT done or not did not affect the final disposition of the patient; 71.4% of those with CT were admitted vs 66.7% of those without CT were admitted (pП0.99). All 5 patients having an esophagogram were admitted to the hospital. One patient had a concomitant pneumothorax, and chest tube was not required. Overall 86.4% had more than 30 days of follow-up, for a median follow-up of 3 years, and none of them had a recurrent episode of SPM. Conclusion: SPM is a rare benign condition seen primarily in older male children. Most patients will either have chest pain or neck pain. SPM appears to be strongly associated with asthma with near half of the cohort having past history of asthma. Although SPM may be spontaneous, an identifiable trigger is present most of the time. CT of the chest does not change disposition. No recurrences of SPM were found during our study. 52 Endotracheal Tube Cuff Pressures in Pediatric Patients Intubated Prior to Aeromedical Transport Tollefsen WW, Chapman J, Frakes M, Gallagher M, Shear M, Thomas SH/ Harvard University, Boston, MA; Massachusetts General Hospital, Boston, MA; Boston MedFlight, Boston, MA; University of Oklahoma School of Community Medicine, Tulsa, OK Study Objectives: Prolonged endotracheal tube cuff pressures (ETTCP) greater than 30 cm H2O can cause complications. Significantly elevated cuff pressures in an emergency setting have been demonstrated to be commonplace in adults. With increasing utilization of cuffed endotracheal tubes (ETT) in pediatric patients comes the risk of overinflation. This studyвЂ™s goals were to assess pediatric patients intubated with cuffed ETTs undergoing transport by a critical care transport (CCT) service to ascertain ETTCP and whether elevated ETTCP was associated with factors such as patient demographics, diagnostic category and intubator credentials. Methods: In this prospective study, CCT protocols were modified and crews educated to assess ETTCP in all patients intubated (with cuffed ETTs) upon their arrival at the bedside. The study focused on a consecutive sample of the first year Annals of Emergency Medicine S17 Research Forum Abstracts (FY08) of pediatric (ПЅ18 years) patients undergoing CCT, with cuffed ETTs placed prior to CCT arrival. All patients had cuff pressures assessed by the same cuff manometry device (PoseyВ® Cufflator #8199), and recorded at time of arrival at the patient. (Pressures found to be above 30 cm H2O were corrected by the CCT crew.) Results: It is found that 41% met the a priori defined cutoff for elevated ETTCP of 30 cm H2O, and 18% met twice that cutoff. There were no associations between any of the demographic variables, or between physician and nonphysician intubators, or between intubation location (ie, scene vs. ED vs. ICU), in the risk of high ETTCP. Conclusion: A significant number of pediatric patients requiring intubation prior to transport by an aeromedical service were found to have elevated cuff pressures. Furthermore, there was no clear risk factor for elevated cuff pressures. This is further evidence that regardless of patient demographic or intubator credentials, cuff pressures should be measured in all patients. Further research should focus on the effect of educational intervention, and on the possible clinical results of elevated ETTCPs. 53 Does Sex Delay the Diagnosis of Appendicitis in Female Patients With Abdominal Pain? Baquero A, Reynolds T, Waseem M, Leber M/Lincoln Medical Center, Bronx, NY Study Objectives: We believe female patients, especially those who are sexually active, presenting with lower abdominal pain undergo more ancillary testing. These additional tests may lead to a delay in diagnosis and subsequent surgery, placing these patients at higher risk of perforation or increased morbidity and mortality. This study looks at the present dayвЂ™s pediatric population and attempts to determine any surgical delay in male versus female patients diagnosed with appendicitis as well as looks at what adjuvant studies do in the emergency department before surgery. Methods: We designed a retrospective chart review study at an urban academic pediatric ED. Subjects were patients under 22 years of age. Two hundred and twenty five consecutive retrospective records of subjects with the diagnosis of appendicitis as per surgical pathology were reviewed. Patients were divided into two groups, female (study population) and male (control). Inclusion criteria included patients presenting to the pediatric ED and positive post-surgical pathological specimen showing appendicitis. Exclusion criteria include patients with unstable vital signs at time of presentation. We collected the following data: sex, age, time to OR from ED triage, whether CT was done and whether an abdominal and/or pelvic ultrasound was performed. Length of hospital stay, whether patient were admitted to the ICU and duration of symptoms before ED presentation were also noted. Data underwent univariate, bivariate, Kaplan Meier Survival, and Cox regression analysis. Significance was set at pП0.05 and 95% confidence intervals (95% CI) were calculated. Results: 223 consecutive charts meeting inclusion criteria where analyzed. 95 (43%) were female. Mean age was 12.7 years with minimum of 3 and maximum of 21. 64% of the patients had CT scan performed. Ultrasound was performed in 29.8% of patients. There were more CT scans (74% versus 54%, PП0.005) and ultrasound (42% versus 20%, PПЅ0.0001) in females versus males. 33% of females had both ultrasound and CT scans as part of their evaluation compared to only 15% of males. Patients with combined studies had a longer time from triage to OR (PП.08). Performing CT scan caused the mean time to go from 564 minutes to 999 minutes (PП.04) while performing ultrasound doubled mean time to OR from 661 minutes to 1289 minutes. However, there were no significant differences between sex using as far as sex and time to OR from triage, hospital stay, age, duration of symptoms, and ICU stay. It is important to note that the standard deviation of time to OR from triage was extremely high making it difficult to attain statistical significance. Statistical differences between performance of ultrasound and incidence of complicated appendicitis 44% vs. 25% (PП.006). Using Kaplan Meier Survival Analysis there is statistical differences in time to OR between men and women (PП.03). Conclusion: More ancillary tests were used in evaluation of females versus males. In addition, there was an increased incidence of complicated appendicitis in those patients undergoing ultrasound. Although these tests increased the amount of time to the operating room, it was difficult to determine significance in terms of sex due to high standard deviation. Further studies should focus on increasing sample size. 54 Characteristics and Risk Factors of Patients Who Refuse Routine HIV Testing in an Urban Emergency Department Calderon Y, Cowan E, Fettig J, Hannon M, Leider J/Jacobi Medical Center, Bronx, NY Study Objectives: CDC guidelines recommend routine HIV screenings in locations including emergency departments (EDs). Characteristics of patients who refuse testing in S18 Annals of Emergency Medicine the ED have not been thoroughly investigated. This study examines the characteristics and risk factors of patients who refused ED-based rapid HIV testing. Methods: A prospective cross-sectional study of patients recruited into an EDbased rapid HIV testing program was conducted for 39 months. Demographics and risk factors were collected from patients who both agreed to and refused testing. Data was analyzed using STATA. Results: 19,454 patients were offered routine HIV testing and 1669 (8.6%) were ineligible. Of the 17,785 eligible patients 16,688 (93.8%) agreed to test and 1097 (6.2%) refused. Characteristics of those who refused testing: 51.2% females, 14.3% Hispanic, 39.8% black, 18.9% married, and 70.8% aged over 30; all characteristics had a p-value ПЅ 0.01 compared to those who agreed to test. Bivariate analysis demonstrated that blacks (OR 1.24, 95% CI: 1.10 to 1.41), women (OR 1.02, 95% CI: 1.01 to 1.03), patients over 30 (OR 1.97, 95% CI: 1.73 to 2.26) and married persons (OR 1.37, 95% CI: 1.17 to 1.61) were more likely to refuse testing. Most refusals (49.6%) felt they were not at risk for HIV infection; their risk factors are in Table 1. Additionally, 12.0% refused testing because they felt they had вЂњno timeвЂќ and 8.6% refused because they were вЂњafraid.вЂќ Conclusion: Patients who refused testing were more likely to be older, black, married and female. The majority of patients who refused testing perceived themselves to be вЂњnot at riskвЂќ even though they exhibited multiple HIV risk factors. Further studies are needed to assess the generalizability of this issue and evaluate interventions that can effectively target this group. 55 STEP-DC: Stop Emergency Department Visits for Hyperglycemia Project -DC Dubin J, Nassar C, Sharretts J, Youssef G, Curran J, Magee M/Washington Hospital Center, Washington, DC; MedStar Diabetes Institute, Washington, DC Study Objectives: Due to a variety of socioeconomic factors, greater numbers of patients both with known diabetes and undiagnosed diabetes present to the emergency department (ED) with uncontrolled hyperglycemia. This interventional study evaluates the implementation of survival skills diabetes self-management education (DSME) and medication management to achieve better control of diabetes and reduce the frequency of repeat emergency department visits for hyperglycemia. Methods: Diabetics with a blood sugar level over 200 mg/dl whom were suitable for discharge were enrolled in this IRB-approved study. The patients received formal DSME (4 sessions over 4 weeks) which included instruction on use of a glucometer and how to self inject insulin if indicated; meal planning; prevention and treatment of hypoglycemia; and medication information. Diabetes medications were initiated and/ or adjusted using an algorithm that provided guidelines for initiating and/or titrating upwards oral agents and/or insulin. Patients with blood glucose over 300 mg/dl were given an injection of glargine insulin prior to discharge from the emergency department. All education was performed by certified diabetes educators who were nurses or registered dieticians. Baseline and follow-up HgA1C and glucose levels were checked on enrollment and at follow-up visits. Results: Of 86 patients enrolled, 60% completed all four follow-up study visits, 21% completed at least two or three visits. 19% did not follow up after enrollment. No patients had hypoglycemia on day one (after therapy initiation). Overall hypoglycemia rate was only 1.6% based on 34 episodes in 2,148 patient days measured. At 2 week follow-up mean blood glucose for 51 patients tested was reduced by 48.9% from 356 (95% CI: 325вЂ“387) to 183 mg/dl (95% CI: 153 to 212), pПЅ.001. Baseline hemoglobin A1C levels were tested on 81 study patients of whom 52% had levels above 13%. Hemoglobin A1C was tested on 46 patients at week two and mean HgA1C levels decreased 3.3% from a pre intervention mean 12.0% (95% CI: 11.6 вЂ“12.5) to mean POST 11.6% (95% CI:11.1вЂ“12.1%), pПѕ0.05. The proportion of patients with HgA1C Пѕ13% trended down from 54.35% PRE to 43.48% POST intervention, but this was not statistically significant (Chi Squared П1.09, pП0.29.) Total number of ED visits/hospitalizations for hypo/hyperglycemia among the study group patients were reduced by 78% from 42 in the six months before the index visit to nine in the six months following study visit one. Conclusion: Formal diabetes teaching and medication management introduced in the ED can significantly reduce hyperglycemia and reduce the frequency of ED visits for uncontrolled diabetes. The diabetes medication management algorithm utilized, which included starting basal insulin in the ED, was safe and effective. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts 56 A Performance Improvement Audit to Assess Airway Documentation: How Well Do Emergency Physicians Document Confirmation of Endotracheal Tube Placement? Phelan MP, Wickline D, Glauser J, Peacock WF, Meredith R, Joyce M, Martin C, Sturges Smith L/Cleveland Clinic, Cleveland, OH; MetroHealth Medical Center, Cleveland, OH Study Objectives: Documentation of correct endotracheal tube (ET) placement is poorly described in patients arriving to the emergency department (ED) already intubated. We sought to determine the rate at which emergency physicians document correct ET location in patients arriving to the ED already intubated. Methods: The study was performed at an urban tertiary referral hospital with an emergency medicine residency and an annual census of 60,000. Using our quality improvement airway registry of all patients presenting to the ED with an ET in place, over a 21-month period (1/1/06 вЂ“9/9/07) trained research assistants reviewed the medical records specifically looking for physician confirmation and documentation of ET placement. Consistent with the American College of Emergency Physician guidelines, ET confirmation was defined as end tidal CO2 (ETCO2) measurement, direct laryngoscopy (DL), or bulb aspiration (BA). Results: 152 patients arrived intubated; 88 (57.9%) were hospital transfers, with the remainder intubated by EMS in the field. Overall, physician documentation of ET placement was found in only 52 (34.3%). In the EMS intubated cohort, 40 (63%) had ET confirmation; 5 (8%) by ETCO2, 35 (55%) by DL, and 24 (38%) had no ET confirmation documentation. Of the transfer patients, 12 (13.6%) had ET confirmation documented in the physician medical record; 7 (8%) by ETCO2, 5 (6%), by DL; 76 (86%) had no physician confirmation documented. Patients transferred from other hospitals were 2.25 times less likely to have physician documentation of correct ET placement than those intubated by EMS, 86% (95% CIП 0.774 to 0.928) vs 38% (95% CI П 0.257 to 0.505), respectively. Conclusion: Physician documentation of correct ET placement is poor for patients arriving intubated, and is worst when patients are transferred between hospitals. 57 Copperhead (Agkistrodon Contortrix) Snakebites in the United States: 2000 вЂ“2007 Bhakta NS, Morgan DL, Borys DJ/Scott and White Memorial Hospital, Temple, TX; Texas A&M University Health Science Center, Temple, TX; Central Texas Poison Center, Temple, TX Background: Bites from copperhead snakes (Agkistrodon contortrix) are the second most common snake envenomation in the United States. There are 5 subspecies of this copperhead that inhabit 27 states. The effects from copperhead bites (such as pain, tissue necrosis, and coagulation abnormalities) are generally considered less severe than those of other pit vipers. However, there have been no large national studies of copperhead bites published. Study Objectives: Our goal was to describe the characteristics of copperhead bite victims reported to all US poison centers. Methods: Retrospective, observational study of telephone calls to all US poison centers (National Poison Data System) for copperhead snakebites to human victims of any age from 2000 to 2007. Results: There were 7,748 total copperhead bites. The annual number of bites reported increased by 65.3% during the 8-year study period. Copperhead bites were reported every month including the nadir in January (0.2%) and the peak in July (21.4%). Copperhead bites occurred in all but 7 states (AK, ID, HI, ND, SD, UT, WY). Seventeen states had only 1 to 3 bites over the 8-year period (AZ, CA, IA, ME, MA, MI, MN, MT, NE, NV, NH, NM, OR, RI, VT, WA, WI). Ten states (TX, NC, MO, GA, VA, KY, OK, TN, LA, WV) accounted for 80.0% of all bites. Most victims were male (71.0%). The average age of all victims was 34.1 years. There were 1,754 (22.6%) children under the age of 18 years, and there were only 481 (6.2%) victims over the age of 65 years. There were 3,135 victims (40.5%; 95%CI: 39.4% вЂ“ 41.6%) who did not have any or had only minimal clinical effects (вЂњdry bitesвЂќ). Almost half (46.3%; 95%CI: 45.2% вЂ“ 47.4%) of the victims had moderate effects, and 249 (3.2%; 95%CI: 2.8% вЂ“ 3.6%) had major effects. Poison centers were unable to record an outcome for 706 victims (9.1%). There was a single death, a 51-year-old male in Maryland. The major limitation of this study is the volunteer reporting of information to poison centers. Conclusion: This is the largest analysis of copperhead snakebites in the US. Very few victims suffered major effects from these bites. Eighty percent of all bites occurred Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ in just 10 states. These results may be useful for snakebite prevention and the planning for snakebite management in each state. 58 Epidemiology of Prolonged Emergency Department Length of Stay Heins A, Liang S, Richardson LD/University of South Alabama College of Medicine, Loxley, AL; University of Maryland, Baltimore, MD; Mt. Sinai School of Medicine, New York, NY Study Objectives: Emergency department (ED) boarding of admitted patients for excessive lengths of time is one of the key determinants of ED crowding, a serious and growing problem for U.S. hospitals. While some studies of patient-level health outcomes have shown considerable harm to patients, no population-based studies have directly examined the public health impact of ED boarding. We designed the present study to describe the epidemiology of prolonged ED length of stay (LOS) in the US and to determine the effects of ED LOS on hospital LOS and in-hospital mortality. Methods: This study was a secondary analysis of data from the 2006 National Hospital Ambulatory Medical Care Survey (NHAMCS), which uses a 4-stage probability sample design to collect a nationally representative sample of visits to emergency departments in non-federal general acute care hospitals. Independent study variables included patient demographics, characteristics of the ED visit, including ED LOS and disposition; outcome variables were hospital LOS and inhospital mortality. Descriptive and regression methods were used to examine predictors of and disparities in outcomes for ED patients admitted to the hospital. Results: The study cohort represents 15,207,497 admitted patients, including 2,242,547 patients admitted to an ICU, out of over 119 million ED visits for 2006. Notable results include the finding that admitted patients in the 3-ПЅ6 hour, 6-ПЅ9 hour and the 9П© hour ED LOS categories had hospital LOS 0.43, 0.91 and 0.55 days longer than the cohort with ED LOS less than 3 hours. For the ICU cohort, the ED LOS 3-ПЅ6 hour group had similar hospital LOS to the ПЅ3 hour group, but the 6-ПЅ9 and 9П© groups had hospital LOS 0.74 and 1.33 days longer than the cohort with ED LOS ПЅ 3 hours. Admitted patients with lower initial triage priority experienced more prolonged ED LOS. Females, blacks, and self-pay patients were held in the ED for prolonged periods more frequently than males, whites, and privately insured patients. Regression analysis of predictors of in-hospital mortality showed that patients with more acute triage assessments and those recommended for critical care admission were more likely to die in the hospital. Females were less like to die than males. Whites and blacks died more often than those in the other race category. Contrary to previous studies, prolonged ED LOS did not contribute to worsened survival. Conclusion: Prolonged length of stay in the ED for admitted patients is a serious operational problem for EDs and may contribute to multibillion dollar increases in medical care costs through extension of hospital length-of-stay for the 15 million patients admitted through the ED each year. Elimination of ED boarding might yield substantial reductions in cost and increases in efficiency. 59 Multicenter Study of Internet Use by Emergency Department Patients in Boston Sullivan AF, Ginde AA, Weiner SG, Pallin DJ, Betz ME, Oldfield JH, Camargo Jr CA/Massachusetts General Hospital, Boston, MA; University of Colorado Denver School of Medicine, Aurora, CO; Tufts Medical Center, Boston, MA; Brigham and WomenвЂ™s Hospital and ChildrenвЂ™s Hospital Boston, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA Study Objectives: The Internet is an important source of health information. We sought to examine emergency department patientsвЂ™ Internet use for health information and its relation with ED utilization. We also sought to determine patientsвЂ™ willingness to use the Internet for participation in future research. Methods: We surveyed consecutive patients age 18П© years for two 24-hour periods at 4 Boston EDs, excluding patients with severe illness or altered mental status. Data analysis used descriptive statistics and multivariate logistic regression. Results: We enrolled 530 patients (73% of those eligible). Overall, 67% (95% confidence interval [CI], 63вЂ“71%) used the Internet over the past 12 months. While 31% (CI 26вЂ“36%) looked on the Internet at least monthly for health information or advice, 24% (CI 20вЂ“29%) never did. Patients were less likely to report any use of the Internet for health information if they were aged Х†65 years (compared to age 18вЂ“26 reference group: OR 0.15 [95%CI, 0.06вЂ“0.37]), were black (compared to white: OR 0.47 [95%CI, 0.23вЂ“0.96], and did not have a primary care provider (OR 0.35 [95%CI, 0.17вЂ“0.70]). Annals of Emergency Medicine S19 Research Forum Abstracts Before going to the ED, 21% (95%CI 17вЂ“26%) of Internet users sought information or advice on the Internet about their health condition; the information they found on the internet made them more likely to go to the ED: yes 46% (95%CI 34вЂ“59%), no 40% (95%CI 28вЂ“53%), and unsure 14% (95%CI 7вЂ“25%). Among patients who used the Internet, 65% (95%CI 60вЂ“70%) would be very or somewhat willing to communicate by email if enrolled in a research project that required follow-up and provide health information for research via a secure online form. Conclusion: The majority of ED patients in Boston use the Internet for health information. Older age, black race, and no primary care provider were all associated with less use of the Internet for health information. Email and the Internet may be effective tools for communication with ED research subjects. 60 The Prevalence of Tobacco and Alcohol Use in Immigrant Emergency Department Patients in Queens, NY Gupta S, Anderson C, Henkel K, Garg N/New York Hospital Queens, Flushing, NY Study Objective: To determine the prevalence of tobacco use in immigrant and non-immigrant emergency department patients. To determine the prevalence of alcohol use and alcoholism using the CAGE questionnaire in immigrant and non immigrant ED patients. Methods: The study is prospective, observational, and survey based in an urban 100K visit ED in Queens, NY, postulated to be the most ethnically diverse county in the USA. Trained volunteer research assistants interviewed a convenience sample of ED patients over 16 months with a 3-page survey regarding demographic information, tobacco and alcohol use, and knowledge of current male or female preventive health recommendations as offered by the U.S. governmentвЂ™s Agency for Health care Research and Quality. The CAGE questionnaire is positive with Х†2 affirmative answers. Translation services were available for all non-English speaking subjects. Data management was performed through Microsoft Access and statistical analysis through SPSS version 13, using Chi-squared analysis and Fisher Exact test for significance. Results: A total of 1380 surveys were collected; 640 male, 217 being immigrant males, 740 female, 256 being immigrant females. Of the men surveyed, 28% of immigrants and 46% of non-immigrant men drink alcohol, PП ПЅ0.001. CAGE was positive in 8/60 immigrant and in 13/196 non-immigrant drinkers, P П 0.166. In tobacco smoking, 13% of immigrant and 23% of non-immigrant men smoke tobacco, P П 0.008. Smoking counseling was done on 67% of immigrant and 85% of non immigrant smokers, P П 0.157. All male smokers know tobacco causes disease, and 67% of immigrants and 90% of non-immigrants have tried to quit, P П 0.028. Of the female subjects, 8% of immigrants and 19% of non-immigrants drink alcohol, P П ПЅ0.001. CAGE was positive in 2/21 immigrant and in 6/91 nonimmigrant drinkers, P П 1.00. In tobacco smoking, 5.6% of immigrant and 17.7% of non-immigrant women smoke tobacco, P П ПЅ0.001. Smoking counseling was done on 75% of immigrant smokers, and 85% non-immigrant smokers. 100% of immigrant and 94% of non-immigrant smokers know tobacco causes disease, and 83% of immigrants and 80% non-immigrants have tried to quit. No significance was achieved in these categories. Conclusion: In this population, immigrant men and women tend to drink alcohol and smoke tobacco less than the native population, but immigrant men and women may receive less counseling on tobacco cessation. 61 National Survey of Preventive Health Services in United States Emergency Departments Delgado MK, Wang N, Acosta C, Khandwala Y, West AM, Strehlow MC, Ginde AA, Camargo Jr CA/Stanford-Kaiser Emergency Medicine Residency, Palo Alto, CA; Stanford University School of Medicine, Palo Alto, CA; University of Colorado Denver School of Medicine, Denver, CO; Massachusetts General Hospital, Harvard Medical School, Boston, MA Study Objectives: Emergency departments (EDs) see a high proportion of patients with unmet primary care needs and who present with illnesses related to unhealthy behaviors. Although various ED-based preventive health services have been reported, nationwide data are sparse. Our goals are to determine: 1) the availability of 11 different preventive health services in U.S. EDs; 2) ED directorsвЂ™ opinions whether these services could be provided with existing funding and staff; 3) ED directorsвЂ™ preferences of services to implement; and 4) perceived barriers to offering preventive services in the ED. S20 Annals of Emergency Medicine Methods: 350 (7%) of the 4,828 U.S. EDs were randomly selected from the 2005 National Emergency Department Inventory (NEDI)-USA database. A survey was sent to ED directors to determine the prevalence of: 1) screening, intervention, and referral programs for alcohol, tobacco use, geriatric falls, intimate partner violence, HIV, diabetes, and hypertension; 2) vaccination programs for influenza and pneumococcus; and 3) linkage programs to primary care and health insurance. ED directors were asked to rank the 3 services they would most like to implement given their patient population and rate 5 potential barriers to offering preventive services on a 5-point Likert scale. Results: The authors have collected responses from 257 institutions (75% response rate). In this random sample of EDs, the median annual patient visit volume was 21,682 (interquartile range 8,543вЂ“37,674); 54% [95% confidence interval - CI 51вЂ“ 63] were urban, 18% [CI 14 вЂ“23] suburban, and 23% [CI 19 вЂ“30] rural; 24% [CI 19 вЂ“29] participated in the Critical Access Hospital program; and 8% [CI 4 вЂ“11] were teaching hospitals. The three most commonly offered preventive services were for: intimate partner violence (66% of hospitals [CI 60 вЂ“72]), primary care linkage (55% [CI 49 вЂ“ 61), and hypertension (51% [CI 44 вЂ“57]). The least commonly offered services were for HIV (19% [CI 14 вЂ“24]) and tobacco (19% [CI 14 вЂ“24]). If not currently offered, the services ED directors perceived could be offered most with existing staff and funding were for: diabetes (an additional 30% [CI 24 вЂ“36] of hospitals) pneumococcal vaccines (28% [CI 22вЂ“34]), and tobacco 27% [CI 22вЂ“33]). The lowest potential capacity was for: geriatric falls (15% [CI 9 вЂ“21]). If not currently available, ED directors most wanted to provide services for primary care linkage (38 % [CI 29 вЂ“ 47]), insurance linkage (19% [CI 13вЂ“26]), and tobacco (17% [CI 12вЂ“ 22]). ED directors вЂњstrongly agreeвЂќ that the following are barriers to offering preventive services: cost (39%), increased patient length of stay (30%), lack of primary care follow-up (27%), resource shifting leading to worse patient outcomes (22%), and philosophical opposition (12%). Conclusion: EDs offer different types of preventive services at varying rates. The perceived capacity to offer new preventive services with existing funding and staff varies by type of service. The service that ED directors would most like to provide is primary care linkage. The three services that have the most capacity for expansion based on utilizing existing resources are: diabetes screening and referral, pneumococcal vaccines, and smoking cessation counseling. Overall, ED directors perceive cost to be a large barrier to offering preventive services, while only a small proportion appear to be philosophically opposed to offering preventive care in the ED. 62 Comparison of the AirtraqВ® to Direct Laryngoscopy by Flight Nurses and Respiratory Therapists in the Simulated Airway Suozzi JC, Bolton L, Nowicki TA, Ventriglia R, Donahue S, Robinson KJ/Hartford Hospital, Hartford, CT Study Objectives: Emergent in-flight endotracheal intubation is an infrequent event that carries additional challenges due to a confined space environment and limited patient/practitioner positioning. The purpose of this study was to compare intubation utilizing the AirtraqВ® with direct laryngoscopy in the manikin model given both normal and difficult airway scenarios in the helicopter setting. We evaluated the number of attempts, time to successful ventilation, Cormack-Lehane view and the AirtraqвЂ™sВ® learning curve. Methods: This was a randomized crossover study involving flight nurses and respiratory therapists. Each subject was given a standardized lecture and a demonstration of the AirtraqВ® device including a set of instructions regarding its use. Participants were then allowed a 5-minute practice session on a Laerdal Airway Management TrainerВ® with the AirtraqВ® and direct laryngoscopy using a Macintosh #3 blade. Subjects then managed the following scenarios in the aircraft on a Laerdal SimManВ® manikin: (1) normal airway; (2) tongue edema; (3) c-spine immobilization; (4) normal airway. Results were analyzed utilizing Wilcoxon Signed Ranks Test. Results: 21 flight personnel participated in this study. For scenario #1 (normal airway) there were no significant differences in either the number of attempts or time to ventilation between the devices. A significantly lower grade view with use of the AirtraqВ® was reported (pП.009). For scenario #2 (tongue edema) the median time to ventilation using direct laryngoscopy was 47.41s and using the AirtraqВ® was 27.25s with a difference of 20.16s (pП.001). There were also significantly fewer intubation attempts (pП.05) and a lower grade view (pППЅ.001) with the AirtraqВ® in this scenario. There were no significant differences in time to ventilation and number of attempts for c-spine immobilization. A significant lower grade view was also reported for this scenario (pППЅ.001). For scenario #4 (normal airway) there were no significant differences in time Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts to ventilation or number of attempts. There was a significantly lower grade view with the AirtraqВ® for this scenario (pП.001). There were no differences in time to ventilation between scenario #1 and #4 (normal airway). Conclusion: The AirtraqВ® was shown to be equal or faster than direct laryngoscopy with the Macintosh #3 blade for easy and difficult airway scenarios in this manikin model. The AirtraqВ® also required fewer intubation attempts than direct laryngoscopy in the tongue edema scenario. Use of the AirtraqВ® resulted in significantly lower Cormack-Lehane airway views compared with direct laryngoscopy for all scenarios. 63 Respiratory Isolation Rooms in the Emergency Department Lobo R, Borges Md, Neves FF, Pazin-Filho A/Medical School of Ribeirao Preto University of Sao Paulo, Ribeirao Preto, Brazil Study Objectives: To analyze the use of other performance parameters in planning isolation room capacity and to evaluate the impact of installing an exclusively dedicate respiratory isolation room in a tertiary emergency department predicted by a time-to-reach facility method. Methods: Two groups of patients with suspected tuberculosis admitted to a tertiary emergency department were evaluated prior and after the implementation of the exclusively dedicated respiratory isolation room. Group I (2004; 29 patients; 44.1П®3.4 years; 68.9% male) and Group II (2007; 50 patients; 43.4П®1.8 years; 41.2% male) were gathered in the same period of the year. We recorded demographic and functional parameters. Unadjusted crude incidence rates for respiratory isolation were obtained by survival methods. Cox proportional hazard models adjusted for age, gender and in-hospital respiratory isolation room availability were obtained. Results: Increasing the isolation room decreased the time from arrival to indication of respiratory isolation (27.5П®9.3 x 3.7П®2.0; p П 0.0180) and from indication to effectively respiratory isolation (13.3П®3.0 x 2.94П®1.06; p П 0.003) but not the respiratory isolation duration and total hospital stay. The impact on crude isolation rates were very significant (8.9 x 75.4/100.000 patients ПЄ pПЅ0.001). The hazard ratio for effectively respiratory isolation was 26.8 (95% CI 7.42 вЂ“ 96.9) ПЄ pПЅ0.001 greater for 2007. Conclusion: Implementing an exclusively dedicated negative-pressure respiratory isolation room in a tertiary emergency department reduced significantly the time to respiratory isolation in suspected tuberculosis patients. Planning capacity based on time-to-isolation could be a better strategy than the traditional occupation rate. 64 Intubator Recall of Hypoxia and Number of Attempts Is Often Inaccurate Compared to Video Review Hill CH, McGill J, Reardon R, Falvey D/Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN Study Objective: Most emergency intubation literature uses intubator recall of the procedure as the method of data collection. This study evaluated the accuracy of intubator recall with regard to hypoxia and number of attempts by comparing video recordings of airway procedures to intubator charting. Methods: This was a retrospective review of emergency intubations at an urban level one trauma center. All emergency intubations were recorded using video cameras Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ from three distinct angles with the cardiac monitor information recorded alongside these images. During video review the lowest oxygen saturation was recorded as the lowest value from medication administration through the minute following successful intubation. Saturations were not recorded if there was no agreement between the pulse obtained from the oxygen saturation probe and the cardiac monitor leads. Hypoxia was defined as oxygen saturation under 90%. The number of attempts was obtained by direct visualization of the video by two reviewers following an agreed upon definition of вЂњattempt.вЂќ An electronic procedure note was created with spaces to record the number of attempts and lowest oxygen saturation for the procedure. Retrospective review of the electronic health record was conducted and the corresponding values for low oxygen saturation and number of attempts were obtained from this procedure note. Results: 104 intubations over a three-month period were reviewed. All procedures had a corresponding computerized procedure note; however, not all notes recorded the low oxygen saturation and the number of attempts. In 8 patients no saturation was recorded by the cardiac monitor due to ongoing CPR (n П 6) or due to emergent intubation that occurred before the cardiac monitor was applied (n П 2). Excluding these, 45/96 patients (47%) became hypoxic. This was correctly recognized in the chart in 15/45 times (33%). In 11/45 cases (24%) satutration was not recorded in the procedure note, in 28 /45 (62%) the recorded low saturation was greater than 5 points higher than the true low saturation. In 11/45 cases (24%) the low saturation was recorded as above 90 when video review revealed hypoxia. The number of attempts were charted correctly in 66/104 cases (63%). In 27 (25%) the number of attempts was not charted and in 12 cases (11%) were charted incorrectly. In patients who required one attempt 57/81 (70%) were charted correctly, 5/81 (6%) were charted incorrectly and 19/81 (23%) were not charted. In patients who required two attempts 9/13 (69%) were charted correctly, 2/13 (15%) were charted incorrectly and 2/13 (15%) were not charted. In patients who required more than two attempts, 0/10 were charted correctly, 5/10 (50%) were charted incorrectly and 5/10 (50%) were not charted. Conclusions: Intubator recall performs poorly when compared to video review of intubations, especially in cases where patients become hypoxic or require multiple intubation attempts. 65 Emergency Physician Ability to Predict Difficult Endotracheal Intubations Shum L, Guyette F, Emlet L/University of Pittsburgh Medical Center, Pittsburgh, PA Study Objective: We examined the ability of emergency physicians to predict difficult endotracheal intubations in patients requiring immediate airway management. Methods: We prospectively collected data on both medical and trauma intubations in the emergency department of a university affiliated, Level 1 trauma hospital. Following intubation, emergency physicians were asked to fill out a data form which included reasons for intubation, airway management technique, number of attempts, level of training, utilization of airway adjuncts, medications used to facilitate intubation, and whether the emergency physician thought the intubation would be difficult. We also collected data on traditional predictors of a difficult airway; including patient anatomy, Mallampati score, thyromental distance, and mouth opening. Data were then extracted from all recorded difficult intubations, defined as Х†3 intubation attempts, use of any adjunct airway device, or a CormackLehane grade III or IV. Results: Two hundred forty intubations were recorded during the study period including 89 trauma and 151 medical intubations. 27/240 (11%) intubations were classified as difficult intubations. 14/27 (52%) were trauma and 13/27 (48%) were medical intubations. This represents 14/89 (15%) of all traumas and 13/151 (8%) of all medical intubations. 14/27 (52%) required Х†3 intubation attempts, 19/27 (70%) had a Cormack-Lehane grade III or IV, and 6/27(22%) had both. 9/27 (33%) required the use of an airway adjunct including cricothyrotomy 4/27 (15%), bougie 3/27 (11%), video laryngoscopy 1/27 (3%), and fiberoptic intubation 1/27 (3%). Rapid sequence induction was utilized in 24/27 (89%) difficult intubations. Mallampati was grade 3 or 4 in 8/27 (30%) while there was no assessment made in 15/27 (56%) of difficult intubations. Thyromental distance was not assessed in 13/27 (48%) and mouth opening in 6/27 (22%). Emergency physicians made the prediction of a difficult airway in 77/240 (32%) of intubations. Among difficult intubations, physicians accurately predicted 17/27. This represents a sensitivity of Annals of Emergency Medicine S21 Research Forum Abstracts 63% (CI 42%вЂ“ 81%) and specificity of 71% (CI 65%вЂ“77%). In the correctly predicted difficult airways, emergency physicians most often listed obesity/big neck 9/17 (53%) and facial trauma/bloody secretions 5/17 (29%) as factors leading them to predict a difficult airway. Conclusion: Difficult airways are frequently encountered in the emergency department and occur more often in trauma versus medical airway management. Emergency physician assessment is moderately effective at predicting difficult intubations. However, emergency physicians did not assess many of the traditional predictors of a difficult airway. Instead, successful difficult airway prediction relied on a clinical evaluation of multiple patient characteristics including body size, secretions, facial trauma, and neck size. 66 Airway Characteristics of Patients With Difficult Airways Wong E, Ngo A/Singapore General Hospital, Singapore, Singapore Study Objectives: The difficult airway is a challenge to most emergency physicians and its incidence is rare. In this study, we attempt to document the airway characteristics of patients with difficult airways. Methods: The department of emergency medicine has an ongoing airway registry from 2000. From 1 October 2008, the emergency department prospectively collected data on airway management with particular emphasis on the difficult airway. Data captured included patient demographics, airway characteristics, diagnoses, indications for intubation, personnel and discipline of the physician performing the intubations, reasons for difficult intubation, rescue methods, success rate, complications and disposition. A difficult airway was defined as at least 3 attempts at intubation by an attending emergency physician or a failed intubation or is deemed difficult by the attending physician after the intubation attempt. Results: There were 172 patients who received advanced airway management from 1 October 2009. There were 117 (68%) men. The mean age was 62 years. The main diagnoses were cardiac arrest (67, 39%), congestive heart failure (27, 15.7%) and cerebrovascular accidents (15, 8.7%). Twenty-four (14%) intubations were felt to be difficult by the practitioners. Twelve cases (7%) had three attempts or more. Five of these cases required the use of the bougie (2) and glidescope (3) as rescue devices. There was no failed intubation or failed airway. The patient characteristics associated with the difficult airway were as follows: Difficult intubations were associated with more complications (OR 8.944, CI 5.322, 15.033). Conclusion: The difficult airway seemed to be more prevalent than in previous studies when the data collection form placed emphasis on describing airway characteristics of intubated patients. Maxillofacial trauma, small mouth opening, thyromental and thyroid spaces, obesity, oral obstruction and neck immobility are associated with difficult intubation. 67 Pulmonary Effects of Atropine in Humans Ly S, Lindberg J, Dershwitz M, Walz M, Gaspari R/University of Massachusetts, Worcester, MA Study Objectives: Atropine increases ventilation by decreasing pulmonary secretions and dilates pulmonary airways but it is unclear if atropine affects pulmonary vascular tone. Animal studies indicate that atropineвЂ™s effect on pulmonary vascular tone causes a dose dependant ventilation-perfusion (VвЂ“Q) S22 Annals of Emergency Medicine mismatch and resultant hypoxia. We hypothesize that atropine causes a VвЂ“Q mismatch in humans. Methods: An interventional human study of patients undergoing general anesthesia at a tertiary care center was performed to get pilot data for a later larger study. Patients were consented to receive 0.02вЂ“ 0.03 mg/kg intravenous atropine with arterial blood gas measurement at baseline and 2 minutes following IV atropine. A comparison of paO2, paCO2 and A-a gradient was made pre- and post-atropine. This study was approved by our IRB. Results: Nine patients were enrolled with complete data sets. The average FiO2 at baseline was 63% and remained unchanged throughout the study with initial paO2, paCO2 and A-a gradient of 222 mmHg, 40.2 mmHg and 180 mmHg respectively. Post-atropine the paO2 increased to 235 mmHg and paCO2 increased to 43.3 mmHg. For all patients the A-a gradient decreased an average of 17.47 mmHg after atropine was given, but 4 of the 5 patients demonstrated the opposite effect with an increase in A-a gradient an average of 7.42 mmHg with an average decrease in paO2 of 13.75 mmHg. Conclusion: Atropine improves gas exchange and oxygenation in most patients but in some patients there is a paradoxical decrease in oxygenation and gas exchange. 68 Spontaneous Pneumomediastinum: A Ten-Year Experience Beatty N, Van Tonder R, Bellolio M, Colletti J/Mayo Medical School, Rochester, MN; Mayo Clinic, Rochester, MN Study Objectives: To assess the clinical presentation, triggers, evaluation and outcomes of patients presenting with spontaneous pneumomediastinum (SPM). Methods: We performed an observational cohort study of 142 consecutive cases from 1998 to 2007. We excluded cases involving trauma and procedures. Results: The final cohort was 84 patients, 65.5% were male, with a median age of 24.5 years. Twenty-two (26.2%) were children less than 18 years. Fourteen (16.7%) had history of drug use, and 22 (26.2%) were active tobacco smokers. Sixteen (19%) had history of obstructive lung disease. Symptoms at presentation are displayed in the Table. Seventy-one subjects (84.5%) had a chest radiograph, and SPM was missed on 17 (21%) of them. Fifty-seven (67.9%) subjects had a chest CT. Twenty-eight (33.3%) had an esophagogram, and 3 of these (12%) had a positive study for esophageal leak. Eight (9.5%) subjects had interventions associated with the SPM, and 17 (26.1%) had an associated pneumothorax. A total of 64 patients (76.2%) were admitted. The median hospital length of stay was 2 days (IQR 1 to 6.5). Children were twice as likely to present with chest pain compared to adults (73% vs 37%; RR 1.96, 95%CI 1.30 вЂ“2.96, pП0.004), and 4 times more likely to present with sore throat or neck pain (64% vs 16%; RR 3.94, 95%CI 2.06 вЂ“7.55, pПЅ0.0001). There was no difference in fever at presentation (9% vs 8%, RR 1.12, 95%CI 0.23 to 5.39, pП1.0). Obstructive lung disease was more common in children (nП9, 41%) compared to adults (nП7, 11.3%), RR 3.62, 95%CI 1.53вЂ“ 8.56, pП0.002. Cough was a trigger in 50% of the children and 30% of adults. There was 1 child with SPM secondary to valsalva/vomiting as compared to 29% of adults. All the children (nП22, 100%) and 49 adults (69%) had a chest radiograph in the initial evaluation (pП0.02), SPM was missed in 14% of children vs 24% adults, pП0.38. Children were half as likely to undergo chest CT (nП7, 31.8%) compared to adults (nП50, 80.6%), RR 0.39, 95%CI 0.21вЂ“ 0.74, pПЅ0.0001. Children were as likely as adults to have an esophagogram, 22.7% vs 37.1%, pП0.22. Patients were followed for up to 1 year, and there were no recurrences of SPM in this cohort. Conclusion: SPM is an uncommon disease. Children are more likely to have history of obstructive lung disease, present with chest pain, sore throat and neck pain. Children are more likely to have a chest radiograph whereas adults are more likely to have a chest CT during evaluation for SPM. While esophagogram is frequently obtained in evaluation of etiology of SPM, it infrequently reveals esophageal leak even when esophageal leak is strongly suspected. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts 69 Patient Outcomes and Resource Utilization for Emergency Department Patients With Suspected Pulmonary Embolism and Initial Chest Computed Tomography Angiography Studies Deemed Suboptimal for Interpretation Weinstein J, Burton J, Katz B/Albany Medical Center, Albany, NY Study Objective: Chest computerized tomography angiography (CTA) has become a standard study for the radiological evaluation of emergency department (ED) patients with suspected pulmonary embolism (PE). Previous studies have described CTA in these patients to be interpreted as вЂњsuboptimalвЂќ for PE diagnosis in as many as one-third of patients imaged. To date there have been no investigations addressing the medical decisionmaking, resource utilization, and patient outcomes in these patients with suboptimal studies. The objective of this study was to examine the subsequent treatment, additional imaging modalities, resource utilization, and clinical outcomes associated with suboptimal ED CTA studies to exclude PE. Methods: This retrospective health record review investigated a consecutive cohort of ED patients who underwent chest CTA for suspected PE during a predefined four-month period in an academic tertiary care medical center. All health records were reviewed by trained personnel for predefined variables including radiological imaging studies, medical therapy and patient outcomes after 30 days. This study was conducted with approval from the institutional review board. Data were analyzed using descriptive statistics. Results: A total of 274 patient encounters occurred and were reviewed during the study period. There were 83 (30%) chest CTAs interpreted as suboptimal in this dataset. Additional imaging studies or interventions in these patients included 9 patients receiving repeat intravenous contrast bolus for an immediate repeat chest CTA, 10 patients undergoing lower extremity duplex ultrasound, 6 patients with ventilation/perfusion scans done the same or next day, and 1 patient with repeat chest CTA within 24 hours of the initial study. Three patients were admitted to hospital solely for further PE consideration. Medical management for suboptimal interpretation patients included 2 patients treated with heparin for anticoagulation prior to further imaging studies with one of these patients having repeat chest CTA the next day and one with heparin treatment and repeat chest CTA 14 days later. None of these additional treatments or imaging modalities yielded a diagnosis of PE. Thirty-day outcomes of patients with suboptimal chest CTA findings demonstrated no diagnosis, morbidity or mortality associated with PE. Conclusion: In this cohort of ED patients with suboptimal chest CTA studies, patients incurred additional imaging studies, medical therapy and in some cases hospital admission for further consideration of PE diagnosis. Suboptimal chest CTA interpretations in ED patients suspected of PE appear to have a substantial impact on health care resource utilization given that many of these patients undergo additional imaging and treatment which may represent an elevated risk for this patient population as well as escalated health care costs. The implications of not pursuing further diagnostic workup or therapy in patients suspected of PE with suboptimal chest CTA interpretations also represent an area for concern. 70 A Regional Study of Emergency Department Visits for Acute Exacerbationof Chronic Obstructive Pulmonary Disease Faig O, Allegra JR, Eskin B/Morristown Memorial Hospital, Morristown, NJ Study Objective: Recent advances have been made in the treatment of chronic obstructive pulmonary disease (COPD), including the use of corticosteroids and noninvasive positive pressure ventilation. However, a recent study using a national database demonstrated no change from 1993 to 2005 in the rates of visits to the emergency department (ED) for acute exacerbations of COPD, of hospital admission and of intubation. Our objective was to examine whether the trend in rates in our local region were similar to those found in the national database. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Methods: Design: Retrospective cohort. Setting: Consecutive patients seen by ED physicians in 28 hospitals in New Jersey and New York between 1/1/1996 and 12/ 31/08. Protocol: We classified patients as having COPD exacerbations based on ICD9 codes. Data Analysis: We compared the annual COPD visits to total ED visits and, for the COPD visits, the annual hospital admission and intubation rates using regression analyses and the Student t test with alpha П 0.05. Results: Of the 7,567,002 ED visits, there were 47,285 visits (0.6%) with an ED diagnosis of COPD. Mean age was 71 П©/ПЄ 12 years and 54% were female. The mean age and percent female were similar for all years. There was no statistically significant correlation in percent of total ED visits for COPD versus year (R2 П 0.08, p П 0.35) and in the percent of COPD patients intubated versus year (R2 П 0.21, p П 0.11). The percent of COPD patient admitted to the hospital increased from 62% in 1996 to 76% in 2008 (difference П 14%, 95% CI: 11%, 16%, p ПЅ0.001). The correlation coefficient for this upward trend was R2 П 0.91 (pПЅ0.0001). Conclusion: Similar to a previous study, we found no statistically significant change in the rate of visits to the emergency department (ED) for acute exacerbations of COPD or of intubation. However, contrary to that study, and despite availability of newer treatments, hospitalization rates for COPD patients in our area have increased. 71 Does the Pulmonary Embolism Severity Index Identify Patients at Risk for Short Term Clinical Deterioration? Hariharan P, Kabrhel C/Massachusetts General Hospital, Boston, MA Study Objectives: The Pulmonary Embolism Severity Index (PESI) aims to differentiate patients with pulmonary embolism (PE) who are at risk for clinical deterioration from those who can safely be treated as outpatients. Previous studies have shown that the PESI predicts 30 and 90 day mortality after PE. However, the decision to admit a patient may incorporate outcomes other than mortality, and the relevance of delayed endpoints to clinical deterioration occurring during an average hospitalization is not known. We sought to determine whether the PESI predicts clinical deterioration during an average length hospitalization for PE. Methods: Retrospective analysis of emergency department patients with radiographically proven acute PE from May 2006 to April 2008. We reviewed the medical record for demographics, data needed to calculate the PESI and our composite outcome. Our outcome was designed to identify hospitalized patients who had any cardiopulmonary instability or required a hospital-based medical intervention (other than anticoagulation). Patients were considered to have the composite outcome if, within the first five days after diagnosis, they: 1) had two consecutive systolic blood pressures below 100mmHg; 2) had an oxygen saturation ПЅ90%; 3) had a new cardiac arrhythmia; 4) had recurrent symptomatic PE; 5) required advanced cardiac life support (ACLS); 6) required respiratory support with more than 2L/min of oxygen; 7) were treated with vasopressors; 8) received thrombolysis or thrombectomy; 9) returned to the hospital after discharge; 10) died. Sensitivity, specificity, NPV and PPV were calculated using SAS 9.1 (Cary, NC). The Partners Human Research Committee approved the study. Results: We identified 249 patients diagnosed with acute PE during the study period. Complete data were available for 244. Of these, 116 (46%) were male, 203 (83%) were white, 16 (7%) black, 14 (6%) Hispanic and 23 (9%) were of other race/ ethnicity. The mean age was 57П®17 years. One hundred thirty eight (57%) had private insurance. The PESI identified 107 (44%) as low risk and 137 (56%) as high risk. Among high risk patients, the most common PESI risk factors (apart from age) were: malignancy (73, [53%]), hypotension (67, [49%]), male sex (65, [47%]) and tachycardia (55, [40%]). There were 131 (54%) patients with the composite outcome. The PESI correctly identified 94 (72%) of these patients as high risk, while 37 (35%) of 107 patients characterized by the PESI as low risk had the composite outcome. Test characteristics were as follows (95%CI): sensitivity 72% (64%вЂ“79%); specificity 62% (53%вЂ“71%); NPV 65 (56%вЂ“74%) and; PPV 79% (61%вЂ“76%). Conclusion: The PESI identifies most patients who clinically deteriorate during the first five days after a diagnosis of acute PE. However, 35% of patients categorized as safe by the PESI clinically deteriorated or required a hospital-based intervention within five days of their PE. The PESI is insufficiently sensitive to use when determining whether a patient should be hospitalized for PE. 72 Outcome of Cardiac Arrest After Accidental Hypothermia and Indication for Cardiopulmonary Bypass Mori K, Sawamoto K, Maekawa K, Warabi R, Tanno K, Uemura S, Nara S, Asai Y/Sapporo Medical University, Sapporo, Japan Study Objectives: Cardio pulmonary bypass (CPB) is effective for resuscitation in cases of cardiac arrest after accidental hypothermia (AH), but the indications for CPB Annals of Emergency Medicine S23 Research Forum Abstracts have not yet been clarified properly. The purpose of this study was to investigate the outcome of cardiac arrest after AH and to clarify the indications for CPB by a retrospective review. Methods: Out of 133 patients carried to our emergency department between May 1994 and April 2008, there were 24 for whom CBP was performed for resuscitation from AH with cardiac arrest. We reviewed the prognostic factors (age, cause of AH, core temperature, electrocardiography, cardiac arrest time, time to introduce CPB, time to restart heart beat) and the values of the blood gas analysis (PH, serum base excess, serum potassium, lactate, glucose, PaCO2, PaO2). Neurological prognosis was measured by the Glasgow Outcome Scale (GOS) at the time of discharge from hospital. Results: The average age of the patients was 43.3П©/ПЄ21.4 years, 16 were male and 8 were female. The causes of AH were drowning 11, mountaineering and exposure to cold air 13. The body temperature was 24.1П©/ПЄ3.6 C. Electrocardiography findings were ventricular fibrillation 5, Asystole 14, pulseless electrical activity 5. The mean interval from discovery of patients to carrying to ED was 44.1П©/ПЄ29.5 minutes. The mean interval from admission to rewarming with CPB was 29.5П©/ПЄ22.5 min, and all of the 24 patients obtained spontaneous heart beats, and the mean interval from CPB to the restart of heart beat was 28.1П©/22.3 min. Nine of 24 patients had neurological recoveries, and neurological prognosis were Good Recovery 8, Moderate Disability 1, Vegetative State 1, and dead 7. The findings of ECG and core temperature at admission did not relate to prognosis at the time of discharge. The patients who had mild acidemia (PHПѕ7.0, SBEПѕ-20mmol/L, lactateПЅ150mg/dl, potassiumПЅ6.0mEq/L) improved in neurological outcome. Conclusion: CPB improved prognosis of AH, and was particularly beneficial for patients whose AH was caused by exposure to cold air and whose acidosis had not progressed. 73 Effects of the Low Dose Radiation on Nerve Cells as a Method to Increase the Survival Rate of Emergency Patients Kim S/Chungnam National University Hospital, Daejeon, Republic of Korea Study Objectives: When ischemic neuronal cell damage inducing acute cardiopulmonary arrest occurs, treatment by emergency personnel is limited other than cardiopulmonary cerebral resuscitation, defibrillation, tracheal intubation, and specific vasopressor injection. In this research, low dose radiation (LDR) was applied to delay ischemic damaged neuronal necrosis and apoptosis. I did isolate and characterize some biofactors having protective and recovery effects for ischemic damaged neuronal cells by LDR, which may role important function of the delaying neural necrosis and the promoting neuroprotection. Methods: Ischemia was induced in PC12 cells by irradiation with the 6 MV linear accelerator. After 0.1 Gy, total mRNA was isolated from PC12 cells. DD-PCR was performed from the total mRNA to find the differentially expressed genes and DNA chip analysis was carried out to compare with the data from DD-PCR. Then, RT-PCR and Northern blotting were executed to confirm the differentially expressed genes. Results: In this study, low doses of radiation at 0.1 Gy clearly showed neuroprotection effect in neuronal cells. Also, it has been demonstrated that all protective responses to single exposures tend to be expressed maximally after about 0.1 Gy dose radiation. From the data, 21 genes were found. I tested these with RTPCR and Northern blot analysis and compared with the data from DNA chip assay. Conclusion: The effect of radiation on neuroprotection seems to be different at low dose levels of irradiation. The mechanism of adaptive responses to low dose radiation is explained by a cell-survival adaptive response with a genotoxic adaptive response. Cells exposed to low dose radiation in vitro or in vivo can develop high resistance to subsequent high dose radiation induced gene mutation, DNA damage, and cell death. Also, ED stress induction by LDR was observed in the results, suggesting that ED chaperones may involve in LDR. If introducing low dose of radiation, it may be possible to ameliorate or rescue individuals at risk from a variety of types of neuronal ischemic injury. And then the results can be directly applied to some fields of emergency medicine. 74 Heat Loss From IV Fluids During the Administration of Pre-Warmed Normal Saline Lyng J, Cooney DR, Scott J, Grant W/SUNY Upstate Medical University, Syracuse, NY Study Objectives: This study was designed to evaluate the amount of heat lost during the administration of pre-warmed normal saline (NS) through IV tubing in S24 Annals of Emergency Medicine two different thermal environments during acute resuscitation. Infusion of warmed IV fluids in hypothermic and trauma patients is considered to have significant benefit. Operating room studies have suggested that administering pre-warmed fluids through standard IV tubing results in a significant amount of heat loss between the source and terminal ends of the tubing. This has led to recommendations for development of techniques/devices designed to reduce this heat loss. No IV fluid heat loss studies have been performed in the emergency department (ED) or out-of-hospital settings. Methods: One liter NS fluid bags were heated to 40В°C and connected to IV tubing. A 16-gauge hypodermic needle was attached to the terminal end and inserted into an empty 1 L bag for collection. Fluid was run at a вЂњwide-openвЂќ flow rate to simulate acute resuscitation. Temperature measurements were made every 1-second using hypodermic thermocouple probes inserted into the source bag and terminal end of the tubing. The ambient air temperature proximate to the IV tubing was measured using an additional probe. Evaluations were performed in both room temperature and sub-freezing environments. Results: At a mean room temperature of 20.44В°C (68.79В°F), the mean heat loss between the proximal and terminal end of the IV tubing of was 1.8В°C, with a maximal loss of 4.25В°C. The maximum and minimum terminal temperatures were 38.01В°C and 34.46В°C respectively. At a mean sub-freezing ambient temperature of ПЄ9.21В°C, the mean heat loss was 4.20В°C, with a maximal loss of 8.58В°C. The maximum and minimum terminal temperatures were 36.04В°C and 29.89В° respectively. Conclusion: Administration of 40В°C NS through IV tubing at a вЂњwide openвЂќ flow rate in a room temperature environment does not seem to result in significant reduction in temperature at the terminal end of the IV tubing. Administration of 40В°C NS through IV tubing in a sub-freezing environment results in more heat loss than in a room temperature environment, but the mean total reduction in fluid temperature does not appear to be clinically significant. This study appears to contradict previous studies that suggested a significant amount of heat was lost as warmed NS was administered through standard IV tubing. Therefore, we do not recommend pursuit of potentially time consuming and/or costly techniques designed to reduce this heat loss for patients receiving warm saline вЂњwide-openвЂќ in either environment. Table 1: Mean, maximum, and minimum temperatures in a room temperature environment Table 2: Mean, maximum, and minimum temperatures in a cold environment 75 Time to Invasive Airway Placement and Resuscitation Outcomes After Inhospital Cardiopulmonary Arrest Wong ML, Carey S, Mader TJ, Wang HE, The American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators/UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ; Johns Hopkins Medicine, Baltimore, MD; Baystate Medical Center/Tufts University School of Medicine, Springfield, MA; University of Pittsburgh, Pittsburgh, PA Study Objectives: Clinicians often emphasize early invasive airway placement during resuscitation from cardiopulmonary arrest (CPA). We examined the association between time to invasive airway (TTIA) placement and patient outcomes after inhospital CPA. Methods: We analyzed data from the National Registry of Cardiopulmonary Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts Resuscitation (NRCPR) for the 2003 to 2007. We evaluated adult patients receiving an invasive airway (endotracheal intubation, laryngeal mask airway, tracheostomy, and cricothyrotomy) after the onset of inhospital CPA but before return of spontaneous circulation or termination of resuscitation. Patients with weights less than 20kg or more than 250kg were excluded for presumed non-standard airway management. We defined TTIA as the elapsed time from CPA recognition to invasive airway establishment. The primary outcome was return of spontaneous circulation. Secondary outcomes were 24-hour survival, survival to hospital discharge, and favorable neurological outcome (Cerebral Performance Category 1 or 2) at discharge. Using logistic regression we evaluated the association between TTIA (early (ПЅ5 minutes) versus late (Х†5 minutes)) and outcomes, adjusting for hospital location, patient age and sex, first documented pulseless ECG rhythm, precipitating etiology, and witnessed arrest. Results: We analyzed the 25,006 CPA that met the inclusion criteria of the total 82,649 CPA in the registry. Observations were most commonly excluded for not having a documented TTIA. Patient outcomes were: return of spontaneous circulation 50.3% (95% CI: 49.7вЂ“51.0%), 24-hour survival 33.7% (33.1вЂ“34.3%), survival to discharge 15.3% (14.9 вЂ“15.8%), and favorable neurological outcome 70.5% (69.1вЂ“72.0%). The mean time to invasive airway placement was 5.9 minutes (95% CI: 5.8 вЂ“ 6.0 min). Early TTIA was not associated with return of spontaneous circulation (adjusted OR 0.96, 95% CI: 0.91вЂ“1.01), but was associated with improved 24-hour survival (adjusted OR 0.94, 0.89 вЂ“ 0.99). The relationships between TTIA and survival to discharge and CPC could not be determined due to poor model fit. Conclusions: Early invasive airway placement is not associated with return of spontaneous circulation, but is associated with slightly improved 24-hour survival. The clinical benefit of early invasive airway placement during CPA resuscitation is limited. 76 Early Goal-Directed Therapy for Severe Sepsis/Septic Shock: Which Components of Treatment Are More Difficult to Implement in a Community-Based Emergency Department? OвЂ™Neill R, Morales J, Jule M/Genesys Regional Medical Center, Grand Blanc, MI Study Objectives: We evaluated the severe sepsis/septic shock protocol at our institution to determine which specific treatment elements were more difficult to implement in a community-based emergency department. Methods: Our community-based teaching hospital developed a severe sepsis/septic shock protocol based on criteria defined by the Surviving Sepsis Campaign 2008 International Guidelines. We conducted a retrospective analysis of adult patients entered into the protocol. Exclusion criteria included age ПЅ 18, pregnancy, trauma, burns, acute coronary syndrome, acute cerebral vascular event, drug overdose, do-not-resuscitate orders, contraindication to central venous catheter insertion, and need for immediate surgery. Charts were reviewed by the principal investigator to determine if the patient had met criteria for severe sepsis/septic shock as well as whether the following had been completed: a fluid resuscitation (defined as a two liter fluid bolus within one hour of identification), antibiotics within one hour of identification, a central venous catheter insertion (subclavian or internal jugular vein) with an initial central venous pressure reading, an arterial line insertion, a vasopressor infusion if indicated, a central venous oxygen saturation measurement (a venous blood gas off the central line), and if the patient was admitted with a standardized order set. Ten percent of the charts were analyzed by an outside reviewer and the inter-rater reliability compared to assess consistency. Results: A total of 98 patients presented over a nine-month period; thirteen were excluded. Median age was 65 years (IQR 55 to 78 years) with 56% female. A total of 79 out of 85 cases (93%, 95% CI: 86 вЂ“92%) were correctly identified as severe sepsis/ septic shock. An appropriate initial fluid bolus was given in 58 of 85 patients (68%, 95% CI: 58 вЂ“78%). Patients received antibiotics within one hour of identification in 66 of 85 cases (78%, 95% CI: 68 вЂ“ 85%). An internal jugular or subclavian line was placed in 55 of 85 patients (65%, 95% CI: 54 вЂ“74%), with only 23 of 85 cases (27%, 95% CI: 18 вЂ“36%) obtaining a central venous pressure. An arterial line was placed in 36 of 85 patients (42%, 95% CI: 32вЂ“52%). Vasopressor administration was given in 50 of the 63 patients (79%, 95% CI: 69 вЂ“ 89%) that required such support. Only 13 of 85 patients (15%, 95% CI: 7вЂ“23%) had an initial central venous oxygen saturation measurement. Fifty-nine of 85 patients (69%, 95% CI: 59 вЂ“79%) were admitted with the standardized order set. The kappa value for inter-rater reliability was calculated at 0.95 among the principal investigator and outside reviewer. Conclusion: The implementation of a severe sepsis/septic shock protocol in our community emergency department was met with variable success. There was high Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ compliance (Х† 70%) with antibiotic administration, and vasopressor utilization. Moderate compliance (50 вЂ“ 69%) was seen with fluid resuscitation, central venous catheter insertion and use of a standardized order set. Low compliance (ПЅ 50%) was observed with central venous pressure calibration, arterial line placement, and initial central venous oxygenation saturation measurement. This study highlights areas where community hospitals implementing EGDT programs in their emergency departments may have difficulty with compliance. 77 Rebound Hyperthermia After Cessation of Mild Therapeutic Hypothermia in Patient With Successful Resuscitation From Cardiac Arrest Park E/Ajou University School of Medicine, Suwon, Kyoung-Gi Do, Republic of Korea Study Objectives: Hyperthermia in patients with successful resuscitation from cardiac arrest may have deleterious effects upon cerebral prognosis especially during the acute stage. We investigate the incidence and risk factors for post-rewarming вЂњrebound hyperthermiaвЂќ (RH) after cessation of therapeutic induced hypothermia in patients with successful resuscitation from cardiac arrest. Methods: 34 patients admitted to the intensive care unit from January 2007 to December 2008 following out-of-hospital cardiac arrest underwent mild induced hypothermia (MIH) using cooling blanket for 24 hours. After MIH, passive rewarming was conducted. Core temperature was monitored continuously using rectal temperature probe for 48 hours after initiation of MIH. We also recorded the mechanism of cardiac arrest, the APACHE II score on admission, standard biological variables. Results: Among the 34 patients who completed the period of MIH, postrewarming вЂњrebound hyperthermia,вЂќ defined as a temperature of 38.0В°C or greater, was observed in 10 patients (29.4%) during the first 24 hours after cessation of MIH. 60% of RH were observed from six to seven hours after cessation of MIH. And among 10 patients with RH, nine patients (90%) have SIRS (systemic inflammatory response syndrome). But no SIRS were observed in patients without rebound hyperthermia. AST and ALT levels of patients with RH were significantly lower than those of patients without RH (147.40130.486 vs 506.92628.855, 106.40412.71.) Conclusion: RH was observed in 29.4% of patients during the first 24 hours after cessation of MIH. Most of cases may be associated with SIRS. 78 Risk of Death in Emergency Department Patients Needing Intubation Irvin MM, Meisner C, Nouhan PP, Irvin CB/St. John Hospital and Medical Center, Detroit, MI Background: Providing outcome information when a patient needs emergent emergency department intubation is important to help families make informed decisions and anticipate potential adverse outcomes. Useful information includes overall mortality rate, proportion that will die in the first 24 hours, and the probability patients will need to be discharged to a nursing home (NH) facility at discharge. Study Objective: To determine outcome estimates including the mortality rate (MORT) in adult patients needing emergent ED intubation based on age, arrival status (Home or NH), arrival blood pressure (BP), and reason for intubation. Methods: A retrospective review of all consecutive patients (Age 18 вЂ“39ПYoung, age 40 вЂ“ 64ПMidAge, and age Пѕ64 yrsПSenior) needing ED intubation from a large urban teaching ED (90,000ED visits/yr) from 10/07вЂ“3/09 was performed. Data on arrival BP, admission location (from a nursing home (NH) or home), ED diagnosis, and outcome (alive/dead) was recorded. Patients arriving without vital signs were excluded. Results: Of the 587 patients intubated, (43% were Senior, 42% were MidAge, and 14% were Young) 36% died. The MORT rate for Seniors was 48%, MidAge was 29% and Young was 16%, pПЅ.001. The MORT rate for the 21% (125/587) NH patients was 44%, compared to 33% (153/462) who came from home, pПЅ.04. Patients with arrival Mean Arterial Pressure ПЅ70 had very high MORT rate of 62% (78% (29/37) MORT in Seniors, 53% (21/40) MORT in MidAge, and 38% (3/8) MORT in Young, pПЅ.04). In the first 24 hours, 39% (82/212) died. Of the 212 patients who died, 44% had comfort care. Of the 309 patients coming from home and discharged (d/c) alive, 24% were discharged to a NH (33% Seniors from home and d/c alive went to a NH, 24% MidAge, and 13% Young, pПЅ.02). Of the ED diagnosis, cardiac arrest in the ED had the highest MORT rate at 67% (29/43), followed by intracranial bleed (64% 29/45) and altered mental status (56%, 41/73). Annals of Emergency Medicine S25 Research Forum Abstracts Intubated septic patients had an overall MORT rate of 47% (43/92) with Seniors MORT 60% (30/50), MidAge MORT of 31% (12/39) and Young at 33% (1/3), pПЅ.04. Intubated congestive heart failure and chronic obstructive pulmonary disease patients had the lowest MORT rates (chronic obstructive pulmonary diseaseП22% (15/69) and CHFП24% (16/66), possibly reflecting the rapidly reversible nature of these conditions. Conclusion: Families of patients needing ED intubation are often distraught and in great need of possible outcome information. Providing some estimates of what to expect may help them anticipate future challenges. Providing rough age related to overall MORT, and potentially diagnosis specific MORT information may assist families in preparing for the potential death of their loved one. About 1/3 of patients needing intubation in the ED die, and this death rate is much higher in Seniors (almost 50% die). Understanding the high (almost 40%) death rate in the first 24 hours may also be helpful information for patientsвЂ™ families asking for some general idea of the severity of the situation. Finally, information about the possibility of NH placement (1/3 Seniors were placed in a nursing home if they survived) may be valuable in understanding how this emergency may affect the overall functional status of their loved one. Although these discussions are never easy, empowering the family with this information and helping them anticipate potential outcomes may improve their ability to cope with this serious situation. 79 Establishment of a Prospective Burn Registry Taira BR, Singer AJ, Cassara G, Salama M, Rodriguez R, Sandoval S/Stony Brook University, Stony Brook, NY Study Objectives: Most published burn registries are retrospective and based in large urban centers. We established a prospective hospital and outpatient-based burn registry to determine patient and burn characteristics in a suburban setting. Methods: Study Design - Prospective, observational study. Setting - Suburban academic medical center with a regional burn unit. Subjects - Burn patients seen by the burn service between 1/08 and 3/09. Measures & Outcomes - Demographic, clinical and burn characteristics. Data Analysis - Descriptive statistics used to characterize the population. Results: 230 burn patients were entered in the registry during the study period. Mean age was 26.7 П©/ПЄ 22.3 years, 55.3% were male; 43.5% were children (ПЅ18 years old). 71.9% were White, 16.7% were Hispanic, 6.6% were Black. 64.1% had only high school or less education and 8.9% were uninsured. 16.7% of burns were work-related and 30.6% were transported by ambulance. 95.6% were thermal burns from scalds (49.8%), flame (25.1%), and contact with hot objects (23.7%). Most burns were on the extremities (29.6%) and trunk (18.7%). Mean total body surface area (TBSA) was 4.4% (П©/ПЄ 6.3). Burn depth was 1st (3.9%), superficial 2nd (53.9%), deep 2nd (33.9%) and 3rd degree (12.2%). Inhalation injury (1.3%) and associated trauma (4.4%) were rare. 11% reported a previous history of trauma and 6.2% a previous history of burn. Conclusion: Most burns in the suburban setting are caused by contact with hot liquids, flame, and hot objects. Mean TBSA is less than 5%. Inhalation injury and associated trauma are rare. More than 1 in 10 patients reported a history of previous trauma suggesting that burn patients should be included in studies of trauma recidivism. Burn prevention and education focused on scald injuries and children are recommended. 80 (62%) followed by lower limb injuries in 18%. Out of the upper limb injuries, 41% had forearm injuries and 10% had supracondylar elbow fractures. The most common mechanism was direct fall off the trampoline in 78%. Nineteen (66%) patients had a procedure done under general anesthesia while 8 (28%) were managed conservatively in plaster, 1 was transferred and 1 unknown. Of the 19 patients who had general anesthesia, 9 (48%) had manipulation under anesthesia and plaster, 5 (26%) had plating, 4 (21%) had manipulation under anesthesia and k-wiring and 1 (5%) had manipulation under anesthesia and screw fixation. There were 19 children who had surgery (67.9%). There was no difference in age between those with conservative management (mean age 9.9 years) versus surgical management (mean age 9.5; pП0.80). Boys were as likely as girls of having surgical management (RR 1.29, 95%CI 0.74 to 2.24; pП0.43). Length of hospital stay was 2 days (range 1 to 4 days). There was no difference in length of stay between those who had limb injuries (mean 2.4 days) versus those with spine/chest injuries (mean 2.0 days; pП0.33). Children having surgical management were more likely to have longer length of hospital stay (mean 2.5 days) versus conservative management (mean 1.9 days; pП0.060). Conclusion: There is an increase in ED visits related to trampoline injuries secondary to their increased popularity for recreational purposes. Trampoline can cause injuries particularly in the upper and lower limbs of children. Up to 68% of children admitted to the hospital will require surgical management, increasing the length of stay and costs. The importance of having safety guidelines for the use of trampolines is emphasized. We strongly advocate the need for prominently displayed warning labels and guidelines on safe and responsible use of domestic trampolines. Key points to enhance safety are: 1) Reinforcement of safety mechanisms (nets) on the trampoline. 2) Adult supervision at all times for under 16 year olds. 3) Parents advice not to allow their children less than 6 years of age to use trampoline. 4) Use of trampoline by only one person at a time. Epidemiology of Trampoline-Related Injuries in Children Attending the Emergency Department Dhillon RJ, Dhillon RK, Maqsood MQ/Mayo Clinic, Rochester, MN; Lincoln County Hospital, Lincoln, Lincolnshire, United Kingdom Study Objective: Epidemiological analysis of trampoline-related injuries in children attending an urban emergency department (ED) and subsequent admission to the hospital. Methods: Observational cohort study of consecutive children attending the ED and admitted to the county hospital with injuries related to trampoline use over 1year period (April 2006 to May 2007) in Lincoln City, England. Results: There were 29 children, 17 boys and 12 girls with a mean age of 9 years 5 months (range 3 to 16 years) and median age of 10 years. Of those, 7 (24%) were under six years of age. There were 24 children with limb injuries (83%), and 5 had spine/chest injuries (17%). There was no difference in age between those who had limb injuries (mean age 9.2 years) versus those with spine/chest injuries (mean age 11.6 years; pП0.25). Boys were as likely as girls of having limb injuries (Relative risk 0.99, 95%CI 0.71 to 1.38; pП0.945). Upper limb injuries were the commonest S26 Annals of Emergency Medicine 81 Use of a Clinical Sobriety Assessment Tool With the NEXUS Low-Risk Cervical Spine Criteria to Reduce Cervical Spine Imaging in Blunt Trauma Patients With Acute Alcohol or Drug Use: A Pilot Study Mahler SA, Pattani S, Caldito G, Conrad SA, Arnold TC/LSUHSC-Shreveport, Shreveport, LA; University of Maryland, Baltimore, MD Study Objectives: To determine if a clinical sobriety assessment tool (CSAT) utilizing objective and reproducible measures of alertness, speech, ability to follow Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts commands, coordination, and conduct can identify reliable patients despite intoxicant use and facilitate clinical exclusion of cervical spine injury. Methods: A convenience sample of blunt trauma patients presenting to the emergency department at Louisiana State University Health Sciences Center-Shreveport, aged 18вЂ“65, with acute drug or alcohol use, were prospectively enrolled. Patients were identified as having acute alcohol or drug use by self admission, smell of alcohol, or behavior consistent with intoxication. Only blunt trauma patients with a mechanism of injury severe enough to necessitate cervical spinal immobilization, as decided by an emergency physician or emergency medical technician, were enrolled. Each subject was assessed by an emergency physician using the CSAT and four of the NEXUS low risk criteria (no distracting injuries, no focal deficits, no midline spinal tenderness, and normal alertness). Following clinical assessment cervical spine computed tomography was completed on all subjects. Patients were assigned to two groups for data analysis: group 1; patients reliable by CSAT that meet all 4 NEXUS low risk criteria and group 2; patients not reliable by CSAT or did not meet all NEXUS low risk criteria. The number of fractures in each group was recorded and the predictive value of the CSAT with NEXUS was calculated. Potential cervical imaging reduction was determined by calculating a percentage using the number of patients in group 1 without a fracture divided by the total number of subjects enrolled. Results: 202 blunt trauma patients with evidence of acute intoxicant use were enrolled. Patients in group 1, reliable by CSAT and low risk by remaining NEXUS criteria, had no cervical spine fractures (0/84). Frequency of cervical spine fractures in group 2 was 2.5%, (3/118). The CSAT used with the NEXUS criteria had a 100% predictive value (84/84) in excluding cervical spine injury. Use of the CSAT could have resulted in a 42% (84/202) 95%CI (32вЂ“53%) reduction of cervical imaging. Conclusion: The CSAT combined with the NEXUS low risk cervical spine criteria had a 100% predictive value for excluding cervical spine fractures in blunt trauma patients with acute alcohol or drug use. Due to the low frequency of cervical spine fractures a much larger study is required to confirm the utility of the CSAT. 82 Beyond BoxerвЂ™s: Bony Injuries Sustained From Punching Perry C, Powers M, Damewood S, Jeanmonod D, Jeanmonod R/ Albany Medical College, Albany, NY; St. LukeвЂ™s Hospital, Bethlehem, PA Study Objective: To define the spectrum of bony injuries sustained from a punch mechanism beyond the classic BoxerвЂ™s fracture (a fracture to the distal 5th metacarpal). Methods: This is a retrospective study of hand injuries evaluated by plain films at an academic emergency department with a census of 72,000. The Patient Archiving and Communication System (PACS) was queried for each hand radiograph performed from July 2007 to June 2008. The mechanism of injury was obtained from the radiology requisition and verified with the electronic medical record. The specific injury was obtained from the attending radiologist read. If the radiologist read was ambiguous, the final clinical diagnosis from the medical record was used. All data points were recorded into a standard spreadsheet. Children under age 13 were excluded. 8% of the collected data was confirmed by a second investigator with a kappa value of 1.0 for identifying punch as the mechanism as well as for the specific injury sustained. Results: Of 1292 patients receiving hand x-rays, 4 had no dictated note available, and were excluded from the study. 172 patients were evaluated (13.3%) secondary to self-inflicted punch mechanisms. There were 76 (40%) identified fractures in 70 patients (41%). Of all the fractures identified, 61% (46) of them were 5th metacarpal fractures. However, the classic BoxerвЂ™s fracture represented only 20 (26%) of these fractures, with the remaining being mid- or proximal metacarpal fractures. 13.3% (10) of the fractures were of the 4th metacarpal, 4% (3) were of the 3rd metacarpal, 2.7% (2) were of the 2nd metacarpal, and 1.3% (1) were of the 1st metacarpal. Other injuries noted were 9 phalanx fractures, 3 carpal fractures and 1 radius/ulna fracture. In addition, there were 9 dislocations: 3 of the 5th metacarpal, 3 of the 4th metacarpal, 1 of the 3rd metacarpal, and 2 of phalanges. Conclusion: There are significant injuries sustained as a result of punching. Although the greatest proportion are to the fifth metacarpal bone, only 1 in 4 fractures meets the definition of a classic BoxerвЂ™s fracture, while 40% of injuries involve other bones of the hand, wrist, and forearm. 83 Utility of Additional Radiographs in Emergency Department Patients With Extremity Injuries Mirhadi M, Suchard J, Leung A, Chang R/UC Irvine, Orange, CA Study Objectives: Emergency department (ED) patients with extremity injuries are typically evaluated with X-rays based on signs or symptoms suggesting potential Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ skeletal injuries. However, a common teaching is get X-rays вЂњabove and belowвЂќ identified bony injuries. When surgical consultation is requested, additional X-rays may be obtained regardless of clinical signs. We were unable to identify prior studies evaluating the utility of such additional X-rays. Our objectives were to determine the incidence of positive radiographic findings found on additional X-rays ordered by the consulting surgeon in cases of extremity trauma seen in the ED, and to find if these newly identified injuries impacted clinical care. Methods: This study was a retrospective chart review in a suburban academic ED with annual census Пі38,000. Extremity trauma cases with surgical consultation were identified from a list obtained from radiology of all ED patients with extremity X-rays (from hip to toe, or from shoulder to finger) from 6/1/08 to 11/30/08. вЂњTrauma activationвЂќ patients, those with only one X-ray, those getting multiple X-rays of noncontiguous body parts, and patients with no positive radiographic findings were excluded. Medical records of the remaining subjects were reviewed for evidence of orthopedic or plastic surgical consultation, the timing of consultation and all X-rays, whether additional X-rays were obtained by consultant request, and whether findings on these X-rays resulted in splinting, reduction, surgery, or admission. Descriptive statistics were used. Results: 1979 patients had 3719 extremity X-rays during the six-month study period. 200 patients had positive radiographic findings and multiple X-rays of contiguous body parts; 142 of these (7.1% of total) also had evidence of surgical consultation, prompting further chart review. 32 patients had additional X-rays ordered by, or at the request of, the consultant (22.5% of consults). These films revealed 4 injuries not detected on initial X-rays (2.8% of consults), 2 of which resulted in an additional intervention (splinting, surgery). It was not possible to determine if these interventions werenвЂ™t already indicated by initial X-ray findings. Conclusion: We found a 2.8% incidence of injuries discovered by additional Xrays ordered by consultants for ED patients with isolated extremity injury. The impact of these X-rays on clinical care is not clear. While obtaining X-rays вЂњabove and belowвЂќ the site of identified bony injury is common, this practice may be of minimal clinical utility. 84 Alcohol-Related Sexual Assault Victimization Among Adolescents Oostema A, Jones JS, Rossman L, Wynn B/MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI; Grand Rapids MERC/ Michigan State University, Ada, MI; YWCA West Central Michigan Nurse Examiner Program, Grand Rapids, MI; MERC/Michigan State University Program in Emergency Medicine, Spectrum Health Hospital, Grand Rapids, MI Background: Alcohol is commonly present in sexual assault incidents with approximately one- to two-thirds of rape incidents involving alcohol use by offenders and/or victims. However, only a few studies of national samples have explored the role of alcohol use in sexual assaults against young women in relation to rape and injury outcomes and the severity of sexual assault. Study Objective: To document the rates of alcohol-related sexual assault among adolescents using a community-based sample and to examine the distinctions between alcohol-related and non-alcohol-related assault. Methods: This retrospective cohort trial evaluated consecutive female patients (ПЅ 18 years old) presenting to a community-based Nurse Examiner Program (NEP) during a 10-year study period. Sexual assault victims presenting directly to four downtown emergency departments are routinely referred to the NEP for evaluation after triage and initial assessment. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medical-legal examinations. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification form. For the purposes of this study, injury was defined as any tissue trauma visible on inspection which was then subsequently classified using the TEARS (tears, ecchymoses, abrasions, redness and swelling) classification system. Primary outcome of interest was the relationship between injury from sexual assault and alcohol use by the victim prior to the assault. Chi-square and ANOVA tests were used to compare anogenital findings in victims examined. Results: A total of 895 adolescent cases (ПЅ 18 years old) were identified; representing 32% percent of all women assault victims. 528 (59%) of adolescents reported alcohol and/or drug use immediately prior to the sexual assault, of which 399 (45%) involved alcohol only. Over the ten-year study period, the annual incidence of alcohol use by adolescent victims remained stable (43% to 47%). Victims who reported alcohol consumption were more likely to be white, victim of multiple assailants, and sleeping prior to the assault. Although this cohort had a smaller incidence of vaginal penetration, they had a greater number of documented Annals of Emergency Medicine S27 Research Forum Abstracts genital injuries (68% vs. 59%, pПЅ.01). In contrast, adolescents who denied alcohol consumption were more likely to be virgins, assaulted in their own home, and file a police report. This group reported a higher incidence of weapon use by the assailant but had fewer non-genital injuries (25% vs. 37%, pПЅ.01) when compared to victims of alcohol-related sexual assault. Conclusions: Alcohol consumption remains an important risk factor in sexual assault, with 45% of rape incidents involving alcohol use by adolescent victims. Preassault alcohol use by victims was associated with more non-genital and genital injury to the victim. The epidemiology and injury patterns in this group are unique and pose special challenges to emergency health care providers. 85 Penile Fracture: Evaluation and Management Hawkins D, Jones JS, Bush C/Michigan State University College of Human Medicine, Grand Rapids, MI; MERC/ Michigan State University, Grand Rapids, MI; MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI Background: Fracture of the penis is a relatively uncommon form of urologic trauma. It is a disruption of the tunica albuginea of one or both corpus cavernosum due to blunt trauma to the erect penis. Unfortunately it is often misdiagnosed and may therefore be mistreated. Study Objective: The purpose of this study was to review the predisposing factors, injury patterns, and treatment of penile fracture in a cohort of patients who presented to the emergency department (ED). Methods: The design was a retrospective analysis of patients presenting to the ED of an urban U.S. academic medical center over a 4-year study period. Patient demographics, presenting complaints, co-morbidity, radiographic studies, treatment in the ED, final disposition, and complications were recorded using a standardized abstraction form. CT reports and procedure or operative notes were reviewed to define the extent of penile injuries and time and type of definitive treatment. To assess accuracy of the data collection, 10% of the records were randomly selected and reexamined by one investigator. Descriptive statistics (frequency tables, confidence intervals) were used to summarize the data. Results: From August 2004 to July 2008, 16 patients presented to the ED with a penile fracture. The mean age was 33.2 П©7.8 years (range, 14 вЂ“ 47). Mechanism of injury included sexual maneuvers (75%), accidental manipulation of erect penis (19%), and fall onto erect penis (6%). Characteristically, all patients heard a cracking sound associated with sharp pain followed by immediate loss of the erection, deformity, discoloration and swelling of the soft tissues. Accurate identification of the fracture site could usually be made on examination by rolling the swollen skin over a fixed, smooth, rounded, tender lump (of clot), deep to BuckвЂ™s fascia: the rolling sign. Blood was present at the meatus in three patients; however, urethrography demonstrated a urethral wall tear in only one man. In all patients the tunica albuginea of the corpora cavemosa in the proximal third of the penis was torn (range, 5 to 20 mm) but the corpus spongiosum was intact. The tear in the tunica albuginea was unilateral and transverse in all cases, involving less than half of the circumference of the corpus cavernosum. Defects in the tunica albuginea were repaired with sutures and the hematoma was evacuated. Operations were performed 3 hours to 4 days after injury. Only 6 patients were treated within 7 hours and no short-term complications were noted. Conclusions: The diagnosis of penile rupture does not require further investigation when the patient presents with typical onset (during sexual intercourse) and typical physical findings, including swelling and ecchymosis of the penis with a deviation toward the side opposite the injury. Ultrasound and retrograde urethrograms, especially in an atypical case, should be performed to rule out other injury and to help determine appropriate surgical management. The management of penile rupture includes conservative treatment and early surgical repair to avoid complications such as persistent clot, angulation, penile abscess and fibrosis. EMF-1 Characteristics of Patients Undergoing Mechanical Ventilation in US Emergency Departments Easter B, Fischer C, Fisher J/Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA Study Objectives: Outside the intensive care unit and the post-operative recovery area, the emergency department (ED) is the most common site for provision of critical care. However, little is known about ED-based mechanical ventilation (MV). S28 Annals of Emergency Medicine We examined the epidemiology of ED MV, including demographic, clinical, and ED length of stay (LOS) variables that may influence subsequent management of mechanically ventilated patients. Methods: We combined the 2002вЂ“2006 ED datasets of the National Hospital Ambulatory Medical Care Survey. Patients were considered to have undergone a period of MV if they were intubated in the ED and survived their ED course to either hospital admission or transfer to another facility. Demographic and clinical characteristics, ED LOS, and indications for MV were analyzed. Point estimates of proportions with confidence intervals were calculated. To categorize indications for MV, we used the Clinical Classifications Software (CCS) 2009 (Agency for Health care Research and Quality) to systematically sort ICD-9 codes. CCS makes use of seventeen predetermined categories, such as respiratory diseases or diseases of the circulatory system. Up to three ICD-9 codes were available for each patient, and patients were assigned multiple categories if their ICD-9 codes so indicated. Results: The combined dataset contained 494 observations of intubations, representing 1,473,000 visits, and 334 observations for MV, representing 994,000 visits. Approximately 0.26 % (95% CI 0.23вЂ“ 0.29) of ED patients were intubated and 0.17% (0.15вЂ“ 0.20) underwent MV. 58.8% of MV patients were male, 75.5% Caucasian, and 66.1% over age 45. 9.1% received CPR. Mean LOS was 278.1 minutes (234.9 вЂ“321.3); 53.5% of visits were greater than four hours, a sufficient amount of time to implement interventions aimed at reducing complications of MV. Against a backdrop of increasing ED visit times nationally, LOS for MV patients actually decreased over the study period (ptrendПЅ.05). In particular, LOS fell precipitously over the last two years of the study period, from 325.9 minutes in 2004 to 192.6 minutes in 2006. By comparison, LOS for all ED visits increased by 7.0 minutes over the same period. Based on CCS, the most frequent indications for intubation were respiratory diseases, circulatory system diseases, and injury and poisoning with 23.5%, 23.1%, and 21.1% of patients, respectively, having an ICD-9 code matching one of these categories. By comparison, these categories accounted for 13.5%, 10.0%, and 20.3%, respectively, of all ED visits over the study period. Conclusions: These data provide a picture of the epidemiology of MV in US EDs. Mean LOS appears sufficient for collaborating with critical care providers on implementing ED-based solutions that will reduce the complications of MV, such as ventilator-associated pneumonia, for ED patients. However, the decline in LOS from 2004 вЂ“2006 may undermine this approach if MV patients are simply not in the ED long enough to impact outcomes. Further investigation of the LOS trend will help determine the utility of such an ED-based approach. EMF-2 Induced Mild Hypothermia Modulates Akt Phosphorylation and Hsp27 Expression in Mouse Hemorrhagic Shock Das A, Li J, Wang H, Vanden Hoek T, Beiser D/University of Chicago, Chicago, IL Study Objective: We characterized the effect of induced hypothermia (HT) on cardiac Akt and Hsp27 signaling in a mouse model of resuscitated hemorrhagic shock. Methods: Mice were bled and maintained at a mean arterial pressure (MAP) of 35 mmHg for 90 minutes. At 30 minutes of shock (S30), animals were randomized to 120 minutes of HT (33П®0.5В°C, nП19) or continued normothermia (NT, 37П®0.5В°C, nП21). After 90 minutes of shock (S90) mice were resuscitated with shed blood and lactated RingerвЂ™s solution. Whole hearts were harvested at S30 and S90, and at 30 (R30) and 180 (R180) minutes following resuscitation for Western blot and immunoprecipitation analysis of Akt and Hsp27, myeloperoxidase (MPO) activity, and TUNEL staining. Plasma myoglobin and cytochrome c were measured as markers of cardiac and mitochondrial injury, respectively. Results: Mice treated with HT responded with sustained improvement in postresuscitation MAP values. After 30 minutes of shock, prior to randomization, cardiac Akt phosphorylation (p-Akt) decreased relative to baseline. At S90, p-Akt levels in the NT group returned to baseline and were significantly higher than those in the HT group. In the NT group, both p-Akt and total Hsp27 expression progressively decreased following resuscitation. By contrast, HT animals displayed progressively increased levels of p-Akt and total Hsp27 expression following resuscitation. Immunoprecipitation analysis revealed an interaction between Akt and Hsp27 at baseline which decreased by R30 in NT animals, but was preserved in HT animals. HT also decreased heart MPO and TUNEL staining, as well as plasma myoglobin and cytochrome c, by R180. Conclusions: HT improves short-term hemodynamic outcomes and leads to increased p-Akt and total Hsp27 within the heart following resuscitation. HT also Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts maintained baseline levels of Akt-Hsp27 interaction and attenuated tissue inflammation and cell death. Akt-Hsp27 signaling may play an important role in mediating HT protection in the setting of hemorrhagic shock. 86 Use of New Cardiac Biomarkers as Diagnostic Tools in the Emergency Department Battista S, Formoso F, Maggiorotto M, Loiacono M, Mengozzi G, Gai V/San Giovanni Battista Hospital of Turin, Turin, Italy Study Objectives: The aim of this study was to retrospectively assess the diagnostic performances of two novel proposed biomarkers, myeloperoxidase (MPO) and midregional fragment of proadrenomedullin (MR-proADM), in the emergency department (ED) workup of patients presenting with symptoms suggestive of cardiac damage. Methods: A cohort of 196 patients (mean age 69.3 years, 76 females) admitted to the ED of a large tertiary referral hospital were selected over a three-week period according to a high degree of suspicion of cardiac involvement. The study population included 25 subjects who were discharged and taken as controls, 33 patients referred to cardiologist counselling who did not undergo further evaluation, 31 patients with negative findings on either ischemia tests or coronary artery examination, 34 with coronary artery changes and stent placement, and 73 subjects with heart failure according to the diagnosis at discharge. Plasma MPO (Abbott Diagnostics, Abbott Park, IL, USA) and MR-proADM (B.R.A.H.M.S AG, Hennigsdorf/Berlin, Germany) concentrations were measured by automated immunoassays. Results: Although with some overlap among study groups, MPO levels showed a significantly different distribution (pП0.014 by one-way ANOVA), higher values being detected in patients with proven coronary artery disease (pПЅ0.05 with respect to controls and patients with negative coronary artery findings, according to Bonferroni correction test). MR-proADM concentrations resulted significantly increased in subjects with myocardial dysfunction and heart failure (pПЅ0.0001 and pПЅ0.05 as compared to all other groups). ROC curve analysis yielded a good diagnostic performance for MR-proADM levels in the differential diagnosis of heart failure in our population, with an area under the curve of 0.78 (0.71 to 0.85, 95% CI), corresponding to 79% sensitivity and 69% specificity (61% and 84% positive and negative predictive values, respectively) at a cut-off threshold of 0.52 nmol/L. Conclusions: Both tested biomarkers might provide an useful diagnostic aid in the ED decisionmaking process. Automated immunoassays allow accurate results to be available to the clinician with short turnaround time. Their diagnostic potential, when considered individually, should be further investigated in a multimarker strategy to be used as a biomarker profile for risk stratification as well as monitoring and targeting therapy. 87 Prognostic Significance of an Estimated Glomerular Filtration Rate for Long-Term Mortality in Patients With Syncope Suzuki M, Tatematsu S, Takeshita AS, Hori S/Keio University, Tokyo, Japan Study Objectives: Underlying cardiovascular conditions are the determinants of mortality for syncopal patients. Impaired renal function also affects the cardiovascular complications. We hypothesized that glomerular filtration rate (GFR) levels is an independent predictor of mortality for patients with syncope. Methods: This retrospective observational study was conducted on patients seen in an academic emergency department (ED) in Tokyo. Nine hundred and twelve consecutive patients who presented with syncope were identified. Of those, 205 patients whose follow-up information regarding mortality was not obtained from mailed questionnaires and/or medical records and 91 patients who had no data of serum creatinine levels in the ED were excluded. The GFR was estimated by the Modification of Diet in Renal Disease equation modified by Japanese coefficient, and the remaining 616 patients were grouped according to their estimated GFR. We compared all cause and cardiac mortality among three GFR groups. Results: The distribution of estimated GFR was wide and normally shaped, with a mean (П®SD) value of 76П®32 ml/min/ 1.73 m2 of body-surface area. Of the 616 patients, the estimated GFR was less than 60 ml/min per 1.73m2 in 196 patients (31.8%). The reduced level of the estimated GFR was associated with the increased incidence of cardiac syncope. The median follow-up period was 37 months (range: 0Пі132 months). During the follow-up period, 49 deaths including 5 sudden cardiac deaths were observed. A graded association was observed between a reduced estimated GFR and the risk of death from any cause and cardiac cause (Log-rank test: PПЅ0.001, Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ PП0.01, respectively). The Cox proportional hazards analysis indicated the level of the estimated GFR was an independent predictor of any cause mortality (odds ratio 2.38, 95% confidence interval: 1.23 to 4.60), although the level of the estimated GFR was not an independent predictor. Conclusion: In patients with syncope, impaired renal function, as assessed by the estimated GFR, was common, and the reduced level of the estimated GFR was associated with an increased risk of death. Impaired renal function should be considered a major risk factor for mortality after syncope. 88 Acute Heart Failure Mortality Prediction Using Copeptin: Results of the Biomarkers in ACute Heart Failure Trial Peacock IV W, Nowak R, Maisel A, Di Somma S, Mockel M, Mueller C, Xavier Neath S, Hartman O, McCord J, Anker S/The Cleveland Clinic, Cleveland, OH; Henry Ford Health System, Detroit, MI; VA San Diego Health Care System, San Diego, CA; SantвЂ™Andrea Hospital, University La Sapienza, Rome, Italy; Charite, Campus Virchow-Klinikum, Berlin, Germany; University Hospital Basel, Basel, Switzerland; University of California, San Diego, CA; BrahmвЂ™s, Berlin, Germany Study Objectives: Emergency physicians have few tools providing objective accurate prediction of short term mortality risk in patients presenting to the emergency department (ED) with acute heart failure (AHF). Our purpose was to describe whether plasma C-terminal pro-vasopressin fragment (Copeptin), a surrogate for circulating arginine vasopressin (AVP), is associated with short term death rates in ED patients presenting with AHF. Methods: The Biomarkers in ACute Heart failure (BACH) trial was a prospective, 15-center, international study of patients presenting to the ED with nontraumatic dyspnea. Copeptin values were blinded. All other lab testing was per standard of care and, when used clinically at the discretion of the treating emergency physician, employed the local hospital reference range. For copeptin, BNP and NTproBNP, a core lab was utilized. Creatinine was measured in the local hospital laboratory. Gold standard diagnoses were determined by 2 cardiologists, blinded to copeptin results, reviewing all data available 90 days post ED visit. Results: Of the 1641 BACH patients, 568 (34.6 %) had a gold standard diagnosis of AHF, 52% were male, and 36% had a prior history of HF. Overall, 21 (3.5%) died within the first 14 days, and 65 (11.4%) were dead by 90 days. Mortality prediction is described by C- statistic; all p values ПЅ0.05, except when noted by * where pПNS. In a multivariable model including systolic and diastolic blood pressure, creatinine (Пѕ1.6 mg/dL), and troponin (high/low), copeptin added significantly to the base model (Chi2П10.5, HR 3.3, pП0.0012). Neither BNP nor NT-proBNP were significant in univariate Cox regression (both p Пѕ0.1). Conclusion: Copeptin demonstrates superior short term mortality prognostic ability when compared to natriuretic peptides, and is independent of other clinical covariates. Objective determination of mortality risk may provide opportunities to improve emergency department acute heart failure decisionmaking and consequent clinical outcomes. 89 90 Abstract Withdrawn A Randomized Comparison of Continuous IV Infusion of Furosemide Versus Repeated IV Bolus Furosemide in Acutely Decompensated Congestive Heart Failure Cienki JJ, Hebert K, Ta AK, Diskin AL/Jackson Memorial Hospital, Miami, FL; Miller School of Medicine of the University of Miami, Miami, FL Study Objectives: Acutely decompensated congestive heart failure (CHF) is a frequent cause of emergency department visits, accounting for over 3% of all Annals of Emergency Medicine S29 Research Forum Abstracts encounters. Diuretic therapy is one of the mainstays of management of CHF with furosemide commonly given in episodes of acute decompensation. Concern exists about intravenous (IV) bolus furosemide resulting in duretic resistance via the braking effect as compared to IV continuous furosemide use resulting in longer hospital stay. Previous studies have shown continuous infusion furosemide to reduce the amount of furosemide given potentially reducing adverse effects. We sought to determine whether continuous (IV) infusion of furosemide initiated in the ED would lead to a more rapid resolution of symptoms than repeated IV bolus therapy. Methods: An institutional review board-approved, prospective convenience sample of patients with acute decompensated CHF were randomized to either continuous IV infusion of furosemide or IV bolus therapy. Inclusion criteria were all patients with acute decompensated CHF with New York Heart Association Class II or above symptoms. Exclusion criteria were patients age Пѕ70, acute myocardial infarction, chronic obstructive pulmonary disease, renal failure, active chest pain, acute cardiac dysrhythmias, or other disease processes which might prolong treatment or length of stay unrelated to CHF. If the patient required positive pressure ventilation or intubation they were excluded from the study. Patients were excluded from enrollment in the study if they already received greater than 40 mg furosemide. Preprinted order sets were used to remind ED staff to include ACE inhibitors, beta blockers and nitroglycerin if medially indicated. Aside from the method of administration of furosemide, the provider could treat the patient at their discretion. Initial orders were written by the ED attending and method of administration of furosemide was maintained throughout the hospital stay. Length of IV therapy was used as a correlate of resolution of symptoms. Results: Twenty patients were randomized to receive either continuous IV infusion or IV bolus furosemide therapy. Mean age for the continuous infusion group was 56.0 and for the IV bolus group was 57.5. Time to discontinuation of continuous IV infusion was shorter than for IV bolus therapy 12.3 hours (95% CI: 5.5, 19.1) versus 33.6 hours (95% CI: 15.7, 59.5) (p ПЅ0.05). Conclusion: Length of treatment of continuous IV infusion of furosemide was statistically shorter than IV bolus therapy in this study. Continuous IV infusion merits continued investigation as an improvement over IV bolus therapy in the treatment of acutely decompensated CHF in the ED. 91 Continuous Non-Invasive Hemodynamic Monitoring Using Novel Finger-Cuff Technology in Emergency Department Patients: A Pilot Study Sen A, Nowak R, Garcia AJ, Wilkie H, Moyer M/Henry Ford Hospital, Detroit, MI Study Objectives: Hemodynamic optimization is one of the most important endpoints of resuscitation of emergency department (ED) patients presenting with acute heart failure, sepsis, and stroke. Various studies have explored the use and clinical relevance of comprehensive point-of-care cardiovascular monitoring in the ED without any one device gaining widespread acceptance. The Nexfin apparatus is a novel, easily applied, non-invasive beat-to-beat hemodynamic cardiovascular monitor based on the measurement principle of the volume-clamp method originally described by Penaz to measure blood pressure at the finger. Previous studies have shown that the trends in the Nexfin-derived variables closely reflect changes when compared to those obtained by invasive hemodynamic measurements in the non ED setting.Our objectives were: (1). To compare the blood pressure and pulse rate measurements obtained by Nexfin finger cuff to those recorded by intermittent brachial cuff in the ED setting. (2). To assess the diagnostic accuracy of the clinician regarding estimates of cardiac output and systemic vascular resistance when compared to those calculated by the Nexfin device in various acute ED presentations. (3). To define the hemodynamics of patients on arrival to the ED prior to receiving any therapy and to document the response to any treatments given. Methods: This is a prospective, blinded, convenience sample study in adult ED patients with suspected acute congestive heart failure, sepsis and stroke. The hospital Institutional Review Board approved the study protocol and informed consent was obtained for all study participants. Patients were enrolled on arrival by a trained research coordinator and the Nexfin finger cuff applied. Conventional and Nexfin hemodynamic measurements were obtained every 15 minutes for a minimum of 2 hours. The results of the Nexfin measurements were blinded to the treating physician. The treating clinician was asked at baseline and after 2 hours of patient management to estimate the cardiac output and systemic vascular resistance as to whether they were low, normal or high. Statistical analysis was conducted using paired t-test for comparison between groups and test of significance was set at pПЅ0.05. Results: To date, a total of 91 blood pressure and pulse rate readings in 12 patients have been analyzed to determine Nexfin device reliability. There was no S30 Annals of Emergency Medicine significant difference between the Nexfin finger-derived and brachial cuff systolic (pП0.08) or diastolic blood pressure (pП0.1) and pulse rates (pП0.12). There was, however, significant difference between the clinician estimation of Nexfin hemodynamics computed from the beat-to-beat waveform analysis (pПЅ0.001). The diagnostic accuracy of ED physicians was only 48% and 50% when estimating cardiac output and systemic vascular resistance respectively suggesting that some patients did not reach optimal hemodynamic resuscitation. Conclusions: Nexfin continuous non-invasive finger cuff monitoring compares well with brachial cuff blood pressure and pulse rate measurements. The Nexfincalculated cardiac output and systemic vascular resistance can aid physicians in better understanding the hemodynamics of ED patients and help them individualize their strategies for therapeutic interventions. Additional studies are needed to further evaluate the use of finger cuff derived hemodynamics in the ED setting. 92 Out-of-Hospital Electrocardiogram Interpretation and Early Activation for ST-Segment Elevation Myocardial Infarction Patients Reduces Door-to-Balloon Times and Hospital Length of Stay Miller A, Coleman G, MacKenzie R, Richardson D, Kleaveland J, Cox D, Feldman B, Crown A, Rupp V/Lehigh Valley Hospital, Allentown, PA Study Objectives: Current national guidelines recommend hospitals treating STelevation myocardial infarction (STEMI) patients achieve a door-to-balloon (D2B) angioplasty time of less than 90 minutes. We have in place a myocardial infarction (MI) alert process where emergency physicians activate the cardiac catheterization (CC) team based on identified STEMI patients. In an effort to reduce D2B times we initiated an out-of-hospital Myocardial Infarction Alert 3 (MI-3) process where trained Emergency Medical Service (EMS) providers interpret a 12-lead electrocardiogram (ECG) in the field and notify the emergency physician allowing for earlier activation of the existing MI Alert process. Methods: This retrospective analysis of our Institutional Review Board (IRB)approved database include all patients who present to our center with a STEMI. Our hospital is a 600-bed academic community medical center with an annual ED census of 56,000 patients. In this cohort study of STEMI patients, we reviewed a one-year period (9/06 вЂ“9/07) pre-implementation of MI-3 and period (10/07вЂ“9/08) postimplementation of MI-3. Six EMS Advanced Life Support (ALS) units took part in a 12 lead ECG and MI-3 process training class. The trained paramedics call the ED via radio communication with their interpretation of the ECG and initiate aspirin therapy. The emergency physician notifies the CC team including the interventional cardiologist prior to patient arrival. The patient stops in the ED for registration, confirmation of STEMI, and initiation of heparin and clopidogrel. The patient is then transported for emergent percutaneous coronary intervention (PCI). Results: From 9/06вЂ“9/07, 127 STEMI patients had activation of the MI Alert process. Of those, 114 underwent emergent PCI with a median D2B time of 67 minutes (min) (86% ПЅ90 min, 36% ПЅ60 min). Four (3.2%) patients were classified as false positives after PCI revealed no coronary artery disease. The remaining 9 patients underwent emergent coronary artery bypass graft, were treated medically, or expired. From 10/07вЂ“9/08, 173 patients presented with STEMI of whom 147 underwent emergent PCI. The median D2B time for this group was 63 min (83%ПЅ90min, 45%ПЅ60 min, pП0.147). Of the 147, 65 patients (44%) had MI-3 activation and 87 (56%) had activation of the MI Alert process. In the MI-3 activated subset, the median D2B was 42 min (97% ПЅ90min, 78% ПЅ60 min, p ПЅ 0.001). 5 patients were classified by the emergency physician to not meet STEMI criteria and were not taken for PCI, yielding a false positive activation rate of 7. 7%. Furthermore, we found the mean length of hospital stay decreased from 5.38 days pre-implementation to 3.78 days (pП0.005) post MI-3 intervention. Conclusion: A process where trained ALS providers in the interpretation of ECGs to identify patients with STEMI and activation prior to patient arrival leads to a decrease in the D2B times with a low false positive rate. In addition, the patients with this process in place appear to have a decreased length of hospital stay. 93 Cost-effectiveness Analysis of Out-of-Hospital 12-Lead Electrocardiogram Programs Gross T, Groeneveld P/University of Pennsylvania, Philadelphia, PA Study Objectives: National guidelines for the treatment of acute myocardial infarction endorse the use of out-of-hospital 12-lead electrocardiograms (PHECGs) Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts to reduce delays in reperfusion therapy for patients transported by emergency medical services (EMS). The cost-effectiveness of this technology has not been established. This study was designed to examine the societal costs and benefits associated with a PHECG program. Methods: A Markov decision analytic model was constructed to model short- and long-term outcomes for a cohort of 65-year-old patients with ST-elevation myocardial infarction. Data was obtained from the medical literature and publicly available sources. Costs were measured in 2006 U.S. dollars and account for EMS capital equipment and personnel, as well as short- and long-term patient health care costs. Effectiveness was measured in quality-adjusted life years (QALYs). Sensitivity analyses were performed to assess the modelвЂ™s robustness. Results: For the base case, the incremental cost-effectiveness ratio of a PHECG program was $17,525 for each additional QALY compared to no PHECG program. The PHECG strategy remained favorable with variation of all model parameters across plausible ranges, given a willingness-to-pay of $50,000 per QALY. Conclusions: The cost-effectiveness of PHECG programs compares favorably with other widely accepted medical interventions. This study demonstrates that PHECG programs offer significant societal benefits at reasonable costs. This evidence should support further development and implementation of PHECG programs in U.S. EMS systems. 94 weeks as the reference standard. Two authors independently conducted the relevance screen of titles and abstracts, selected studies for the final inclusion, extracted data and assessed study quality. Consensus was reached by conference and any disagreements were adjudicated by a third reviewer. Unenhanced computed tomography test performance was assessed using summary receiver operating characteristic (SROC) curve analysis with independently pooled sensitivity and specificity values across studies. Results: The search yielded 1258 publications; 7 studies met the inclusion criteria and provided a sample of 1060 patients. The included studies were of high methodological quality with respect to appropriate patient spectrum and reference standard. Our pooled estimates for sensitivity and specificity were 92% (95% CI: 0.89 to 0.95) and 96% (95% CI: 0.94 to 0.97), respectively; the likelihood ratio (LR) positive П 23 for non-contrast CT and the LR negative П 0.08. Conclusion: We found the diagnostic accuracy of non-contrast CT for diagnosis of acute appendicitis in the adult population to be adequate for clinical decisionmaking in the ED setting. Spontaneous Retroperitoneal Hematoma: Etiology, Characteristics, Management, and Outcome Sunga KL, Bellolio MF, Gilmore RM, Cabrera D/Mayo Clinic, Rochester, MN Study Objectives: To describe the clinical course of patients presenting with spontaneous retroperitoneal hematoma (SRH) during a seven-year period. Methods: We conducted an observational cohort study of all consecutive patients 18 years and older, diagnosed with SRH at Mayo Clinic Rochester from January 2000 to December 2007. SRH was defined as not related to invasive procedures, surgery, trauma, or abdominal aortic aneurysm. For statistical analysis we used Wilcoxon, Chi-square, FisherвЂ™s, or t-test according to data type and distribution. Results: Of 346 identified patients, 89 were eligible. Median age was 72 years (interquartile range 61вЂ“79), and 56.2% were male. Fifty-nine (66.3%) were anticoagulated, with 41.6% on warfarin, 30.3% heparin, and 11.2% low molecular weight heparin. Twenty-seven (30.3%) were on an antiplatelet regimen, with 29.2% on aspirin and 2.5% clopidogrel. Fourteen (15.7%) were taking both classes of medication. Thirteen (14.6%) were on neither. Primary presentation to the Emergency Department was seen in 36%, whereas 64% developed SRH during inpatient anticoagulation therapy. 11.1% were initially misdiagnosed. Computed tomography (CT) was performed in 95.5%, ultrasound in 21.3%, and magnetic resonance imaging in 3.3%. 40.4% were managed by the intensive care unit. 24.7% underwent interventional radiology, and 5.6% required surgical management. 75.3% received blood transfusion. Mortality was 5.6% within 7 days, 10.1% within 30 days, and 19.1% within 6 months. The most common symptoms were abdominal pain (60.7%), leg pain (21.3%), hip pain (20.2%) and back pain (19.1%). Conclusion: SRH is an uncommon but lethal entity with a non-specific presentation that can lead to misdiagnosis. It should be suspected in patients who present with atraumatic abdominal, leg, hip, or back pain, regardless of anticoagulation history. CT is frequently used and effective for diagnosis. The majority of patients will require aggressive support in the form of blood transfusion or interventional radiology. Surgery is rarely performed. 95 Diagnostic Accuracy of Non-Contrast Computed Tomography for Appendicitis in Adults: A Systematic Review Hlibczuk V, Dattaro JA, Jin Z, Falzon L, Brown MD/New York Presbyterian Hospital, New York, NY; Columbia University, New York, NY; Mount Sinai Medical Center, New York, NY; Michigan State University, Grand Rapids, MI Study Objective: We sought to determine the diagnostic test characteristics of non-contrast computed tomography (CT) for appendicitis in the adult emergency department (ED) population. Methods: We conducted a search of MEDLINE, EMBASE, the Cochrane Library, and the bibliographies of previous systematic reviews. Included studies assessed the diagnostic accuracy of non-contrast CT scans for acute appendicitis using the final diagnosis at the time of surgery or follow-up at a minimum of two Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 96 Comparison of Traditional Pediatric-Age, Nontraditional Pediatric-Age and Adult-Age Patients With Intussusception: A Case Series Cochran AM, Higgins III GL, Strout TD/Maine Medical Center, Portland, ME Study Objectives: Most medical texts cite the typical patient age range of intussusception (INT) as being between 2 months and 6 years old. Our clinical observations and experience suggested INT is more common in nontraditional age groups than commonly described. We sought to determine the incidence of INT in 3 age groups (traditional pediatric-age, 0 to 6 years [T]; nontraditional pediatric-age, Пѕ6 to 18 years [N]; and adult-age, Пѕ18 years [A]) and to compare characteristics among these groups. Methods: Maine Medical Center is a 600-bed academic medical center with an emergency medicine training program that provides care to 58,000 emergency department (ED) patients annually. This retrospective case series used a standardized data extraction tool to collect multiple historical, physical exam and diagnostic testing data elements on each subject. Patients discharged with a proven diagnosis of INT between October 1999 and June 2008 were included. This project was reviewed and approved by the Institutional Review Board. Results: 95 cases of INT were diagnosed: 61 T (64%), 12 N (13%), 22 A (23%). 34% T, 50% N, and 37% A patients visited a primary care provider and/or an emergency medicine provider for related complaints prior to the diagnosis of INT being made. The presence of bloody stool was more common in T than N and A patients: 16% vs. 0% vs. 4% (pП0.016). An intermittent pain pattern was most frequent in all groups. 70% T, but only 42% N and 50% A patients, were admitted with a diagnosis of INT (pП0.015). Air contrast barium enema (36%) and ultrasound (33%) were the most common diagnostic tests in T, while CT was the test of choice in N (83%) and A (68%) patients. Bowel resection was required more frequently in older patients: 23% T, 75% N, 43% A (pП0.001). The most frequent causative pathologies for T, N and A patients respectively were adenitis, Peutz-Jeghers polyp and carcinoma. 10 A patients (11% of the entire cohort) had prior gastric bypass surgery as a cause. Conclusions: The incidence of INT is substantially higher in nontraditional age groups than previously reported. Older patients are more likely to have prior visits for related complaints prior to being diagnosed, are less likely to have bloody stool, are less likely to be admitted with a diagnosis of INT, are more likely to have causative pathologies of concern, and are more likely to require bowel resection. Gastric bypass surgical procedures are an emerging cause of INT in adults. Annals of Emergency Medicine S31 Research Forum Abstracts 97 An Analysis of Emergency Department Utilization by Intellectually Disabled Adults Venkat A, Pastin RB, Hegde GG, Shea JM, Cook JT, Culig C/Allegheny General Hospital, Pittsburgh, PA; Allegheny Valley School, Coraopolis, PA; University of Pittsburgh Katz School of Business, Pittsburgh, PA; Veterans Administration Medical Center, Pittsburgh, PA Study Objectives: Intellectually disabled (ID) adults are a growing and rarely studied emergency department (ED) population. To aid in their ED management, our objectives were to identify what factors increase the likelihood of ED utilization among ID adults and determine how their ED and hospital discharge diagnoses differ from the general adult ED population. Methods: This was a retrospective, observational study of all adult (age Пѕ 18 on 1/1/07) residents of an intermediate care facility (ICF) for ID individuals & their ED visits to a tertiary center (1/1/07вЂ“ 6/30/08). The investigators abstracted from the ICF clinical database the subjectsвЂ™ demographic (age, sex, race), intellectual disability (ID degree and related diagnosis, autism and cerebral palsy presence), health (number of prescribed medications, hearing and visual impairment, body mass index, tracheostomy presence) and adaptive status (bowel and bladder continence, ambulatory and feeding ability) variables and whether they required ED care/hospitalization via an ED. We abstracted from the hospital database the International Classification of Disease (ICD)-9 coded ED and hospital discharge diagnoses of the study and general adult population presenting to this ED. We used multivariate logistic regression to compute odds ratios (OR) of ED utilization and hospitalization among the subjects from the abstracted variables and the conditional large sample binomial test (z-statistic) to determine if the ICD-9 ED and hospital discharge diagnoses of the study and general adult ED population were significantly (pПЅ.05) different. Results: 433 subjects met inclusion criteria - Mean Age 45, 49.4% Male and 92.1% White. 57% had profound ID (Intelligence Quotient [IQ] ПЅ25), 22.4% significant ID (IQ 25вЂ“ 40), and 20.6% mild/moderate ID (IQ 40 вЂ“70). 7.4% had autism, 39.7% cerebral palsy. 222 subjects required ED care (741 visits, 90.6% to this ED); 132 subjects required hospitalization via an ED (323/741 visits, 92.9% to this ED). In the study cohort, feeding status (gastrostomy/jejunostomy: OR 4.16(95CI 1.64 вЂ“10.58)) alone increased the likelihood of ED utilization (pПЅ.05); feeding status (partial help to feed: OR 2.59(1.14 вЂ“5.88)), gastrostomy/jejunostomy: OR 3.26(1.30 вЂ“ 8.18)) and number of prescribed medications (OR 1.08(1.03вЂ“1.14)) that of hospitalization. For ED discharge diagnoses, ID adults were more likely (pПЅ.05) than the general adult ED population to have ICD-9 diagnoses in Blood (z 3.59), Mental (z 10.55), Nervous System (z 6.26) & Digestive disorders (z 3.10) and Ill-Defined Symptoms/Signs (z 4.60), less likely in Circulatory (z ПЄ3.45), Musculoskeletal (z ПЄ3.32) & Injury/Poisoning (z ПЄ5.61) disorders. For hospital discharge diagnoses, ID adults were more likely (pПЅ.05) than the general adult ED population to have ICD-9 diagnoses in Infectious (z 8.82), Mental (z 2.78), Nervous System (z 29.42), Respiratory (z 11.58), Digestive (z 10.24), Skin (z 4.46) & Musculoskeletal (z 14.47) disorders and Ill-Defined Symptoms/Signs (z 8.73), less likely in Neoplastic (z ПЄ6.02), Endocrine (z ПЄ2.43), Circulatory (z ПЄ19.66) & Injury/Poisoning (z ПЄ13.14) disorders. Conclusion: In this study of ID adults, feeding status alone increased the likelihood of ED utilization. Feeding status and number of prescribed medications increased the likelihood of hospitalization. The ED and hospital discharge diagnoses of ID adults differed significantly from the general adult ED population. 98 Management of the Bariatric Surgery Patient in the Emergency Department Kiebel W, Hawkins D, Meyers L, Ray D, Jones JS/Michigan State University College of Human Medicine, Grand Rapids, MI; MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI Background: Nearly two-thirds of Americans are considered overweight and half of these individuals are considered obese. With advances in health care and technology and the rising prevalence of the condition, bariatric surgery has become an increasingly common procedure. As more patients have weight loss surgery, clinicians working in the emergency department will frequently encounter complications of these procedures. Study Objective: To identify the complications that can arise post-operatively, and the assessment and management of the bariatric surgery patient who presents to the emergency department (ED). Methods: From our hospital information system, retrospective data was obtained S32 Annals of Emergency Medicine on consecutive emergency department patients with a definite diagnosis relating to bariatric surgery complications. The study took place at two urban U.S. academic medical centers over a 3-year study period. Patients were stratified based on surgical technique (laparoscopic vs. open) and type of surgical procedure (gastric bypass vs. stapling). The patients were further differentiated based on when they presented to the ED following surgery: within 30 days, 30 вЂ“ 60 days, 60 вЂ“90 days, and 90 вЂ“120 days. In addition to demographic data, charts were reviewed for presenting symptoms, clinical features, diagnostic studies and treatment modalities. Chi-square and ANOVA tests were used to compare clinical features among the cohorts examined. Relative risk was also calculated. Results: During the 3-year study period, 2735 patients underwent bariatric surgery; 519 (17%) were evaluated in the ED within 120 days of surgery. A total of 46 post-op complications were identified. Early complications (seen within 30 days of surgery) were documented in 61% (317/519) of patients. These included post-op pain, vomiting/dehydration, electrolyte disorders, gastrointestinal reflux/spasm, gastric distension and pneumonia. Gastric bypass patients tended to have more wound problems, abdominal hernias, and dumping syndrome when compared to gastric stapling (pПЅ.01). Late complications were documented in 39% (202/519) of patients and ranged from respiratory failure to not life-threatening but clinically important conditions such as wound infection, hernias, and pneumonia. Overall 30% of patients were readmitted to the hospital; the most important risk factor for admission was the presence of three or more co-morbidities. Patients who had laprascopic surgery and/or gastric stapling were less likely to be admitted to the hospital (RRП0.5, [95% CI: 0.3вЂ“ 0.7]). Conclusions: In this community-based study, 17% of patients undergoing bariatric surgery were evaluated in the ED within 120 days of surgery. Clinicians working in the ED should have a basic understanding of the various procedures performed for weight loss, as well as management of common early and late complications. 99 Clinical Features of Acute Diverticulitis in Very Young Patients Oosterhouse T, Loyson A, Bianco M, McNinch D, Jones JS/Michigan State University College of Human Medicine, Grand Rapids, MI; MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI Study Objective: Acute diverticulitis is relatively rare in patients younger than the age of 40, which may lead to a delay in diagnosis. The purpose of this study was to characterize the clinical presentation, laboratory and radiologic findings, as well as the treatment and outcome of patients 40 years of age and younger diagnosed with acute colonic diverticulitis. Methods: This retrospective cohort analysis evaluated consecutive adult patients presenting to the emergency department with a discharge diagnosis of acute colonic diverticulitis. The study took place at two urban U.S. academic medical centers over a ten-year study period (1998 вЂ“2007). Patients 40 years of age and younger were compared to a group of older patients (age 41вЂ“ 65 years old) with acute diverticulitis who presented to the ED during the same time period. The diagnosis was confirmed by at least one of the following: computerized tomography (CT), contrast enema study, colonoscopy, or surgical findings. Patient demographics, clinical findings, and imaging studies were recorded using a standardized classification system. Treatment modalities, length of hospital stay, and outcome were assessed as well. Comparative data were analyzed using chi-square, t-tests, and relative risk. One investigator performed a blinded critical review of a random sample of 10% of the charts to determine reliability (Kappa statistic). Results: A total of 2,407 cases of acute colonic diverticulitis were identified during the study period that met the inclusion criteria. Overall, 9% (208/2609) of the patients were 40 years of age and younger; mean age was 33.9 П© 5.9 years. In comparison, 60% (1454/2407) of patients were between 41вЂ“ 65 years old; mean age 51.4 П© 7.8 years. The older age group were more likely to be female (64% vs. 33%, pПЅ.001), Caucasian (88% vs. 71%, pПЅ.001), and have вЂњtext-bookвЂќ signs and symptoms (73% vs. 43%, pПЅ.001). There were no differences between the two groups with respect to duration of symptoms or leukocyte count .As expected, the associated co-morbidities were far more common in the older age group, though only hypertension and ischemic heart disease reached statistical significance. Younger patients were more likely to be misdiagnosed in the ED (RRП5.0 [95% CI: 4.3вЂ“ 5.7]). Analysis of hospital admission rates, complication rates, type of surgical procedures and length of hospital stay, showed no significant differences between the two age groups. The consistency of the recording of data was excellent, with a median kappa statistic of 0.89. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts Conclusions: Nine percent of patients presenting to the ED with acute diverticulitis were under 41 years of age. Although the disease does not appear to take a more aggressive course in younger patients, the epidemiology and clinical features in this group are unique and pose special challenges to emergency health care providers. 100 Fecal Occult Blood Testing Does Not Predict Major Gastrointestinal Bleeding in Heparinized Patients Bennett CJ, Moskovitz J, Mayo DD, Witting MD/University of Maryland, Baltimore, MD Study Objectives: It is a generally accepted practice to perform a digital rectal examination and a fecal occult blood test (FOBT) prior to administering intravenous heparin. However, the ability of a positive FOBT result to predict gastrointestinal (GI) bleeding after administration of heparin has not been documented. The goal of this study was to estimate the likelihood of GI bleeding associated with a positive FOBT result in patients receiving intravenous heparin. Methods: This was a retrospective, double-cohort study. Inclusion criteria were the following: age Пѕ18 years, admission during the 6-year study period, treatment with continuous heparin infusion, completion of a FOBT in the 48 hours prior to initiation of heparin, and at least two sequential high partial thromboplastin time (PTT) measurements. Patients receiving anticoagulation as outpatients were excluded. The main outcome was major GI bleed, as defined by physical exam evidence of GI bleed plus a drop in hematocrit of Пѕ5 points, need for transfusion, or death within 1 hour after detection of the bleed. Data were collected using standard chart review methodology. We categorized patients with bleeding into those with major GI bleed, minor GI bleed, and major bleed of questionable source. Results: A total of 624 patients were included in the analysis, of which 61 had positive FOBT results and 563 had negative results. Eleven patients had GI bleeds: 3 major GI bleeds, 1 minor GI bleed, and 7 major bleeds of questionable source. One of the 61 (1.6%) patients with a positive FOBT result had a major GI bleed, compared with 2 of the 563 (0.4%) with a negative FOBT result, for a risk difference of 1.2% [(ПЄ)2% - (П©)5%, 95% CI, pП0.3]. If major bleeds of questionable source were categorized as a major GI bleed, then 2 of the 61 (3.3%) patients with positive FOBT results had a GI bleed, compared with 8 of the 563 (1.4%) patients with negative FOBT results, for a risk difference of 1.9% [(ПЄ)3% - (П©)6%, 95% CI, pП0.3]. Conclusion: We found no significant difference in the incidence of major GI bleeding between patients with positive FOBT results and those with negative FOBT results prior to heparinization. This observation was consistent whether or not we included major bleeds of questionable source in the major GI bleed category. We estimate the risk difference of major GI bleeding associated with a positive FOBT result at 1.2% in patients receiving heparin. 101 The Utility of Routine Reticulocyte Count in Uncomplicated Vaso-Occlusive Crisis Due to Sickle Cell Disease diagnosed. Data was recorded on a standardized data sheet and 20% of the charts were reviewed by both reviewers to assure consistent data collection. Results: Over an 8-year period, 346 SC patients presented to the ED. Limiting the patient population to those presenting with pain who were patients of the institutionвЂ™s SC clinic yielded 192 patients with 1885 ED visits. This correlates to an average of 9.8 ED visits over the study period per patient. There were 7 (0.4 %) cases of aplastic crisis diagnosed in the ED using the initial reticulocyte count. However, all of these patients met at least one of the studyвЂ™s exclusion criterion. Two additional patients were diagnosed with aplastic crisis after during their hospital admission. Each had an elevated reticulocyte count during the ED evaluation. One presented with a hemoglobin of 8.3 mg/dl (baseline 14 mg/dl) and a reticulocyte count of 8.3%. The other presented with a hemoglobin of 3.9 mg/dl (baseline 8.3 mg/dl) and a reticulocyte count of 4.7%. Conclusion: In patients presenting to the ED with otherwise uncomplicated sickle cell VOC, routine utilization of the reticulocyte count to diagnose aplastic crisis is of little utility. 102 Does Correlation of Faculty Assessment of Emergency Medicine ResidentsвЂ™ Medical Knowledge Competency With Performance on the In-Training Examination Improve With Advancement Through the Program? Barlas D, Ryan JG/New York Hospital Queens, Flushing, NY Study Objectives: Faculty assessment of emergency medicine (EM) residents on the medical knowledge (MK) core competency may or may not be predictive of performance on the annual in-training examination. We sought to determine if a greater degree of faculty exposure and experience with EM residents, as determined by PGY level, improved the correlation of the facultyвЂ™s assessment of MK on quarterly summative evaluations with the score received on the EM in-training examination taken during the same time period. Methods: Data was obtained from the records of residents from an urban, established PGY 1вЂ“3 EM residency program in this observational, cohort study. Fixed, 9-point (1П Level of a medical student, 9ПLevel of an attending) MK core competency summative assessments by 25 board prepared/certified EM faculty during the 3rd academic quarter (JanвЂ“Mar) were compared with the score received on the EM in-training exam for individual residents grouped by PGY year. Degree of correlation was determined using Pearson Correlation Coefficients. Results: Data from 73 quarters for 37 EM residents over 4 years was analyzed. Correlation between faculty assessment of medical knowledge and performance on the in-training exam was poor across all PGY years, but improved with each year. For PGY1 residents rППЄ0.08, for PGY2, rП0.03, and for PGY3 residents, rП0.43. Conclusions: Assessment of medical knowledge by EM faculty does not correlate well with residentsвЂ™ performance on the in-training exam given during the same evaluation period, but improves somewhat as residents advance through their training. Alternative MK evaluation tools that better correlate with exam performance should be sought, especially for residents early in their training. Garman A, Lyon M, Kutlar A/Medical College of Georgia, Augusta, GA Study Objectives: A common component of emergency department (ED) care of sickle cell (SC) patients presenting with vaso-occlusive crisis is measurement of the reticulocyte count. The reticulocyte count is a measure of immature red blood cells (RBC) and should be elevated with acute RBC destruction that occurs during a vasoocclusive crisis (VOC). When the bone marrow fails to respond to the acute anemia due to RBC destruction, an aplastic crisis may be present. However, aplastic crises are quite rare. Our objective is to evaluate the utility of routine reticulocyte count measurement in uncomplicated VOC due to SC disease. Methods: This was a retrospective chart review of all patients with SC disease and pain suggestive of VOC presenting to an academic ED with an average annual census of 78,000 patients. Inclusion criteria included any SC patient older than 18 years presenting to the ED with pain and had a reticulocyte measurement as part of their ED evaluation. Exclusion criteria included fever (Пѕ38.5 oC), hypotension (BP ПЅ90/ 60), hypoxia (oxygen saturation 100) was not regarded as an exclusion criterion. Patients who did not receive routine care at the institutionвЂ™s SC clinic were excluded. Reticulocyte count along with presenting hemoglobin and baseline hemoglobin were the variables used to determine the presence of aplastic crisis on presentation to the ED. Charts of SC patients admitted to the hospital were reviewed for development of aplastic crisis. All discharged patients were evaluated for a return visit within 10 days to the ED or the SC clinic in which symptomatic anemia or aplastic crisis was Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 103 Is There a Doctor in the House? The Experience of Medical Students as Responders to Out-of-Hospital Emergency Medical Situations Greene T, Cho E, Shearer P/Mount Sinai School of Medicine, New York, NY Study Objectives: Outside of a hospital anyone can be called upon to deliver emergency care, but medical students exist on a spectrum between a lay person and a credentialed provider. Most medical schools teach only BLS and few have a course at the beginning of the first year to teach an approach to basic medical situations. There is no past research on this topic so how often medical students are called upon to provide such care remains unclear. We hypothesized that medical students encounter a wide variety of medical and trauma situations outside of the hospital during their medical school years. Methods: An anonymous Web-based survey was distributed to all medical students of the Mount Sinai School of Medicine, an urban institution, to assess their experience with medical situations outside of the hospital setting during their years as medical students. Multiple choice questions asked respondents to describe the type of event encountered (eg, seizure, trauma, choking) and how they responded (eg, called 911, administered CPR). When respondents entered free text the information was kept confidential and later stripped of identifiers. Annals of Emergency Medicine S33 Research Forum Abstracts Results: 139 of 520 possible Mount Sinai medical students completed the survey for a response rate of 27%; 46 first years, 30 second years, 18 third years, and 45 fourth years. 40 students (28.8% П©/ПЄ 7.4%, 95% CI) reported 50 medical events encountered outside of the hospital since beginning school. Only 32% of those who encountered emergent situations had any medical training before medical school. Location of these incidents was most commonly on the street (40%), at home (22%), or on the subway (16%). Trauma of varying degree (40%), seizure activity (14%), and syncopal episodes (14%) were most commonly encountered. Student interventions included: calling 911 (42%); providing medical advice (46%); checking vitals (36%); wound dressing (10%); performing CPR (4%). One student delivered a baby in the back of a taxicab. Conclusion: Medical students in an urban area are potential first responders to emergency situations outside of their schools and hospitals. In our student body over one quarter of those responding had encountered such situations while in medical school. The variety of encounters reflects the types of clinical scenarios typical to emergency medicine and supports providing medical students with basic clinical training for emergency situations early in medical school. 104 Performance of an Ultrasound-Guided Thoracentesis Teaching Model Nomura JT, Goodgame BR, Bauman MJ, Schofer JM, Bollinger M, Reed III JF, Sierzenski PR/Christiana Care Health System, New Castle, DE Study Objectives: Ultrasound (US) use for thoracentesis guidance is becoming more common. US-guided procedural skills must be practiced prior to patient care situations, most commonly with ultrasound procedure phantoms. Commercial phantoms are available, but are costly. Our goal was to construct a low cost thoracentesis phantom and report its performance by physicians skilled in ultrasound. Methods: A fluid bladder to simulate fluid-filled pleura was embedded in an opacified gelled mineral oil tissue analog with interspersed solid echo-dense rib analogs. Models were presented to physicians skilled at both ultrasound procedures and thoracentesis for use and evaluation. The model was rated on a 10-point scale regarding realism, usefulness, and likelihood of use. Results: Ten physicians skilled in US and thoracentesis evaluated the model on a 10-point rating scale. The model had an average score of 8.2 П© 0.9 (95% CI 7.6 вЂ“ 8.8) for realistic appearance. The realism of the procedure was rated at 8.4 П© 1.2 (95% CI 7.7вЂ“9.1) and the usefulness of the model was 8.9 П© 0.9 (95% CI 8.3вЂ“9.5). The physicians rated their likelihood to use this model as a teaching aid at 8.8 П© 1.5 (95% CI 8.0 вЂ“9.6). Conclusion: This low cost and easily constructed ultrasound-guided thoracentesis model performed well and is a reasonable alternative to expensive commercial phantoms. This model provides affordable access to a procedural education model. 105 Results: The maximum obtainable score on the critical actions checklist was 50 points. In addition to improper technique, residents lost points if they breached sterile precautions or if it took more than 3 attempts to puncture the target vessel. Of the forty residents, three received all 50 points (one R1, one R2, and one R3). The minimum score obtained was 27 and the average score was 43 for all three levels of training. R1вЂ™s averaged 42 points (SDП®6.7), R2вЂ™s averaged 43.5 points (SDП®4.8), and R3вЂ™s averaged 43.9 points (SDП®3.4). One R1 had performed ПЅ5 central lines but scored a perfect 50. Two R3вЂ™s reported they had completed Пѕ15 central lines and still scored one standard deviation below the mean. Three R2вЂ™s reported they had completed Пѕ10 central lines, but still scored more than one standard deviation below the mean. There was no statistically significant association between level of training, number of central lines completed, and the total score obtained. Conclusions: Quantitative competency assessments for procedure credentialing are needed to ensure appropriate mastery of skills. The number of procedures completed or logged may not be an adequate predictor of competency and proficiency. Current credentialing standards can be improved via the development of valid metrics and benchmarks, in conjunction with expert assessment and feedback in both simulated and live settings. Evaluation of Quantity-Based Credentialing: The Need for Competency Metrics Wu TS, Rosenberg M, Simpson C/Orlando Health, Orlando, FL Study Objective: Institutions nationwide have demonstrated interest in utilizing simulation-based training (SBT) modules and standardized metrics for procedure credentialing. Currently, most credentialing departments require residents to log and report the number of procedures they have performed. Once a sufficient number of supervised procedures have been performed, the resident is deemed competent to perform those specific procedures in an unsupervised setting. In this study, we obtained a quantitative assessment of resident performance during ultrasound-guided central venous access training and sought to evaluate the difference between the scores obtained, the residentsвЂ™ level of training, and the reported number of central lines logged. Methods: This was a prospective study conducted in a simulation-based training center at an academic institution with an annual census of 90,000 patients. Forty residents participated in a simulation session where they were asked to place a central line under ultrasound guidance on a central venous access trainer. Each resident was given two separate attempts to complete the procedure. A rigorous checklist of critical actions was devised by a panel of experts and utilized to score each residentвЂ™s performance. Video recordings of each procedure were independently reviewed and scored by three members of the research team. Scores from the critical action checklist were analyzed against the residentвЂ™s level of training (R1, R2, R3) and the reported number of central lines completed prior to the training session. The critical actions checklist was used to provide both formative and summative feedback during individual debriefing sessions. S34 Annals of Emergency Medicine 106 Improved Resident Knowledge and Adherence to Care Guidelines Using an Algorithm for Ectopic Pregnancy Evaluation Nelson BP, Noble VE, Choi J, Truong T, Levine AC/Mount Sinai School of Medicine, New York, NY; Harvard Medical School, Boston, MA; Walnut Creek Medical Center, Walnut Creek, CA; Santa Clara Valley Medical Center, Santa Clara, CA Study Objectives: Bedside pelvic ultrasound has gained widespread use in emergency medicine (EM) residency programs. In an effort to improve residentsвЂ™ knowledge and increase awareness of a new interdepartmental protocol, a poster demonstrating pelvic ultrasound images and an ectopic pregnancy evaluation algorithm was created. This study assessed whether this simple intervention could improve resident knowledge and impact the care of patients being evaluated for ectopic pregnancy. Methods: There were 2 phases: 1. Prospective, controlled study of resident knowledge performed at two urban academic EM programs, and 2. Before-after study assessing adherence to inderdepartmental ectopic pregnancy evaluation guidelines. EM residents completed a 22-question test on the evaluation of ectopic pregnancy. Half of the questions were image-based. In the study program, a poster containing pelvic ultrasound images and the ectopic pregnancy evaluation algorithm was installed in each obstetric evaluation room. There was no intervention in the control program. The study group completed a post-test after a four-week block in the emergency department where the posters were exhibited. The control group took the post-test about one month after the pre-test. To assess impact on patient care, patient charts before and after the posters were installed were reviewed. A score was given to each chart, marking adherence to key components of the algorithm (maximum score 7 points). Length of stay (LOS) and other demographic information was recorded as well. Results: Phase 1: Pre-test scores for the control group (median, 72.7%; interquartile range [IQR], 65.9% to 84.1%) and study group (median, 72.7%; IQR 68.2% to 81.8%) did not differ significantly (pПЅ0.984). For the control group, there was no significant change between the pre-test and post-test scores (post-test median, 72.7%; IQR 65.9% to 86.4%; pПЅ0.205). The study group demonstrated a significant improvement from its pre-test to post-test scores (post-test median, 86.4%; IQR 75.0% to 90.9%; pПЅ0.001). The study group achieved significant increases in both image recognition questions (median 75.0% to 83.3%; pПЅ0.001) and non-image recognition questions (median 80.0% to 90%; pПЅ0.004). Phase 2: 89 patients charts were reviewed before poster installation and 85 charts after. The mean score for adherence to the departmental guidelines improved from 5.7 to 6.1 (out of 7) after installation of the posters (pПЅ0.05). There was no difference in LOS before and after the posters were installed. Conclusion: In this study, a novel educational intervention improved emergency medicine residentsвЂ™ fund of knowledge on ectopic pregnancy evaluation compared to controls. In addition, adherence to departmental guidelines improved without specific in-servicing, lectures, or other cumbersome interventions. This poster, targeted in a high-yield area of the emergency department for ectopic pregnancy evaluation, may be a low-cost and simple tool to educate residents and improve patient care. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts 107 Assessing Reaction Time Among Emergency Medicine Residents Working Different Shift Hours Berios I, Surani S, Simmons M/Christus Spohn Memorial Hospital, Texas A&M University, Corpus Christi, TX Study Objectives: To assess reaction time and sleepiness among emergency medicine residents after 9-hour and 12-hour shifts. Background: Fatigue and sleepiness leading to increased medical error is a paramount factor in the implementation of the resident work hours mandated in 2003 by the ACGME. There are a variety of ways that emergency medicine programs comply with these rules. Most commonly, EM residents work either 9 or 12-hour shifts. Methods: We conducted a prospective study of emergency medicine residents using psychomotor vigilance testing (PVT) using a validated PVT 192 tool, Stanford sleepiness scales and Epworth sleepiness scales. Six emergency medicine residents completed Stanford sleepiness scales and PVT before and after working 12 and 9hour shifts, as well as an Epworth sleepiness scale after one week of 12-hour shifts and one week of 9-hour shifts. Results: Our results showed an increasing trend in mean reaction time (rt), minimum rt, and maximum rt. There was a significant increase in sleepiness towards the end of shift as manifested by Stanford sleepiness score. The mean rt increased from 275 milliseconds pre shift, 300ms post 9-hour shift and 327ms post 12-hour shift, as well as increasing pre minimum rt (171ms), post 9-hour shift minimum rt (185ms) and post 12-hour shift minimum rt (197ms). The Stanford sleepiness scale scores increased significantly from a score of 1.66 pre shift, to 2 post 9-hour shift (p value П 0.027), and 4.16 post 12-hour shift (p value П 0.002). There were no differences between the pre shift and post shift PVT in false starts or errors, such as lapses, or differences in Epworth sleepiness scales (7.67 for 12-hour shifts and 8.33 for 9-hour shifts). One interesting side note is that residents consumed more caffeine while working 12-hour shifts (50%) than they did on 9-hour shifts (33%). Limitation: This is a single center study with a small sample size. Conclusion: Excessive sleepiness was seen at the end of both shifts among EM residents. In addition, even with a small sample size, there seems to be an increasing trend in slower reaction times as length of shift increases. 108 The Effect of Video Demonstration to Improve the Quality of Dispatcher-Assisted Chest CompressionOnly Cardiopulmonary Resuscitation Amongst Middle-Age Persons 109 Airway Management by Critical Care Teams Is Not Associated With Physiologic Decompensation Starr GA, Stewart CE, Thomas SH, CCT CORE Research Group/University of Oklahoma School of Community Medicine Department of Emergency Medicine, Tulsa, OK Study Objectives: This study was performed to: 1) assess the incidence of critical care transport (CCT) crewsвЂ™ airway management-associated physiologic derangement, and 2) assess for predictors of new physiologic derangement, that could be used to identify future foci for education and practice improvement. Methods: Over 2008, 603 airway management attempts (nearly all oral endotracheal intubation {ETI}) were performed by 11 CCT services (all but one, helicopter EMS). Data included patient demographics, diagnoses, indications for airway management, airway management setting, and peri-airway management physiology including pulse rate, systolic blood pressure, pulse oximetry (SpO2), and end-tidal CO2. This abstract focuses on вЂњnew SpO2 abnormality,вЂќ defined as SpO2 ПЅ 90% during or after airway management by the CCT crew, in a patient who had pre-airway management SpO2 exceeding 90%. The study aimed to provide descriptive assessment of SpO2 derangement. Additionally, in order to ascertain foci for future education and research efforts, we performed analytic testing to assess associations between new SpO2 drop and patient/airway management factors. Results: Of 603 patients, 163 were in-hospital, 162 attempts in-transport, and 314 in the field; 2/3rds were scene missions. Casemix included 70% trauma, 11% neurologic, 9% cardiac, 8% general medical/surgical, and 2% neonatal. The difficulty of airways is exemplified by the fact that 182 (30%) had at least 1 failed attempt by a practitioner prior to arrival of the CCT team. CCT crew ETI was successful in 582 patients (96.5%). In 130 cases (22%) multiple attempts at ETI were performed. The final airways in the study included: 2 BVM (0.3%), 3 Cricothyroidotomy (0.5%), 4 Combitube (0.7%), 12 Laryngeal Mask Airway (LMA, 2%), 16 Nasal Endotracheal Intubation (2.7%), 566 Oral Endotracheal Intubation (93.9%). Physiologic deterioration in the study was unusual, with new hypoxemia occurring in 6 cases (1.6% of the 365 cases with ongoing SpO2 monitoring; 95% binomial exact confidence interval .61вЂ“3.5%). There were no associations other than pre-existing hypotension (p ПЅ .001), with development of new hypoxemia. Requirement for multiple ETI attempts by CCT crews was not associated with new hypoxemia (FisherвЂ™s exact p П 0.13). Conclusions: CCT crewsвЂ™ ETI success rates were very high, and even when ETI required multiple attempts, airway management was rarely associated with SpO2 derangement. 110 The Impact of Unit Hour Utilization on Out-ofHospital Interventions You Jr Y, Ji sook Sr L/Ajou University, Suwon, Republic of Korea Myers LA, Russi CS/Mayo Clinic Medical Transport, Rochester, MN; Mayo Clinic, Rochester, MN Study Objectives: Bystander cardiopulmonary resuscitation (CPR) significantly improves survival of cardiac arrest victims. Dispatcher assistance increases bystander to do CPR but the quality of CPR remains unsatisfactory. This study was conducted to assess the effect of video demonstration performing CPR by non-trained middleage person compared with traditional voice instructions in simulated cardiac arrest. Methods: The subjects of middle age were randomized to receive voice dispatcher assistance instruction (voice groupП39), and the other to voice and demonstrated video instruction (video groupП39) via a cell phone on chest compression to scenario-based simulated cardiac arrest situation. Performance of chest compressiononly CPR throughout the scenario was video recorded. The quality of CPR was evaluated by reviewing videos and mannequin reports (skill reporting systemTM, Laerdal). Results: In video group, chest compressions per minutes were more adequate (99.5/min vs 77.4/min, pПЅ0.01) and shorter period from initial phone call to first compressions (184sec vs 211sec, pПЅ0.01). Depth of compression were deeper in voice group (31.3mm vs 27.5mm, pП.21) but not matched to recommended levels in both groups. Hand positions of compression were more appropriate in video group (62.2% vs 37.8%, pП0.012). 71.8% of video group performed no вЂњhands offвЂќ compressions ( vs 46.15%, pП0.21). Conclusion: Dispatching with video demonstration to do CPR improved time to initiate compression, compressions per minute, correct hand positioning and also reduced вЂњhands-offвЂќ events. But more emphasized instruction to improve depth of compression is needed through video demonstration. Study Objectives: To evaluate differences in out-of-hospital interventions and care provided to patients based on the activity or unit hour utilization (UHU) of an ambulance service. Methods: This was a retrospective analysis of out-of-hospital electronic records from January 2007 through February 2008. All non-interfacility ground transports in which the patient was taken to a hospital were included for analysis. Patient records were examined for interventions; defined as any treatment or diagnostic tool (ie, ECG, blood glucose monitor). Advanced life support (ALS) intervention is defined as any advanced procedure, assessment or treatment such as IV medication administration or ECG monitoring. UHU is a measurement of the productivity of an ambulance system calculated by dividing the number of transports by the number of unit hours over a given time period. In this study, 4 of the 12 sites had a UHU number greater than .25 (Пѕ25% productivity). The remaining 8 sites had UHU of less than .25 (ПЅ25% productivity). Data abstraction and statistical analysis was completed using JMP v6.0 software. This study was approved by Mayo Clinic IRB. Results: There were 33,067 patients included for analysis. The Пѕ25% group had 22,954 (69.4%) in which 15,703 (68.4%) patients received at least one intervention. In those that received an intervention, 8,175 (35.6%) received an ALS intervention. The remaining 10,113 (30.6%) patients from the entire sample were designated as the ПЅ25% group. An intervention was performed on 8,056 (79.7%) of these patients. This is a difference of 11.3%. An ALS intervention was performed on 4,265 (42.2%) patients which is a difference of 6.6%. The median transport times for the two groups; Пѕ25% П 8 minutes, ПЅ25% П 9 minutes. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Annals of Emergency Medicine S35 Research Forum Abstracts Morphine administration for pain occurred in 537 (2.3%) of the Пѕ.25% group while it was administered to 487 (4.8%) of the ПЅ.25% group. This is a difference of 2.5%. Conclusion: Ambulance services with UHU of ПЅ25% have a higher rate of delivering at least one intervention to a patient, providing an ALS intervention and treating pain with morphine sulfate. Further study is necessary to determine what these differences have on patient outcomes. 111 Insurance Status as a Predictor of Mode of Arrival for Patients Who Present to the Emergency Department With Chest Pain Wu JT, Bhatti P, Goetz JD, Weiner SG/Tufts University School of Medicine, Boston, MA; Tufts Medical Center, Boston, MA Study Objectives: Previous studies have evaluated patient-specific factors for patients who choose to take an ambulance to the ED. We wished to determine if insurance status was a predictor for EMS arrival for the common, but potentially lifethreatening, complaint of chest pain. Methods: All adult patients ages 18 вЂ“99 who presented to an urban academic ED between 1/06 and 7/06 with a chief complaint that included вЂњchest painвЂќ were eligible for retrospective analysis. For patients with multiple visits, only the first visit for this complaint during the study period was included. Patients who were transferred, incarcerated or who left without being seen or against medical advice were excluded. Insurance status was documented by registration personnel on a computerized record. Results: There were 690 visits for chest pain during the study period, representing 4% of total ED census. A total of 42 visits met exclusion criteria, and 37 patients had 52 repeat visits, leaving 596 visits included for analysis. 22% (56/250) of patients with private insurance arrived via EMS. Using private insurance as a reference, 36% (46/129) of Medicare patients (OR 1.92, 95% CI 1.20 вЂ“3.06), 24% (36/152) of Medicaid patients (OR 1.08, 95% CI 0.67вЂ“1.73) and 25% (16/65) of Self Pay patients (OR 1.13, 95% CI 0.60 вЂ“2.14) arrived by ambulance. Only Medicare patients had a statistically significant increased likelihood of EMS transport (OR 1.84, 95% CI 1.21вЂ“2.80) when compared with private, Medicaid and Self Pay patients (pП0.005). Patients who arrived via ambulance were more likely to be admitted to the hospital (OR 1.75, 95% CI 1.21вЂ“2.55) but there was no difference in final diagnosis of вЂњmyocardial infarctionвЂќ among the different insurance types (pП0.40). Conclusion: Of the four major types of insurance, only Medicare patients with a chief complaint of chest pain were more likely to utilize EMS. There was no significant difference among patients with private insurance, Medicaid or self-pay status. 112 Knowledge of Self-Injectable Epinephrine Technique Among Emergency Medical Services Providers Davis JE, Churosh N, Borloz M, Howell J/Georgetown University Hospital & Washington Hospital Center, Washington, DC; Inova Fairfax Hospital, Fairfax, VA Study Objectives: Emergency medical services (EMS) personnel may be the first to encounter a patient with an allergic emergency. Several studies have revealed that health care provider (physician, nurse) knowledge of the technique of self-injectable epinephrine (such as EpiPenВ® or EpiPenВ® Jr) administration is deficient in general. Studies focusing specifically on EMS personnel are lacking. We therefore sought to assess emergency medical technician (EMT) knowledge of self-injectable epinephrine use, and evaluate the efficacy of a brief, directed educational intervention. Methods: We assessed baseline knowledge of self-injectable epinephrine technique among EMT providers, then provided an educational intervention (we created an online training module lasting less than 5 minutes). Study subjects were retested immediately following training module completion, and again at 3-months. Proper technique was defined in 5 steps, per self-injectable epinephrine medication package insert instructions: (1) grasp device, (2) remove safety cap, (3) inject into lateral thigh, (4) hold in place for 10 seconds, and (5) rub injection site for 10 seconds following device removal. This study was approved by our institutional review board. Nominal data were analyzed using chi square and FisherвЂ™s Exact tests. Alpha was set at 0.05 for all comparisons. Data were analyzed using GraphPad Prism version 5.00 for Macintosh, GraphPad Software, San Diego, California, USA, www.graphpad.com. Results: All participants were EMT basic certified providers from a single collegiate EMS system, with a mean of 1.8 years of experience (range: ПЅ1 year to 3.5 S36 Annals of Emergency Medicine years). At baseline, 4.6% of 22 participants correctly demonstrated all 5 steps compared with 73% (95% confidence interval: 50 вЂ“ 89%) immediately post intervention, and 72% (95% confidence interval: 49 вЂ“ 88%) at 3-month follow-up. Four participants were lost to 3-month follow-up. Baseline measurements were significantly different than immediate and 3-month post-intervention measurements. Conclusion: Similar to studies of other health care providers, EMT basic providers demonstrated poor baseline knowledge of proper self-injectable epinephrine technique. Knowledge improved significantly following a brief educational intervention, and was well retained at 3-month follow-up. Brief, focused educational interventions may assist health care providers in learning and retaining knowledge regarding the proper technique for self-injectable epinephrine administration. 113 The Treatment of Motion Sickness in the Out-ofHospital Setting: A Comparison of Metoclopramide and Diphenhydramine to Placebo Weichenthal LA, Andrews J, Rubio S/UCSF-Fresno, Fresno, CA Study Objectives: To determine the incidence of motion sickness in patients being transported via ambulance in a mountainous setting while comparing metoclopramide and diphenhydramine to placebo in the treatment of these patients. Methods: This was a prospective, randomized, double-blinded, placebo controlled study of patients transported by ambulance in the mountainous regions of Fresno County. Patients who met inclusion criteria and who agreed to participate in the study were asked to rate their motion sickness every 5 minutes on a visual analog scale (VAS) during transport. If they developed motion sickness, they were randomized to recieve metoclopramide (20 mg IV), diphenhydramine (50 mg IV), or placebo (saline). Symptoms then continued to be recorded every 5 minutes on a VAS. If subjects continued to have signs and symptoms of motion sickness after 15 minutes, a rescue dose of metoclopramide was offered. Results: Twenty six subjects were enrolled in the study. Twenty two (84.6 %) developed motion sickness during transport. These patients were randomized to the three different treatment arms: Eight receive metoclopramide, seven received diphenhydramine, and seven recieved placebo. The metoclopramide group showed a significant decrease in mean VAS score at 15 minutes compared to the dihenydramine and placebo groups (pП0.0226). Twelve of the twenty two patients required a rescue dose of metoclpramide after 15 minues. Eleven of these patients were from the diphenhydramine and placebo groups. At twenty five minutes, there was no difference in the VAS score between the three groups. Conclusion: There is a significant incidence of motion sickness in patients being transported by anbulance in a mountainous setting. Metoclopramide is superior to diphenhydramine and placebo in the treatment of motion sickness in this environment. 114 A Comparison of Out-of-Hospital Rapid Sequence Intubation Success to Non-Paralyzed Patients Felderman H, Walsh B, Yasbin P/Morristown Memorial Hospital, Morristown, NJ; Atlantic Ambulance, Morristown, NJ Study Objectives: Out-of-hospital intubation, and especially out-of-hospital rapid sequence intubation (RSI), is a controversial procedure that is frequently debated in the literature. Our paramedics intubate frequently, have regular educational updates, and are evaluated routinely in cadaver labs. In order to fine-tune our educational process, we sought to determine our paramedicsвЂ™ baseline intubation skills and the impact of RSI on success rates. Methods: We retrospectively analyzed all patients in which intubation was attempted by our ground and air units over a 23-month period. In order to determine baseline procedural competence and the impact of RSI, we subdivided patients in to three groups: those in cardiac arrest (CA), those with a pulse who underwent RSI (RSI), and those with a pulse who did not receive RSI (I). We compared the group in terms of вЂњsuccessfulвЂќ intubation (ПЅП 2 attempts) and вЂњoverallвЂќ intubation (ПЅП4 attempts) using a Chi-Square test with a Marasciullo correction for multiple comparisons. Results: Of the 751 patients with intubation attempts, 330 were in cardiac arrest, 196 received RSI, 225 did not receive RSI. In terms of вЂњsuccessfulвЂќ intubations: 88% of CA patients were intubated within 2 attempts, 90% of RSI patients were intubated within 2 attempts, and 82% of I patients were intubated within 2 attempts. The differences in вЂњsuccessfulвЂќ intubation rates between these groups did not reach statistical significance. In terms of вЂњoverallвЂќ intubation rates, there were a total of 687 Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts patients (91.5%) who were intubated out-of-hospitally: 94% of the CA group, 94% of the RSI group and 85% of the I group. Patients in the CA and RSI groups were significantly more likely to be intubated than those in the I group (pПЅ0.05 for both comparisons). Conclusion: Although rates approached significance, we found no difference in rates of вЂњsuccessfulвЂќ intubation in the three groups. In terms of вЂњoverallвЂќ intubation rates, paramedics have higher intubation rates in patients with a pulse when utilizing RSI, and the success rate of RSI approaches that of patients in CA. This suggests that RSI is an effective adjunct to intubation for patients with a pulse. Prospective, outcome-based studies are needed to determine the true impact of RSI in our group of paramedics. 115 The Predictive Value of Arrival With EMS Felderman H, Walsh B, Shih S, Luk J, Sturm D/Morristown Memorial Hospital, Morristown, NJ Study Objectives: Estimating the severity of illness is a crucial part of the initial triage in an emergency department. arrival with emergency medical services (EMS) is considered to be associated with increased severity, although it is unproven to date. We sought to determine the significance of mode of arrival in patients who present to the emergency department. Methods: A retrospective analysis of all patients seen in four emergency departments between 11/1/04 and 10/31/06 was conducted. Patients were evaluated with the following chief complaints: 1) All Diagnoses (AD), 2) Dyspnea (SOB), 3) Abdominal Pain (AP), 4) Mood Disorders (MD), 5) Palpitations (HR), 6) Syncope (S), and 7) Alcohol Abuse (AA). These patients were then subdivided into 20-year age groups (0 вЂ“20, 21вЂ“ 40, 41вЂ“ 60, 61вЂ“ 80, Пѕ80). We used admission to the hospital as a marker for severity of illness. We calculated the odds ratio (OR) and 95% confidence intervals for admission to the hospital for those who arrived with EMS compared with those who did not. Results: Of the 231,219 patients in our database, 222,619 patients had delineated modes of arrival; 50,700 arrived via EMS, 171,919 patients did not. Arrival by EMS was associated with an increased rate of admission for AD: OR 4.9[4.8 вЂ“5.0], SOB: OR 7.2[6.9 вЂ“7.7], AP: OR 2.4[2.1вЂ“2.6], and MD: OR 1.23[1.1вЂ“1.4]. These positive associations were significant in all age groups. For HR, positive associations were found in all age groups except 0 вЂ“20: OR 1.8[0.3вЂ“11.6], and Пѕ80: OR 1.4[0.9 вЂ“2.2]. For S there were no significant associations when corrected for age. Interestingly, for patient arriving with AA, arrival by EMS is a negative predictor of admission: OR 0.4[0.3вЂ“ 0.5]. Conclusion: While arrival by EMS, in general, is associated with an increased rate of admission, there are many important exceptions to this rule. This study suggests that arrival by EMS should not be used alone to make triage decisions. 116 Postural Hypotension in the Elderly: Predictors for Intervention Chan W, Foo C/Tan Tock Seng Hospital, Singapore, Singapore, Singapore Background: Postural hypotension in an elderly patient usually demands a search for, and management of, reversible causes. To date, however, there are no studies examining postural hypotension in elderly patients who present to the emergency department (ED). This study aims to identify predictors for intervention in patients with postural hypotension. Study Objectives: This study examines: 1. The characteristics of postural hypotension 2. The possible causes of postural hypotension 3. The factors that may predict the need for intervention Methods: This is a retrospective study evaluating elderly patients aged 65-andabove who were found to have postural hypotension prior to discharge from a 24hour ED short stay ward (Emergency Diagnostic and Treatment Centre; EDTC) from 1st April 2007 to 31st December 2008. Nursing home residents, patients with severe cognitive or functional impairment, patients already on follow-up with a geriatrician, and patients who refused geriatric assessment were excluded. Patient demographics, characteristics of postural hypotension and the likely causes were examined. Through review of case records by an independent reviewer, patients who required and benefited from intervention were identified and compared against those who did not, to determine if there were any variables that predicted the need for intervention. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Results: Of the 869 patients aged 65 years and above who were admitted to EDTC during the study period and received geriatric screening, 157 (18.1%) had postural hypotension, of which 92 (58.6%) were female and 140 (89.2%) required intervention. The mean age in the intervention group was 79.4, compared to 73.7 in the non-intervention group (pП0.01). The intervention group had a lower mean abbreviated mental test (AMT) score (7.4) when compared to the non-intervention group (8.7; pП0.02). With regards to the characteristics of postural hypotension, 145 (92.4%) had a systolic blood pressure (SBP) drop of 20mmHg, 149 (94.9%) were detected in the first minute of standing, 91 (63.6%) were reproducible, 75 (47.8%) were symptomatic and 64 (40.8%) had a history of falls or near falls. In 46.5% of cases, medications were found to be a contributor to postural hypotension. Dehydration (28.0%), sepsis (26.1%) and diabetic autonomic neuropathy (22.3%) were other common causes. 74 (47.1%) of postural hypotension cases were multifactorial. An etiology was not found in 29 (18.5%) of cases. We also found that postural hypotensive patients who were symptomatic (OR 3.3; 95% CI 1.0 to 10.8) and on 3 or more medications (OR 3.3; 95% CI 1.1 to 9.4) were more likely to have received intervention. Conclusions: Postural hypotension was found in 18.1% of elderly patients in the EDTC. Medications, dehydration, sepsis and diabetes were common causes. The majority required treatment and follow-up. Increased age, lower AMT score, polypharmacy and being symptomatic were predictors for need for intervention. 117 Do HIV-Positive Patients With Severe Sepsis Receive Adequate Initial Antibiotics in the Emergency Department When Compared With HIVNegative Patients? McGrath ME, Bullock HN, Whitney D/Boston Medical Center, Boston, MA Study Objectives: To determine if HIV-positive (HIVП©) patients with severe sepsis received adequate initial antibiotics (abx) in the emergency department (ED) compared to HIV-negative (HIVПЄ) patients. Methods: Retrospective observational study of HIVП© and HIVПЄ patients with severe sepsis (2П© SIRS criteria) admitted to the ICU from an urban academic ED over 18 months. HIV status was determined by review of ED and hospital records 6 months prior to presentation for CD4 counts and viral load. Patient characteristics, mortality, and length of stay was compared between groups using Chi-square, FisherвЂ™s exact, and Wilcoxon rank sum tests. Cochran-Mantzel-Haenszel(CMH) test calculated relative risk (RR) of infection. Adequacy of coverage was determined by comparing initial abx ordered in the ED with sensitivities of pathogens cultured. Results: 325 patients were included: 39 HIVП© and 286 HIVПЄ. HIVП© patients more often were younger (mean 47 yrs vs 62 yrs, pПЅ0.001), black (59% vs 38%, pП0.02), used drugs (28% vs 7%, pП0.001) and smoked (41% vs 11%, pПЅ0.001). No difference was found in length of hospital/ICU stay, MEDS score or mortality; 13% HIVП© patients died in hospital vs 18% HIVПЄ patients (pП0.41). Abx-resistant pathogens were common overall (20% MRSA, 7% VRE). In HIVП© patients, 21/ 24(88%) pathogens cultured were gram pos, 3/24(12%) gram neg. In HIVПЄ patients 122/208(59%) pathogens cultured were gram pos, 83/208(40%) gram neg, and 3/ 208(1%) fungal (pПЅ0.001). HIVПЄ patients had 3.2 times RR of infection by gram neg pathogen than HIVП© patients (95%CI, 1.1вЂ“9.5). In HIVП© patients, 19/24(79%) pathogens were adequately covered by initial ED abx and 5/24(21%) were not. In HIVПЄ patients, 148/208(71%) pathogens were adequately covered and 60/208(29%) were not. No difference was found in adequacy of abx coverage between the groups (pП0.41). Conclusion: We found no difference in adequacy of initial ED abx coverage, length of stay, or hospital mortality of HIVП© patients with severe sepsis compared to HIVПЄ patients. HIVП© patients had more gram pos infections and there was a high prevalence of abx resistant pathogens overall. 118 External Site Testing of an Instrument to Predict Endocarditis in Injection Drug Users With Fever Romero K, Rodriguez R, Chiang W, Fortman J, Colucci A/University of California, San Francisco, San Francisco, CA; Bellevue Hospital, New York City, NY Study Objective: To externally test a previously derived decision instrument (100% sensitivity and 44% specificity in prior study) for endocarditis prediction in injection drug users (IDUs) admitted from the ED with fever. Methods: Blinded to the prior instrument, an investigator used the same chart Annals of Emergency Medicine S37 Research Forum Abstracts abstraction tool to review ED and inpatient charts of all IDUs admitted to rule out endocarditis at another hospital in 2006 вЂ“ 07. Individual criteria screening performance was determined. Classification tree analysis was used to derive optimal combinations of predictive criteria and test the prior instrument. Results: Of 75 IDUs admitted with fever, 6 (8%) were diagnosed with endocarditis. Consistent with the previous study, criteria with the highest diagnostic odds ratios (95% CIs) were prior endocarditis 6.5 (1.3, 33.9), pneumonia on chest x-ray 5.3 (0.9, 31.1), lack of skin infection 4.9 (0.7, 32.6), hyponatremia 2.7 (0.4, 22.3), and murmur 2.6 (0.4, 14.8); WBC count and degree of fever again showed no diagnostic utility, with diagnostic odds ratios of .2 (0.0, 1.5) and 0.7 (.1, 5.1). Thrombocytopenia showed no diagnostic utility as well, with a diagnostic odds ratio of 0.0 (.0, 0.2). The most sensitive combinations of criteria were pneumonia on chest x-ray П© lack of skin infection (100% sensitivity and 47% specificity) and lack of skin infection П© murmur (100% sensitivity and 39% specificity). The previously derived instrument of thrombocytopenia П© pneumonia on chest x-ray П© absence of skin infection predicted endocarditis with 100% sensitivity (63вЂ“100%) and 36% specificity (33вЂ“36%). Conclusions: The previously derived instrument for the prediction of endocarditis in IDUs with fever retained high sensitivity and moderate specificity at another site. 119 Diagnostic Testing and Site-of-Care Assigned to 608 Pneumonia Patients Admitted to the Hospital After Evaluation at the Emergency Department Ferre C, Llopis F, Jacob J, Juan A, Alonso G, Corbella X, Salazar A/Bellvitge Universitary Hospital, LвЂ™Hospitalet de Llobregat, Spain; Sant Joan de Deu Hospital, Sant Boi de Llobregat, Spain Study Objectives: To review diagnostic testing procedures and site-of-care assigned to community-acquired pneumonia (CAP) patients admitted to the hospital after evaluation at the emergency department (ED). Methods: Design: Descriptive and retrospective study. Setting: ED of a 960-bed tertiary care teaching hospital in the metropolitan area of Barcelona, Spain. Period: a total of 18 months from October 2005 to April 2007. Patients: All patients with CAP according to clinical and radiological findings admitted to the hospital after evaluation at the ED with exclusion of those admitted to the Intensive Care Unit and patients with empyema, immunosuppression, renal failure requiring dialysis and HIV infection. Data were collected for demographic variables, Fine and CURB-65 scores, blood cultures (BC), urinary antigen tests (UAT), sputum culture (SC) and site-ofcare assigned either the ED Short-Stay Unit (EDSSU) or a general ward (pneumology or infectious diseases unit). Results: During the study period, 608 patients with CAP were admitted to the hospital (general ward or EDSSU) after evaluation at the ED. Mean age was 70.7П®SD 15, 391 male /217 female. Globally, 581 patients (95.5%) had at least one diagnostic test performed and 140 (23%) had 3 of them (blood culture, UAT and sputum culture). From 202 sputum samples, 112 (55.4%) yielded a positive result, blood cultures were positive in 65 cases (13.4%) out of 484 and 517 UAT gave a positive result in 262 cases (50.7%). A presumed or confirmed microbiological diagnosis was achieved in 335 cases (55.1%). Regarding Fine score, 121 patients (19.9%) were IвЂ“II, 188 (30.9%) III, 255 (41.9%) IV and 40 (6.5%) V. When considered CURB-65, 96 patients (15.8%) scored 0, 225 (37%) 1, 211 (34.7%) 2, 65 (10.2%) 3 and 7 (1.1%) 4 вЂ“5. In total 419 (69%) of patients were admitted to a general ward and 189 (31%) to the EDSSU. Patients assigned to the EDSSU were older (mean age 77 vs 67.9), around 3вЃ„4 of cases with lower scores (Fine IвЂ“II and CURB 0 вЂ“1) were admitted to a general ward and one third of patients scored Fine IIIвЂ“IV or CURB 2вЂ“3 were admitted to the EDSSU. Conclusion: 1. In our experience, there is a great variability in diagnostic testing in community-acquired pneumonia. 2. Implementation of local guidelines considering cost-benefit ratio for diagnostic strategy may be needed. 3. A significant number of patients, although suposed to be eligible for treatment in an outpatient basis according to Fine and CURB-65 scores, were admitted to the hospital. 4. The proportion of patients admitted to the ED Short-Stay Unit increased with higher Fine or CURB-65 scores. S38 Annals of Emergency Medicine 120 How Many Methicillin-Resistant Staphylococeus Aureus Infections Are Missed Upon Admission to the Emergency Department? Akpunonu P, Ruggiero L, Pearce A, Snow J, Brickman K/University of Toledo College of Medicine, Toledo, OH Study Objective: The objective of the study was to assess the carriage rates of methicillin-resistant Staphylococcus aureus (MRSA) at different body sites. Background: MRSA is a significant cause of morbidity and mortality. Knowledge of frequently colonized sites may prevent nosocomial and post-procedural MRSA infection. Current practice focuses on the internal nares as the primary source. This study suggests that addition sites should be screened. Methods: This prospective case cohort study was conducted at a university medical center. The internal nares, axilla and groin of eligble emergency department patients and visitors were cultured bilaterally. Eligible participants were adults with decisional capacity and minors who assented with parental or guardian consent. Swabs were plated on BBL CHROMagar MRSA plates. Agar plates were observed at 24 and 48 hours for growth. Suspected MRSA colonies were biochemically tested to confirm their identity. Results: Among 93 participants, 82% cultured negative for MRSA, 16% had MRSA colonization at one site, while 2% cultured were positive at two sites. Of the positive cultures the nares(48%), groin (47%) and axilla (5%) were the most common sites of colonization. Approximately 53% of patients who cultured positive at least one site were positive in the groin, while the remaining 47% cultured positive from the internal nares. No participants cultured positive from all three sites. Conclusion: The greatest proportions of ED patients were positive at the internal nares and groin respectively (48%, 47%). The internal nares and groin are likely sites of MRSA colonization but with minimal overlap. Based on this study nasal swabs alone do not provide a clear picture of MRSA prevalence in our patient population. Axillary swabbing is not an effective means of detecting MRSA carriage in our population. 121 Prognosis of Urosepsis Patients Who Are Treated by Inappropriate Initial Antimicrobial Therapy in the Emergency Department Imamura T, Ohta B, Tanaka E, Branch J/Shonan Kamakura General Hospital, Kamakura, Japan Study Objectives: Urosepsis is known to have a better prognosis than other types of sepsis. However, it is not clear whether there is an increase in adverse outcome if there is erroneous initial antimicrobial therapy administration followed later, by a change to appropriate therapy after cultures results become available. We categorized patients with urosepsis into two groups with regard to appropriate and inappropriate initial antibiotic choice and measured the outcome, which included the difference of mortality rate and cost of hospitalization. Methods: We retrospectively analyzed all patients diagnosed with urinary tract infection and bacteremia in our community general hospital from January 2008 to December 2008 inclusive. Patients were included if they met the criteria for systemic inflammatory response syndrome and positive blood cultures. Urinary tract infection with bacteremia was defined by the identification of the identical organism in both the blood and urine cultures. Bacterial isolation and subsequent antibiotic susceptibilities were determined using an automatic system (VITEKВ®2). Mortality rate and cost of hospitalization were compared using Wilcoxon test. Results: A total of 105 patients met the criteria for urinary tract infection and bacteremia. The mean age was 76.09 П® 2.44 years old and 69% of the study sample were female. Thirty patients (28.6%) were both bedridden and fecally incontinent. Isolated pathogens included 94 (89.5%) gram negative bacilli, 11 (10.5%) gram positive cocci. Thirty-eight patients had a history of recent hospitalization, 29 came from a nursing home and 31 had a history of antibiotics use within the previous 3 months. Of the 105 patients, Group A composed 85 (81%) appropriately treated patients and Group B composed 20 (19%) patients who received inappropriate initial therapy. A total of 91 antibiotics were initially administered to Group A patients, (37.6% ceftriaxone, 34.1% cefotiam, 10.5% carbapenem, 7.1% cefmetazole, 3.5% vancomycin 3.5%, ampicillin, 2.4% ampicillin/sulbactam) and a total of 23 antibiotics were initially administered to Group B patients (35% ceftriaxone, 20% cefotiam, 15% cefmetazole, 10% ampicillin/sulbactam, 5% ampicillin, 5% vancomycin, 0% carbapenem). All of the Group B patients had their antimicrobial therapy changed after culture results were obtained (43.4 П® 6.7 hours later). Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts The 12-week mortality rate of Group A was 13 of 85 (15%) and Group B was 2 of 20 (10%) respectively, (PП0.56). The median total cost of hospitalization for Group A was $ 3916 and for Group B was $ 7151 (1$П100 JPY) respectively (PП0.006). Conclusion: Patients with urosepsis who were given inappropriate initial antimicrobial therapy in the emergency department had a similar 12-week mortality rate compared to those patients receiving correct therapy. However, the cost of hospitalization for inappropriate treatment increased significantly. The difference in cost is explained by the fact that patients who were administered inappropriate antibiotics had more severe medical problems and were bedridden, which are risks for developing multi-resistant organism infection. The increased cost was positively correlated to longer inpatient admission. 122 Vancomycin Minimum Inhibitory Concentration Values >1.0 вђ®g/mL Do Not Predict a Worse Clinical Outcome in Non-ICU, Adult, MethicillinResistant Staphylococus Aureus-Positive Patients Virk PS, Berkeley RP, King J, Saripella S, Abrahamian FM, Slattery DE/University of Nevada School of Medicine, Las Vegas, NV; University Medical Center of Southern Nevada, Las Vegas, NV; University of Nevada, Las Vegas, NV; Olive View-UCLA Medical Center, Sylmar, CA Background: Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for an increasing number of infections worldwide. Heightened vancomycin resistance of MRSA may predict a more virulent infection. Study Objective: To determine whether vancomycin minimum inhibitory concentration (MIC values) Пѕ1.0 вђ®g/mL (MICПѕ1) in non-ICU, adult, MRSApositive patients predict a worse clinical outcome as compared with MRSA-positive isolates with vancomycin MIC values Х…1.0 вђ®g/mL (MICХ…1). Methods: IRB-approved, structured chart review over a 12-month period (7/1/ 07вЂ“7/1/08). Setting: Academic, urban, emergency department (ED) with 70,000 annual visits. Inclusion criteria: Adult patients who received vancomycin in the ED, admitted, and had a MRSA-positive source identified from ED-collected cultures. ICU admissions were excluded. Trained abstractors, who underwent periodic monitoring, utilized a standardized data collection tool to extract elements from an electronic records system. 25% of the data were adjudicated by the lead investigator. Baseline patient demographics, co-morbidities, laboratory values, in-hospital antibiotic profiles, and clinical outcomes were captured. The primary outcome measure was a composite triple-endpoint: development of severe sepsis/septic shock after admission; upgrade to ICU; or death. Our secondary measure was hospital length of stay (LOS). Data were analyzed as appropriate using NCSS statistical software. We utilized Chi-square and calculated 95% confidence intervals for differences and set statistical significance at pПЅ0.05. Results: Sixty-five of 115 identified MRSA-positive patients met inclusion criteria and comprised our study cohort. 36/65 (55%) had MIC values Х…1, and 29/65 (45%) had MIC values Пѕ1. The mean (П®SEM) age was 51.3 (1.8) years, and 21/65 (32%) were female. MRSA-positive culture sources were wound 42 (65%), blood 16 (25%), urine 4 (6%), and sputum 3 (5%). There were no statistical differences between baseline demographics, prevalence of comorbidities, or lab values (lactate, peak WBC, peak creatinine, and vancomycin trough levels) between the two groups. The MICХ…1 group had a higher prevalence of wounds as the source, 27/36 (75%) than the MICПѕ1 group, 15/29 (65%); difference П 0.41 (0.19,0.63). Primary outcome: We found no difference in the prevalence of the triple-endpoint between the two groups: MICХ…1 П 24/36 (66.7%) vs. MICПѕ1.0 П 22/29 (75.9%); difference (95% CI) П ПЄ0.092 (ПЄ0.09,0.16); П¬2 П 0.66, p П 0.58. The mean (95% CI) hospital LOS was not different between the two groups: MICХ…1 П 12.2 (8.5,16.0) days vs. MICПѕ1 П 12.3 (5.7,18.8) days, p П 0.99. Limitations: Our study is limited by the small size, the inherent limitations of retrospective data collection, and by the fact that the abstractors were not blinded to the study hypothesis. Conclusion: In our cohort, vancomycin MIC values Пѕ1 did not predict a worse clinical outcome. 123 The Significance of Lactate Clearance Rate as a Predictor of Organ Failure Cho YD, Hong Y, Choi S, Lee S, Moon S, Lee S, Kim J/Korea University Medical Center, Seoul, Republic of Korea Study Objectives: Serum lactate level is one of many variables with prognostic values in sepsis and septic shock. Its correlation to mortality rate and the duration of Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ admission in patients with sepsis had been acknowledged to a certain extent, but its value as a predictor of organ failure - the main cause of death, had not yet been examined in detail. With increasing emphasis of role of lactate in sepsis, a вЂњlactate clearance rateвЂќ is recently being proposed by many as an effective predictor of organ failure. We thus attempted to estimate the role of lactate clearance rate (in contrast to classical serum lactate level measurements), in predicting the mortality rate, duration of admission, and organ failure in patients with sepsis. Methods: Fifty-nine patients over the age of 18, who presented to the emergency department of Korea University Medical Center during January 2005 to June 2006, and were consequently diagnosed with sepsis and septic shock, were the major candidiates in this study. Serum lactate level was measured initially upon presentation and once more 4hours later. Lactate clearance rate, defined as [(initial lactate-lactate level 4hrs later)/initial lactate*100] was further determined, and patients were sorted into 2 groups, either low or high lactate group, based on initial serum lactate level and lactate clearance rate (4mmol/L and 10% as the cutoff value, respectively). Organ failure as described by the sepsis-related organ failure assessment score, duration of ICU stay, duration of admission, and mortality rates were compared for both groups. The data was processed with Student t-test and kai-square test using SPSS 12.0. Results: In relevance to the initial serum lactate level, whereas a mortality rate of 38% and shorter duration of ICU stay was observed in the low lactate group, a mortality rate of 66% and longer duration of ICU stay was observed in the high lactate group, revealing a statistically significant difference in the 2 groups. Also, in the case of initial lactate clearance, a mortality rate of 71%, and ICU stay of 14 days was observed in the low lactate clearance group, which was significantly higher than 29% and 7 days respectively observed in the high lactate clearance group, thus suggesting a worse prognosis. Furthermore, concerning organ failure, SOFA scores calculated at 24, 48, 72hrs after admission revealed correlation of initial lactate level and lactate clearance rate, suggesting significant potency in predicting the severity of multiple organ failure (pПЅ0.05). In comparing the relevance to various organ failures, total number of organ failure was summed up 24, 48, 72hrs after admission, and lactate clearance rate was found to be statistically significantly related to renal failure (pПЅ0.05), hepatic failure (pПЅ0.05), and failure of other organs (pПЅ0.05). Initial serum lactate levels alone failed to demonstate any significant relation to each organ failure. Conclusion: Initial serum lactate level may have some implication in predicting the overall development of multiple organ failure and its prognosis, but was found to be limited in predicting the likelihood or outcome of each specific organ failure. Lactate clearance rate, however, may have a role not only in predicting the mortality rate and duration of ICU stay, but also in predicting the likelihood or outcome of each specified organ failure. 124 Rapid HIV Testing in a Large Urban Emergency Department Lowman E, Harper JB, Livak M, Jain S, Rush A, Kessler A, Purin-Shem-Tov Y, Rumoro DP, Kessler HA/Rush University, Chicago, IL Background: In 2006 the CDC recommended universal HIV testing for patients 13вЂ“ 64 in all health care settings where the seroprevalence is greater than 0.1%. They noted several advantages of using rapid HIV testing; however, recent studies have raised concerns of false positives using rapid HIV tests in populations with a low seroprevalence. Methods: A serosurvey using a convenience sample of 1348 patients seen in our emergency department (ED) were offered rapid HIV 1/2 testing (OraQuick ADVANCE, Bethlehem, PA) using an oral mucosal swab beginning August 13, 2008. Subjects with a preliminary positive result were told of their preliminary results and blood was obtained for a confirmatory Western blot. Subjects declining participation were asked to complete an opt-out survey. Results: 1000 patients were tested. 12 had positive results, all but 1 were previously known to have serologically confirmed HIV infection. 988 patients tested negative. Of these 335 (33.3%) had never been tested (640 had a prior history of a negative HIV test). No false positives results occurred. 98.7% received the results of their preliminary HIV test, including 100% of those who tested positive. All 348 subjects who declined testing completed the opt-out survey. Most cited either a recent negative HIV test (160/348) or a belief they were at low risk for HIV (65/348) as their reason for declining testing. A minority cited a concern regarding their privacy (11/348) or that the test might delay their treatment (7/348). The remainder (93/ 348) declined to give a reason for not accepting the test. Annals of Emergency Medicine S39 Research Forum Abstracts Conclusions: There were no false positive rapid HIV results using oral mucosa swabs. The seroprevalence rate suggests we should adopt routine universal testing in this setting. The acceptance rate of rapid HIV testing in our patient population was high, as was the percentage of patients who received their results. In our setting the rapid HIV test has performed well. Reasons for the better performance in our study compared to other recent reports requires further investigation. 125 Trauma Care Access for Road Traffic Injuries in Hanoi City Nagata T, Kimura A/Himeno Hospital, Hirokawa-city, Japan; International Medical Center of Japan, Tokyo, Japan Background: Road traffic injury (RTI) is the leading cause of death in Vietnam now. The economic growth of Vietnam has recently accelerated in the last ten years; however, reducing the number of RTIs is difficult despite the varieties of effort for injury prevention in Vietnam. The aim of this research is to understand epidemiological characteristics of RTIs in Hanoi City and evaluate the trauma care access by applying a geographical analysis. Methods: A cross-sectional study by using Hanoi City police reports in 2006. In addition to descriptive epidemiology of RTIs that occurred in Hanoi City, geographic patterns will be investigated by applying geographical information system (GIS) software. The association of RTIs distribution in Hanoi City and location of ten major hospitals with capability for trauma care is analyzed by geographical information system. Results: 1271 cases were mapped in Hanoi City. About 40% of RTIs occur among people aged 20 вЂ“29 years old. 78% of RTIs were associated with motorcycles. RTIs in males occurred significantly more than in females in all age groups (pvalueПЅ0.05). There were two high peaks of occurrence time of RTIs (14:00 вЂ“15:59 and 20:00 вЂ“23:59) In Kernel density estimation, вЂњhot spotsвЂќ for road traffic injuries/ fatalities in the city area and main highways were found. Two major trauma hospitals (Viet Doc hospital and Saint Paul Municipal hospital) are located in the city area, and about 50% of RTIs occurred within 5 km from these two trauma hospitals. RTIs occurring along the two south-north highways are not in the range of easy access to the hospitals. Conclusions: The difference of geographical patterns of RTIs in Hanoi City by sex, time, and injury mechanism will be a clue for injury prevention. To provide the trauma care for the RTIs occurring in the two south-north highways, a new hospital should be built or an emergency medical service system should be established. 126 Road Traffic Injury Hot Spots in Yerevan, Armenia Lynch CA, Crape B, Tadevosyan M, Lyman T, Chekijian S/ Yale School of Medicine, New Haven, CT; American University of Armenia, Yerevan, Armenia; Erebouni Medical Center, Yerevan, Armenia Study Objectives: To identify locations and characteristics of road traffic injuries within the city of Yerevan, Armenia. Methods: A retrospective review of out-of-hospital records from the city of Yerevan identified incident location, injury type and severity, out-of-hospital treatment, and transport information. Locations for ambulance substations, hospitals and road traffic injuries were then visited; global positioning (GPS) data, car and pedestrian densities were collected between 12 noon and 6 PM on regular business days. Data was entered into ARCGIS 9.2 software/ Global Information System (GIS) for spatial analysis. Road traffic injury characteristics were analyzed for frequencies. Results: To date, 63 patient records from 52 accidents had 66% male patients with the average age of 39. They showed a death on scene rate of 3%, refusal of hospital transfer rate of 20% and refusal of out-of-hospital care of 3%. Total call time, or time from dispatcher receiving a call to the ambulance becoming available, ranged from 14 minutes to 3 hours 13 minutes with an average of 46 minutes. Time to locate the scene averaged 2 minutes while time to gain access to the patient averaged 8 minutes. Total treatment and transport time averaged 22 minutes. Localization of road traffic injuries reveled a significant hot spot of road traffic injuries with 7 of 63 injured patients at the same location. Conclusion: Preliminary data has revealed a road traffic injury hotspot where a local park entrance is around a bend from a heavily trafficked, high-speed road. Although a recent underground pedestrian walkway has been built pedestrians fail to use the walkway. Based on this localization of road traffic injury hotspot, interventions to protect pedestrians and drivers are planned. Continued localization of road traffic can be used to monitor success of planned interventions. S40 Annals of Emergency Medicine 127 Comparison of Acidosis Markers Associated With Law Enforcement Applications of Force Ho JD, Dawes DM, Lundin EJ, Miner JR/Hennepin County Medical Center, Minneapolis, MN; University of Louisville, Louisville, KY Study Objective: Force applied by Law Enforcement Authorities (LEA) has inherent risk for injury and sometimes death. Occasionally, unexpected sudden death (SD) occurs. A hypothesized cause of SD is a worsening acidosis leading to a cardiopulmonary arrest. It is not clear if this acidosis is due to volitional suspect behaviors or to LEA tools/tactics. Our objective is to compare volitional suspect behaviors and commonly used LEA tools/tactics to determine which, if any, cause the highest levels of acidosis. Methods: This was a prospective evaluation of human volunteers in a LEA training class. Randomization to 1 of 5 study arms occurred: 1. Maximal вЂњheavy bagвЂќ exertion x 45 sec (simulating suspect resistance) 2. 10 sec TASERВ® X26 application 3. Full face exposure to Oleoresin Capsicum (OC) spray 4. 150 meter sprint П© scaling a 4 foot wall (simulating suspect fleeing) 5. 40 yard flee П© 20 sec fight with a police K9. Volunteers had venous sampling before and after their events. Sampling continued at 2-minute intervals until 12-minutes post event. Values for pH and Lactate were determined and compared between study arms using k-sample equality of medians tests. Results: Sixty-two volunteers enrolled. The median age was 35 (range 19 to 67), 85.5% male, median BMI 27.8 (range 19.1 to 44.1). There was no difference between age, sex, or BMI between the groups. The median baseline pH was 7.36 (range 7.28 to 7.44) with no difference between the groups (pП0.23). The median post exposure pH for group 1 was 7.01 (range 6.94 to 7.18, IQR 6.99 to 7.05), for group 2 was 7.29 (range 7.24 to 7.35, IQR 7.26 to 7.33), for group 3 was 7.37 (range 7.33 to 7.40, IQR 7.38 to 7.39) for group 4 was 7.16 (range 7.05 to 7.31, IQR 7.13 to 7.31) and for group 5 was 7.26 (range 7.30 to 7.40, IQR 7.22 to 7.31)(pПЅ0.001). These differences persisted over the subsequent 6 measured time points. The median baseline lactate was 1.15 (range 0.61 to 3.55, IQR 0.75 to 2.35) with no difference between the groups (pП0.07). Median post exposure lactate for group 1 was 14.71 (range 8.9 to 18.7, IQR 13.7 to 17.40, for group 2 was 5.49 (range 1.3 to 7.2, IQR 4.3 to 5.9), for group 3 was 1.39 (range 0.6 to 2.4, IQR 1.3 to 1.7), for group 4 was 10.98 (range 3.3 to 14.6, IQR 7.4 to 13.2) and for group 5 was 5.01 (range 1.5 to 9.6, IQR 3.5 to 7.0)(pПЅ0.001). These differences persisted over the subsequent 6 measured time points. Conclusion: The exertional groups of heavy bag and sprint had a lower pH and higher lactate after the exposure than the other groups. The painful exposures of the TASER and the OC spray had higher pH and lower lactate than the other groups. Volitional behaviors of resistance and fleeing induced the most profound levels of acidosis. Measured LEA tools/tactics did not induce acidosis to the same levels as volitional subject behavior. This work represents the first known study to evaluate acidosis that may be associated with LEA applications of force. 128 Radiation Exposure in Emergency Physicians Working in an Urban Emergency Department: A Prospective Cohort Study Gottesman B, Gutman A, Lindsell CJ, Larrabee H/University of Cincinnati College of Medicine, Cincinnati, OH; Unviersity of Cincinnati College of Medicine, Cincinnati, OH Study Objectives: The National Council on Radiation Protection (NCRP) has established limits on health care associated occupational exposures to radiation of 5000 mrem/year. While prior studies suggest that emergency physicians were not exposed over this limit, their relevance to contemporary practice is unknown. Due to increased radiographic imaging in the emergency department (ED), we hypothesized that resident and attending emergency physicians are currently exposed to radiation levels above the acceptable limits for health care workers. Methods: This prospective cohort study was conducted at an urban, academic, level 1 trauma center ED; annual census of Пі85,000 patients. Thermoluminescent dosimeter (TLD) radiation badges were placed on the torso and ring finger of all resident and attending physicians staffing the ED during May 2008; investigators were present at every shift change to ensure placement of badges and rings. In addition, TLD badges were affixed to each of eight portable phones that are carried by physicians 24 hours a day. At the end of the study period, torso and extremity TLD badges were analyzed to obtain mrem exposure doses for each subject. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts Results: There were 41 resident and 34 attending physicians enrolled. Residents worked a median of 94 hours (range 24 вЂ“186) and attendings worked a median of 54 hours (range 12вЂ“162) during the study period. Compliance for physician badge wearing was 99%, for physician ring wearing was 98%, and for phone wearing was 100%. Two subjects had detectable levels of radiation on their torso TLDs of four and one mrem respectively. One phone TLD badge had a detectable level of radiation of one mrem. No other TLD indicated any detectable radiation exposure. The annual extrapolated exposure for the subject with the highest radiation level would have been 48mrem, well below the 5000 mrem exposure limit for health care workers. Conclusion: Emergency physicians working in an urban, academic, level 1 trauma center ED do not appear to be at risk of exceeding the NCRP dose limits for ionizing radiation exposure to their torso or extremities. 129 Industrial Accidents: An Epidemiological Profile of 866 Emergency Admissions in a Tertiary Care Teaching Hospital, S. India Banala SR, Cattamanchi S, Trichur RV/Sri Ramchandra Medical College & Research Institute, Chennai, India Study Objectives: в—Џ To study epidemiological profile of industrial accidents registered in emergency department. в—Џ To find the annual overall rate of ED visits following industrial accidents. в—Џ To identify population at risk & enumerate preventable aetiological factors from industrial accidents. Methods: A prospective, descriptive analytical study done in the emergency department of a tertiary care university hospital in Chennai, India, from 1st September 2007 to 31st August 2008. A pre-formatted questionnaire used as instrument. Consecutive sampling technique employed. Data on demographics, clinical and disability-adjusted life years were collected and analyzed using done using SPSS ver. 15. Inclusion criteria: All injured patients attending ED with accidental industrial injuries. Exclusion criteria: Old injuries, and injuries sustained while not at work or in the workplace. Results: There were 866 patients, 3.61% of ED visits after an industrial accident in the study period. Majority of these patients (49%) were young adults of the age group 20 вЂ“29 (Mean age П 29.2 years; SDП11.1). Male predominance (92%) was observed. Of these, 31% were injured at large scale industries, 29% at small scale industries, and 21% at construction site. Among them 19% were permanent workers, 31% contractual workers, and 39% daily laborers. Crush injury (33%) is main mechanism, injury due to fall 21%, and 4% due to explosion. About 19% sustained complete amputation of a limb and 25% sustained partial amputation. Trauma team activated for 16 patients (1.84%). Incidences of mass casualty activated 2 times in ED with a total of 23 patients (2.6%). Mean duration of stay in ED was 5.31 П® 3.67 hours. Only 19% wore protective gear during injury. A total of 19,386 DALYs lost. A total of 155 patients were discharged AMA, 346 admitted to wards, and 285 discharged from ED. Death rate of 1.1% recorded. Conclusion: The studies gave us a quantitative insight into burden on ED and on society and necessitate development of a good quality out-of-hospital care and implement prevention measures like strict use of helmets, gloves and restrain belts while at work. It also gives us scope for societal education on first aid and injury prevention directed at industrial workers. It also highlights need for proper, effective rehabilitation program to decrease burden on the society. 130 131 Abstract Withdrawn Impact of Rapid Streptococcal Test on Antibiotic Use in a Pediatric Emergency Department streptococcal tests for streptococcal pharyngitis have made diagnosis simpler and reduced the use of antibiotics. Overuse of antibiotics leads to drug-resistant bacterial strains. Reducing the number of antibiotic prescriptions provided for upper respiratory infections has been recommended as a way to limit bacterial resistance. Study Objective: To assess the impact of rapid streptococcal tests (RST) on the antibiotic prescriptions in children with pharyngitis in the emergency department. Methods: A retrospective study from September 2005вЂ“September 2007 of all children (3 to 18 years) presenting to the pediatric emergency department with sore throat as the chief complaint, or suspected clinically to have acute pharyngitis, and had rapid streptococcal test performed. Patients with negative rapid strep test have culture performed. The information in patients with the diagnosis of pharyngitis was also collected in a two-year control period prior to the availability of the test. Patients with negative rapid strep test had culture performed. In addition, the antibiotic prescription for these patients was also recorded. Results: A total of 8280 patients were included in the study. Throat culture results of 1723 patients were reviewed in the pre-rapid phase. During the post rapid phase, 6,557 children underwent rapid strep testing. The RST results were positive for 1474 children (22.5 %), and negative in 5,083 patients (77.5%). Rapid strep testing was associated with a lower antibiotic prescription rate for children with pharyngitis (41.38% treated in pre-rapid phase vs. 22.45% in post-rapid phase; P ПЅ.001). Conclusions: The availability of RST could substantially reduce the unnecessary prescription of antibiotics. This study supports screening of all children with pharyngitis by performing an RST to guide decisionmaking for antibiotic administration. This strategy has a significant impact in reducing the antibiotic prescription rate to almost 50%. 132 Obesity in Children Chohan JK, Singer AJ/Stony Brook University, Stony Brook, NY Study Objectives: Compare the characteristics of pediatric patients by weight categories to see if obesity is associated with outcome. Methods: Study Design: Observational retrospective chart review. Setting: Academic, suburban emergency department, annual census 70,000. Subjects: ED pediatric patients 2вЂ“17 years of age with recorded height and weight in 2007. Measures: Height and weight were used to calculate body mass index (BMI); age-sex specific BMI percentile charts were used to classify patients into 4 weight categories; outcomes were admission and hospital length of stay (LOS). Analysis: Univariate comparisons, logistic/linear regression for multivariate analysis. Results: 6,304 pediatric visits during the study period. Mean age was 10.2 (sd 4.9), 53% male, 76% white. 12% were admitted. 6.9% were underweight, 16.8% were at risk of overweight and 18.4% were overweight. Fewer males were in the healthy weight range than females (54% vs 63%, diffП9%, CI 6 вЂ“11). Underweight patients were younger (6.9 CI 5.9 вЂ“ 6.7) compared to other weight categories (mean ages 10.5, 11.4, 9.7 by increasing weight, p ПЅ.001). Patients outside of the healthy range (both under and over) were more likely to be admitted (47% vs 41%, diffП6%, CI 2вЂ“10). In multivariate analysis sex, age and obesity class were all associated with admission: Males more likely to be admitted than females (OR 1.2, CI 1.02вЂ“1.40), younger more likely than older (OR 0.98 per year, CI 0.96 вЂ“ 0.99), and healthy weight range less likely than overweight class (OR 0.80, CI 0.65вЂ“ 0.96). Mean LOS for admitted patients was 5.1 (sd 17.2); underweight patients had the shortest mean LOS (2.0 vs 4.1, 8.3, 6.1 for the other weight classes, pП.04). Males had a higher LOS (6.0 vs 3.7, diffП2.3, CI 0.1вЂ“ 4.5), and there was no association of age with LOS. In multiple regression, only obesity class remained statistically associated with LOS. Conclusion: Admission and hospital length of stay are associated with unhealthy weight in pediatric patients, even after adjusting for demographic factors. 133 Emergency Department Blood Cultures Have Limited Usefulness in the Management of Children Hospitalized for Community-Acquired Pneumonia Waseem M, Ayanruoh S, Humphrey A, Reynolds T/Lincoln Hospital, Bronx, NY; Lincoln Medical & Mental Health Center, Bronx, NY Davis V, Gupta P, Monroe K/University of Alabama at Birmingham, Birmingham, AL Background: Acute pharyngitis is commonly seen in children. Group A beta hemolytic Streptococcus (GABHS) is the most common bacterial cause of acute pharyngitis, but accounts for approximately 15% to 30% of cases in children. Rapid Study Objectives: Community-acquired pneumonia (CAP) is a frequent cause of hospitalization in children. The Joint Commission mandates obtaining two sets of blood cultures before treating hospitalized adult CAP patients in effort to identify the Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Annals of Emergency Medicine S41 Research Forum Abstracts pathogens and narrow the spectrum of antibiotic coverage. Many practitioners routinely obtain blood cultures in children hospitalized for CAP. However, since the introduction of Prevnar, limited data exists on the clinical value of blood cultures and pneumonia. The purpose of this study was to investigate the utility of blood cultures obtained at admission in the management of pediatric CAP. Methods: We conducted a retrospective chart review of patients aged 3 months to 18 years with a discharge diagnosis of pneumonia who were admitted to an urban tertiary care childrenвЂ™s hospital from 2004 to 2007. Study protocol was approved by the IRB. Cases were excluded for sickle cell (55); immunodeficiency including cancer and transplant (77); central venous access (7); tracheostomy (32); hospitalized in the last 2 weeks (44); in-patient transfer (80); or incorrect diagnosis or incomplete chart (30). Results: 988 cases were identified. After exclusions, 663 cases were included in the study. 473 (71%) of these children had a blood culture obtained at admission. Of these cultures, 442 (93.5%) were negative. Contaminates grew in 17 patients (3.6%) while pathogens grew in 14 (3.0%). Streptococcus pneumoniae (nП10, 71%) was the most common pathogen. There was no difference in the 3 groups with respect to age, race, length of stay, or initial temperature. The presence of an effusion on admission was likely to predict a positive culture (pП0.02). Of the 473 blood cultures obtained, culture results influenced antibiotic selection in only 2 cases (ПЅ0.5%). Conclusion: Our data indicate that bacteremic pneumonia is rare in children. The presence of effusion at the time of admission increases the likelihood of bacteremia. Cultures were unlikely to influence therapy and appear to have limited utility in the management of children admitted to the hospital for CAP. Routinely obtaining blood cultures for pediatric patients cannot be recommended. 134 Does a Novel Abscess Drainage Technique Differ in Procedural Times and Times to Discharge From Traditional Incision and Drainage at a Level I Pediatric Trauma Center? Ladde J, Wan M, Baker S, Rodgers N, Carballo N, Papa L/Orlando Regional Medical Center, Orlando, FL Study Objective: The LOOP is a novel incision and drainage (I&D) technique for pediatric skin abscesses that uses 2 polar incisions and a LOOP drain through the abscess pocket that has lower failure rates than standard I&D. This study compared length of procedure and time to discharge between the LOOP and standard I&D in pediatric patients requiring sedation. Methods: This retrospective cohort of pediatric patients age birth to 18 years was conducted at a Level I pediatric trauma emergency department (ED). Patients with ICD-9 codes for skin abscesses from January to December 2007 were identified. Over 900 charts were reviewed by three different emergency physicians using a standard data extraction form. Inter-rater reliability of extraction was assessed in 100% of charts. Inclusion criteria were patients presenting to the ED with chief complaint of skin abscess who had their I&D in the ED under sedation. Exclusion criteria included surgical debridement and facial, hand, and foot abscesses. The main outcomes were length of procedure (minutes) and ED length of stay (hours). Results: Over a 1-year period there were 233 pediatric abscesses identified. Of the 79 who received sedation; 50 (63%) were treated with LOOP technique and 29 (37%) with standard I&D. The overall mean age of patients was 3.3 yrs (range 5mo18yrs), with 3.1 yrs in the LOOP group and 3.7 yrs in the standard group (PП0.50). Females comprised 56% of the LOOP group and 62% of the standard group (PП0.64). Mean procedure time in the LOOP versus standard I&D group was 12.4 min (SD6.1) and 14.4 min (SD6.8) respectively (PП©0.15). Mean ED length of stay in the LOOP versus standard I&D group was 4.5 hrs (SD 2.25) versus 4.25 hrs (SD2.2) respectively (PП©0.61). Conclusion: There were no significant differences in procedure time or length of stay in the LOOP and the standard I&D groups. This novel procedure shows promise as an alternative technique in the management of skin abscesses in pediatric ED patients. 135 Provider Compliance With the Food and Drug Administration Recommendation to Avoid the Use of Over the Counter (Nonprescription) Cough and Cold Medications in Children Under Two Years Old Goo R, Miller M, Coon TP/Tripler Army Medical Center, Honolulu, HI Study Objectives: On January 17, 2007 the Food and Drug Administration (FDA) issued a public health advisory recommending that the use of over-the-counter S42 Annals of Emergency Medicine (OTC) cough and cold medications be avoided in children under the age of two years old. We performed a system-wide quality assurance project to evaluate the compliance of prescribing health care providers with this public health advisory. Our primary focus was upon ensuring compliance within our hosting department, the department of emergency medicine (ED). Methods: Outpatient prescription information for prescriptions written and dispensed to patients under the age of 2 years old between 01Feb2007 to 31July2007 and 01Feb2008 and 31July2008 were collected and compiled from the Department of Defense (DoD) order processing database. Following provider visits within our system, a majority of typically OTC medications are dispensed via prescription through local pharmacies. Data collected included patientвЂ™s date of birth (DOB), medication prescribed, American Hospital Formulary Service (AHFS) therapeutic classification and the originating location of prescriber. All provider and patient identification information was excluded from the data collection. The percentage of prescriptions written by various departments for вЂњexcludedвЂќ OTC cough and cold medications in children under two years old was examined relative to the total percentage of prescriptions written for children under two. Feedback was given to each prescribing group to guide further education efforts if needed. Clearance of this quality assurance project was gained through our department chief and the Department of Clinical Investigations prior to conducting this project. Results: Before the release of the FDA public health advisory recommending that the use of OTC cough and cold medications be avoided in children under the age of two years old, prescription data from 01Feb2007 to 31Jul2007 revealed that 1.5% of all prescriptions generated by ED providers and issued to children under the age of two years old were written for OTC cough and cold medications. This percentage of prescriptions was slightly lower then the average for all departments which was 2.35%. Following the FDAвЂ™s advisory statement the percentage of ED prescriptions written for OTC cough and cold medications in the same patient population fell to 0.2%, which was below the clinic average of 1.07%. Conclusion: Prior to the release of the FDA advisory statement regarding the use of OTC cough and cold medications in children under the age of two years old, providers in this network seldom prescribed these classes of medications to young children. Following the FDAвЂ™s advisory statement the ED use of these medications in this particular patient population fell even further to 0.2% of all prescriptions written. Furthermore, on average ED-dedicated providers appeared to use these medications less frequently then the average across all providers. This data supports the compliance of ED-based providers with current standards and recommendations issued by the FDA regarding the use of OTC cough and cold medications in young children. This data also demonstrates widespread compliance across our local providers prescribing medications to children less than two years of age. 136 Fever in Children Less Than 60 Days Old: What Are Current Cerebrospinal Fluid, Blood, and Urine Culture Positive Rates in the Vaccination Era? Morley EJ, Lapoint JM, Wittick L, Wojcik SM, Cantor R, Grant WD/SUNY Upstate Medical University, Syracuse, NY Study Objectives: Newborn children (ПЅ 60-days-old) who present to the emergency department with fever are subjected to several invasive procedures as part of their workup including blood cultures, bladder catheterization, and often lumbar puncture. The practice of performing these tests stems from historically high rates of occult serious bacterial infection (SBI) in children less than 2-months-old, who have fever over 100.4В°F and do not appear clinically ill. The advent and widespread use of the H. influenza and S. pneumoniae vaccines has dramatically decreased the incidence of SBI in older children. The primary objective of this study is to determine the current rate of positive cerebrospinal fluid (CSF), blood, and urine cultures in febrile children less than 2 months old. Methods: This study is a retrospective chart review performed from December 2006 вЂ“ June 2008. The study was performed in an academic tertiary care center which sees approximately 14,000 children per year. A structured data extraction form was used. The electronic medical record was queried for all children less than 60 days old who had urine, blood, or CSF culture performed. Emergency department notes were read for all children. Inclusion criteria were age ПЅ 60 days-old, recorded temperature of 100.4В° F in the emergency department or by history, and the workup had to be done for fever or sepsis. Exclusion criteria included a workup done outside the emergency department, the presence of a ventriculoperitoneal shunt, multiple visits to the emergency department in the past week, and antibiotics prior to the ED visit. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts Results: 112 subjects met our eligibility criteria. Blood cultures were sent on all 112, urine cultures were sent on 110, and CSF cultures were sent on 68 subjects. Blood cultures were positive in 4.6% of subjects (5/112). Medical records indicated that four of these cases were likely due to skin contaminants. Urine cultures were positive in 8.2% of subjects (9/110). All 68 CSF cultures were negative. Conclusion: Positive blood and CSF cultures are extremely rare in the vaccination era and a large prospective study should be performed to determine there utility these test in the febrile child who is less than 60 days old. 137 Frequency of Preschoolers Positive for Drugs or Alcohol After Suffering Traumatic Injuries Irvin CB, Eadeh H, Ma M/St. John Hospital and Medical Center, Detroit, MI Background: Although alcohol-related traumatic injuries in young adults are common, there is little discussed in the literature regarding alcohol or drug involvement in preschool children suffering traumatic injuries. Children in this age group may ingest alcohol or drugs accidentally; however, the presence of alcohol or drugs in this age group may also raise concerns regarding the supervisory status for the child, or even the possibility of child abuse. Study Objective: To estimate the frequency of alcohol or drug presence in preschool children suffering traumatic injuries using the National Trauma Data Bank (NTDB). Methods: Data extracted from the NTDB (v6.2) included: age (1вЂ“5 years), race, sex, presence of alcohol, presence of drugs, Injury Severity Score (ISS), emergency department disposition, and discharge status (alive or dead). Results: Of the 53140 children, 18% (9605/53140) had alcohol tests performed, and 13% (6783/53140) had drug testing done. Although only 1.9% (187/9605) tested positive for alcohol the mortality rate was 6.4%, compared to those negative for alcohol with a mortality rate of only 2.0% (pПЅ.01), with no significant difference in ISS score in those testing positive or negative for alcohol. Of children who were tested for drugs, 54% (3658/6783) were positive with a mortality rate of 2.0%, compared to those testing negative for drugs with a mortality rate of 3.0% (pПЅ.01), with no difference between mean ISS scores in the two groups. Black children were more likely to be tested for both alcohol (20% tested compared to white 17% tested) pПЅ.01, and for drugs (17% blacks tested compared to 13% whites tested) pПЅ.01. Black children were also more likely to test positive for alcohol (4.8% tested positive for alcohol compared to 0.3% for whites) pПЅ.01, and drugs (66% tested positive for drugs compared to 60% for whites) pПЅ.05. Conclusions: Although drug and alcohol testing in preschool trauma victims is uncommon (less than 20% overall tested), numerous preschoolers may actually test positive. Additionally, those preschoolers testing positive for alcohol had substantially increased mortality. Reasons for children testing positive for alcohol or drugs is unknown, but this study suggests there may be value in more liberal testing for alcohol or drugs in these preschool children and further research in this area is needed. 138 ondansetron (85%). The mean volume of NS administration was 1400 П® 700ml. All groups improved significantly over the course of the study period (pПЅ0.001); however, the mean VAS at 120 minutes was higher for the AE alone group (PП0.02). There was no significant difference in the change in VAS among the groups over time when controlling for the volume of NS administration or physical evidence of dehydration. There was no significant difference in admission rates between the groups (total admission rate 26%). Conclusion: Nausea and vomiting improved regardless of treatment with AE and/or NS. Patients treated with AE alone, although improved, had a higher nausea VAS after 120 minutes. Nausea and Vomiting: Are We Treating the Patients or Ourselves? Garra G, Singer AJ, Chohan JK, Thode Jr HC/Stony Brook University, Stony Brook, NY Study Objectives: A number of studies have compared the relative efficacy of anti-emetics (AE) and intravenous hydration with normal saline (NS) for the treatment of nausea and vomiting (N/V). No study has examined the natural course without any treatment. We hypothesized that patients with any treatment (NS or AE) would have greater improvement in nausea severity compared to no treatment. Methods: Study Design: Prospective observational. Setting: University emergency department. Subjects: Convenience sample of patients presenting with N/V. Measures: Standardized collection of demographic and clinical measures, severity of nausea on a 100mm Visual Analog Scale (VAS) and qualitative rating scale at 0, 30, 60 and 120 minutes. Outcomes: Change in nausea VAS over time. Analysis: t-test, chi square and repeated measures analysis for VAS. Results: We enrolled 103 patients, mean age 39 П® 16 years, 63% female, 44 had physical evidence of dehydration. Complete VAS data was available on 97. AE alone were administered to 12 patients, AE and NS to 47 patients, NS alone to 13 patients and no treatment was given in 25 patients. Groups were similar in age, sex, presence of vomiting and baseline nausea VAS. The most frequently prescribed AE was Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 139 Comparison in the Management of Inhalational Injuries Presenting to a Tertiary Hospital Emergency Department Ngo AS, Wong E, Ponampalam R/Singapore General Hospital, Singapore, Singapore Study Objectives: To compare the management and outcome in patients with inhalational injuries presenting to the emergency department before and after the implementation of the emergency observation ward (EOW) toxic inhalation protocol in a tertiary hospital setting. The protocol was developed to be evidence-based and reduce variation in clinical practice. Methods: We conducted a retrospective chart review of all patients presenting to an urban tertiary hospital, Singapore General hospital emergency department between 2006 вЂ“2008 via the hospitalвЂ™s EMERGE Version 4.9.1 system with a diagnosis of inhalational injuries, smoke inhalation, gas inhalation, carbon monoxide poisoning, toxic gas inhalation, poisoning by gas and burn injury to airway. Included patients had no or mild symptoms at presentation. Patients were excluded if they had potential for deterioration, needed inpatient care, had abnormal physical findings such as stridor and abnormal initial investigations including chest x-ray, arterial blood gas, carboxyhaemoglobin levels and electrocardiography with evidence of cardiac arrythmias or ischaemia. Data collected included signs and symptoms, physical examination, laboratory determinations, treatment, and outcomes. Patients admitted under the EOW protocol were observed for a duration of between 8 to 23 hours. Results: There were 48 patients in 2007 and 49 patients in 2008. In 2007, 30 patients (62.5%) had smoke inhalation and 8 patients (16.7%) had eloxatin exposure from a single Hazmat exposure. In 2008, 31 patients (63.2%) had smoke inhalation and 11 patients (22.4%) had tear gas exposures from a single Hazmat exposure. Respiratory symptoms were the main complaint (43.8% in 2007, 59.2% in 2008). Other symptoms were neurological (16.7% in 2007, 32.7% in 2008) and chest pain (19.4% in 2007 and 22.4% in 2008). There were 45.8% asymptomatic patients in 2007 and 30.6% in 2008. Investigations done included electrocardiography (18.8% in 2007, 42.7% in 2008), blood gas (47.9% in 2007, 44.9% in 2008), carboxyhaemoglobin level (47.9% in 2007, 59.2% in 2008), chest x-ray (58.3% in 2007, 67.3% in 2008) and endonasoscopy (29.2% in 2007, 34.7% in 2008). In 2007, 88.3% of patients were discharged from the emergency department after an average observation period of 3.1 hours. 12.5% of patients were admitted for an average of 1.5 days. They were given an average of 9 days of medical leave if discharged from the inpatient and 2.6 days if discharged from the emergency department. In 2008, 20.4% of patients were discharged from the emergency department after observing an average of 3.8 hours. 45.2% of patients were admitted for an average of 1.4 days. 30.6 % of patients were admitted to the EOW. They were given an average of 5.1 days of medical leave if discharged from the inpatient and 2.8 days if discharged from the emergency department. There was less variation in patient management after the implemention of the EOW protocol with better documentation observed. There was 1 reattendance in 2008 in a patient who was discharged after inpatient admission for persistent chest pain. There was no bad outcomes due to observing the patient in EOW. Conclusion: There were more patients admitted and more investigations ordered following the implementation of the EOW inhalation protocol. However, there was improvement in the documentation and less variation in the management of patients. Annals of Emergency Medicine S43 Research Forum Abstracts 140 A Prospective Observational Study of Medication Errors in a Tertiary Care Academic Emergency Department Patanwala A, Warholak-Jackson T, Sanders A, Erstad B/University of Arizona, Tucson, AZ Study Objectives: The objective of this study was to evaluate the rate of medication errors identified in the emergency department (ED) using a continuous observation technique and to categorize these errors based on severity and stage of occurrence. Factors that are associated with a higher risk for medication errors were determined. Methods: An observer was present in the ED for a total of 14 days (28 12вЂ“ hour shifts) during a nine-month timeframe. All information regarding the medication use process, including the occurrence of errors, was recorded. The observer intervened only if it was determined that a medication error had the potential to cause patient harm. The errors were categorized by two independent investigators (an emergency physician and a clinical pharmacist) into categories defined by the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). Factors that affected the occurrence of a medication error were analyzed by logistic regression analysis. Results: The observer identified 178 medication errors in 192 patients during the observation period. Overall, 59.4% of patients had one or more errors. Only one medication error resulted in patient harm, but interventions by the observer to prevent possible harm did occur. Medication errors were categorized according to NCCMERP as follows: circumstances or events that have the capacity to cause error (category A П 19.1%); an error occurred but the error did not reach the patient (category B П 11.8%); an error occurred that reached the patient but did not cause patient harm (category C П 39.9%); an error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm (category D П 28.7%); One error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention (category E П 0.5%). There were no errors that exceeded the severity of the latter category. Errors categorized according to stage of occurrence were as follows: administering (34.8%), dispensing (0.6%), prescribing (53.9%) and transcribing (10.7%). In the logistic regression analysis, variables that were predictive of medication errors were: number of medication orders (OR 1.25, pПЅ0.001); boarded patient status (OR 2.15, pП0.043); nursing employment status (less error if full-time) (OR 0.37, pП0.021). Variables that were not significant were patient age, patient sex, years of nursing experience and shift type (day or night). Conclusion: Medication errors in the ED are common when identified by a direct observational approach, particularly those that occur during the prescribing and administration stages of the medication use process. Number of medication orders, boarded patient status and part-time nursing status are associated with a significantly increased risk of medication errors. 141 Patient Satisfaction of Emergency Department Boarders With Inpatient Hallway Admission Zito JA, Viccellio P, Sayage V, Chohan JK, Singer AJ/Stony Brook University, Stony Brook, NY Study Objectives: Boarding of admitted patients in the emergency department is a major cause of crowding. Objections to admitting boarders to in-patient hallway beds include the concern for decreased patient satisfaction. The current study examined patient satisfaction with admission to in-patient hallways due to crowding. We hypothesized that most patients would prefer to board on in-patient hallways than the ED. Methods: Study Design-Telephone survey. Setting: Suburban academic ED with an annual census of 80,000. Subjects: Admitted ED patients transferred to in-patient hallways during the year of 2008. Measures and Outcomes: Demographic and clinical characteristics as well as patient preferences based on a structured telephone survey including items related to patient comfort and safety using a 5-point Likert scale. Analysis: Descriptive statistics. Results: There were a total of 445 patients boarded in the ED with in-patient hallway admission in 2008. Of the 445 patients boarded, 358 were contacted and of that 347 (78%) consented to participate. Mean age was 57 П©/ПЄ 16; 52% were female. All patients were initially boarded in the ED prior to their transfer to an inpatient hallway bed. 100% of respondents agreed with the following statements: it was alright to move another person into an in-patient hall so that they could be seen quicker and it was alright to move themselves into an in-patient hall so that another S44 Annals of Emergency Medicine ED patient could be seen quicker. In comparing ED vs. in-patient hallway boarding, the following % of respondents preferred in-patient boarding with regards to: rest (87%), safety (82%), confidentiality (85%), treatment (77%), comfort (77%), quiet (86%), staff availability (85%), and privacy (84%). The overall preferred location after admission was the in-patient hallway in 87% (95% CI 75вЂ“90) of respondents. There were no differences by age or sex. Conclusion: Patients overwhelmingly preferred the in-patient hallway rather than the ED hallway when admitted to the hospital. Patients are very willing to be moved out of their ED rooms after being seen so that another patient can be seen and vice versa. 142 Medication Errors Recovered by Emergency Department Pharmacists Rothschild JM, Churchill W, Erickson A, Munz K, Schuur JD, Salzberg CA, Shane R, Patka J, Steffenhegan A, Bates DW/Brigham and WomenвЂ™s Hospital, Boston, MA; Cedars-Sinai Medical Center, Los Angelos, CA; Grady Medical Health System, Atlanta, GA; University of Wisconsin Hospital and Clinics, Madison, WI Study Objectives: Medication errors (MEs) in emergency departments (EDs) are an important patient safety concern. This is not surprising since over 3вЃ„4 of ED visits are associated with medication administration or prescribing. EDs are considered a high risk environment due to many factors including multitasking, frequent interruptions, potent drugs, the fast pace of care and incomplete medical histories. Previous studies have demonstrated that inpatient clinical pharmacists improve medication safety. We sought to study the impact of dedicated clinical ED pharmacists on reducing MEs during the ordering, administration and monitoring phases of the ED medication use system. Methods: This direct observational study was conducted in 2008 in four academic EDs in CA, WI, GA and MA. The ED volumes ranged from 37,000 to 104,000 annual visits. Experienced ED pharmacists consented to be observed during 3 to 5 hour periods during daytime and evening shifts. Pharmacy resident researchers were trained in the technique of direct observation. The primary outcome was MEs recovered by ED pharmacists. Following recovery of a ME, observers identified if the pharmacist recommendations, for example reducing a dangerous medication dose, were accepted by the clinician. Recovered MEs are: MEs with no potential for harm; potentially harmful MEs intercepted by the pharmacist before reaching the patient (potential adverse drug event or potential ADE); MEs caught after reaching the patient but before causing harm (mitigated ADE); and MEs caught after causing some harm but before additional harm (ameliorated ADE). Paired physician and pharmacist reviewers confirmed the presence of recovered MEs and assessed their potential for harm. Results: We conducted 227 observation periods over 791 hours at the 4 EDs. We observed pharmacists reviewing a total of 17320 medications ordered or administered to 6471 patients, a mean of 76.6 medications and 28.6 patients during the average 3.5 hour observation period. We identified 505 recovered MEs or a mean of 7.8 MEs (range 6.2 вЂ“ 9.6) per 100 patients and 29.2 MEs (range 21.6 вЂ“ 42.9) per 1000 medications. Most recovered potentially harmful MEs were intercepted potential ADEs (90.3%), with fewer mitigated (3.9%) and ameliorated (0.2%) ADEs. The potential severities of the recovered MEs were most often serious (47.9%) and significant (36.2%); additionally 4.4% were life-threatening. Almost all pharmacist recommendations were accepted by the physician or nurse (96.8%). The most common type of recovered MEs were underdose (16.4%), overdose (14.7%), drug omission (11.7%) and wrong strength (9.5%). The most common medication classifications associated with recovered MEs were antimicrobial agents (32.3%), central nervous system agents (16.3%) and anticoagulant and thrombolytic agents (14.1%). Conclusion: Emergency department pharmacists commonly recover potentially harmful MEs. The effects of other responsibilities of ED pharmacists including toxicological consultations, formulary substitution, assisting guideline compliance, therapy optimization including dose and route adjustments, and staff and patient education were not included in this study. Controlled trials are necessary to determine the net cost-benefit effects of ED pharmacist staffing on safety, quality and costs, which are especially important considerations for smaller EDs and pharmacy departments. 143 Materials Management of a Busy Emergency Department Richardson D, Rupp V, Fredericks K, Talmage C, Reed J/Lehigh Valley Hospital, Allentown, PA Study Objectives: Proper materials management in an emergency department (ED) is crucial in order to efficiently and effectively take care of patients. Studies Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts suggest that stocking should be done routinely to ensure that at least 95% of the time patient rooms do not run out of stock during a shift. However, one study proposed that at a minimum 8% of a shift, almost one full hour of a 12-hour shift, is lost retrieving supplies that are not available in the room. The study objectives were to determine the amount of time ED nurses spend outside of a patient room obtaining supplies to care for the patient, and what supplies are most commonly retrieved. Methods: This was a prospective, observation study of nurses in a 43-bed ED of a tertiary, suburban hospital. Nurses were observed for an entire shift each time they left a patientвЂ™s room to obtain patient care items that were not found in the room. The amount of time spent outside of the patient room obtaining supplies, and what supplies the nurses obtained was recorded. Observations occurred when the nurse began searching for supplies related to procedural tasks associated with patient care and did not include items such as medications or stationary supplies. Results: The total number of observations was 610, of these, 75 were excluded; 20 due to discrepancies noted with an observer, and the remaining 55 due to observation of searching for exclusionary supplies. The average time nurses spent away from the bedside each time they left to look for stock, was 1.4 minutes. Nurses working either eight or 12- hour shifts left the bedside an average of nine times per shift to look for stock. Therefore, with an average of 15 nurses working in any given 12-hour time period, the overall amount of time spent away from the bedside looking for stock was 282 minutes (4 hours and 42 minutes). In a 24-hour time period with an average of 15 nurses working, the overall amount of time spent away from the bedside looking for stock was approximately 564 minutes (9 hours and 24 minutes). Nurses were sidetracked during their search for supplies 113 times out of a total of 535 observations (21%). The most commonly searched for supplies were: IV supplies/tubing, thermometer, phlebotomy supplies, blankets, saline flushes, syringes, personal hygiene products, gown/clothing, catheter/urine kit, linens, and needles. Conclusion: Nurses spend a substantial amount of time leaving patient rooms to search for patient care items during eight and 12- hour shifts. The most common items searched for were items that would be found in the patient room if properly stocked. Materials management is a strategy that, when implemented efficiently, could help to reduce time wasted searching for patient care items as a result of understocked rooms in the ED. 144 Evaluating Predictors of Door-to-EKG Times Borquez EA, Susim SS, Garcia UJ, Desai S, Challoner K, McClung CD/Los Angeles County/University of Southern California, Los Angeles, CA Study Objectives: To review qualitative descriptors of chest pain and impediments to timely EKGs within the American Heart Association Guidelines. Methods: Retrospective chart review of patients presenting to the emergency department (ED) with a chief complaint of chest pain. Charts were abstracted from a single calendar month. This occurred in a large academic, county-based hospital with an annual ED census of 160,000 visits. Patients arriving by ambulance were stratified from walk-in patients. Statistical analyses was performed using STATA 10.0, differences between groups were compared using one-way analysis of variance and logistic regression. Results: There were 244 patients who met inclusion criteria. The median time to receive an EKG from arrival was 19 minutes (IQR 11вЂ“52 minutes). The median difference for men was significantly better than women (16 min vs. 21 min, pПЅ0.001). Patients with complaints of severe chest pain 8 вЂ“10/10 were significantly associated with timely EKG (EKG ПЅ 10min) (ORП2.2; 95%CI 1.16,3.99). The quality, radiation, and location of the chest pain, and age were not predictive of receiving a timely EKG. Conclusion: The majority of patients presenting to a high-volume emergency department do not receive screening EKGвЂ™s within the AHA recommended timeframe. Sex and severity of pain are significant predictors of timely EKG. These results support prior evidence that women continue to suffer health disparities with potential coronary heart disease. 145 Content Validity Testing for the Agitation Severity Scale: Development of a Measure for Use With Acute Presentation Behavioral Management Patients Strout TD, Baumann MR/Maine Medical Center, Portland, ME Study Objective: Agitation is a condition frequently observed in behavior management patients presenting to the emergency department (ED). The Joint Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Commission on standards for the assessment and monitoring of behavioral health patients would be easier implemented with a reliable, valid agitation rating scale appropriate for use in the emergency setting. The purpose of this research was to conduct primary content validity testing for an initial version of an observation-based, ED-focused, agitation rating tool. Methods: This project used a methodological design and was approved by both university and hospital institutional review boards. A panel of eight experts from the fields of emergency medicine, emergency nursing, acute psychiatry, and psychiatry was used to examine the representativeness and clarity of twenty-six items for potential inclusion on the agitation rating scale. The twenty-six items considered for inclusion were previously developed utilizing focus groups of direct patient care providers and a survey of emergency department and acute psychiatry clinicians. Measures of interrater agreement, the content validity index, and factorial validity index were calculated for both representativeness and clarity on a by-item and acrossthe-scale basis. Results: Initial evaluation of the potential scale items yielded an average content validity index of 0.725 for the representativeness of the items and of 0.725 for the clarity of the items. Eliminating four items with item-level content validity indexes of 0.142 вЂ“ 0.375 improved scale-level content validity to 0.80 for both representativeness and clarity. Experts had difficulty consistently identifying domains for the scale items, with a factorial validity index of 0.50. Interrater agreement was good to very good for the majority of the individual items, and with k П 0.80 for the scale as a whole. Conclusions: Utilizing a panel of experts to develop and evaluate content validity, an initial version of the Agitation Severity Scale has been constructed. Additional psychometric evaluation is necessary to evaluate the reliability and validity of the newly developed instrument, as well as to refine domains for the individual items. 146 Punch Injuries and Psychiatric Comorbidity in Men and Women Damewood S, Perry C, Powers M, Jeanmonod D, Jeanmonod R/Albany Medical College, Albany, NY; St. LukeвЂ™s Hospital, Bethlehem, PA Study Objective: To determine what differences exist between men and women in regards to injuries sustained after intentionally striking an object with a closed fist. Methods: This is a retrospective study of patients who presented to an academic tertiary care emergency department (ED), with an annual volume of 72,000 patients, who underwent a radiographic study of their hand from July 1st 2007 to June 30th 2008. Research associates queried the electronic Patient Archiving and Communication System for patients who had hand films performed and then identified the mechanism of injury through the electronic medical record for that visit only. For patients receiving radiographs for punch injuries, the electronic medical record was queried for details regarding that ED visit, including presence of fracture, patient age and sex, and psychiatric history defined as diagnoses corresponding to the DSM IV classification system mentioned in the past medical history or history of present illness for the visit. Previous hand radiographs for punch injury in the Patient Archiving and Communication System was also recorded. All data points were recorded into a standard spreadsheet. Children under the age of 13 were excluded. 8% of the collected data was confirmed by a second investigator with a kappa value of 1.0 for agreement of punch mechanism. Descriptive statistics were used to analyze the data. The study protocol was reviewed and approved by the institutional review board. Results: During the 12-month study period, 1292 patients underwent hand radiographs from the ED. Four patients had no dictated ED chart, and were therefore excluded. 172 patients sought medical attention after intentionally striking an object. Only 35 (20%) of those patients were women. Of those patients, four (11%) patients sustained a fracture, and 17 (49%) had underlying psychiatric disease. On the other hand, of the 137 patients in the male group, 65(48%) patients sustained fractures, and 36 (26%) had underlying psychiatric disease. 29% of women and 23% of men had had prior radiographs for intentional punch injuries. Conclusion: Women are far less likely to punch objects or sustain a fracture after a punch compared to men. The lack of serious injury in most women after punching an object appears to be in line with past data regarding differences between the sexes in selfdestructive behavior, such as suicide attempts. This may be due to last minute hesitation or that women typically have less upper body strength than men. Nearly half of the women in this study who did intentionally strike an object had underlying psychiatric disease, compared to less than 1вЃ„4 of the men. This is much higher than the incidence of psychiatric disease in the general population, which is estimated to be about 16%. Since these injuries can be disabling and occur in a young group of patients with a high rate of recidivism, these patients might benefit from psychiatric referral. Annals of Emergency Medicine S45 Research Forum Abstracts 147 Psychiatric Clearance in the Pediatric Emergency Department Waseem M/Lincoln Hospital, Bronx, NY Study Objectives: Do emergency physicians obtain psychiatric consult in all children with psychiatric complaints or do they feel comfortable to clear some of these patients without psychiatric consultation and which patients they clear without psychiatric referral? Methods: This is a simple observation study. 100 questionnaires were sent by mail to physicians working in pediatric emergency department. 1. Do you refer all children with psychiatric complaints to a psychiatrist? 2. Do you give psychiatric clearance yourself without psychiatric consultation if the patients are Not suicidal Not homicidal Not hallucinating 3. Did your training prepare you to evaluate patients with psychiatric complaints and teach you when to or not to obtain psychiatric consultation? Results: Out of 73, twenty eight were emergency medicine trained (EM) physicians (38%), thirty seven were pediatric emergency medicine trained (PEM) physicians (51%), six were pediatricians (8%) and two (3%) respondents did not mark their specialty. 42 (56%) physicians obtained psychiatric consultation on all pediatric patients with psychiatric complaints and behavioral issues. 30 physicians (41%) still obtained psychiatric consultation, even if they felt the patients were not suicidal, homicidal or actively hallucinating. 80% emergency physicians thought that their previous training adequately prepared them to evaluate pediatric patients with psychiatric conditions, but 19% felt that they were not fully trained. Emergency physicians were less likely to obtain psychiatric consultation on all pediatric psychiatric patients (50%), followed by PEM trained physicians (59%) and pediatricians (83%). Emergency physicians (82%) were more willing to psychiatrically clear pediatric patients than PEM (38%) or pediatric trained physicians if the patients were not obviously suicidal, homicidal or actively hallucinating. Emergency physicians (93%) felt better prepared by their training to evaluate pediatric patients with psychiatric complaints than PEM or pediatric trained physicians. Conclusion: 1. The majority of physicians working in the ED obtained psychiatric consultations on all children who presented to the ED with psychiatric complaints. 2. Almost half of these physicians obtained psychiatric consultation on these patients and would not discharge the patient without it even if the patient was felt by them not to be suicidal, homicidal or hallucinating. 3. EM-trained physicians felt better prepared to evaluate and clear psychiatric patients. 148 Factors Predicting Return Visits Among Emergency Department Patients With Psychiatric Complaints Groke S, Zink A, Bennett A, Knapp S, Phanthavady T, Madsen T/University of Utah School of Medicine, N Salt Lake, UT Study Objectives: We have previously reported that psychiatric patients return to the emergency department (ED) within 30 days at significantly higher rates than nonpsychiatric patients. In this study, we attempted to determine which factors among psychiatric patients may predict return ED visits within 30 days. Methods: We reviewed the charts of all ED patients evaluated by licensed clinical social workers between JanuaryвЂ“February 2007. Prior history of a psychiatric-related admission or a suicide attempt, current suicide attempt or parasuicidal gestures, drug or alcohol use, feelings of hopelessness/depression, violent behavior, length of symptoms, presence of stressors or the availability of a caregiver were recorded. We then reviewed subsequent hospital records to determine if the patient returned to the ED within 30 days. Multivariate analysis was used to identify factors predicting a return visit. Results: 92 patients presented during the study period expressing suicidal ideations or having attempted suicide vs. 142 patients with non-suicidal psychiatric complaints. 31.5% of suicidal patients vs. 20.4% of non-suicidal patients were admitted to an inpatient psychiatric facility at the time of their initial presentation to the ED. Of the patients who were discharged, 17.5% (11/63) of the suicidal patients and 23% (26/113) of the non-suicidal patients returned to the ED within 30 days with psychiatric complaints (pП0.386). Predictors of return ED visit among S46 Annals of Emergency Medicine psychiatric patients included not having a caregiver available at the time of discharge and a history of a previous suicide attempt. There were no completed suicides among study patients. Conclusion: Among psychiatric patients discharged from the ED, significant predictors of return ED visits within 30 days include lack of a caregiver at the time of discharge and a history of a previous suicide attempt. This study identified factors which may allow for interventions to reduce return visits among emergency department psychiatric patients. 149 Psychiatric Transfers From the Emergency Department: Factors Associated With Length of Stay Klope JL, Jordan MT, French SC, Burkard W/Resurrection Medical Center, Chicago, IL; St. Francis Hospital, Evanston, IL Study Objectives: Psychiatric complaints remain a common emergency department (ED) problem. Transfer of these patients from EDs without inpatient psychiatric capability continues to occupy significant resources. In this study, we sought to investigate factors associated with ED length of stay (LOS) of psychiatric transfers. Methods: We performed a retrospective review of all psychiatric transfers from two urban academic EDвЂ™s over a four-month period. Such data as age, sex, insurance type, lab studies, vital signs, and prior medical history was examined. A univariate and multivariate analysis of mean LOS concerning these factors was performed. Statistical significance was set at 0.05. Results: Ninety-two patients were reviewed. The mean LOS for all patients was 562 minutes. The mean number of labs performed was 5.0, with only 1.1 being abnormal. 37% had an ancillary study (EKG/CT/x-ray) performed. Only two ancillary studies had abnormalities, and neither was clinically relevant. The performance of any ancillary study added an additional 63 minutes to LOS. 43% were provided an ED medication for their condition. On univariate and multivariate analysis, such factors as insurance status (pПЅ.001), day of the week (pП.012), abnormal lab values (pП.044), and ancillary studies performed (.043), all affected LOS. Conclusion: Numerous factors appear to affect ED LOS for psychiatric transfers. In particular, insurance status, the day of the week, abnormal lab data, and ancillary studies performed all affected mean LOS. This study demonstrated that for each ancillary test performed an additional 63 minutes was added to the LOS. 150 The Effect of Access to Health Care and SocioEconomic Status on the Availability and Effectiveness of Medical Treatment for Asthma and Hypertension Among Patients Presenting to the Emergency Department Miner JR, Olives T, Westgaard BC, Patel R, Patel S, Biros MH/Hennepin County Medical Center, Minneapolis, MN Study Objectives: To estimate the availability and effectiveness of treatment for asthma or hypertension among patients presenting to the emergency department based on various socio-economic factors and access to health care. Methods: This was a cross-sectional study at an urban, Level 1 trauma center with 98,000 annual visits. We prospectively screened all patients presenting to the ED during a randomized distribution of 8-hour periods between June 1 and August 31, 2008. Consenting patients completed a survey on living situation, employment, family income, education, access to primary care, how often they experienced hunger, whether or not they ever had to chose between buying food and buying medicine and the frequency at which this occurred, whether or not they had hypertension or asthma, what medications they took, their blood pressure and the peak flow. Effective treatment was defined as a systolic blood pressure ПЅ140 in a patient with a history of hypertension or a peak flow Пѕ50% of predicted in a patient with asthma. Data was analyzed using descriptive statistics and ordinal logistic regression using a generalized log linear model. Results: 8340 patients presented during the study. 2654 were eligible, 2336 (88.0%) were enrolled. 6.1% were homeless, 3.6% lived in a halfway house, 17.3% were living with friends (non-renters), 54.8% were renting, 16.2% were property owners, 1.4% lived in nursing homes. Hunger from food scarcity was reported in: 3.8% daily, 4.4% 2вЂ“3 times/week, 3.0% weekly, 4.4% monthly, 4.6% yearly, and 78.7% never. 59.4% claimed access to primary care medical facilities. 42.8% of Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts patients were unemployed, 42.8% reported having a chronic illness. 33.8% of patients did not have insurance health insurance, 40.7% had Medicaid or Medicare. 23.9% had private health insurance. Having to choose between buying food and buying medicine was reported in: 4.5% weekly, 5.4% monthly, 7.5% yearly, and 76.8% never. 20.4% of patients reported having asthma, 46.7% of whom were on an asthma medication, 58.1% of whom had a peak flow ПЅ50% of predicted (median 260, range 60 вЂ“700). 33.7% of patients reported having hypertension, 13.5% of whom were on a medication for hypertension, 44.5% of whom had a blood pressure Пѕ140 while in the ED. A blood pressure Пѕ140 in a patient with HTN or a peak flow ПЅ50% of predicted in a patient with asthma was associated with (coefficient and 95% CI included): being on a hypertension or asthma medication (ПЄ0.42, ПЄ0.83 to 0.02), and choosing between food and medicine (0.32, 0.07 to 0.63), being on a medication for hypertension or asthma in patients with the disease was associated with; access to a primary care provider (0.61, 0.41 to 0.81). Conclusions: Being treated for asthma or hypertension was associated with access to a primary care provider, but not insurance, employment, housing, or hunger status. Not having effective control of asthma or hypertension was associated with not being on a medication for the problem and having to choose between buying medication and buying food. 151 Emergency Department Patient Acceptance of Rapid HIV Testing Practices, Revisited: The 2006 CDC Recommendations for Non-Targeted, Opt-Out HIV Screening Prekker ME, Olives T, Hanley O, Miner JR/Hennepin County Medical Center, Minneapolis, MN Study Objective: Patient acceptance of non-targeted, opt-out HIV screening in the emergency department (ED) is variable based on published reports. We sought to evaluate patient approval of Centers for Disease Control and Prevention (CDC)recommended HIV testing practices in an urban ED without rapid HIV testing currently available, apart from occupational exposures. Methods: Cross-sectional survey conducted in an urban, county hospital with 98,000 annual visits. The estimated prevalence of known HIV infection in the ED population is 1.8%. Trained research assistants administered a previously developed, standardized survey to all adult, non-critically ill, English-speaking patients who presented to the ED during randomized shifts over a three-month period. Results: Of the 2197 enrolled patients, 53% were men, 41% were black, 37% were white, 7% were Native American, 6% were Hispanic, 9% were another ethnicity, and the median age was 39 years (interquartile range 27вЂ“50 years). A larger proportion of patients would accept testing if an opt-out methodology were used (78%, 95% confidence interval [CI] 76% to 80%) versus an opt-in methodology (73%, 95% CI 72% to 75%) (absolute difference 5%, 95% CI 4 to 6%). If their physician recommended an HIV test during the ED visit, 87% (95% CI 86 вЂ“ 89%) would accept testing. A minority of patients believed that consent for HIV testing needed to be separate from general consent for medical care (37%, 95% CI 35% to 39%). Regarding counseling, 65% (95% CI 63% to 67%) of patients did not feel pretest counseling was necessary, while 60% (95% CI 58% to 62%) of patients did not feel post-test counseling was necessary after a negative result. Conclusion: The majority of ED patients in an institution naД±ВЁve to HIV screening would accept an HIV test regardless of selection strategy or criteria. This finding supports continued efforts to expand non-targeted, opt-out HIV screening in the ED, in accordance with current CDC recommendations. 152 Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department Wall JJ, Hiestand BC/The Ohio State University, Columbus, OH Study Objectives: In the emergency department (ED), the documented existence of an advance directive (AD) or Do-Not-Resuscitate (DNR) order may affect initial treatment decisions, even in non-life threatening situations. We performed an epidemiologic evaluation of AD and DNR prevalence among residents of extended care facilities (ECF) presenting to the ED of a large university hospital. Methods: We retrospectively identified patients originating from an ECF from the ED medical record. Data was collected from the hospital electronic medical record on age, sex, race (white vs. non-white), triage acuity, ED disposition, and AD status. In Ohio, AD consist of DNR-CC (comfort measures only), DNRCC-Arrest Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ (complete care up to arrest), living wills (LW) and health care power of attorney (POA). Descriptive statistics were generated, FisherвЂ™s exact test was used to compare categorical variables, and multiple variable logistic regression was used to evaluate predictors of DNR status. Results: A total of 238 patients were identified over 4 months. 170 (71%) were white, 107 (45%) were male, and the mean age was 64 П©/ПЄ 16.3 years, with 163 (68%) admitted. Of the 238 patients, 44 (18.5%, CI95 13.5вЂ“23.4%) had DNR orders, of which 15 were DNR-CC. In addition, 94 (39.5%, CI95 33.2вЂ“ 45.8%) had a POA, and 60 (25.2%, CI95 19.7вЂ“30.8%) had LW. There was a significant difference in AD by race (51% whites with AD vs. 37% non-whites, pП0.046) and DNR by race (24% of whites with DNR vs. 6% of non-whites, pПЅ0.001). Using multiple variable logistic regression, the variables significant in predicting DNR status (both CC and CC-Arrest) were LW (OR 11.54, CI95 5.03вЂ“26.46, pПЅ0.0005), age (OR 1.061 per year increase in age, CI95 1.03вЂ“1.10, pПЅ0.0005) and white race (OR 3.83, CI95 1.16 вЂ“12.65, pПЅ0.028). Sex was not found to be a significant predictor (pП0.18) of DNR use. There were no interaction terms that affected the model. Patients with DNR orders were more likely to be transported by EMS than private ambulance (pП0.032), although though there was no relationship between DNR status and initial triage acuity (pП0.527) or admission rate (34/44 [77%, CI95 64 вЂ“ 90%] DNR vs. 129/194 [66%, CI95 60 вЂ“73%] pП0.21). We also found that DNR status was not a significant predictor of death in the hospital (3/44 DNR [6.8%, CI95 0 вЂ“15%] vs. 41/194 non-DNR [4.1%, CI95 1.3вЂ“ 6.9%] pП0.43). Conclusion: Age and LW use are strong predictors of ECF patient DNR use. Non-white race greatly decreases the odds of DNR use; whether this represents a preference or a lack access to full patient education cannot be determined from this retrospective study. AD provide the ability to decide care prior to incapacitation and are an invaluable tool in respecting patient decisions. ED clinicians should be alert for opportunities to discuss end-of-life care preferences in appropriate patients. 153 Do Attitudes About Homosexuality Affect Emergency Medicine Practice? Results of a Survey Shearer P/Mount Sinai School of Medicine, New York, NY Study Objectives: The diversity of patients in the emergency department provides unexpected rewards and challenges. There are no studies in the emergency medicine literature that address emergency physicians attitudes towards homosexuals. The purpose of this study was to evaluate emergency physicians beliefs about homosexuality and whether such beliefs impact patient care. Methods: An anonymous, self-administered survey was competed by emergency physicians, physicians assistants (PAs) and nurse practitioners (NPs) attending the 2003 ACEP Scientific Assembly. Data were analyzed using a chi-square analysis; a pvalue Х… 0.05 indicated statistical significance. Results: 608 surveys were completed; 379 (63%) attending physicians; 169 (28%) residents/fellows; 54 (9%) PA or NP; 44 (73%) were male; respondents came from all regions of the United States. 15.5% of emergency physicians agreed with the statement вЂњhomosexuality is immoral.вЂќ More respondents from the Southeast agreed with that statement (pП.02) than from other areas of the country. 76.7% of the respondents reported having co-workers who are gay, lesbian, bisexual or transgender (GLBT). Significantly more emergency physicians with a known GLBT co-worker disagreed that вЂњhomosexuality is immoralвЂќ (73.9%) compared to those without a GLBT co-worker (57.3%) (absolute difference 16.6; 95%CI [4.9, 28.3]). Emergency physicians who believe that homosexuality is immoral were more likely to be uncomfortable giving post-exposure prophylaxis to males after unprotected same-sex intercourse (26.9%) than emergency physicians who do not believe that homosexuality is immoral (14.2%) (absolute difference 12.6; 95%CI [2.4, 22.9]). Conclusion: Emergency physicians attitudes and acceptance of homosexuality differ geographically. Positive attitudes towards homosexuality are reported by emergency physicians with GLBT co-workers. Negative attitudes towards homosexuality affect some aspects of the care received by GLBT patients in the ED. 154 Impact of Care Management on the Highest Utilizers of Camden NJвЂ™s Emergency Departments Sciorra D, Brenner J, Gill J, Linden A, Mazzarelli A/University of Medicine and Dentistry of New Jersey, Camden, NJ; Cooper University Hospital, Camden, NJ; Delaware Valley Outcomes Research, Newark, DE; Linden Consulting Group, Hillsboro, OR Study Objectives: The highest utilizers of emergency department (ED) services typically have complex medical conditions compounded by an array of social issues. Annals of Emergency Medicine S47 Research Forum Abstracts Programs that improve the outpatient management of these complicated patients are likely to reduce ED utilization. The objective of this study was to examine the effect of a citywide care management (CM) project on the subsequent ED utilization of enrolled high utilizers. Methods: We conducted a retrospective cohort study of 33 patients who met the CM project enrollment criteria of Camden City residency with five or more ED visits during a one-year period of time. Enrolled high-utilizing patients were provided with targeted care management to help them towards stabilizing their social environment and finding an appropriate medical home. CM patients were recruited from 11/1/ 2007вЂ“ 4/30/2008 and followed until 6/30/2008. These patients were then retrospectively matched into a citywide database of all Camden City hospital visits to determine both utilization rates before and after project enrollment. Based on each individual CM patientвЂ™s age, sex, and baseline utilization, three matched control patients were selected from the database to form a comparison group of 99 patients. Time to event analysis was performed using multivariable Cox regression. Insurance status, a history of substance abuse, and homelessness were explored as potential confounders. The event of interest was defined as a subsequent ED visit and censoring took place in the event of death, loss to follow-up, and at study completion on 6/30/2008. Results: Fourteen patients in the CM group (42.4%) and 60 patients in the matched control group (60.6%) experienced a subsequent ED visit. Through multivariable Cox regression, having a history of substance abuse was associated with a 60% increased risk of a returning ED visit (hazard ratio 1.60 [CI, 1.01 to 2.55]). After adjustment for a history of substance abuse, CM project enrollment was associated with a 69% reduced risk of subsequent ED utilization (hazard ratio 0.31 [CI, 0.15 to 0.62]). Conclusion: In the early evaluation of this intervention, participation in the CM project was associated with a significantly lower risk of experiencing a subsequent ED visit. This suggests that providing primary medical care and social support, over a relatively short period of time, is effective in decreasing ED visits for high utilizers. 155 Preliminary Results of the Survivors of Torture Presenting to an Urban Emergency Department Prevalence Study Hexom B, Beattie L/Mount Sinai School of Medicine, New York, NY Study Objectives: It has been reported that 8 вЂ“11% of patients presenting to urban primary care clinics have experienced torture. Given potential barriers to health care access, we hypothesize that emergency departments (EDs) may see higher rates of survivors of torture. As our medical center is located in the most ethnically diverse county in the United States, with the highest portion of foreign-born New York City residents, we sought to determine the prevalence of survivors of torture presenting to our urban ED. Methods: A previously validated survey instrument regarding exposure to torture - the Detection of Torture Survivors Survey - was administered by convenience sample to patients presenting to a New York City ED. Additional questions were asked to determine whether individualsвЂ™ experiences met internationally accepted definitions of torture. Surveys were verbally administered to patients regardless of ethnicity or complaint and language interpretation was provided if needed. Prisoners, children under 18 years, critically ill, demented, or disoriented patients were excluded. Results: Preliminary results of the first 185 surveys are presented here and enrollment is ongoing. Mean age was 49.21, 48.6% were female, and 79.5% foreign born. 41 countries of origin were represented; most frequently the United States (nП38), Columbia (23), Dominican Republic (18), Mexico (12), Bangladesh (11), and Ecuador (11). Mean duration of residence in the United States for foreign-born patients was 19 years. 9.2% of respondents (17) stated that they had been harmed by groups such as the government, police, military, or rebel soldiers. 10.8% (20) stated they or their family had experienced torture (10 self, 5 family, 5 both). 23 were further asked about their experiences including torture by military (7), police (6), family (5), rebel soldiers (3), individuals (1), or groups of individuals (1). 73.9% (17) of these suffered physical harm, 47.8% (11) emotional harm, 8.7% (2) sexual harm, and 21.7% (5) other. Countries of origin for those reporting torture include the U.S. (7), Columbia (5), Dominican Republic (4), and 1 each for Bangladesh, El Salvador, Honduras, Morocco, Nepal, and Tanzania. Reasons for torture included ethnicity/ tribal affiliation (4), political affiliation (3), religion (2), local customs (2), sexual orientation (1), no reason (4), and other (9). 13 of 22 (59%) left home or country as a result of their torture. 5 of 22 (22.7%) have physical disabilities, 6 of 22 (27.3%) S48 Annals of Emergency Medicine have recurrent intrusive or distressing memories, 6 of 22 (27.3%) have ever had a physician ask them about their torture and 3 have requested political asylum. Conclusion: Survivors of torture are a distinct cohort of patients presenting to our urban ED and are of diverse background. We found prevalence rates similar to previously reported studies. Patients self-report torture by many groups including abuse by family, governments, military, and police and for varied reasons including no reason at all. Further data collection will help determine significance and whether self-identification of torture is a significant predictor of torture as defined by international standards. Practitioners should consider asking patients about torture. 156 Large Increase in Emergency Department Visits for Head Trauma After Natasha RichardsonвЂ™s Death Campo C, Walsh B, Cochrane D, Allegra J/Morristown Memorial Hospital, Morristown, NJ Study Objective: Actress Natasha Richardson died from a head injury on March 18, 2009. According to some reports, she initially appeared well after sustaining the injury. We hypothesize that the publicity surrounding this tragic event would be associated with an increase in emergency department (ED) visits for evaluation of head trauma. Methods: Design: Retrospective cohort. Setting: Consecutive patients seen by ED physicians in 19 urban, suburban and rural EDs in New Jersey and New York during March 2009. Protocol: We classified patients as having head injury based on ICD9 codes. A priori, we chose to compare the daily visits for head injury for the ten days before and after March 18. We used the StudentвЂ™s t-test for statistical significance with alpha set at 0.05. Results: Of the 86,791 total ED visits in March, 2009, 2567 (3%) were for head trauma. Of these, females comprised 46%. The median age was 21 years (interquartile range: 7 years to 51 years). There was a 73% (95% confidence interval, 53% to 94%, p ПЅ 0.0001) increase in daily ED visits for head trauma for the 10 days following March 18, 2009 compared to the 10 days before. There was little difference in median age, interquartile age range and sex before and after March 18 for patients presenting to the ED with head injuries. The number of visits for head trauma returned to the pre-March 18 range by March 31. Conclusion: There was a large increase in ED visits for head trauma for a brief period following the death of Natasha Richardson. Media coverage can have a profound influence on ED visits. 157 Patient Perceived Alcohol and Substance Abuse Treatment Needs: An Urban Emergency Department Pilot Study Scott S, Kassem JN, Nagurka R, Velasco W, Valenzuela R, Grant WD, Lamba S/ The University of Medicine and Dentistry of New Jersey, Newark, NJ; State University of New York Upstate Medical University-University Hospital, Syracuse, NY Background: Substance abuse (SA) increases the risk of disease, injury, and disability, and this vulnerable population often seeks the emergency department (ED) for their routine health care needs. The ED may represent the only opportunity to connect these patients with adequate referrals to SA rehabilitation facilities. Study Objective: This study is a needs assessment to identify alcohol and SA treatment needs among our ED population with our purpose to further address the patient-perceived barriers. Methods: This pilot study is a convenience sample using a cross-sectional descriptive design to explore the prevalence of alcohol and SA. We used the selfreport survey methodology to assess demographics and patient-perceived barriers. Our study population consisted of consenting adult patients presenting to our urban hospital ED from September вЂ�08 вЂ“February вЂ�09. Data were analyzed using Microsoft SPSS. Results: We enrolled: 102 patients; 51 male and 51 female; 58% of the respondents were in the age range 30 вЂ“53; 57% (58/102) African-Americans; 20% (20/102) Hispanic; 58% (59/101) were high school educated; 72% (72/100) were health insured; 44% (45/101) did not have a primary care provider; 92% (94/102) sought treatment in the ED within the past 1 year; 31% (32/101) identified the ED as their sole health care provider. Sixty-three percent (64/102) of respondents reported depression and 66% (67/102) reported anxiety within the past month. Forty-seven percent (41/88) of respondents reported using drugs for non-medical reasons with 38% (9/24) perceiving a need for drug rehabilitation now. Half (12/24) of those perceiving a need for rehabilitation, used cocaine; 38% (9/24) used heroin; Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts 10% (10/101) used intravenous drugs. Seventy-six percent (74/97) of respondents stated they would be willing to speak with someone while in the ED, if available. Twenty-two percent (14/65) of respondents considered themselves to be moderate or heavy drinkers and 39% (25/65) of all alcohol consumers felt they should cut down on their drinking. Of these, 6% (4/65) felt they needed to be in an alcohol treatment program now. Furthermore, of these, 100% (4/4) patients are willing to speak to someone while in the ED, if available. Seventy-two percent of respondents said the ED is a good place to get information about drug and alcohol treatment. Conclusions: One-third of our respondents reported using the ED as their sole health care provider and more than 90% visited the ED in the past 1 year, providing an opportunity for lifestyle interventions. Nearly half of our respondents reported SA. Threequarters of the patients in need of these services are willing to talk about rehabilitation while in the ED. This pilot study serves as an initial needs assessment to identify the prevalence and barriers preventing access to community resources for SA treatment. 158 Interobserver Reliability of a Novel Scar Evaluation Scale Singer AJ, Taira BR, Dagum AB, Hollander JE/Stony Brook University, Stony Brook, NY; University of Pennsylvania, Philadelphia, PA Study Objectives: We have recently described a novel scale to measure the appearance of healed wounds based on photographs of scars. The current study evaluated the interobserver reliability of the scar appearance scale (SES) on emergency department patients with repaired lacerations. Methods: Study Design-Prospective, observational. Setting-Academic suburban emergency department with emergency medicine residency. Subjects-Convenience sample of ED patients participating in multi-center randomized trial of new topical skin adhesive. Measures-Demographic and clinical information were collected using standardized data collection forms. Two emergency physicians (masked to each other) evaluated all patients one month after wound repair and determined the cosmetic appearance of the scars on a scar evaluation scale (SES). Scars were assigned 0 or 1 point each for the presence or absence of the following: width Пѕ 2mm, elevation or depression, suture or staple marks, discoloration, and overall poor appearance. A total cosmetic score was then calculated by adding the individual scores on each of the 5 categories ranging from 0 (worst) to 5 (best). Scars were also scored on a validated 100-mm VAS marked вЂњworst scarвЂќ and вЂњbest scarвЂќ at the low and high ends. Data Analysis-Interobserver agreement was calculated using PearsonвЂ™s, SpearmanвЂ™s and Kappa coefficients. Results: The wounds of 33 patients were evaluated. Interobserver agreements for the total SES and VAS scores were 0.83 and 0.60 (PПЅ0.001 and PПЅ0.01), respectively. Interobserver agreement on the individual elements of the SES ranged from 0.47 to 0.86. The agreement between the total SES and VAS scores for the 2 observers were 0.91 and 0.77 (PПЅ0.001 for both). Conclusion: The new scar evaluation scale was highly reliable and correlated with the VAS in ED patients with repaired lacerations supporting its construct validity. 159 Use of the Descriptive Term вЂњExperimentвЂќ Does Not Significantly Influence a Potential SubjectвЂ™s Decision to Participate in Research Schroeder JW, Carter MA, Jerusik B, Verma M, Heard K, OвЂ™Malley GF/ Philadelphia College of Osteopathic Medicine, Philadelphia, PA; Albert Einstein Medical Center, Philadelphia, PA; University of Colorado, Denver, CO Background: In an informal survey at our institution, 85% of emergency department attending and resident physicians thought the word вЂњexperimentвЂќ is inflammatory when used to describe a research study and would negatively impact a patientвЂ™s decision to enroll. Study Objective: Compare the willingness to participate among potential research subjects when a hypothetical research proposal is described as an вЂњexperimentвЂќ versus a вЂњresearch project.вЂќ We hypothesize that potential subjects will be less likely to agree to participate if the word вЂњexperimentвЂќ is employed. Methods: Survey of patients presenting to an urban level 1 trauma center. Two hypothetical scenarios were described to 200 subjects; one study described a relatively noxious minor procedure, the other study described taking a pain medication. The descriptions were randomly alternated so that one was described as an вЂњexperimentвЂќ and the other was described as a вЂњresearch project.вЂќ Subjects were then asked which study they would prefer to participate in. Results: There were no baseline (age, sex, race) differences between groups. 176 Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ subjects expressed a preference for one study, 7 had no preference and 17 refused to participate in either study. Of those who selected a specific study, 91/176 (51% [CI: 44 вЂ“59]) chose the study described as a вЂњresearch project.вЂќ 99/176 (56% [CI:49 вЂ“ 64]) chose the medication study, over the intervention. Older patents were less likely to choose the study described as an вЂњexperimentвЂќ (Odds Ratio 0.97 per year); sex and ethnicity were not associated with preference. Conclusion: In general, describing a study as either an вЂњexperimentвЂќ or вЂњresearch projectвЂќ did not affect subject preference or willingness to participate. Older subjects were less likely to prefer studies described as experiments compared to younger subjects. 160 Survey of Medical Decisionmaking: Ability of the Public to Self-Triage and Recognize Symptoms of Emergency Conditions Plonk T, Gough JE, Brewer KL/East Carolina University, Greenville, NC; Department of EM, East Carolina University, Greenville, NC Study Objectives: Emergency department (ED) utilization continues to be a major concern. The decision as to where to receive care is based on many factors such as ability to pay, availability of alternatives, and ability to self-triage. The authors sought to survey how individuals make decisions about medical care. Methods: An anonymous online survey was sent to North Carolina residents. In addition to collecting demographic information, participants were asked to indicate where they would seek care based on 10 common complaints. Respondents were able to choose from the following options: go to an ED; go to a primary care physician (PCP); go to urgent care; go to pharmacy for over the counter medications, do nothing - it will get better; or other. Participation in the survey was voluntary and without compensation. The survey was approved by the institutionвЂ™s institutional review board under an exempt category. Results: 506 responses were obtained. Of respondents, 73% were female and the mean age was 49.9 years (SD П© 14.9), Race was predominantly Caucasian (77.1%) with 13% African American and ПЅ1% Hispanic. Educationally, the majority (58%) had completed all or some college. Older age, higher income, and higher education were associated with having a PCP while younger age, lower income and less education were associated with obtaining usual care from an ED, urgent care, or no care at all. The majority (74%) indicated they receive most of their health care through a PCP, while only 4% identified EDs as their primary source. For minor complaints such as sore throat, fever, sprained ankles, cough and congestion, and abdominal pain the majority indicated they would present to a PCP rather than an ED. When respondents were asked if they thought they were having a heart attack 90% noted they would present to an ED and only 1% said they would do nothing. However, when asked what they would do if they were having chest pain, trouble breathing and sweating, only 69% stated they would go to an ED and 6% said they would do nothing. Similarly, when asked if they thought they were having a stroke, 88% stated they would go to an ED and 1% would do nothing. However, when asked if they had the sudden onset of the worst headache of their life, 30% said they would go to an ED and 8% would do nothing. When asked if they experienced abrupt onset of slurred speech 65% would seek care in an ED and 5% would do nothing. Conclusion: These data indicate that the majority of respondents would present to an ED for major complaints and utilize alternative resources for less acute complaints. Further studies should examine if this population is a representative sample of ED patients and if these responses reflect actual behavior. Of note, participants appeared to recognize the need for ED presentation for complaints such as heart attack and stroke; however, they did not appear to recognize common presenting symptoms of such diagnoses which may be an area for future study and patient education. 161 Do Prolonged Emergency Department Waiting Times Reduce Emergency Research Consent Rates? Limkakeng Jr AT, Glickman SW, Freeman D, Drake W, Mani G, Chandra A, Cairns CB/Duke University, Durham, NC; University of North Carolina, Chapel Hill, Chapel Hill, NC Study Objectives: Emergency department (ED) crowding has resulted in increased waiting times for patients, with deleterious effects on patient care and resident education. There are unique challenges to enrolling patients in emergency department clinical research studies, including the time-sensitive nature of emergency Annals of Emergency Medicine S49 Research Forum Abstracts conditions, the acute care environment, and the lack of an established relationship with patients. The objective of this study was to assess the impact of emergency department wait times on patient participation in clinical research in the emergency department. We hypothesized increased ED waiting times will be associated with reduced research consent rates. Methods: Prospective study of all patients eligible for 2 diagnostic clinical research studies from 01/01/08 to 12/31/08 in an academic emergency department. The times to registration and to see a physician (MD) were obtained from administrative databases, and sex, age, race, study eligibility and consent were recorded by trained, dedicated study personnel. An analysis of association between consent rate and patient waiting times was performed using an adjusted logistic regression model (dependent variable consent yes/no) with independent variables being time to registration, time to physician and other patient demographic factors previously described to predict enrollment (age, race, sex). Results: 877 patients were eligible for enrollment and consent requested. 572 of 877 eligible patients (65%) gave consent and were enrolled. The median time to registration did not differ between those consenting to enrollment (9 minutes (min); interquartile range (IQR) 15,36 min) versus those that did not consent (10 min; IQR 15,39 min) [pП0.80, OR 1.00 (0.99, 1.01)]. Similarly, there was no difference in the median time to MD between those consenting (15 min; IQR 25, 55 min) versus those that did not consent (15 min; IQR 25,56 min) [pП 0.70, OR 1.00 (0.99, 1.01)]. Furthermore, consent rates did not change when stratified for the highest and lowest quartile wait times to registration (68%, 65%) or MD (65%, 66%). Conclusion: Regardless of waiting times to registration and to see a physician, two-thirds of eligible patients were willing to consent to diagnostic research studies in the emergency department. These findings suggest that effective enrollment in clinical research is possible despite challenges with crowding and prolonged waits in the emergency department. 162 Trends and Disparities in Emergency Department Asthma Care, 1992вЂ“2006 Heins A, Rask K, Houry D/University of South Alabama College of Medicine, Loxley, AL; Emory University, Atlanta, GA Study Objectives: To describe temporal trends and racial and sex disparities in asthma morbidity, as measured by emergency department visits and episodes of hospitalization, from 1992вЂ“2006, testing the hypotheses that asthma morbidity is decreasing and that disparities in asthma morbidity are narrowing across all demographic categories of the U.S. population. Methods: We conducted a secondary analysis of the National Hospital and Ambulatory Care Surveys from 1992вЂ“2006. Data on all patients with a primary diagnosis of asthma, ICD-9 493.xx, were collected including demographics, characteristics of the ED visit, and disposition. Descriptive and regression methods were used to examine the temporal trends and disparities in ED asthma visits and admissions. Results: Approximately 27 million visits for asthma occurred during the study period, representing about 2.0% of ED visits and 0.3% of admissions, from 1992вЂ“ 1999, but only about 1.5% of visits and 0.2% of admissions for 2000 вЂ“2006. Emergency department visits and hospital admissions for asthma declined for most of the population over the study period; however, children 0 вЂ“5 years of age, with a consistent 15 visits per 1,000 population through the study period, had about double the rates of ED visits compared to 6 вЂ“11 (8 per 1,000 in 2006) and 12вЂ“17 (6 per 1,000 in 2006) years and 5 times the rate for the 65П© group (ПЅ3 per 1,000). In addition, rates of admissions for age group 0 вЂ“5 (2.7 per 1,000 in the early 1990s and 1.8 in 2006) were more than twice that for the 6 вЂ“11 age group (1.3 in early 1990s and about 0.5 in 2006). Males had higher sex-standardized rates of asthma visits (3.8 per 1,000 average in 1990s, down to about 3 in 2006) and admissions compared to females (about 3 in the 1990s, down under 2.5 in 2006), but the gap between the sexes appeared to be narrowing. Blacks, in 2006, had about 4 times the ED visits and admissions for asthma compared to whites (17 visits per 1,000 versus about 4 for whites, and 2 admissions versus ПЅ0.5), up from about 2 1вЃ„2 times the visits and admissions in 2000 (14 visits versus 6 and 1.6 admissions versus 0.7). Conclusions: Persistent disparities in the burden of asthma continue to affect children and males, but the disparities are increasing for blacks. Research priority should focus on determining the causes of the worsening burden of asthma among Blacks and developing effective interventions to reduce the burden among all demographic groups at highest risk. S50 Annals of Emergency Medicine 163 Educational Intervention in Adult Asthma: A Randomized Clinical Trial to Determine If Adult Patients With Asthma Can Learn How to Use a Metered Dose Inhaler Acosta JF, Eckardt P, Negron D, Rubin D/Yakima Regional Medical & Cardiac Center, Yakima, WA; Adelphi University, Garden City, NY; St. Barnabas Hospital, Bronx, NY Background: Asthma patients have difficulty using the metered dose inhaler (MDI) correctly. Prior studies have shown that adequate training helps in the correct usage of this method of drug administration. The aim of this study is to determine if patients can be taught the use of the MDI with a video intervention. We will examine retention of this information as well. Methods: Patients were randomized into an experimental group (MDI training video) and a control group (asthma information video). Demographic information was obtained as well as the initial peak flow (PF). Every patient had a pre, post and one month follow-up evaluation by the same examiner to avoid examiner bias. The examiner was blinded to the intervention. This study was approved by the hospital institutional review board. Results: There were 133 patients enrolled in the study; 116 completed the study. On average, the experimental group (MDI training video) had a 15.92% increase in correct usage after intervention, whereas the control group (asthma information video) had a 1.16% increase in correct usage (t П ПЄ 6.682 (95%CI for a mean diff of ПЄ14.77, ПЄ19.149, ПЄ10.391 pПЅ 001). Comparing percent correct change from pre video to one-month later post-video, the experimental group (MDI training video) had a 15% increase in percent correct after intervention, whereas the control group (asthma information video) had an increase in percent correct of 1.62% (t П ПЄ5.772 (95CI for mean diff of ПЄ13.298 was: ПЄ17.862, ПЄ8.735) pПЅ 001). Conclusion: The MDI video training was demonstrated to improve subjectsвЂ™ use of the MDI. Study subjects with the MDI training video were also shown to retain this information after one month. 164 Percutaneous Vagal Electrical Stimulation for Severe Asthma Lewis L, Theodoro D, Purim-Shem-Tov Y, Mosnaim G, Sepulveda P, Staats P, Hoffman T/Washington University, St. Louis, MO; Rush University Medical Center, Chicago, IL; Alamo Clinical Research Center, San Antonio, TX; Johns Hopkins Medical Institutions, Baltimore, MD; ElectroCore LLC, Morris Plains, NJ Study Objectives: 1) Determine if percutaneous electrical stimulation of the vagus nerve in patients with acute asthma causes any adverse events. 2) Determine if percutaneous electrical stimulation of the vagus nerve improves airflow in patients with acute asthma, who have failed to respond to inhaled вђ¤ adrenergic agonist therapy. Methods: Study Design: Prospective within-group, non-randomized, noncontrolled interventional study. Setting: Multi-center emergency department (ED) trial. Participants: Adult patients, seen in the ED for moderately severe asthma (FEV1 40%вЂ“70%), who failed to respond to 60 minutes of conventional pharmacologic therapy (inhaled bronchodilators П® steroids) were eligible for the study. Response failure was defined as a post-treatment FEV1ПЅ 70%. Four patients met criteria and consented to the procedure. Following consent, patients were prepped and draped, and an electrode lead was placed percutaneously using ultrasound guidance in the vicinity of the vagus nerve, posterior to the carotid sheath. The procedure was conducted in fully conscious and responsive patients using local anesthesia at the insertion site. Treatment consisted of up to 180 minutes of continuous electrical stimulation at 25Hz and 200ms pulse width at amplitude ranging between 1вЂ“12 volts. End points for voltage increase were symptomatic improvement, muscle twitching, or discomfort. FEV1 measurements were obtained pre-stimulation, at 30min intervals during stimulation, and post stimulation. Pre/post results were compared using paired t-tests. Results: All patients were unresponsive to standard pharmacologic therapy, including вђ¤2-adrenergic receptor agonists (4/4) and (3/4) steroid treatment. Following 30 minutes of continuous electrical stimulation therapy (mean 7.6v; range 6.5 вЂ“ 8.9v), the mean % predicted FEV1 increased from 59.5П®4.7 to 68.3П® 5.2 (pП0.014). FEV1 continued to improve during the 180 minutes of treatment and achieved a mean peak % predicted FEV1 of 75.2 П® 5.5 (pП0.004). Additionally, the FEV1 remained significantly improved at 30 minutes (pП0.035) after treatment was completed. No patients required discontinuation of the device, and there were no Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts episodes of worsening bronchoconstriction, hypotension, bradycardia, diaphoresis, or increased tachycardia. Conclusion: Electrical stimulation may be safely used to reduce bronchoconstriction in certain patients with acute asthma. This presents a novel, non-pharmacologic, and non-airflow dependent therapy for the treatment of asthma in critical care settings. 165 Initial Out-of-Hospital End-Tidal Carbon Dioxide Measurements in Adult Asthmatic Patients Lamba S, Gluckman W, Nagurka R, Rosania A, Bechmann S, Langley DJ, Scott S, Compton S/The University of Medicine and Dentistry of New Jersey, Newark, NJ; St. JosephвЂ™s Regional Medical Center, Paterson, NJ Background: Early recognition of asthma severity is dependent upon the health care providerвЂ™s physical assessment of the patient and is not usually aided by the additional use of pulse-oximeter or peak-flow measurements. End-tidal carbon dioxide (EtCO2) monitoring may provide out-of-hospital personnel supplemental information on a patientвЂ™s ventilatory status and assist in the early recognition of severe asthma exacerbations. Study Objectives: To describe the distribution of initial out-of-hospital EtCO2 measurements in adult, non-chronic obstructive pulmonary diseases (COPD), asthmatic patients, in relation to patient outcomes. Methods: This observational study is a review of EtCO2 assessment data in a convenience sample of adult, asthmatic patients transported via advanced life support units (ALS) to a large, urban, Northeastern teaching hospital between October, 2005 and January 2008. Initial EtCO2 measurements were obtained routinely on all respiratory distress patients in the field and emergency physicians were not aware of the results. Data were analyzed using descriptive statistics, including percentages, means, and 95% confidence intervals (CI). In addition, comparisons between patients with and without markers of poor outcome were performed using chi-square analyses and FisherвЂ™s exact tests, with an aim toward hypothesis generation for future prospective studies of the potential added value of initial EtCO2 measurements to aid in the recognition of severe asthma. Results: We reviewed data for out-of-hospital initial EtCO2 measurements on 299 unique asthma patients. Mean (SD) age was 43.1 years (12.5) and 142 (47.5%) were male. Overall, the mean EtCO2 measurement was 38.8 mmHg (CI: 37.7 вЂ“ 39.9; range: 14 to 82). Examination of initial EtCO2 measurements by deciles revealed that extreme values, in the lowest (14 to 28mmHg) and highest (50 to 82mmHg) deciles, experienced more markers of poor outcome than less extreme measurements. Patients were thus dichotomized by extreme (nП59) or non-extreme (nП240) EtCO2 measurements. More extreme patients were ultimately intubated (30.5% vs. 5.8%; pПЅ0.001), and/or admitted to the intensive care unit (28.8% vs. 6.7%; pПЅ0.001), and/or expired [5.1% vs. 0%; pП0.007 (FisherвЂ™s Exact test)], than non-extreme patients, respectively. Conclusion: The results of this study suggest that extreme (both low and high) out-of-hospital initial EtCO2 measurements may be associated with markers of poor patient outcomes. Future work will prospectively determine whether the addition of this information improves early recognition of severe asthma episodes beyond clinical assessment. 166 Emergency Department Operational ImprovementsвЂ™ Impact on Volume, Quality Core Measures, Patient Stay and Satisfaction Sayah A, Lobon L, Rivard L, Skura S/Cambridge Health Alliance, Cambridge, MA Study Objectives: Emergency department (ED) crowding and the resulting ambulance diversion, long patient waits, and many patients leaving without being evaluated have been major issues that have affected the satisfaction of patients with their emergency visits. This is an observational, descriptive, retrospective study in a community teaching hospital that looks at the impact of a series of ED changes on volume, quality core measures, patient flow and satisfaction. Methods: Between August 2006 and July 2008, multiple ED changes were implemented in the areas of personnel and leadership, culture, technologies, communication, policies and procedures, and flow. The ED leadership team in collaboration with many hospital services reengineered the patient ED experience from arrival to departure. Implemented changes included rapid assessment protocol with bedside registration, electronic triage and patient tracking. Various ED metrics were followed including diversion rates, ED volume, ED patient length of stay, ED Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ patient left before treatment complete (LWOT) rates, Press Ganey patient satisfaction scores, and ED-specific quality core measures. Results: Ambulance diversion decreased from a historical 3.6% of time in FY05 and FY 06 to zero since September 2006. ED length of stay decreased from a mean of 187 minutes in August 2006 to 150 minutes during Q2 FY09. Patient satisfaction Press Ganey scores rose from 76.1 (5th percentile) in Q4 FY06 to 85.6 (64th percentile) in Q2FY09. ED patient volume is growing by a projected 7.2% between FY06 and FY09 (28,481 to 30,500) resulting in a 30% increase in inpatient admissions from the ED for the same period (2,905 to 3,781). ED-specific quality core measures increased from 82% in Q4 FY06 to 98% in Q4FY08. The rate of ED patients who left before treatment was completed dropped from 3.7% in FY06 to 0.80% during Q2 FY09. Conclusion: The ED operational changes have had a significant positive impact on all measured metrics. While the volume of ED visits and resulting inpatient admissions have increased, ambulance diversion was eliminated, patient length of stay was reduced, the rate of patients who left without evaluation was reduced, and patient satisfaction and quality measures increased to a record high. Improving ED operational efficiency has provided our department with the ability to accommodate increasing volume and acuity and improve the quality of care and the experience of patients who visit our ED. 167 Implementation of Crowding Solutions From the American College of Emergency Physicians Task Force Report on Boarding Handel DA, Boehland A, Ginde AA, Raja AS, Rogers J, Sullivan AF, Camargo CA/ Oregon Health & Science University, Portland, OR; University of Colorado, Denver, CO; Brigham and WomenвЂ™s Hospital, Boston, MA; Monroe County Hospital, Forsyth, GA; Massachusetts General Hospital, Boston, MA Study Objectives: In 2008, the Task Force Report on Boarding proposed highimpact crowding solutions such as hospital discharge coordination, inpatient full capacity protocols, and the coordination of elective surgeries. To date, there are no data on the implementation of these crowding solutions. The purpose of this study is to crowding and solutions in EDs of different annual visit volumes in a single state. Methods: We mailed surveys to all physician and nursing emergency department (ED) directors in Oregon. Federal and military hospitals were excluded. Survey questions related to crowding were drafted based on the ACEP Task ForceвЂ™s recommended solutions, and responders were asked to provide data pertaining to 2008. Initial non-responders received two subsequent mailings of the survey. Respondents were contacted via telephone and e-mail to obtain missing data. EDs were classified according to their average visit volume: ПЅ 1 patient per hour (ie, ПЅ8760 ED visits/year), 1вЂ“1.9 patients per hour, 2вЂ“2.9 patients per hour, and 3 or more patients per hour. Results: 51 of 59 EDs responded (86% response rate). 14% (7/49) EDs stated that they cared for patients in the hallway, a practice most prevalent amongst EDs seeing 3 or more patients per hour (29%). 61% (30/49) of all EDs, except for those that saw ПЅ1 patient per hour (14% in this group), stated that they boarded patients for Пѕ2 hours on a typical day at 6 pm until an inpatient bed became available. The ED attending was the physician of record for boarded patients in 73% (30/41) across all volume categories. The median elopement rate was 1.5% (range 0 вЂ“9%) with no significant difference between ED groups. Overall, 45% (22/49) of EDs stated they went on ambulance diversion in 2008. Diversion was most prevalent in EDs with 3 or more patients per hour (71%, 12/17). The median number of hours on diversion per month was 24. In EDs that saw 3 or more patients per hour, the median number of diversion hours per month was 55 hours vs. 6 or less for the other three groups (pП0.03). Of the hospital-wide crowding solutions, 10% (5/48) had inpatient full capacity protocols, 54% (26/48) had inpatient discharge coordination, 34% (15/44) had surgical schedule smoothing, and 26% (12/47) cancelled elective surgeries if needed. In terms of ED solutions, 47% (23/49) had bedside registration, 25% (12/ 48) had a fast track unit, 12% (6/49) had an observation unit, 4% (2/49) had a physician at triage, and 37% (18/49) had expanded the number of ED beds in the past 3 years. Conclusion: While many of the ACEP strategies have been employed, there remains room for increased implementation. Diversion is more prevalent in larger EDs but is seen EDs of all sizes in Oregon. Annals of Emergency Medicine S51 Research Forum Abstracts 168 Utilization of the Situation-BackgroundAssessment-Request, Companion Phones, and Cell Phones Improves Communication With Consultants in the Emergency Department Farley H, Choy H, Ellicott A, Mascioli S, Reed III J, Weintraub W, Reese IV CL/ Christiana Care Health System, Newark, DE Study Objective: Timely and effective interdepartmental communication is a vital component of ED patient care. Objective: To determine if emergency physicians and cardiologists perceive an improvement in interdepartmental communication after implementation of situation-background-assessment-request (SBAR) guidelines and the use of companion and cell phones. Methods: A 4-question survey assessing the timeliness and effectiveness of interdepartmental communications was distributed to all emergency medicine attendings, EM residents, and cardiologists in 1 hospital in 9/07. Responses were recorded on a 5-point Likert scale from 1(poor)вЂ“5(excellent). The SBAR guidelines were then introduced to the EM residents and incoming consultant calls were routed directly to EM resident companion phones and EM attending cell phones.The survey was repeated in 9/08 and the results compared using PearsonвЂ™s chi-square. A p-value of ПЅ0.05 was significant. Results: 76 physicians (56.3%) responsed to the 1st survey, 55 (40.7%) to the 2nd. Analysis of EM responses revealed an improvement in perceived responsiveness of the cardiologist (3.44П®0.80vs.2.83П®1.06,pПЅ0.01), ability to anticipate information requests (4.43П®0.70vs.3.72П®0.98,pПЅ0.01), and overall interdepartmental communications (3.41П®0.80vs.2.91П®1.05,pП0.01). There was no change in the perceived ability of the emergency physician to reach the cardiologist on the first call (3.14П®1.21vs.2.83П®1.15,pП0.21). Analysis of cardiologist responses revealed no improvement in perceived responsiveness of the emergency physician (2.83П®1.47vs.2.32П®1.09,pП0.25), ability to contact the emergency physician on the first attempt (2.17П®1.19vs.2.14П®1.13,pП0.94), emergency physician communication of necessary information (3.42П®0.9vs.2.68П®1.32,pП0.96), or overall interdepartmental communications (2.17П®1.12vs.2.14П®1.08,pП0.94). Conclusion: By implementing SBAR guidelines and direct routing of consultant calls to emergency physician companion and cell phones, emergency physicians perceived an improvement in interdepartmental communications. 169 A Protocol to Improve Door-to-EKG Times in the Emergency Department Mostofi M, Tivnan E, Barnewolt B, Penzias A, Weiner S/Tufts Medical Center, Boston, MA Study Objectives: Time is of the essence in the treatment of acute myocardial infarction. As part of a multi-disciplinary process to improve our hospitalвЂ™s door-toballoon times in these patients, we instituted various techniques focusing on improving the door-to-electrocardiogram (EKG) times in all eligible emergency department (ED) patients. Methods: In 2007, our department instituted a protocol in which all patients over age 35 with chest pain or possible angina equivalent (including epigastric pain, shortness of breath, dizziness, upper back pain, palpitations and others) receive an EKG within 10 minutes of arrival to the ED. For walk-in patients, we provided a chair and additional EKG machine at triage to rapidly perform the EKG by an ED technician who received specific training. For emergency medical service (EMS) patients, nurses were instructed to immediately obtain the EKG in a designated area and then move the patient if necessary. EKGs were handed to any attending physician in the ED for quick review. We measured the time from arrival to EKG in all such patients during an 18-day period after the intervention and a similar control time period prior to the intervention. Chief complaints, modes of arrival, time to EKG and rates of performance of EKGs in eligible patients were recorded. Results: 145 patients met inclusion criteria (by chief complaint and age) in the control cohort, and 105 (72.4%) had an EKG. 163 patients were included in the study cohort, of which 126 (77.3%) had an EKG. The average time to EKG before the intervention was 71.3 minutes (95% CI 55.8 вЂ“ 86.8), median 36 minutes (IQR 19.0 вЂ“92.5), and 9/105 (8.6%) were performed in 10 minutes or less. The average time to EKG after initiation of our protocol was 30.3 minutes (95% CI 23.4 вЂ“37.3), median 16 minutes (IQR 10 вЂ“29), and 35/126 (27.8%) were performed in 10 minutes or less. The difference in time to EKG was statistically significant (pПЅ0.001), as was the percentage of EKG performance ПЅ10 minutes (pП0.004). Conclusion: A multi-focal process to improve door-to-EKG times, including S52 Annals of Emergency Medicine institution of a formal protocol, EKGs from triage and a designated area for obtaining EKGs for EMS patients is useful to decrease door-to-EKG times in patients with chest pain or angina equivalents. 170 Managing Patient Expectations at Emergency Department Triage Rumoro D, Shah S, Patel A, Hohmann S, Fullam F/Rush University Medical Center, Chicago, IL; University HealthSystem Consortium and Rush University Medical Center, Chicago, IL Study Objectives: Crowding, closure of emergency departments (ED), long waits coupled with reductions in resources (eg, limited staff), lower reimbursement rates, and uncomfortable waiting room conditions may contribute to lowering the perceived quality of the patient experience and patient satisfaction. This study investigates the relationship between patient satisfaction and communication of expected wait times (ie, managing expectations), at the point of triage. Methods: A pre-post non-equivalent group study design with convenience sample of all discharge to home adult ED patients was utilized for this study. Patients returning within 72 hours were removed from the analysis. A static expected wait time model (ie, average wait time plus one standard deviation calculated with twelve months of data) based on time of the day, day of the week and triage levels was employed (ie, communicating expected wait time) at the triage while an in-house survey with five-point Likert-scale patient satisfaction questions (satisfied with wait time in triage, informed about delays, and overall ED rating) was administrated at the discharge desk. The pre- and post- implementation time periods were November 4, 2008 вЂ“ January 3, 2009 (nП887) and January 4, 2009 вЂ“ February 5, 2009 (nП322), respectively. Results: Though the actual communication of delays intervention wasnвЂ™t significant for patient satisfaction questions (ie, wait time in triage and being informed of delays except for the overall ED rating), the communication status (yes/ no) and other known factors of ED crowding (eg, time of day, day of week, ED length of stay, and acuity) were significantly associated with patient satisfaction. The patients who did not receive communication about delays, whether before or after the intervention, were between 1.5 to 5.0 times more likely to rate the three satisfaction questions lower than very good. Patients during the pre- and post-implementation who did not receive communication about expected wait times were 2.6 and 2.83 times more likely to rate the item on satisfaction with wait time as fair compared to a rating of very good. The percentage of patients responding very good and very poor for the item on satisfaction with wait time were 15% higher and 6% lower, respectively, with the communication status as yes. Conclusion: Although communication of delays was not significant in the initial analysis, the patients who received information about wait times were significantly more satisfied. This indicates that patients are more likely to accept longer wait times provided their expectations are managed (ie, delays were communicated). The limited sample size of post-implementation justifies future studies which will incorporate longer post-implementation sample, more rigorous implementation (communication of delays to patients) and adherence of the intervention. 171 Characteristics of an Emergency Medicine-Led Rapid Response Team at an Academic Tertiary Care Hospital in the United States Mace SE, Buller L, Thallner E, Tallman T/Cleveland Clinic, Cleveland, OH Study Objectives: Rapid response teams (RRTs) have been developed to respond to changes in a patientвЂ™s condition. Intensivists often lead RRT in large academic teaching hospitals. The Cleveland Clinic, a 1000 bed, academic, tertiary care hospital began an Adult Medical Emergency Response Team (AMET) in January 2008. Methods: AMET is staffed by a 3 member emergency medicine (EM) team: nurse, respiratory therapist, and physician. Each AMET team member has AMET as their primary assignment and responds to the patientвЂ™s bedside within 10 minutes of being paged. Hospital employees activate AMET by dialing 122. AMET carries 2 bags containing emergency medications, respiratory supplies including intubation equipment, and point-of-care testing via a portable rolling luggage cart. Criteria for calling AMET include acute respiratory, cardiac, neurologic or BP change defined as any of the following: RRПЅ8 or Пѕ32, pulse oxygen saturation ПЅ90%, HR ПЅ40 or Пѕ140 with symptoms, HR Пѕ160, BP Пѕ220 with symptoms, BPПЅ80, chest pain (CP) with ECG changes or unresponsive to NTG, mental status change, loss of consciousness, lethargy, new focal weakness or loss of movement, sudden collapse. AMET calls for the first year of operation were evaluated. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts Results: 1284 in first 15 months of operation. Calls gradually increased with a spike in July, then leveled off averaging 90/month. Demographics: age (mean) 61.4 years (range 15вЂ“99), 51% male, 49% female, 68% Caucasian, 28% African American, 4% other. Reasons for call were any acute change in: respiratory 42%, cardiac 21%, neurologic 20%, BP 16%, other 1%. Respiratory calls (42%) were abnormal RR 27%, decreased oxygen saturation 15%. Neurologic calls (20%) were loss of consciousness 11%, lethargy 5%, sudden collapse 3%, new focal weakness 1%. Cardiac calls (21%) were bradycardia or tachycardia 17%, CP 4%. Conclusion: Demographic data indicates over 3вЃ„4 of the patients were Пѕ50 years old (78.2%) and, by decade of age 1вЃ„4 (26.4%) of the patients were between 60 and 70. Sex and race reflected our patient population. The majority of calls were respiratory (42%) followed by cardiac (21%) then neurologic (20%). Call analysis reveals that there were no inappropriate calls, as reflected by the call criteria. To our knowledge, this is the first emergency medicine led RRT. There are many benefits to an emergency medicine-led team including: increased throughput for emergency department patients due to additional ED staffing when team members are not on an AMET call, maintenance of technical skills by emergency medicine staff and increased teaching for medical/surgical residents by emergency medicine attending staff. 172 An Analysis of Patients Treated by a Rapid Response Team: A High Acuity, Critically Ill Patient Population Requiring Multiple Procedures and Transfer to a Higher Level of Care Mace SE, Buller L, Thallner E, Tallman T/Cleveland Clinic, Cleveland, OH Study Objectives: Rapid response teams (RRTs) were developed to improve patient outcomes. An Adult Medical Emergency Team (AMET) was initiated January 2008 to respond to acute changes in patient status. Emergency medicine (EM) personnel: nurse/respiratory therapist/physician respond to AMET calls within 10 minutes of being paged. The team brings emergency supplies including: respiratory/ intubation equipment, intravenous line setup, point of care testing, medications. Methods: 2008 AMET calls were analyzed re interventions, patient dispositions, outcomes (mortality). Follow-up of AMET patients as of March 31, 2009 regarding mortality was done. Results: 1284 AMET calls in the first 15 months of operation; 87.9% to nonintensive care unit (ICU) inpatient medical/surgical floor, 12.1% for visitors/outpatients. Interventions on all AMET calls: Airway interventions: pulse oximetry 76%, supplemental oxygen 75%, oral/nasal airway 21%, suctioning 10%, nebulizer treatment 8%, BiPAP 6.5%, intubated 23%. Intravenous (IV) interventions: bolus IV fluids 50%, second peripheral IV line 34%, central IV line 5%. Diagnostic testing: ECG 57%, chest x-ray 22%, point-of-care testing (POCT): blood gas 50%, electrolytes/BUN/creatinine 42%, hemoglobin/hematocrit 34%, lactate 33%. Cardiopulmonary resuscitation was needed in 8%. AMET Call Disposition: Only 27% (347/1284) of all patients remained on their medical/surgical floor, while 73% (937/1284) were emergently transferred to a higher level of care or expired during the AMET call. вЂњImmediateвЂќ transfers during AMET call were ICU 50%, emergency department (ED) 12%, telemetry 5%, operating room (OR) 1%, cardiac catheterization lab 1%, expired 5%. Of the 27% (nП347) remaining on their original floor, 85% were transferred or expired within hours when they failed to improve despite initial AMET therapy. вЂњDelayedвЂќ transfers in these 347 patients included: 29% ICU, 6% ED, 10% OR, 4% telemetry, 1% cardiac catheterization lab, 35% expired. Overall analysis reveals that 4% (52/1284) of AMET patients remained on the same floor during their hospital stay, with 96% eventually transferred to a higher level of care or expired (includes visitors/outpatients). Patient status as of March 25, 2009: 30% of AMET patients (nП385) have since expired. Conclusion: AMET patients are critically ill, need numerous diagnostic interventions, multiple therapeutic interventions, especially airway and venous access procedures. They require transfer to a higher level of care and have a high eventual mortality. Only 4% of the patients remained at their initial inpatient floor. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 173 Effect of an Attending Physician Float Shift to Care for Boarding Patients in a Crowded Emergency Department Holt S, Hardy L, Mistry C, Kulstad E/Advocate Christ Medical Center, Chicago, IL Study Objectives: Despite the increasing problem of emergency department (ED) crowding, few solutions that can be readily implemented in the ED have been examined. Patients backlogged in the ED waiting for an inpatient bed (boarders) continue to require the attention of emergency physicians, further exacerbating crowded conditions. To address this problem, our department added a вЂќfloat shiftвЂќ to our winter schedule solely to provide care to boarders. We sought to quantify the effect of this float shift, hypothesizing greater physician productivity when this shift was utilized. Methods: We performed a retrospective observational study in our community hospital ED, measuring the number of new patients seen in each 10-hour shift in the presence or absence of a float shift physician. By querying our ED electronic tracking board, we extracted the number of new patients seen for each of 7 daily shifts during the months of February (when the float shift was present) and May (when the float shift was absent) of 2008. We then compared the mean number of patients seen per shift in February with the mean number seen per shift in May. Results: Total monthly patient volume was 6656 for February and 6775 for May, with the mean daily census being 230 and 219 patients, respectively. Mean door-todisposition time (256 minutes versus 222 minutes) and total time on diversion (83 hours versus 43 hours) was greater in February than in May. However, the number of new patients seen during each shift in February was greater than in May (mean increase of 1.1 patients per shift), with 2 daily shifts having significantly greater mean new patient volume (19 versus 17 patients, PП.049, and 22 versus 19 patients, PП.012). Conclusion: The presence of a вЂњfloat shiftвЂќ physician caring only for boarding patients allows other physicians to maintain and even increase their productivity in our ED, despite the presence of longer throughput times and increased time on diversion. 174 Emergency Severity Index Triage System Correlation With Emergency Department Evaluation and Management Billing Codes Hendry D, Wiler J, Poirier RF, Griffey RT, Farley HL, Zirkin W/Washington University St. Louis, St. Louis, MO; Washington University, St. Louis, MO; Christiana Care Health System, Newark, DE; Greater Baltimore Medical Center, Baltimore, MD Study Objectives: Estimating financial data from patient information is valuable for operations management. Emergency Severity Index (ESI) triage acuity levels predict facility resource utilization, but correlation to physician billing as a forecast surrogate for revenue has not been studied. We investigate and describe the correlation between Emergency Severity Index levels and (i) emergency department evaluation and management billing codes 99281-99285 and 99291, and (ii) total provider service charges (procedure and E&M charges). Methods: Multi-centered retrospective study of 192,147 adult patients at 3 institutions. Using Spearman rank correlation coefficient, we determined the correlation of ESI levels with evaluation and management billing codes and total provider charges. Analysis of ESI and evaluation and management code associations were broken down by center type. Demographics were analyzed using regression analysis. Results: ESI level and emergency department evaluation and management billing codes were moderately correlated, Spearman rП 0.51. ESI high acuity levels 1, 2 and 3 were most frequently associated with evaluation and management level 5 code (99285) at 50, 63, and 44% of the time respectively. ESI less-acute levels 4 and 5 were most frequently associated with an evaluation and management level 3 code (99283) at 56 and 67%, respectively. ESI acuity level was correlated with emergency physician billing charges at rП0.33. This relationship was preserved across settings. Average total provider charges for ESI 1 was $604 and ESI 5 $265. Conclusion: We found a consistent relationship between ESI triage level and (i) emergency department evaluation and management billing codes and (ii) total physician billing charges which was preserved across practice settings. ESI levels 1 and 2 corresponding to evaluation and management level 5 code (99285) and ESI levels 4 and 5 corresponding to evaluation and management level 3 code (99283). This correlation can be used for forecasting financial outcome data which may be helpful for operations management. Annals of Emergency Medicine S53 Research Forum Abstracts 175 Emergency Department Inpatient Bed Management Inventory System Shah S, Silva J, Ward E, Rumoro D/Rush University Medical Center, Chicago, IL Study Objective: Emergency department (ED) crowding is an important issue affecting patient care, quality, and safety as well as increasing health care costs. To improve these factors, streamlining ED operations and reducing waste (ie, delays) are essential. One of the areas to improve ED throughput is to reduce disposition delays, which are divided into time-to-bed-ready and bed-ready-to-patient-out delays. Thus, the objective of the project is to develop a quantitative methodology to reduce ED crowding and increase ED capacity by eliminating process (time to bed ready) delays at ED disposition. Methods: Theoretical inventory bed management policy (IBMP) was developed and applied (current and proposed strategies) to a large academic medical center (AMC) with a 34-bed ED to reduce delays associated with ED patient disposition to inpatient general medicine beds. The goal of IBMP is to optimally balance between additional charges/revenue opportunities for ED and maximum utilization of requested inpatient beds. The data elements utilized for this study included the time to bed ready delays, type of bed, day of week, hour of the day, distribution of bed request, and financial charges (ie, ED charges per hour per patient and general medicine bed charges per day). Results: Based on the policy, the recommended general medicine bed requests, for the AMC with 34 ED beds, was 14, 12, 10, and 8 general medicine beds for Monday-Thursday, Friday, Saturday, and Sunday, respectively. The anticipated additional charges (revenue) in the first year and each subsequent year were estimated at $1.47 million (revenue П $513,000) and $160,000 (revenue П $50,000), respectively with the time to bed ready substantially (Пі 0 minute) reduced. Conclusion: Apart from improving the direct outcomes such as time to bed ready delays and financial profitability, IBMP will also improve patient and staff satisfaction, length of stay, and left without been seen statistics. The first steps in implementing the IBMP intervention were to place the bed request demands per day of the week on the capacity management dashboard, which allows bed controllers to plan for anticipated ED to inpatient bed requests. Full implementation will result in additional ED capacity and further streamlining of ED operations. 176 D-ECG times between PRE and month 1 (pПЅ0.0001), month 2 (pПЅ0.0001), month 3 (pПЅ0.0001), month 4 (pПЅ0.0001), and month 5 (pП0.0001). See tables below. In the POST cohort, patients with final diagnosis of ACS had significantly shorter D-ECG times when compared to NC-CP, with a median D-ECG time 10 min for ACS (IQR 5 to 20), versus 20 min (IQR 10 to 41) for NC-CP (pПЅ0.0001). In patients with final diagnosis of ACS and with final diagnosis of NC-CP, there was a significant difference in D-ECG times between PRE and each following month, except for month 5 in de ACS group that was not significant (pП0.53). Conclusions: The educational intervention significantly reduced overall door to ECG times during the study period. This intervention effectively maintained D-ECG times within current national recommendations. However, there is a trend in the ACS group to returning to baseline times, suggesting that a new intervention is needed after this period. Further work should be done to explore additional strategies that focus on standardized process improvement to benefit patients presenting to the ED with CP and possible ACS. Evolution of Door to Electrocardiogram Times After an Educational Strategy in Patients Presenting With Chest Pain to the Emergency Department in a Chilean Academic Center Aguilera P, Altamirano R, Bellolio M, Pineda N, Morales JF, Alcayaga A, Gabrielli L, Castro P, MardoВґnez JM/Pontificia Universidad CatoВґlica de Chile, Santiago, Chile; Mayo Clinic, Rochester, MN Study Objective: To evaluate the effect over time of an educational strategy for reduction on door to ECG times (D-ECG) among patients presenting with chest pain (CP). Methods: This was a prospective cohort study of door to first ECG times for patients presenting to an urban, academic emergency department (ED) in Santiago, Chile, with non traumatic CP. All patients with CP who had an ECG recorded during the ED evaluation were included. Our previous study showed a significant reduction in D-ECG times one month after intervention. The intervention consisted on education to all the ED staff about the importance of providing prompt care of CP patients, as well as letting the staff know that the D-ECG time and final ED diagnosis will be recorded. Times were collected for 5 consecutive months and were compared with the times before the intervention. D-ECG times did not follow a normal distribution, Wilcoxon rank sum test was used, and median with interquartile ranges (IQR) were reported. Results: 711 patients presenting with CP to the ED were included in this study; there were 163 patients in the pre-intervention (PRE) period, and 548 in the postintervention (POST) period (months 1вЂ“5). The ED diagnosis for the PRE cohort was: 20.3% acute coronary syndrome (ACS), defined as myocardial infarction or unstable angina, and 79.8% non-coronary CP (NC-CP), including any other non traumatic chest pain etiologies. In the POST cohort, the diagnosis was 23.7% ACS and 76.3% NC-CP. The difference in diagnosis PRE vs POST was not significant (pП0.35). The median D-ECG time PRE was 29 minutes (min) (IQR 15 to 52), and POST was 15 min (IQR 8 to 33), (pПЅ0.0001). There was a significant difference in S54 Annals of Emergency Medicine 177 A Comparative Analysis of Screening Hypertensive Patients for Left Ventricular Abnormality With Electrocardiograph and NT-proBNP Chandra A, Freeman D, Mani G, Drake W, Limkakeng A/Duke University Medical Center, Durham, NC Study Objective: A new heart failure (HF) classification system recommends therapeutic interventions performed on hypertensive patients before the appearance of left ventricular dysfunction symptoms in order to reduce the morbidity and mortality of HF. We evaluated the effectiveness of electrocardiograph (ECG), NTproBNP, and ECG with NT-proBNP in identifying left ventricular abnormality. Methods: This was an interventional, prospective trial performed at an urban, tertiary care hospital. Convenience sampling was used to identify and enroll patients with two emergency department blood pressure (BP) measurements in the JNC-7 Stage 2 category. Patients were excluded if they exhibited moderate or severe renal dysfunction, acute coronary syndrome, pulmonary embolism, or a history of congestive heart failure as they may influence NT-proBNP values. Blood was obtained and NT-proBNP determined using the Response Biomedical RAMP platform technology. A NT-proBNP of 250 ng/L was used as a cutoff. Left ventricular dysfunction was defined as the presence of any hypertrophy. Descriptive statistics are used to report diagnostic performance. Area under the curve (AUC) analysis is performed to identify ideal NT-proBNP value. Results: Forty-nine patients were enrolled with a mean age of 58 yo. Twenty-four percent of these patients were not being treated for hypertension. The AUC was 0.67 (CI 95 0.52вЂ“ 0.80). The best diagnostic performance occurred when NT-proBNP Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts and ECG were combined to screen for left ventricular hypertrophy, sensitivity 65% (CI 95 43вЂ“ 83%) and specificity 83% (CI 95 51вЂ“97%). Conclusion: NT-proBNP combined with an ECG is effective at screening for left ventricular abnormality in patients with hypertension. These findings may be initially used to screen for end-organ changes of the heart when echocardiography is not easily available. 178 The Percent of Total Emergency Department Visits for Congestive Heart Failure Declined From 1996 to 2008 Wreschner BM, Allegra JR, Eskin B/Morristown Memorial Hospital, Morristown, NJ Study Objectives: Many advances have been made over the last decade in the treatment of congestive heart failure (CHF) patients, including the use of beta blockers and a focus on patient education. We hypothesized that this should result in a decrease in patients presenting to the emergency department (ED) with CHF. Our objective was to test this hypothesis in a large database of ED visits. Methods: Design: Retrospective cohort. Setting: Consecutive patients seen by emergency physicians in 28 urban, suburban and rural hospitals in New Jersey and New York between 1/1/1996 and 12/31/08. Protocol: We classified patients as having CHF if the first ED diagnosis was congestive heart failure, heart failure or pulmonary edema or if one of these was listed as the second diagnosis and the first diagnosis was a respiratory diagnosis (shortness of breath, dyspnea, respiratory failure or wheezing). Data Analysis: We compared the annual CHF visits to total annual ED visits using the Student t test and performed a regression analysis. Alpha was set at 0.05. Results: Of the 7,567,002 ED visits in the database, there were 104,489 visits (1.4%) with an ED diagnosis of CHF. The mean age of the patients with CHF was 73 П©/ПЄ 18 years; 54% were female. There was a 49% (95% CI: 46% to 51%, pПЅ0.001) decline in the percent of total ED patients that had CHF, from 1.6% in 1996 to 0.8% in 2008. The correlation coefficient for this downward trend was R2 П 0.75 (pПЅ0.0001). Conclusion: We found a 49% decline in the percent of total ED visits for CHF from 1996 to 2008. We speculate the cause for this decline is likely due to advances in treatment for CHF. 179 Disposition and Final Diagnosis of Patients Presenting with Chest Pain to an Academic Emergency Department in Chile Aguilera P, Altamirano R, Pineda N, Bellolio M, AlvizuВґ S, MardoВґnez JM/Pontificia Universidad CatoВґlica de Chile, Santiago, Chile; Mayo Clinic, Rochester, MN Study Objectives: To describe and evaluate the hospital admission rate and final diagnosis of a cohort of patients presenting to the emergency department (ED) with non-traumatic chest pain (CP). Methods: This was a prospective cohort study of a consecutive cohort of patients presenting with CP to an academic ED during a 4 month period. Information was collected on demographics, signs and symptoms at presentation, comorbidities, medication use, final ED diagnosis, troponin values, disposition, and final hospitalization diagnosis. Patients discharged from the ED were followed through a telephone call at 30 days. As per our protocol, all patients presenting with CP in whom an acute coronary syndrome (ACS) was suspected, were assessed by a cardiologist in the ED. Results were analyzed with T test, Chi-square and nonparametric test according to the type and distribution of the data. Results: A total of 541 patients with CP were included. The mean age was Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 48.3 П® 18.2 years, 58% were men. A total of 489 (90.7%) had an ECG recorded in the ED, with a median door to ECG time of 16 minutes, 293 (54.2%) had Troponin measured, and 195 (36%) were evaluated by a cardiologist in the ED. There were 114 patients with suspected ACS (21.1%), and 3 of these were transferred to a different hospital. A total of 154 (28.5%) patients were admitted with the following ED diagnoses: 111(72.1% of admissions and 20.5% of the study cohort) ACS, including 23 patients with ST elevation MI; 17 (11%) respiratory causes, 9 (5.8%) non differentiated CP, 6 (3.9%) supraventricular arrhythmias, 9 (5.8%) other causes. Comparison of the clinical characteristics of the ACS vs non-coronary CP (NCCP) are displayed in Table 1. Among patients admitted as an ACS to our hospital (nП111), 16 of the 23 STEMI (70%) went to cardiac catheterization. When comparing ED diagnosis of ACS vs hospital diagnosis, we found overall agreement of 71%. There was 86.3% follow up at 30 days. We found that 26 of 333 (7.8%) patients discharged directly from the ED, 11 of the 130 (8.5%) admitted to the hospital, and 1 of the 4 (25%) transferred patients had an unscheduled return ED visit. There was no difference in return to ED between ACS and NC-CP (RR 1.23, 95%CI 0.6 вЂ“2.5, pП0.57). There were no fatal outcomes in this cohort. Conclusions: There was good overall agreement between the diagnosis of ACS by the emergency physician and cardiologist, this might be related to the high rate of consulting to cardiologist, and however, 29% of the patients admitted for ACS were discharged after hospitalization with non-coronary CP as the principal diagnosis, increasing costs and hospitalization days. The implementation of a chest pain unit with a standardized protocol could be an alternative for this problem. There was an 8% of unscheduled ED visits, and there were no adverse outcomes in this cohort. 180 Epidemiology of Elevated Blood Pressure in Emergency Department Adhikari S, Shostrom V, Carson R/University of Nebraska Medical Center, Omaha, NE Study Objectives: Knowledge of distribution of elevated blood pressure (BP) in emergency department (ED) patients is useful for developing ED-based interventions for hypertension. No prior studies reported the prevalence of elevated blood pressure in different age groups, ethnic categories, different shifts, and severity of elevated BP in ED patients. The objective of this study is to determine the prevalence and demographics of elevated BP in ED patients. Methods: Retrospective, cross-sectional review of a tertiary care center ED electronic medical records. Patients with any systolic blood pressure (SBP) Пѕ140 mm Hg or diastolic blood pressure (DBP) Пѕ90 mm Hg over a one-year period were included. Two reviewers extracted data using a standardized data extraction form. Descriptive statistics are used to summarize the data. Data are presented as percentages with 95% confidence intervals. A Chi-Square test was used for comparisons. Results: A total of 44,435 charts were accessed. Overall, 47.6% (CI 47.2вЂ“ 48.1%) of patients had elevated BP, 53% (CI 52вЂ“54%) were women. Patients Пѕ 45 years were more likely to have elevated BP. The difference in age-specific prevalence of elevated BP among different age groups ПЅ 44 years (33%), 45вЂ“ 64 years (67%), and Пѕ 64 years (77%) was statistically significant (pПЅ0.01). The prevalence of isolated SBP elevation increased by age. But isolated DBP elevation was more prevalent among younger age groups. 59% of patients with isolated DBP elevation were ПЅ 45 years old. No significant differences were noted in the prevalence of elevated BP between whites (52% CI 51.6%вЂ“52.8%) and blacks (45% CI Annals of Emergency Medicine S55 Research Forum Abstracts 44%вЂ“ 46%). White women (48.8% CI 48 вЂ“ 49.6%) were slightly more likely to have elevated BP than all other groups. Blacks (45%) were more likely to have elevated BP compared to Hispanics (31%) (pПЅ0.01). Across all ethnic groups BP increased with age. 8.6% (CI 8.3вЂ“ 8.9%) had severe BP elevation (SBP Пѕ180 or DBP Пѕ120), 61% (CI 59 вЂ“ 62%) were women. 12% (CI 11вЂ“13%) of patients Пѕ 45 years and 30% (CI 28 вЂ“31%) of patients Пѕ75 years had severe BP elevation. Blacks (9%) were more likely to have severe BP elevation compared to Hispanics (4%) (pПЅ0.01). 64.3% (CI 63.6 вЂ“ 64.9%) of patients with elevated BP were discharged from ED. 44% (CI 42вЂ“ 45%) of patients with severe BP elevation were also discharged from ED. No statistically significant differences were noted in between different shifts and days of a week. Conclusions: This study provides knowledge of distribution of elevated BP among different age, sex and ethnic groups in ED which can be used to develop specific interventions to improve prevention, detection, and treatment of hypertension. 181 Describing Global and Tissue Level Perfusion in Congestive Heart Failure Patients Presenting to an Urban Emergency Department: A Pilot Study Sherwin R, Mango L, Medado P, Levy P/Wayne State University, Detroit, MI Study Objective: The primary objective of this study was to describe the initial (ПЅ 2 hours from arrival) hemodynamic and perfusion state in a prospective cohort of congestive heart failure (CHF) patients presenting to an urban emergency department (ED). Methods (Design, Setting, Type of Participants): This was an observational study at a Level I tertiary care center with an annual volume of Пѕ96,000 patients. All patients presenting to the ED with a chief complaint of dyspnea in whom CHF was a diagnostic consideration by the treating physician were consented and enrolled. Perfusion status was assessed in each patient using capillary lactate measurement (systemic perfusion), near infrared spectroscopy (tissue level perfusion) and impedance cardiography (cardic output). Furthermore, each patient underwent a vascular occlusion test (VOT) during which tissue oxygenation (StO2) response was monitoring during and following a three-minute period of arterial occlusion. Only patients whose final ED or hospital discharge diagnosis was CHF were included in the final analysis for this study. Results: Twenty-three patients were enrolled who had a final diagnosis of acute decompensated CHF. The mean age was 58.9 П® 13.6 years, 15/23 (70%) were male and 100% were black. All the patients were admitted to the hospital and the inhospital mortality was zero. The media BNP was 753 (IQR 463, 1410). Twelve patients (52%) had baseline capillary lactate levels Пѕ 2.0 mmoL suggesting systemic hypoperfusion. The mean capillary lactate, cardiac index and StO2 (tissue level oxygenation) was 2.6 П® 2.1 mmol/dL, 2.1 П® 1.1 L/min/m2, 74.3 П® 9.3% respectively. The mean measured minimum StO2 following the VOT was 52.9 П® 14.2%. In univariate analysis only BNP (p П 0.043), the minimum StO2 value (pП0.028) and time to peak StO2 Recovery (pП 0.031) were significantly associated with a hospital length of stay Пѕ 48 hours. Conclusions: In this pilot study, we found evidence of baseline hypoperfusion in patients with acute decompesated CHF which may be associated hospital outcome. Further defining these variables in this cohort may be useful in the initial assessment of these patients. 182 Performance of a Novel Spanish-Language Chest Pain Tool for Evaluation, Risk-Stratification, and Dissection/Fibrinolysis Screening in SpanishSpeaking Emergency Department Patients Slattery DE, Munassi D, Khine L, McCoy G, Forred W/University of Nevada School of Medicine, Las Vegas, NV; University of Nevada at Las Vegas, Las Vegas, NV; Kern Medical Center/UCLA, Bakersfield, CA; University Medical Center of Southern Nevada, Las Vegas, NV Background: Assessing Spanish (SP) speaking chest pain (CP) patients represents a unique, time-sensitive challenge for emergency physicians. It is critical to have the ability to quickly gather the necessary information to recognize and act on lifethreatening causes of CP; however, immediately available (in the emergency department) language translators are scarce. Study Objective: We sought to assess the performance of a novel CP tool that helps obtain pivotal history elements to: 1) Characterize the chest pain presentation; S56 Annals of Emergency Medicine 2) Obtain history for appropriate risk stratification; 3) Screen for factors suggestive of aortic dissection; and 4) Screen for absolute contraindications to fibrolinoysis. Design: Institutional review board-approved, prospective observational trial. Inclusion criteria: Adult (Пѕ18), solely SP-speaking patients, presenting to an academic, urban, ED via triage with non-traumatic CP. Exclusion criteria: patients with acute myocardial infarction, clinical instability, illiteracy. After initial electrocardiograms (EKG), subjects completed a 72-item SP questionnaire which was time stamped and collected prior to emergency physician assessment. Emergency physicians blinded to tool answers, utilized in-person certified SP translators to conduct their usual patient evaluation. Emergency physicians records were reviewed retrospectively by trained/monitored abstractors utilizing a standardized data collection tool. Our primary performance measure was the proportion of the history elements captured. (Пѕ 75% capture proportion was considered useful). We also compared capture proportions using the CP tool to those obtained during the usual ED evaluation. Data were analyzed as appropriate using NCSS statistical software. Results: We enrolled 54 patients, 8 were excluded, leaving 46 that comprised our cohort. The mean (SEM) age was 45.6(1.9) years and 67% were female. 7(15%) were diagnosed with ACS. The mean (SEM) 95%CI time to complete the tool was 13.9 (0.97); (11.9,15.8) minutes. The CP tool performed in the useful range for the following: determination of the quality П39(84%), pain intensity П38(82%), radiation 41(89%). Compared to the usual history, the CP Tool performed better for: determining quality of CP, time of onset, radiation, Framingham risk factors, TIMI score, and screening for fibrinolysis contraindications. The toolвЂ™s performance was equivalent to usual history taking for all other elements. (See table.) Limitations: Small sample size, high illiteracy rates. Conclusion: Our Spanish CP tool, in isolation, allowed proper characterization of CP but did not perform well enough for excluding dissection or fibrinolytic contraindications. Compared to the usual history taking, the tool performed better for some, and was at least equivalent on all other, pivotal historical elements. 183 Effects of Body Mass Index and B-type Natriuretic Peptide Level in Chronic Heart Failure Patients Phelan T, Chan W, Ewing J, Mahler S, Wang H/LSUHSC-Shreveport, Shreveport, LA Study Objectives: Obesity is known to be one of the risk factors for the development of chronic heart failure (CHF). The incidence and prevalence of both obesity and CHF are increasing rapidly in the United States and these 2 conditions are likely to be co-existed in 1 patient. The aim of this study is to investigate the relationship between obesity and the severity of CHF patient in the emergency department (ED). Methods: Clinical data and lab results were obtained from 125 CHF patients seen in ED from Jan. 2006 till Dec. 2007. These patients were all admitted to hospital. Patients were divided into 4 groups according to their body mass index (BMI). (Group 1 was morbid obese patients with BMI Х†40kg/m2, group 2 was obese patients with BMI 30 вЂ“ 40kg/m2, group 3 was overweight patients with BMI 24 вЂ“30 kg/m2, and group 4 was normal/ underweight patients with BMI Х…24 kg/m2.) Btype natriuretic peptide level (BNP) was compared in obese (group 1 and 2) and nonobese (group 3 and 4) groups. Multivariate regression analyses were performed to measure the severity of CHF and level of BNP in obese and non-obese groups. Results: BNP level was 832П®1259 pg/ml in group 1, 1349П®1425 pg/ml in group 2, 2064П®1548pg/ml in group 3, and 2772П®2466 pg/ml in group 4. The average BNP level in group1 and 2 was 1163П®1381pg/ml compared with 2451П®2115pg/ml in group 3 and 4 (pПЅ0.001). When analyzed using multivariate Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts regression model, there is no statistically significant difference between the level of BNP and the severity of CHF in non-obese patient group (pПѕ0.05). However, in obese CHF patients, when divided into 3 subgroups according to the level of BNP (higher BNP group with level Х†1000pg/ml, mid-level group with level between 500 to 1000pg/ml and lower BNP group with level Х…500pg/ml), BUN in higher BNP group was 42.2П®26.7mg/dl and low BNP group was 21.0П®13.5mg/dl (pПЅ0.03), Creatinine level in higher BNP group was 2.54П®1.69mg/dl and 1.25П®0.51mg/dl in lower BNP group (PПЅ0.03), The length of hospitalization in higher BNP group was 5.2П®2.3 days and lower BNP group was 3.9П®1.6 days (pП0.045). Conclusion: Higher BMI is associated with relatively lower level of BNP and the level of BNP is also reversely proportional to the severity of obesity in CHF patients. However, only in obese CHF patients, higher BNP is associated with worsening renal function and longer hospitalization stay. 184 Quantitative Meaning of Common Terms Like вЂњVery Low RiskвЂќ and вЂњLow RiskвЂќ for Chest Pain Patients Menchine M, Wiechmann W/University of California, Irvine, Irvine, CA Study Objectives: Although emergency physicians often use the terms low risk or high risk to describe chest pain patients, little is known about their quantitative meaning. We sought to assign a quantitative meaning for these common qualitative terms with respect to acute coronary syndrome and serious outcomes in chest pain patients. We also sought to identify the risk threshold at which emergency physicians admit or discharge these patients. Methods: We conducted a web-based survey of emergency medicine residents at 11 academic medical centers. Participants were given 5 case scenarios of common ED presentations for chest pain. The scenarios were designed to encompass a broad range of risk, although none had frank ST-elevation myocardial infarction. All participants received the same clinical scenarios - half were asked to qualitatively assess the risk of ACS and half were asked to assess the risk of serious complications (death, dysrhythmia, or congestive heart failure). For each scenario, participants were asked to evaluate the patientsвЂ™ risk as Very Low, Low, Moderate, High, or Very High. Once this determination was made, subjects were asked to quantify the exact risk the patient had and choose an appropriate disposition for the patient. Responses were grouped according to the qualitative risk categorization and the mean quantitative response was tabulated for each of the 5 categories. The admission rate for each risk category was also evaluated. Descriptive statistics are presented. Results: 217 physicians (90.6% residents) completed the questionnaire. For cases that were categorically coded as Very Low Risk of ACS, the median quantitative risk was 0.088% [IQR 0.009 вЂ“ 0.20%] with an associated admission rate of 7.14% [CI 0 вЂ“15.2%]. Those coded as Low, Moderate, High, and Very High Risk had values of 0.45% [IQR 0.1вЂ“1.0%], 1.05% [IQR 1.0 вЂ“2.29%], 3.33% [IQR 1.6 вЂ“10%], and 10% [IQR 2.94 вЂ“20%], respectively, with admission rates of 31.6% [CI 23.1вЂ“ 40.1%], 93.8% [CI 90.1вЂ“97.3%], 100% [CI 97.1вЂ“100%], and 100% [CI 93.7вЂ“100%] respectively. Cases coded as Very Low Risk for serious complications had a median quantitative risk of 0.015% [IQR 0.009 вЂ“ 0.1%] with an associated admission rate of 1.89% [CI 0 вЂ“5.7%]. Those coded as Low, Moderate, High, and Very High Risk had values of 0.25% [IQR 0.09 вЂ“1.0%], 1% [IQR 0.49 вЂ“2%], 1.68% [IQR 1вЂ“ 4%], and 5%[IQR 1.0 вЂ“10%] respectively, with admission rates of 42.3 [CI 33.7вЂ“50.9%], 92.4% [CI 88.4 вЂ“96.4%], 99.3% [CI 98.1вЂ“100%], and 100% [CI 92.1вЂ“100%] respectively. Conclusion: This is the first study to determine the quantitative meaning of the common terms Very Low, Low, Moderate, High, and Very High Risk with respect to chest pain scenarios. High rates of admission are seen for patients assessed as Moderate, High, and Very High risk. Quantitative risk assessments were similar when physicians were asked to assess the risk of ACS or assess the risk of serious complications despite epidemiologic evidence that these should markedly differ. This finding merits further study. 185 Asymptomatic Bacteriuria: Is the Presence of Microscopic Bacteriuria Without Pyuria in Asymptomatic Pregnant Females Associated With Positive Urine Culture? A Retrospective CrossSectional Study Hile D, Cashin B, Crouch R, Strode C/Madigan Army Medical Center, Tacoma, WA Study Objectives: Urine samples are frequently collected from pregnant females in the acute care setting during triage, or as part of initial workup, regardless of the Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ presence of symptoms consistent with urinary tract infection. Asymptomatic cultureproven bacteriuria in pregnant females is typically treated with antibiotics due to concern for risks to the pregnancy and the development of pyelonephritis. In the acute care setting, it is common practice to treat patients with abnormal urinalysis results, as patient follow-up for culture results may be problematic. While the sensitivity and specificity of the various components of microscopic urinalysis have been well described, there is a paucity of literature comparing culture results of abnormal urinalyses to normal urinalyses in asymptomatic pregnant females. Our objective was to determine if there is a significant difference in positive culture results in pregnant patients whose urinalysis is positive only for microscopic bacteria, as compared to those with normal urinalysis. Methods: A retrospective cross-sectional study was performed on pregnant females who presented as outpatients to a military treatment facility (MTF), and had both a urinalysis and urine culture performed. Pregnant females aged 18 вЂ“50 were included who denied symptoms of urinary tract infection. Exclusion criteria included symptoms of urinary tract infection, urinalysis positive for markers other than bacteria, or incomplete information regarding symptoms, urinalysis or culture results. The study variables included positive or negative microscopic bacteria on urinalysis, and positive or negative urine culture. The data was summarized by comparing proportions with 95% confidence interval for positive culture results in both groups. Results: All pregnant females who presented to an MTF in 2008 вЂ“ February 2009, and had a urinalysis and urine culture performed, were identified via computer data extraction. A total of 3547 charts were reviewed. 2552 charts were excluded due to incomplete data or exclusion criteria. 995 patients were included; 473 with urinalysis abnormal only for presence of bacteria, and 522 with normal urinalysis. Nine patients with bacteria noted on urinalysis had positive urine cultures; 1.9% (95% confidence interval, .95% to 3.6%). Twelve patients with normal urinalysis had positive urine cultures, 2.2% (95 % confidence interval, 1.3% to 4.0%). Conclusion: There was no significant difference between proportions of positive culture results in the groups evaluated in our study. In this study population, pregnant patients without symptoms of urinary tract infection whose urinalysis is positive only for bacteria do not have a significantly greater incidence of bacteriuria as defined by culture results, compared to those with completely negative urinalyses. It may be reasonable to withhold antibiotics from asymptomatic pregnant females whose microscopic urinalysis demonstrates presence of bacteria without other indicators of infection. 186 Tamsulosin Does Not Increase One-Week Rate of Passage of Ureteral Stones in Emergency Department Patients Lipe KM, Ziadeh J, Bui D, Swor R, Jackson R, Ross M/William Beaumont Hospital, Royal Oak, MI Study Objective: Our objective was to determine if tamsulosin monotherapy improves rates of ureteral stone passage at one week or time to pain resolution, compared to placebo. Methods: We conducted a prospective, double-blind, randomized, trial of Tamsulosin compared to placebo in the treatment of ureterolithiasis, with a primary outcome of proportion of stones passed at 7 days. Emergency department (ED) patients who presented with documented kidney stone by Helical CT between April 2007 and February 2009 were considered for inclusion. Patients received standard analgesia and either tamsulosin or placebo for a total of 10 days. A structured telephone survey was conducted at days 2, 3, 5, 7, and 10 to assess for stone passage and pain scores. Exclusion criteria included stone Пѕ 8mm, patients who required immediate surgical intervention, concurrent infection, and presence of ureteral stent. Our power analysis, based on previous reports, assumed a one-week passage rate with tamsulosin of 85% and placebo of 60%. Based on an alpha error of 0.05 and power of 80%, we needed 57 subjects per group. Chi square and FisherвЂ™s exact test were used for analysis. Results: 127 patients were enrolled over a 22-month period; 15 were lost to follow-up and 12 required a surgical intervention before 7 days, leaving 100 patients for analysis. Of these, 47 received placebo and 53 received tamsulosin. Groups were similar for age, sex, initial serum creatinine, initial pain score on ED presentation, location of stone, proportion of stone ПЅ 6 mm, history of prior stone or stent, and degree of hydronephrosis. There was no difference in pain medication usage between the two groups at days 2, 3, and 7. The percentage of patients who had stone passage Annals of Emergency Medicine S57 Research Forum Abstracts within seven days was 42.2% in the placebo group and 44.2% in the tamsulosin group, with FisherвЂ™s exact П 1.00. Conclusion and Discussion: In this study, there was no statistical difference in the proportion of stone passage at 7 days between tamsulosin and placebo. We observed a lower one-week pass rate than previous reports. We also did not find a difference in pain medication requirements between patients in the two groups. Limitations of this study include non-consecutive enrollment and small sample size. Further investigation should be performed with a larger sample size and should include combination therapy. 187 Value of Head CT in Syncope Patients in the Emergency Department VeВґlez I, Bellolio MF, GonzaВґlez JA, Decker W, Stead L, Serrano LA/University of Puerto Rico School of Medicine, Carolina, PR; Mayo Clinic, Rochester, MN; University of Rochester, Rochester, NY Background: Patients with syncope often undergo extensive and expensive workup in order to rule out serious causes for the event. Current guidelines do not recommend the routine screening of syncope with advance imaging, such as head computed tomography (head CT) in the absence of focal neurologic findings, but it is still a common practice among physicians. Study Objectives: Our goal was to determine the usefulness of head CT scan aiding in diagnosing the cause of syncope in patients presenting to an academic emergency department (ED) in Puerto Rico. Methods: Retrospective cohort study of consecutive patients who presented to a single academic ED in Puerto Rico during a 12-month period with documented syncope. We evaluated how many patients had a head CT ordered and among them, how many had abnormal results. The primary outcome was an abnormal head CT with relevant findings to the cause of syncope defined as: epidural or subdural hematoma, intracerebral hemorrhage, ischemic stroke or brain mass. Non-parametric test were used accordingly to the skewed distribution of the data. Results: A total of 210 patients presented to the ED with a diagnosis of syncope between January and December 2007, 47 patients were excluded because have neurological deficit, seizures, hypoglycemia, near syncope or were younger than 18 years old. A total of 163 patients were included in the study. The mean age was 63.2 П© 19.9 years and 56% were females. A total of 141 (87%) patients had a head CT ordered, and among them only 2 (1%) had an abnormal head CT. Those with a head CT ordered were older (72 vs. 46 years, pП0.0001), had a first-time syncope (69% vs. 31%, pП0.0001) and had history of hypertension (92% vs. 8%) when compared to those without head CT performed. Conclusions: Head CT is frequently used in syncope patients. This study supports the evidence that head CT for syncope in the absence of focal neurologic findings or significant head trauma may not be indicated and does not aid in the clinical management. By limiting its use we will decrease the overall cost of syncope evaluations. 188 Evaluation of a Non-Contact Infrared Thermometer in an Adult Emergency Department Patyrak S, Luber S/UT Southwestern, Dallas, TX Study Objectives: Temperature measurement is an essential component of patient vital signs. While the pulmonary artery catheter thermistor is the gold standard for core temperature measurement, this method is invasive and impractical in emergency department (ED) patients. ED providers need a rapid, accurate and non-invasive method to measure patient temperatures. The ThermoFocusв„ў non-contact infrared thermometer is a novel device that meets these needs while also eliminating the need for probe covers. Therefore, we set out to evaluate this thermometer and compare its agreement with the currently used non-invasive methods of oral and tympanic thermometry. Methods: A convenience sample of adult patients presenting to an urban, teaching hospital ED with a census of 87,000 patients was evaluated June thru August 2008. Patients were screened prior to enrollment for oral and/or facial trauma. In addition, patients were equilibrated to ambient temperature for a period of 5 minutes and any residual moisture was wiped from face. Temperatures were taken three times at each of four locations: Left sublingual fossa using the Filacв„ў 3000 AD (Kendall, Mansfield, MA), left tympanic membrane using Genius 2в„ў (Kendall, Mansfield, MA), center of forehead and left temple using the Thermofocusв„ў Infrared Thermometer (Technimed, Italy). S58 Annals of Emergency Medicine Results: 298 patients aged 18 вЂ“ 88 years (mean 44.1 years, SD 13.9) were evaluated. Oral temperatures ranged from 92.3В°F ПЄ102.2В°F (mean 97.7В°F, SD 0.95). Tympanic temperatures ranged from 93.4В°F ПЄ101.5В°F (mean 97.0В°F, SD 0.96). Center of forehead temperatures ranged from 94.2В°F ПЄ100.0В°F (mean 97.2В°F, SD 0.89). Temple temperatures ranged 95.7В°F ПЄ101.4В°F (mean 97.7В°F, SD 0.88). Bland-Altman analysis was used to evaluate agreement between temperatures at the different locations. Center of forehead to tympanic measurements demonstrated a bias of 0.26В°F (SD 0.90) with 95% limits of agreement (LOA) of ПЄ1.51 to 2.02В°F. Center of forehead to oral comparison demonstrated bias of ПЄ0.51В°F (SD 1.03) with 95% LOA of ПЄ2.52 and 1.51. Center of forehead to temple demonstrated bias of ПЄ0.49 (SD 0.63) with 95% LOA of ПЄ1.72 and 0.75В°F. Oral to tympanic comparison demonstrated bias of 0.76 (SD 0.74) with 95% LOA of 0.69 to 2.22В°F. Temple to tympanic comparison demonstrated bias of 0.74 (SD 0.95) with 95% LOA of ПЄ1.11 to 2.56В°F. Temple to oral comparison demonstrated bias of ПЄ0.02 (SD 0.99) with 95% LOA of 1.96 to 1.92В°F. Conclusion: While the bias between the Thermofocusв„ў and oral/tympanic thermometers was less than 1В°F, the disagreement between thermometers was as large as 2.5В°F. This disagreement would be unacceptable in many clinical circumstances. Of note, the tympanic and oral thermometers demonstrated poor agreement with each other. Ultimately, we cannot recommend the use of the Thermofocusв„ў thermometer in adult ED patients at this time and recommend further investigation into the accuracy of oral and tympanic thermometers. 189 Accuracy of Point-of-Care Finger Stick Hemoglobin Compared to Laboratory Value Morris DF, Guluma K/UCSD, San Diego, CA Study Objective: Point-of-care finger-stick hemoglobin (FS Hgb) measurement is frequently used in the emergency department (ED) to obtain a rapid estimate of a patientвЂ™s Hgb concentration. In many cases the value obtained influences patient care by leading the emergency physician to conclude that either clinically significant or insignificant bleeding is occurring. The device used to determine FS Hgb in our ED uses azide-methethemoglobin spectrophotometry to measure capillary Hgb concentration. Prior studies have only evaluated the accuracy of such a device in a stable outpatient population. There is no published data on the accuracy of the this type of FS Hgb measurement compared to a Hgb from a hematology laboratory complete blood count (Lab Hgb) as performed in an ED setting, where it might be used to screen patients suspected of having acute or critical blood loss. Methods: We examined all patients evaluated in the ED over a six-year span (Jan2003вЂ“Dec-2008) who had both a FS Hgb and a Lab Hgb. At our institution, we use electronic records into which point-of-care and laboratory results are incorporated. Records are retrieved utilizing searchable criteria, and using this system, 8585 records were retrieved. Since patient clinical status may change or bleeding may be ongoing between the two types of measures, we used a maximum of two hours between the FS Hg and correlating Lab Hgb in order to minimize this effect. 1884 records were excluded due to a time difference of greater than two hours leaving 6701 total records. Results: The Lab Hgb had a median of 12.2 g/dl with an interquartile range (IQR) of 10.1 to 13.8. The FS Hgb had a median of 12.0 g/dl with an IQR of 9.8 to 13.8. The average difference between the two values was 0.77 g/dl (6.8%) with a standard deviation of 0.96 g/dl. The difference between the FS Hgb and Lab Hgb values was statistically significant with a P-value ПЅ0.05. The correlation coefficient was 0.91. 74.8% of the FS Hgb values were within 1g/dl of the Lab Hgb value; however, 7.5% were more than 2g/dl apart, with a maximum difference of 11.2 g/dl. There was a normal distribution to the difference between the FS Hgb and Lab Hgb (47.1% of FS HgbвЂ™s were less and, 46.6% were greater than their counterpart Lab Hgbs). Conclusion: For a large majority of patients the FS Hgb is moderately accurate and represents a value within 1 g/dl of the patientвЂ™s Lab Hgb. However, in almost 8% of patients the discrepancy between the FS Hgb and the Lab Hgb was П® 2 g/dl (approaching 10 to 11 g/dl in some patients), which we consider to be clinically significant, given the distinct possibility that such a difference in the two might lead to different clinical decisions with regards to transfusion, disposition, and evaluation in certain clinical scenarios. Based upon this it seems that it would be risky to base clinical decisions upon only the value of the FS Hgb. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts 190 Fear of Brain Herniation From Lumbar Puncture: Do History and Physical Exam Indicate Abnormalities on Head Computed Tomography? OвЂ™Laughlin KN, Go S, Gabayan GZ, Iqbal E, Merchant G, Lopez-Freeman R, Zucker MI, Hoffman J, Mower W/Harvard Medical School, Boston, MA; University of Kentucky Medical Center, Lexington, KY; Greater Los Angeles VeteransвЂ™ Affairs, Los Angeles, CA; UCLA School of Medicine, Los Angeles, CA; UCLA Medical Center, Los Angeles, CA; University Hospital in Cincinnati, Cincinnati, OH Study Objectives: There is a fear that performing a lumbar puncture (LP) on a patient with increased intracranial pressure (ICP) may lead to tonsillar herniation. Because of this, many physicians first check a screening head computed tomography (CT) looking for abnormalities suggestive of elevated ICP. Checking a head CT on every patient prior to LP is time consuming, costly, and exposes patients to significant radiation. Our goal was to define clinically significant head CT abnormalities and then to analyze the ability of certain history and physical exam findings to predict those radiographic findings. Methods: This was a secondary analysis of a prospectively maintained head CT database of patients presenting to the UCLA Medical Center Emergency Department between April 2006 and February 2007. We used the Delphi method to define clinically significant radiographic head CT abnormalities. We then analyzed the test characteristics for history and physical exam findings in predicting clinically significant head CT abnormalities. Results: When analyzed individually, the history and physical exam findings did not predict significant head CT abnormalities well. The most sensitive individual findings were: the presence of a neurological deficit, sensitivity 68.9% (CI 53.4, 81.8) and NPV 93.4% (CI 89.1, 96.3); altered level of consciousness, sensitivity 67.39% (CI 52.0, 80.5) and NPV 91.8% (CI 86.8, 95.3); and lack of proper orientation, sensitivity 65.1% (CI 49.1, 79.0) and NPV 92.1 (CI 87.3, 95.5). Using the combined criteria of all of the history and physical exam findings together, the sensitivity for predicting clinically significant head CT abnormalities was good but not perfect. The sensitivity for the combined criteria was 95.7% (CI 85.5, 99.5) and the NPV was 96.1% (86.5, 99.5). Conclusions: Our data suggests that history and physical exam alone may be inadequate to detect the subtle head CT changes that could indicate potential for brain herniation as defined by the Delphi criteria. Despite that finding, we acknowledge the major limitation that our outcome measure was radiographic abnormalities rather than actual brain herniation, which makes it difficult to extrapolate concrete conclusions regarding the clinical relevance of this information. We think that the likelihood of herniation is much lower than the Delphi criteria caution and that because of this the head CT criteria we used are too sensitive. 191 Disease and Non-Battle Traumatic Injuries Evaluated by Emergency Physicians in a U.S. Tertiary Combat Hospital Bebarta VS, Mason PE, Ferre RM, Eadie JS, Muck AE, Joseph J, Pitotti RL/ Wilford Hall Medical Center, San Antonio, TX; University of Pittsburgh, Pittsburgh, PA Study Objectives: Emergency physicians have played a central role in medical care delivery in Operation Iraqi Freedom. Medical war planning has focused on combatrelated injuries; however, since 2004 nearly half of the patients treated in a tertiary U.S. combat hospital in Iraq are not combat related. In order to plan for future wars and properly train emergency physicians, the common emergent and urgent noncombat diagnoses and complex procedures performed should be identified. These data have not been previously collected or studied to determine the types of noncombat injuries and illnesses seen at a tertiary combat hospital and the types of procedures performed to manage these patients. Methods: In our institutional review board-approved study, we enrolled all noncombat injured patients over one year who were evaluated in the emergency department (ED) of a US military tertiary hospital in Iraq. The treating emergency physician used a standard data collection form to enroll all patients who arrived to the ED whose injury or illness was unrelated to combat. Data collected included age, time of visit, ED diagnoses, emergency procedures, disposition, and consultations. The diagnosis and procedure lists were defined before study start. Results: Data were gathered on 1745 patients with a mean age of 30.2 years (range 6 months вЂ“ 72 years). 1460 (83%) patients were male and 1316 (75.4%) were U.S. military personnel, with Iraqis, foreign military members and third country nationals making up the remaining. The most common diagnoses evaluated in the ED were abdominal disorders (302 cases, 17.3%), orthopedic injuries (209, 12%), headache (108, 6.2%), ophthalmologic injuries (106, 6.1%), lacerations or abrasions (99, 5.7%), soft tissue Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ infections (94, 5.4%), and renal colic (88, 4.7%). Emergent medical diagnoses consisted of 10.2% (179) of cases (aortic dissection, meningitis, altered mental status, overdose, pulmonary embolism, intestinal bleeding, acute myocardial infarction, chest pain, atrial fibrillation). Urgent medical diagnoses consisted of 4.4% (78) of cases (pneumonia, diverticulitis, deep venous thrombosis, seizure, syncope). Emergent surgical diagnoses consisted of 10.7% (186) of cases (appendicitis, cholecystitis, bowel obstruction, peritonsillar abscess, fracture, dislocation, gunshot wound, eye trauma, brain injury). 52% (909 cases) required IV access, 45% (793) received laboratory testing, 31% (537) received radiographs, and 28% (488) received CT scans. Complex procedures include ECG interpretation (9%, 160 cases), lumbar puncture (1.1%, 20), procedural sedation (0.8%, 14), endotracheal intubation (10), and central line (4). 4.5% of cases were admitted to the operating room, 6.5% to the ICU, and 21.6% to the ward. 12.6% of patients were evacuated out of Iraq. Conclusion: Life-threatening diseases and non-battle traumatic injuries are common in a tertiary-combat hospital emergency department. Providers working in similar settings should have diagnostic and procedural skills to evaluate and treat a range of emergently ill patients. 192 The Utility of HbA1C Screening in Low Risk Chest Pain Patients in the Emergency Department Observation Unit Wiederhold H, Swor R, Robinson D, Clark CL/William Beaumont Hospital, Royal Oak, MI Background: The American Heart Association and The American Diabetes Association recommend early identification of pre-diabetic and undiagnosed diabetic populations. HbA1C has been shown to be an independent predictor of Type 2 diabetes. Previous studies have shown low yield for the use of HbA1C as a screening tool in the general emergency department population. Study Objective: To identify the proportion of non-diabetic patients with abnormal HbA1C within an Emergency Department Observation Unit (EDOU) population of low risk chest pain patients. Methods: We performed a retrospective review of patients admitted to the EDOU at a large academic community hospital for low risk chest pain evaluation from August 1, 2008 through September 18, 2008. Patient data was extracted for patient demographics, known history of diabetes, current treatment for hyperglycemia, random glucose and HbA1C levels. We dichotomized values of random glucose levels Пѕ 110 mg/dl and HbA1C levels greater than 5.9%, per recommended screening levels, and calculated the proportion of possibly undiagnosed diabetic patients. We assessed whether abnormal random glucose levels might identify a similar proportion of non-diabetic patients as found by abnormal HbA1C levels. Results: During the study period, 457 low risk chest pain patients were admitted to the EDOU. Of these, 342 received HbA1C and random glucose testing. These patients were 60.8% male, their mean age was 57.9 П©/ПЄ 15.38 years and 279 patients had no known history of diabetes. Of patients with no known history of diabetes, 66 (23.7%) were found to have elevated HbA1C and 85 (30.5%) were found to have elevated random glucose. 36 (54.5 %) patients with elevated HbA1C had random glucose levels within the normal range. Conclusion: Screening evaluation by HbA1C of EDOU low risk chest pain patients appears to identify patients with impaired glucose metabolism not found by random glucose screening alone. Prospective studies of low risk chest pain patients should be done to validate and assess the value of using elevation of HbA1C as a screening tool. 193 A New Study of Intraosseous Blood for CBC and Chemistry Profile Miller L, Philbeck T, Montez D, Spadaccini C/Vidacare Corporation, San Antonio, TX; Ameripath, Inc., San Antonio, TX Study Objectives: Recent studies have indicated a resurgence in using the intraosseous (IO) route for vascular access because of improved devices that enable providers to deliver critically needed drugs systemically as quickly as central lines, and faster than peripheral lines. Increased awareness of IO vascular access has led to questions about other uses of the IO space, including the viability of IO blood for routine laboratory analysis. Despite earlier studies, some laboratory personnel have voiced concern over the adequacy of the data supporting the use of IO-derived blood for routine laboratory tests. This study was designed to validate earlier studies and address these concerns. Methods: The study was approved by IntegReview Institutional Review Board and 10 healthy adult volunteers were recruited. After written consent, standard phlebotomy blood samples were obtained. Following phlebotomy, an IO catheter (EZ-IOВ®, Vidacare Annals of Emergency Medicine S59 Research Forum Abstracts Corporation, San Antonio, TX, USA) was placed in the proximal humerus and two sets of IO blood samples were obtained; one following 2ml of marrow/blood waste, and one following 6ml of waste. All three samples sets were sent to a reference laboratory for chemistry profile and complete blood count (CBC) analysis. Means for each value for the three blood draws (designated IV, IO-1, and IO-2) were calculated and compared with the intravascular (IV) blood serving as a control for the IO draws. Results: For IO-1, mean red blood cells (RBC), hemoglobin (Hgb), hematocrit, glucose, blood urea nitrogen (BUN), sodium, chloride, total protein and albumin levels were within 5% of mean values from IV blood. For IO-2, mean Hgb, glucose, BUN, sodium, chloride, total protein and albumin levels were within 5% of mean values from IV blood. For both IO samples, most other values were within 10% of IV blood. Conclusion: In the first study of its kind in 15 years, we have found that the intraosseous space is a reliable source for blood used for laboratory analysis commonly performed in emergency medicine, including CBC and chemistry profile. Results may be moderately reliable for carbon dioxide, but unreliable for WBC counts that appear to be elevated and platelets counts that appear lower. 194 The Use of a Subcutaneous Insulin Aspart Protocol for the Treatment of Hyperglycemia in the Emergency Department: A Randomized Clinical Trial Harper JB, Barnard J, Munoz C, Baldwin D/Rush University, Chicago, IL Study Objective: Emergency physicians have a unique and challenging interaction with patients who have diabetes. Such patients commonly present with significant hyperglycemia. Patients presenting with a specific diabetes-associated illness routinely have the complaint directly addressed and treated. However, when patients present with a non-diabetic chief complaint, there are no established protocols for how best to address the common issue of hyperglycemia. We prospectively evaluated a SQ insulin protocol for use in the emergency department (ED) in patients with known Type 2 diabetes mellitus (DM) and hyperglycemia. Methods: Patients with Type 2 diabetes had a point-of-care blood glucose (BG) measured soon after ED presentation; those with BG Пѕ200mg/dL were randomized to an intervention group (INT) vs. usual care (UC). All INT subjects (nП66) received subcutaneous insulin aspart (0.05 U/kg for BG 200 вЂ“299mg/dL, 0.1 U/kg for BG 300 вЂ“399mg/dL, 0.15 U/kg for BG Х† 400mg/dL) every 2 hours until BG ПЅ200 mg/dL. Insulin aspart was chosen for this protocol because its onset of action is 30 minutes and it can be redosed every 2 hours, thus making it easy for implementation in a busy ED. Emergency physicians treated UC subjects (nП72) at their discretion, and 49% did not receive insulin. Subsequent blood glucose was measured every 2 hours in the ED until discharge home or hospital admission. Results: Mean initial ED BG for all subjects enrolled in the study was 299 П®78 mg/ dL. At ED discharge either to home or the hospital, the mean BG decreased by 76 П®67 mg/dL with INT, and by 82 П®77 mg/dL with UC (ns). 47 UC subjects were admitted to the hospital, and 43% of those had received SQ insulin aspart in the ED, while 40% of INT subjects were admitted. When the first BG after admission to the hospital was assessed, however, the mean decreases from the first ED BG were greater: UC subjects who received insulin decreased 131 П®104 mg/dL, while UC subjects who did not receive insulin only decreased 33 П®67 mg/dL (pП 0.04). INT subjects decreased 104 П®80 mg/ dL. Only 1 subject had a BG reading less than 100 mg/dL (76 mg/dL). Mean ED length of stay was similar, INT 5.4 П®1.8 hours, UC 4.8 П®1.8 hours (ns). Conclusion: A weight-based protocol for dosing SQ insulin aspart every 2 hours in the ED for the treatment of hyperglycemia in patients with Type 2 diabetes was safe and effective. This protocol was easy for physicians to determine insulin dosing and nursing to administer without significantly increasing ED length of stay. The insulin treatment of ED patients with hyperglycemia achieves rapid and significant lowering of BG. A higher unit per kg insulin dosing algorithm can achieve greater decreases in BG; however, our previous pilot study found an excess of hypoglycemia. Thus these doses seem optimal. Further study is required to delineate possible benefits to patients who are subsequently admitted to the hospital. 195 Refusals of Medical Aid in the Out-of-Hospital Setting Waldron R, Finalle C, Mogelof D/New York Hospital Queens, Flushing, NY Study Objective: Our research examined the characteristics of both patients and EMTs who are involved in the Refusal of Medical Aid (RMAs.) As well, we studied the timing of RMAs both by shift and within an individual shift. Methods: The study was carried out using data from the New York Hospital S60 Annals of Emergency Medicine Queens (NYHQ) ambulance service, which is a large urban ambulance service providing 9-1-1 basic life support and advanced life support care. This was a retrospective chart review of all patient charts in which the patient RMAвЂ™d for the time period 8/1/05 through 7/31/06, a one-year period. These patients were then compared to a control set of patients that was created by reviewing every chart in a 24-hour period for ten randomly selected days within the same one-year period. The data was obtained from the patient care reports that are scanned by NYHQ EMTs into HealthEMS database. Data analysis was performed using SAS 9.1 for Windows. For continuous variables, the StudentвЂ™s t test was used to test for differences between the control and research groups. For categorical variables, the Chi-Square test was used and the FisherвЂ™s Exact test was used if cell counts were less than 5. Results: The RMA data set had a total of 238 patients, 58% female and 42% male, with a mean age of 56. The control data set had a total of 303 patients, 53% female and 47% male, with a mean age of 53. There was no difference in the sex distribution between the RMA and control groups (P ПЅП 0.2965.) There was also no difference in average age of the RMA and control patients on the day and evening shifts (P П 0.1764 & 0.0711). However, on the night shift the patients in the RMA group were significantly younger mean age of 47 in the research group versus 55 in the control group (P П 0.0160). The EMS team consists of two EMTs. The presence of a male on the team increased the likelihood of an RMA. The EMT teams in the RMA set were 0.42% female/female, 7.1% male/female, and 92.4% male/male. The EMT teams in the control set were 4.6% female/female, 34.7% male/female, and 60.7% male/male. The higher percentage of male EMTs in the RMA set achieved statistical significance (P ПЅ 0.0001). The sex of the EMT team versus the sex of the patient had no effect on increasing RMAs (P П 0.9936). The patientвЂ™s chief complaint was significantly different in the RMA versus control groups. The RMA group had more neurological, psychiatric, and social chief complaints. (P ПЅ 0.0001) This difference holds true for both day and evening shifts (P П 0.0003, 0.0001); however, on night shifts there is no significant difference in chief complaints (P П 0.0812). In the RMA group, the shifts were 35.7% day, 41.6% evening, and 22.7% night. In the control group, the shifts were 51% day, 30% evening, and 18.5% night. RMAs were more common on the evening and night shifts (P П 0.0011). The calls were also broken down as to whether occurring in the first two hours of the shift, the middle four, or the last two hours. There was no difference in the frequency of RMAs based on the timing within the shift. (P П 0.5488). Conclusions: The call most likely to generate an RMA contains the following set of characteristics: a younger patient with a chief complaint falling out of the usual medical categories like trauma or cardiac, two male EMTs on the team, and an evening or night shift. The commonly held perception that RMAs are more common at the end of a shift (to avoid working late) was proven to be untrue. 196 Intubation Success Rates in Helicopter Emergency Medical Services: A Prospective Multicenter Analysis Patel P, Melissa S, Brunko M, Domeier R, Funk D, Greenberg R, Judge T, Lowell M, MacDonald R, Madden J, Thomas S, Howard Z/Harvard Affiliated Emergency Medicine Residency, Boston, MA; Massachusetts General Hospital, Boston, MA; Flight for Life Colorado, Denver, CO; Midwest MedFlight, St. JosephвЂ™s Mercy Hospital, Ypsilanti, MI; LifeNet of New York, Albany Medical College, Albany, NY; PHI Air Medical StatAir, Texas A&M University, Temple, TX; LifeFlight of Maine, Bangor, ME; Survival Flight, University of Michigan Health Sciences Center, Ann Arbor, MI; ORNGE Transport Medicine, University of Toronto, Toronto, Ontario, Canada; Christiana Care, Wilmington, DE; University of Oklahoma School of Community Medicine, Tulsa, OK; Brigham and WomenвЂ™s Hospital, Boston, MA Study Objectives: The Critical Care Transport Collaborative Outcome Research Effort (CCT-CORE) Airway Study is a multicenter analysis of air medical programsвЂ™ performance on airway management variables defined by the National Association of Emergency Medical Services Physicians (NAEMSP). This study examines the success rate of endotracheal intubation (ETI) in air transport programs across a variety of settings. It also examines whether there are lower success rates for air medical crews attempting ETI in patients in whom ETI by non-air medical providers has already failed. Methods: This was a prospective consecutive-case series of patients undergoing air medical transport in whom advanced airway management was attempted. There were 11 participating sites, and all crews had access to RSI drugs. Eligible subjects included all patients in whom air transport crews attempted advanced airway management. Prospectively defined data points were collected and entered into a secure Web-based data entry system. The primary analysis for this report was descriptive, focusing on ETI success rates (reported with exact binomial 95% Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts confidence intervals); for analysis of categorical variables FisherвЂ™s exact and Pearson chi-square was used (p ПЅ .05 for all tests). Results: There were 603 total attempts at airway management, and 582 (96.5%, 95% CI 94.7вЂ“97.8%) were successful with either oral or nasal ETI. Of 603 total attempts, 182 cases (30.2%, 95% CI 26.5вЂ“34.0%) had failed ETI attempts prior to the arrival of flight crews. Air medical crews successfully intubated 175 of the 182 patients (96.2%, 95% CI 92.2вЂ“98.4%) in whom pre-air medical airway management failed; pre-CCT crew airway management failure was not associated (p П .81) with likelihood of CCT crewsвЂ™ ability to successfully perform ETI. Success of intubation was not associated with age, weight, or presence of cervical spine immobilization. It was, however, associated with need for multiple attempts (Pearson chi-square pПЅ0.001) and a more limited Cormack-Lehane grade view (FisherвЂ™s exact pП0.001). Conclusion: ETI success rates remain high in air medical programs. It is not necessarily unsafe for air medical crews to proceed with ETI attempts, even if previous attempts at airway management have failed. 197 Endotracheal Tube and Laryngeal Mask Airway Cuff Pressures Can Exceed Critical Values During Air Transport Miyashiro R, Yamamoto L/University of Hawaii John A. Burns School of Medicine, Honolulu, HI Study Objectives: Aeromedical transport planes keep cabin pressure between 1700 to 2500 meters of equivalent altitude. Unpressurized helicopter transports fly at about 1700 meters. During ascent, ambient pressure decreases and any fixed volume of gas will expand, therefore increasing the relative pressure in the container. It has been shown that tracheal mucosa perfusion is compromised at an endotracheal tube (ETT) cuff pressure of 30 cmH2O, and blood flow is obstructed at pressure of 50 cmH2O. Methods: We measured the change in pressure of the inflated cuffs of 6.0 and 7.5 ETTs and a size 4 laryngeal mask airway (LMA) from sea level to 2400 meters. The ETTs and cuff measurements were done with the devices uncontained, and an additional 6.0 ETT was placed in a 10 mL syringe barrel to mimic placement in a trachea. This latter model restricted cuff expansion simulating what would occur when it is placed within the trachea. Results: By linear regression, the pressure within the ETT cuffs increased with elevation by 3.0 cmH2O (6.5 ETT), 2.1 cmH2O (7.5 ETT), 7.4 cmH2O (LMA), and 6.4 cmH2O (6.5 ETT contained within trachea) per 100 meters of increasing elevation. Note that pressure increases faster when the ETT cuff is contained within the rigid syringe barrel because cuff size expansion is restricted. The trachea is not as rigid as the syringe barrel, thus, the ETT cuff pressure within the trachea should increase at a rate of somewhere between 3.0 and 6.4 cmH2O per 100 meters. Starting at an ETT cuff pressure of 20 cmH2O would result in a pressure of 50 cmH2O (the critical value) somewhere between 468 and 1000 meters elevation. At a typical flight altitude of 2000 meters, the ETT cuff pressure would increase to a pressure of somewhere between 80 and 148 cmH2O. LMA cuff pressures increase more rapidly despite being unrestricted because of the greater thickness and lower compliance of the plastic comprising the cuff. Conclusion: This model indicates that ETT cuffs inflated prior to air transport are likely to exceed critical pressure levels rapidly during flight. Additionally, there will be loss of ETT cuff pressure (with loss of a good seal) during descent if a cuff is inflated at peak higher altitudes. ETT cuff pressures should be monitored and adjusted continuously during ascent and decent. 198 Injury Incidence and Predictors on a Mass Bicycle Ride Boeke P, House H/University of Iowa, Iowa City, IA Study Objectives: The вЂњRegisterвЂ™s Annual Great Bike Ride Across IowaвЂќ (RAGBRAI) is a 7-day recreational bicycle ride with over 10,000 participants covering 500 miles. The heat and humidity of late July in Iowa, the prevalence of amateur riders, and the abundant consumption of alcohol can combine creating the potential for a significant number of injuries. The purpose of this study is to determine the type, quantity and severity of injuries on RAGBRAI and gather data on the factors related to these incidents. Methods: This retrospective chart review examined paramedic run sheets for patients requiring transport to the hospital from the bike route between 2004 and 2008. The age, sex, date of incident, weather, chief complaint, mechanism, injury location, and care administered from each patient was recorded.. Chi-square tests, Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ PearsonвЂ™s correlation tests, and t-tests were applied to determine significant statistical outcomes. Results: From 2004 вЂ“2008, 419 RAGBRAI participants were attended to by paramedics. 190 of these participants required transport. Female patients were more likely to require transport; 53.7% of transports were male and 46.3% were females yet 65% of RAGBRAI riders are male (p П 0.0011). Accidents were caused by riderto-rider contact (46.6%), rider error (30.4%), road conditions (19.6%), and bike malfunctions (3.4%). Age was a significant predictor of transport for injury in older males (p П 0.0277). Of participants asked, 90.1% had not imbibed any alcohol prior to their injury and 85.1% had completed at least minimal training prior to RAGBRAI. Higher temperatures were correlated with an increased number of dehydration/heat stroke cases (r П 0.953, p П 0.046). Abrasions and lacerations were located on the head (20.0%), upper extremity (43.0 %) and lower extremity (37.0%). Fractures occurred to the clavicle (44.4%), shoulder (22.2%), wrist (13.3%) and ankle (8.8%). Conclusion: This study suggests that females and older males are more likely to require transport for injuries sustained on RAGBRAI, that the majority of injuries occur around the head and upper extremities, dehydration/heat stroke is correlated with temperature, and that incidents are usually caused by rider-to-rider contact or rider error. This research could be used by multiday recreational bicycle tour organizers to continue educating riders on riding carelessness and etiquette and prepare medical services for certain quantities and types of injuries. 199 Does вЂњOff-HourвЂќ Presentation Contribute to Out-ofHospital Process Delays Among Patients With STElevation Myocardial Infarction? Agarwal A, Koneru S, Griffen D, Pfeiffer AM, Brennan J, Gilmore J, Markwell SJ, Aguirre FV/Southern Illinois University, Springfield, IL; Prairie Education & Research Cooperative, Springfield, IL; Memorial Medical Center, Springfield, IL; St. Johns Hospital, Springfield, IL; Prairie Cardiovascular Consultants, Ltd., Springfield, IL Study Objectives: Increasing emphasis is being placed on refining out-of-hospital processes of care among ST-elevation myocardial infarction (STEMI) patients transported via ambulance (EMS) with the goal of reducing delays initiating reperfusion therapy. Prior studies have shown that вЂњoff-hourвЂќ (OFF) presentation (ie, weekdays: 5:00 PMвЂ“7:00 AM and weekends) contributes to greater in-hospital treatment delays compared to вЂњon-hourвЂќ (ON) presentation (ie, weekday: 7:00 AMвЂ“ 5:00 PM) among STEMI patients undergoing mechanical reperfusion (PCI). The objective of this study was to determine the impact of time-of-day on out-of-hospital STEMI times. Methods: Between 1/2005вЂ“12/2008 we retrospectively evaluated both pre- and in-hospital time interval components of care among a consecutive group of STEMI patients brought by EMS during ON vs OFF to 2 tertiary hospitals in rural, Central Illinois with 24-hour, 7 day/week primary PCI capabilities. Out-of-hospital process components evaluated among EMS-transported patients included: a.) EMS dispatchscene arrival, b.) Scene arrival-scene departure (on-scene time), c.) Scene departureemergency department (ED) arrival (transport time), d.) EMS Dispatch-ED arrival. In-hospital process components included: a.) ED arrival (door)-ECG acquisition, b.) ED door-cardiac cath lab (triage time), d.) Cardiac cath lab-balloon (procedure time), d.) ED door-balloon (D2B time). Our EMS system consisted of 10 independent transport services. There was no utilization of out-of-hospital ECG in this EMS system. Results: Of the 358 consecutive STEMI patients, 158 (44%) were EMS transported. The median (25th, 75th percentile) distance traveled from scene to ED was 6 (3, 16) miles. EMS utilization increased from 2005 (38/114; 33%) to 2008 (43/80; 54%; pП0.01). Among the EMS-transported group, 10 (6%) did not receive PCI, and 14 (9%) had incomplete analyzable data. Of the remaining 134 patients, 85 (63%) presented OFF and 49 (37%) presented ON. There were no differences in baseline demographics among the STEMI patients presenting ON vs OFF. Table 1 lists the differences between out-of- and in-hospital process of care components among the EMS-transported patients presenting ON vs OFF. Conclusions: Despite longer in-hospital delays among STEMI patients presenting OFF vs ON, there was no difference in proportion of patients achieving D2B Х… 90 minutes between these two groups. Importantly, there is no significant difference among any out-of-hospital component, including: a.) EMS dispatch-to-scene arrival, b.) on-scene, and c.) transport times, demonstrating a consistency of EMS-associated out-of-hospital STEMI care, regardless of time of day. Annals of Emergency Medicine S61 Research Forum Abstracts 200 The Impact of 24-Hour Shifts on Paramedics Providing Out-of-Hospital Analgesia in PatientReported Pain Scales Myers LA, Russi CS/Mayo Clinic Medical Transport, Rochester, MN; Mayo Clinic, Rochester, MN Study Objectives: To evaluate out-of-hospital pain management by timeframe in ambulance crews working twenty-four hour shifts. These lengthy clinical shifts are a unique characteristic of EMS with little research evaluating pain management to the time of day. Methods: A retrospective data review from January 2007 through May 2008 in a large multi-site EMS system, examined the administration of morphine sulfate (MS) in patients categorizing their pain between a вЂњ1вЂќ and вЂњ10вЂќ on a 1-10 pain scale during 24-hour paramedic clinical shifts. Patients with cardiac-related chest pain, hemorrhagic injuries, altered mental status and an allergy to MS were excluded. Data abstraction and statistical analysis was completed using JMP v6.0 software. This study was approved by Mayo Clinic institutional review board. Results: There were 16,450 patients identified to have reported pain in EMS documentation. There were 2,236 cases where pain scales were reported by paramedics. There were 214 instances of a вЂњ0вЂќ score leaving 2,022 cases with a score of 1вЂ“10. The proportion of treatment by timeframe in scores of 1вЂ“5: 0700 вЂ“1259 nП16/ 252 (6.0%); 1300 вЂ“1859 nП22/269 (7.4%); 1900 вЂ“ 0059 nП10/199 (5.3%); 0100 вЂ“ 0659 nП7/139 (5.0%). The proportion of treatment by timeframe in scores of 6 вЂ“10: 0700 вЂ“1259 nП83/373 (22.3%); 1300 вЂ“1859 nП106/354 (29.9%); 1900 вЂ“ 0059 nП80/282 (28.4%); 0100 вЂ“ 0659 nП22/153 (14.4%). The total proportions of treatment and pain scales: вЂњ1вЂќ nП 2/120 (1.7%), вЂњ2вЂќ nП 35/148 (3.4%), вЂњ3вЂќ nП 14/187 (7.5%), вЂњ4вЂќ nП11/201 (5.5%), вЂњ5вЂќ nП23/203 (11.3%), вЂњ6вЂќ nП18/162 (11.1%), вЂњ7вЂќ nП37/217 (17.1%); вЂњ8вЂќ nП 59/245 (24.1%); вЂњ9вЂќ nП41/155 (26.5%), вЂњ10вЂќ nП136/383 (35.5%). Conclusion: The percentage of pain scales that were documented (12.6%) is low. Treatment of patients with moderate to severe pain (scales 6 вЂ“10), declines after 1:00 AM in ambulance crews working 24-hour shifts. Further investigation is needed to determine the reasons for this decrease, including crew workload. 201 Safety and Efficacy of a Novel Abdominal Aortic Tourniquet Device for the Control of Pelvic and Lower Extremity Hemorrhage Greenfield EM, McManus J, Cooke WH, Pittman D, Shiver SA, Beatty J, Croushorn J, Schwartz R/Medical College of Georgia, Augusta, GA; US Army Medical Department Center and School, Fort Sam Houston, TX; The University of Texas at San Antonio, San Antonio, TX Study Objectives: Hemorrhage from the pelvis and lower extremities is a leading cause of potentially preventable death and morbidity in both the military and civilian setting. Current commonly employed out-of-hospital strategies to achieve hemostasis in these areas have limited to no efficacy. This study examines the safety and efficacy S62 Annals of Emergency Medicine of a novel externally applied pneumatic abdominal aortic tourniquet device to significantly decrease or halt blood flow from the abdominal aorta. Methods: Eight anesthetized (nП8) swine were instrumented with catheters inserted in the carotid and femoral arteries and internal jugular vein. A urinary bladder catheter with a pressure transducer was placed as a marker of intra-abdominal pressure. The tourniquet was applied to the animal, inflated, and left in place for 60 minutes. Pressures were recorded in 5-minute intervals. Serum potassium and lactate levels were obtained at 0 minutes, 55 minutes, and 65 minutes. Doppler ultrasound was utilized at 5-minute intervals to measure blood flow through the femoral artery. After release of the device, an open laparotomy was performed and tissue samples from the large and small intestine were collected. End points were mean arterial pressure, central venous pressure, intraabdominal pressure, potassium levels, lactate levels, and tissue histology. Results: Flow was essentially undetectable in the femoral catheter during the tourniquet application. For hemodynamic variables, there were no significant differences in mean arterial pressure or central venous pressure measurements among animals. However, using one way repeated measures analysis of variance, there was a significant difference in mean arterial pressure (P П 0.008) between 0 and 55 minutes for each subject. Serum potassium and lactate did not reach clinically significant numbers. However, serum lactate was significantly different between times 55 minutes (3.6 mmol/L П©/ПЄ .95) and after tourniquet release 65 minutes 5.9 mmol/L П©/ПЄ .87) (p ПЅ0.001). Gross and histological examination revealed no signs of significant ischemia or necrosis of the small and large intestine. Conclusion: The abdominal aortic tourniquet appears safe and efficacious in decreasing or eliminating blood flow to the pelvis and lower extremities when deployed for sixty minutes. 202 Improvement in Bag-Mask Ventilation Performance After Training With a Novel Terminal Feedback Manikin System Salvucci Jr AA, Squire BT, Kaji AH, Niemann JT, Chase DG/Ventura County Medical Center, Ventura, CA; Harbor-UCLA Medical Center, Torrance, CA Study Objectives: Bag-mask ventilation (BMV) is commonly used in emergency and out-of-hospital care. With the de-emphasis of endotracheal intubation, BMV has become increasingly important in cardiac arrest and traumatic brain injury. It is considered a basic skill, often taught only by demonstration and brief practice. However, poorly performed BMV is common, resulting in brief, high-volume inspirations delivered at a rapid rate. Consequences include gastric inflation, an increase in intrathoracic pressure with resultant hypotension, and hypocarbia reducing cerebral blood flow. Despite known complications, training methods have remained largely unchanged. A well-known and effective method to learn motor skills is terminal feedback - performance assessment provided after task completion. We investigated the effect of a novel terminal feedback system to train out-ofhospital personnel in BMV. Methods: Prospective pre-post interventional study design using 28 volunteer on-duty EMTs and paramedics who had completed an American Heart Association basic life support course within the previous 2 years. All subjects were tested by performing one minute of BMV on a SmartManВ© manikin (Ambu, Inc.) per local protocols which conformed to the AHA CPR/ECC Guidelines 2005. Subjects then practiced for 1 minute using the SmartMan continuous terminal feedback (bandwidth knowledge of results) training system, utilizing a color bar display to indicate specified ranges for вЂњacceptable,вЂќ вЂњtoo highвЂќ and вЂњtoo lowвЂќ on each of three parameters: duration of inspiration, volume of inspiration, and duration of breath-tobreath interval. After training, subjects repeated the 1-minute BMV test. Descriptive statistics were calculated, and when appropriate, pre-post results of the ventilation tests were compared using the non-parametric Wilcoxon rank sum test and are reported as medians with interquartile ranges. To account for potential correlations among ventilations for each paramedic, a cluster analysis was performed using generalized estimating equations and an exchangeable covariance matrix; proportional odds ratios (OR) with 95% confidence intervals were calculated. Results: Twenty-eight subjects performed a total of 672 total breaths, 336 per trial. Individual measurements were considered correct if performed to within 20% of the AHA Guidelines for inspiration (500 вЂ“ 600 mL over 1 second) and breath-tobreath interval (5вЂ“ 6 seconds). Correctly performed duration of inspiration increased from 34% of ventilations to 80%, and the proportion that were delivered too rapidly decreased from 50% to 15%. Correct volume of inspiration increased from 63% to 96%. Correct breath-to-breath interval increased from 63% to 93%. All differences were significant (PПЅ0.0001). When adjusted for subject and clustering of breaths, OR for the intervention remained statistically significant. Conclusion: Initial BMV was performed inconsistently over a wide range of durations Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts and volumes. Too-rapid inspiration was the most common error, occurring in nearly 50% of breaths. A brief visual terminal feedback training session substantially improved performance, with a large majority of breaths delivered within acceptable ranges. Correct rate and volume with bag-mask ventilation appears to be a learnable skill. Terminal feedback methods of training can optimize motor skills learning and performance. 203 Hospital Processes, Not EMS Transport Times, Are Crucial Predictors of Rapid Reperfusion for ST Segment Myocardial Infarction Patients Swor R, Robinson D, Clark C, Berman A, Roe E/William Beaumont Hospital, Royal Oak, MI Background: Regional EMS networks to treat ST segment myocardial infarction (STEMI) are being developed to provide rapid mechanical reperfusion (PCI). Key elements debated in this process include transport times to PCI hospitals. Study Objective: To assess whether EMS scene and transport intervals or internal hospital process intervals are associated with rapid reperfusion after EMS contact and hospital arrival in STEMI patients. Methods: Secondary analysis of a prospectively collected database of STEMI patients transported to a large single academic community hospital from 2004- 4/ 2009. Population: EMS patients transported with 12-lead EKG to hospital with STEMI. The hospital utilizes a single page acute myocardial infarction team, which is activated by emergency physicians based on out-of-hospital data (telemetry or voice) from paramedics or after hospital arrival. Patients transferred from another hospital, Do-Not-Resuscitate patients, or patients whose care was delayed because of refusal of care were excluded. All cases were reviewed by two physicians to confirm STEMI diagnosis. EMS and hospital data intervals including EMS scene, EMS transport, arrival to myocardial infarction team activation (D2page), and arrival to lab (D2lab). Our outcomes are proportion with arrival to reperfusion (D2b)ПЅ90 minutes, and EMS EKG to reperfusion (E2b)ПЅ 90 minutes. Means and proportions are reported, T-test and FisherвЂ™s exact used for analysis. Results: We included 267 STEMI patients, 246 (92.1%) MI team activations, 240 (90.0%)to lab, 208 (77.9%) had PCI. EMS intervals were; scene 20 min (5вЂ“50); transport 15.5 min (1вЂ“46). Of PCI patients, 48.8% had pre-arrival activation, 81.8% had D2bПЅ 90 min and 54.9% with E2BПЅ 90 min.. Mean intervals were: D2page 2.7 min; D2lab 35.1 min; D2B 70.6 min. Comparison of key intervals are listed in table: Conclusion: Hospital process intervals (time to page and time to lab), but not EMS process intervals (scene and transport) were associated with short D2b and E2B times. Hospital processes, rather than EMS scene and transport times, are crucial factors in producing rapid reperfusion for STEMI patients. 204 Endotracheal Intubation Success in an Ambulance by Emergency Medical Out-of-Hospital Personnel Using Direct and GlidescopeВ® Laryngoscopes Toofan M, Bhakta N, Greenberg R, Rush C, Kjar D, Drigalla D/Scott & White Memorial Hospital, Temple, TX Study Objectives: Previous studies have reported increased success in endotracheal intubation among individuals with limited airway management experience when using the GlideScopeВ® video laryngoscope (GS) as compared to direct laryngoscopy (DL). Out-of-hospital providers are trained in endotracheal intubation and frequently face the added challenge of implementing this skill in various environments. Our study investigated intubation success of out-of-hospital providers using GS vs. DL in an ambulance setting. Methods: Design: Institutional review board-approved, randomized, crossover study. Setting: Volunteer subjects were recruited during a statewide emergency medical services (EMS) professional conference. Participants: 49 conference attendees enrolled. Interventions: Following a brief demonstration of the use of the GlideScopeВ® and orientation to the Cormack & Lehane (CL) airway grading scale, subjects were randomized to initially use the GS or a DL to intubate a LaerdalВ® Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Difficult Airway Manikin. The manikin was positioned on a stretcher in an ambulance to simulate an EMS environment. Each subject then intubated both the normal and difficult (severe glossitis) airway using both GS and DL. Level of training certification, prior intubation experience, time and number of attempts to intubation, failed airways, glottic view using the CL scale, and ease of use (by numerical scale) were recorded. Numerical means and CL grades were compared using paired t-tests. Results: There were 49 out-of-hospital providers (still in-training to 25 years experience, EMT-basic to EMT-paramedic) with average monthly intubations ranging from 0 to 6. Ten of the 49 (20.4%) volunteers had previous experience with the GS. Normal Airway Scenario: Time to intubate was faster for GS [35.4 sec] vs. DL [53.1 sec], but not statistically significant (pП0.8429). GS required fewer attempts on average for successful intubation (GS 1.1 vs. DL 1.4, pП0.0205). CL glottic view was significantly better with GS (1.2П®0.5 vs. 2.2П®0.9, pПЅ0.0001). 2 (4.1%) airway failures occurred with DL, zero with GS. Difficult Airway Scenario: Time to intubate was faster for GS [34.8 sec] vs. DL [100.0 sec] and was statistically significant (pПЅ0.0001). GS required fewer attempts on average for successful intubation (GS 1.1 vs. DL 2.0, pПЅ0.0001). CL glottic view was again significantly better with GS (1.6П®0.8 vs. 3.1П®1.0, pПЅ0.0001). GS had fewer airway failures (1 vs. 14, 2.0% vs. 28.6%). Ease of use: Subjects found the GS overall easier to perform an intubation (1.5 vs. 2.9, pПЅ0.0001). Conclusion: In the hands of out-of-hospital providers in both airway scenarios, the GS required fewer intubation attempts, provided a better glottic view, and resulted in more successful intubations. GS was also significantly faster than DL in the difficult airway. This study attempts to replicate the unique intubation environment of an ambulance. The GlideScopeВ® appears to be a useful tool in both normal and difficult airways in the out-of-hospital setting. 205 Accountability, Transparency, and Interoperability: Developing a Database of Federal Efforts in Emergency Medical Care Johnson KA, Handrigan MT/Dept. of Health and Human Services, Washington, DC Study Objectives: The Emergency Care Coordination Center (ECCC) has been established within the Dept. of Health and Human Services (HHS). Through collaboration with the Council on Emergency Medical Care (CEMC), a coordinating body consisting of Federal partners from the Departments of Transportation (DOT), Defense (DoD), Homeland Security (DHS), and VeteransвЂ™ Affairs (VA), the ECCC aims to inform the development of joint strategies and cohesive policies to collaborate and coordinate ongoing Federal efforts to improve emergency medical care (EMC) systems nationwide. The first step in achieving this goal is developing situational awareness, gaining an understanding of existing efforts addressing EMC within each of the relevant departments and agencies. The purpose of the present research project is to demonstrate the feasibility and potential of a searchable online database dedicated to identifying and organizing the myriad Federal EMC initiatives in a systematic, logical, and accessible fashion. Methods: A survey device was distributed for input from CEMC members representing relevant agencies within DoD, DOT, DHS, HHS, and the VA. Responders were asked to provide information on their agenciesвЂ™ existing EMC programs, describing each initiative with respect to the following categories: program name, responsible agency subcomponent, program description and goals, classification as a grant or research program, total funding and mechanism, start and end dates, legal authority/authorizing legislation, and contact information. Results were compiled in a master database with an eye toward gaining perspective on the breadth, scope, and focus of current Federal EMC efforts. Results: A total of 20 survey responses were received from representatives of 19 Federal agencies, with each of the 5 targeted Federal departments well represented. Responses were typically detailed and thorough, demonstrating Federal partnersвЂ™ willingness to share related EMC activities and participate in a process designed to promote collaboration and interoperability throughout the US Government. The resulting database represents 110 individual Federal EMC programs, organized by department, agency, focus area, and specified characteristics. Conclusion: Having demonstrated the feasibility of collecting and systematically organizing data on existing Federal EMC efforts, this projectвЂ™s template spreadsheet should be further developed into a functional online database operating in conjunction with the ECCC Web site. With both an external component open to the public вЂ” allowing interested parties to search for specific programs, research, or grant opportunities вЂ” and an internal face allowing CEMC members to update and edit their agenciesвЂ™ entries, this database would serve to open the lines of communication Annals of Emergency Medicine S63 Research Forum Abstracts amongst EMC stakeholders. Ultimately, this tool could help identify both areas of overlap and opportunities for collaboration, reducing duplication of effort and promoting continuity and synergy throughout the EMC community. 206 Poor and Sick: Do Low-Income Areas Have Fewer Emergency Departments? Ravikumar D, Hsia R/University of California, San Francisco, San Francisco, CA Study Objectives: No previous study has attempted to describe access to emergency care based on socioeconomic status. This study attempts to characterize one aspect of health disparities by attempting to find out whether low socioeconomic areas have less access to emergency care. The objective of this study is to examine the relationship between number of emergency departments per capita and median household income in California FIPS (Federal Information Processing Standard) county codes. Methods: This study is a retrospective analysis using cross-sectional data from the American Hospital Association (AHA) Annual Survey of Hospitals from 2005. FIPS county codes for the state of California were used to delineate socioeconomic areas. The outcome variable we examined was the number of emergency departments per capita (100,000) for FIPS county codes in California. The main independent variable we used was median household income. We included two other measures of socioeconomic status as independent variables: percent uninsured and percent of people of age 25 or more with less than nine years of education. Outcomes were transformed for normality and correlations were performed using STATA IC10. Results: We analyzed 58 FIPS county codes in California. The correlation between number of EDs per capita in California to median household income showed a small negative relationship, where poorer areas actually had a larger number of EDs (Pearson correlation ПЄ0.322, 95% CI [ПЄ0.544 to ПЄ0.081]). The number of of EDs per capita was neither correlated with percentage of the population without insurance nor those with low education. Conclusion: Our findings show that, contrary to our hypothesis, the number of EDs per capita is inversely related to median household income in a particular area. In other words, there are a greater number of EDs per 100,000 people in lower socioeconomic areas. This study has important policy implications for emergency department patients as well as the delivery of emergency services in California. If there is indeed a negative relationship between number of emergency departments per capita and income, more research needs to be conducted to determine the factors leading to crowding in low socioeconomic areas. 207 Penetration of Board Certified Emergency Physicians Into Rural Emergency Departments in Iowa House H, Young R, DeRoo E/University of Iowa, Iowa City, IA Study Objectives: The American College of Emergency Physicians (ACEP) endorses emergency medicine (EM) residency training as the only legitimate pathway to an EM career, yet the economic reality of IowaвЂ™s rural population will continue to support the hiring of non-board certified physicians. Rural communities struggle to support emergency physicians because of their smaller populations and inadequate patient volumes. This survey will determine the minimum population needed to support an emergency physician and examine the market forces that contribute to emergency department (ED) staffing with emergency physicians versus family physicians in Iowa. This project was supported by an ACEP Chapter Development Grant. Methods: The research team identified a member of the ED administration at all 119 Iowa hospitals and asked the following: 1. What are the qualifications of your emergency staff? a. Do you hire emergency physicians only? b. Do you hire family physicians only? c. Do you hire a combination of family and emergency physicians 2. What area of the state do you provide emergency medical care to? 3. What are your reasons for hiring your choice of ED staff in question 1? The population of the catch area of each hospital was calculated to determine the minimum population that supports the ED categories listed in question 1. Results: 119 of 119 hospitals responded to this survey (100% response rate). It was found that only 14 (11.8%) of Iowa emergency departments exclusively utilize emergency physicians in order to staff their ED. 76 (63.9%) utilize a combination of emergency physicians and family physicians, while 27 (22.7%) of Iowa hospitals solely use family physicians in their ED. It was also found that 46 (38.7%) of Iowa emergency departments utilize physicianвЂ™s assistants or NPвЂ™s in solo coverage. It was determined that the minimum population in the state of Iowa to support exclusive BCEP coverage is 25,136, with a mean population of 88,143. Also, the minimum population to support a combination (emergency physicians and family physicians) is S64 Annals of Emergency Medicine 1465, with a mean population of 18,244. The most common reasons cited by emergency departments hiring only family physicians included recruiting difficulties of emergency physicians, the low patient census did not require emergency physician specialty training, and the hospital was satisfied with the quality of care provided by family physicians. Emergency departments that hired a combination of family physicians and emergency physicians cited factors that included the ability to increase recruiting of family physicians for local clinic with the incentive of no required ED coverage, less ED call increases time off for local physicians, and the care of patients in clinic increases with family physicians not being called away from clinic. Finally, emergency departments that hired only emergency physicians cited factors that included the quality of care provided by emergency physicians, high patient acuity best supported by emergency physicians, and a high patient census best supported by emergency physicians. Conclusion: Many emergency departments in Iowa, a predominantly rural state, remain staffed by family physicians. In fact, without the contribution of family physicians, large areas of the state would be unable to provide adequate emergency care. Emergency physicians remain concentrated in urban areas of the state, where patient volumes and acuity support their hiring. 208 Does Having and Using a Usual Source of Care Decrease Emergency Department Use? Gabayan GZ, Asch SM, Starks SL, Sun BC/VA Greater Los Angeles Health System, Los Angeles, CA; UCLA, Los Angeles, CA Background: One of the most widely prescribed solutions to emergency department (ED) crowding is increased access to a regular source of care. However, previous studies have found conflicting associations between regular source of care and ED use. Study Objectives: To evaluate the relationship between having and using a usual source of care and emergency department use. Methods: Data from the 2005 California Health Interview Survey (CHIS) were used. The study was conducted as a two-stage cross-sectional population-based random-digit dial survey of California households between 07/05 and 04/06. ED use was assessed based on a respondents reporting of having an ED visit over the past 12 months. The relationship between usual source of care, visits to primary medical doctor (PMD) and ED use was evaluated using multivariate logistic regression accounting for potential confounders and comorbidities. Results: Of 44,500 households contacted, there were 43, 020 adults interviewed. Over ninety percent (n П 39, 094) of subjects reported having a usual source of care. Visits to primary medical doctors (PMDs) were made by 19,774 (46%) 1вЂ“3 times per year and by 14,178 (33%) 4 вЂ“ 8 times a year. Having a usual source of care was not significantly associated with visiting the emergency department. Compared to subjects with no visits, subjects with 1вЂ“3 PMD visits per year had 2.4 times the odds of visiting an ED (OR 2.4, 95%CI 2.1вЂ“2.7), subjects with 4 вЂ“ 8 PMD visits per year had 5.4 times the odds of visiting an ED (OR 5.4, 95%CI 4.8 вЂ“ 6.0), and subjects with greater than 8 visits per year had 10.4 times the odds of visiting an ED (OR 10.4, 95%CI 9.1вЂ“11.9). Additional associations of emergency department use included household annual income below $10,000 (OR 1.3, 95%CI 1.1вЂ“1.4), public fee-forservice insurance (OR 1.3, 95%CI 1.1вЂ“1.4), having an emotional or physical disability (OR 1.3, 95%CI 1.3вЂ“4.3), and suffering from one of number of chronic diseases: cerebrovascular disease (OR 1.3, 95%CI 1.2вЂ“1.5), epilepsy (OR 1.5, 95%CI 1.3вЂ“1.8), lung disease (OR 1.3, 95%CI 1.1вЂ“1.4), and diabetes (OR 1.1, 95%CI 1.0вЂ“1.2). Conclusion: CHIS is the largest state-level health survey in the nation and is descriptive of a state in which emergency services are in crisis. Controlling for potential covariates, we found that having a usual source of care was not associated with reduced ED use. Greater use of PMDs was associated with a greater likelihood of visiting an ED, though this could be confounded by unmeasured disease severity. As expected, poor, sick and disabled patients, as well as those with public fee for service insurance were most likely to visit the ED. This suggests that providing access to PMDs may not be sufficient for improving ED crowding and further work is needed to help understand this complex problem. 209 Determinants of Health Care Access on the U.S.Mexico Border Watts S, Tarwater P/Texas Tech University Health Sciences Center, El Paso, TX Study Objectives: Emergency departments (EDs) are the health care safety nets in many communities and are being flooded with increasing numbers of patients who lack any other source of primary care. This study was conducted to identify the determinants associated with health care access in a U.S.-Mexico border community. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts Methods: Using multiple variable logistic modeling, cross-sectional data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) for El Paso County, TX was analyzed to identify factors associated with 2 different health care access measures: 1) having insurance and 2) having a primary care provider (PCP). Exposure variables considered for the multivariable model and which were univariately associated with either outcome were age, sex, ethnicity, income, employment status, education, and history of chronic disease (diabetes, hypertension, or asthma). Final model selection was based on backwards elimination using a p-value Пѕ0.10 as exclusion criteria. Results: The age-adjusted model of having insurance found income level and employment status to be significantly associated. Specifically, those with income greater than $50,000 had eight times greater odds of having insurance (pПЅ0.001) than those with income less than $25,000. Those with income between $25,000 and $50,000 had almost 6 times greater odds of having insurance (pПЅ0.001). Also, unemployed persons had a 73% decrease in odds of having insurance compared to employed persons (pП0.008). Ethnicity and education level were retained in the final model, whereby non-Hispanics were twice as likely to have insurance along with those who had attained at least some college education. Similarly, in the age-adjusted multivariable model of having a PCP, education level had a significant positive association, whereby college graduates had 3 times greater odds of having a PCP than those who did not finish high school (pПЅ0.0001). In addition, diabetics had 2 1вЃ„2 times greater odds than non-diabetics (pП0.018) of having a PCP. Conclusion: In this large U.S.-Mexico border community where emergency departments are the health care safety nets for those who lack access to primary care, we found age, income, and education to be significant determinants of health care access. In addition, ethnicity and employment were associated with having insurance while being diabetic was associated with having a primary care provider. Therefore, intervention programs addressing determinants of access may require separate or tailored implementation strategies, at least along the U.S.-Mexico border. 210 Severity of Illness Does Not Differ Based on Insurance Status in Two Urban Emergency Departments Shukla KT, Eilbert W, Sloan E/University of Illinois, Chicago, IL Study Objectives: It is the opinion of many emergency department (ED) health care providers that patients with no insurance or Medicaid present to the ED for nonurgent care causing ED crowding. We seek to determine if the type of insurance, or lack thereof, is correlated with the severity of illness for which patients present to the ED. Methods: Data was collected from two urban EDs that treat a total of 75,000 patients per year, one a university tertiary medical center and the other a community teaching hospital with an emergency medicine residency. Billing level of service (LOS) and admission rates were used as indicators of overall illness severity. This injury severity data was compared among patients with Medicare, Medicaid, private insurance and those with no health insurance. The time period of the study was from January 2005 to April 2008. Results: The total number of patients treated was 264,849, with 52% treated in the community ED and 48% treated in the university hospital ED. The distribution was 13% Medicare, 42% Medicaid, 27% private insurance, 13% no insurance, and 7% other. The most common LOS was level 3 (45% of patients). The LOS distributions did not differ between the two hospitals. Admission information was available for the 136,658 patients treated in the community hospital, 22% of these patients were admitted. Medicare patients had a higher LOS distribution (71% in the top 3 levels) when compared to all other groups together (46%) (pПЅ0.05). Medicare patients also had a 3-fold higher admission rate compared with the other groups, 51% vs.15% (pПЅ.05). There was no significant difference in the LOS and admission rates when comparing those patients with Medicaid, private insurance, and no insurance. Conclusion: Medicare patients, who presumably are older and have more medical illnesses, are treated with a higher ED LOS and have a higher hospital admission rate than patients with other insurance types. This finding suggests that LOS and admission rate are a reasonable proxy for illness severity. The absence of a difference in ED LOS and admission rates among Medicaid, privately insured and uninsured patients refutes a widely held assumption that patients with Medicaid or no insurance are more likely to use the ED as a source of primary care and non-urgent care. Instead, all patients, regardless of insurance type, access the ED because of the need for both emergency and unscheduled care. ED crowding is a complex issue that involves all economic groups. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 211 Does Pay for Performance Lead to Potential Misuse of Antibiotics Among Patients With Congestive Heart Failure? Duseja R, Nsa W, Belk K, Schwartz S, Bratzler D/Wharton School, University of Pennsylvania, Philadelphia, PA; Oklahoma Quality Improvement Organization, Oklahoma City, OK; Premier, Inc, Charlotte, NC Background: Pay for performance is intended to accelerate improvements in hospital care, yet little is known about whether such incentives lead to worsening performance on unmeasured quality metrics or if it decreases the variation of care delivered. Study Objective: To determine whether the performance incentive measures, antibiotic timing in pneumonia patients (receiving antibiotics within four hours) and blood cultures drawn prior to antibiotic administration is associated with an unintended increase in antibiotic administration and blood cultures drawn among patients with congestive heart failure. Design and Setting: An observational study of all hospitals (NП266) in the payfor-performance demonstration project ran by Premier, Inc. and the Centers for Medicare and Medicare Services, from the fourth quarter of 2003 through the third quarter of 2006. We retrospectively look at hospital billing data, and perform a time series analysis of antibiotic use in and blood cultures drawn on heart failure and pneumonia patients. We then examine correlations between changes in antibiotic timing and blood cultures drawn in pneumonia patients and antibiotic administration and blood cultures in heart failure patients. Results: We find that with the incentivized quality measures, time to antibiotic within four hours for pneumonia patients and blood cultures drawn prior to antibiotic administration, there is no significant correlation with antibiotics administered to patients admitted in day one for patients with congestive heart failure (pП.19), as well as blood cultures drawn before antibiotic administration (pП.13). Over time, there is improvement and decrease in variation in the incentivized measures across hospitals. Conclusion: Hospitals engaged in the pay-for-performance project show little evidence that incentivizing performance on hospital antibiotic timing scores lead to adverse consequences with inappropriate antibiotic administration, and inappropriate drawing of blood cultures. Additional research is required to determine whether other financial or payment models can minimize or exacerbate unintended consequences within the health system. 212 Resident Alertness, Stress, and Self-Reported Medical Errors in an Urban Teaching Hospital Emergency Department Hansen KN, Marshall AJ, Heitmann A, Santiago MJ/University of Maryland School of Medicine, Baltimore, MD; Awake Institute, LLC., Arlington, MA Background: Overnight shift work causes fatigue due to circadian rhythm disruption and sleep loss. Fatigue has been shown to be a significant factor contributing to the occurrence of medical error. Study Objectives: We sought to investigate the frequency of medical errors reported by residents, and to determine whether the occurrence of errors varied by shift type or other parameters. We also sought to identify factors related to resident stress and fatigue. Methods: We conducted a prospective observational study of emergency medicine residents working in an urban academic emergency department between 6/08 and 11/08. Subjects worked at least 10 consecutive shifts, including a minimum of 2 night shifts. Subjects performed computerized visual analog score (VAS) tests of alertness before, during, and after each shift. At the end of each shift subjects filled out confidential questionnaires to collect information including an estimate of hours slept in the preceding 24 hours, number of patients seen, stressfulness of the shift, and subjective measures of fatigue. Subjects were asked to report the occurrence and number of any errors they recalled making during the shift. Errors were categorized into medication, charting, diagnostic, or other types of error, and included minor problems such as forgetting to place an order or check an Xray. Results: Twenty residents (PGY 1вЂ“5) completed VAS tests and questionnaires for 206 total shifts. Of these, 59 were day shifts (7AвЂ“7P), 28 evening (1PвЂ“1A), and 119 night (7PвЂ“7A). A total of 302 errors were reported, occurring during 123 (60%) of all shifts. Of these, 91 (30.1%) were medication errors, 71 (23.5%) charting errors, 62 (20.5%) non-medication-related ordering errors, 42 (13.9%) diagnostic errors, 16 (5.3%) communication errors, and 20 (6.6%) вЂњother.вЂќ Forgetting to place a medication order was the most common specific type of error, occurring 24 times (7.9%). Errors occurred with similar frequency during day, evening, and night shifts. The occurrence or number of errors did not vary significantly in relation to VAS score, hours slept, subjective busyness or stressfulness of shift, or number of patients Annals of Emergency Medicine S65 Research Forum Abstracts seen. Average stressfulness was higher when residents saw Х† 20 patients per shift (p П .03), or if acting in a supervisory role (p П .03). Stressfulness correlated with subjective busyness of the department (r2 П 0.57, pПЅ.001). Average VAS scores were lower for all overnight measurements compared with day and evening (p ПЅ .001), and were consistently lowest at the end of the night shift. Conclusion: Errors were reported often in this setting, and most commonly involved medication, charting, or ordering mistakes. Number of errors did not vary by shift type, or other measured parameters. Residents reported more stress when acting in a supervisory role or when caring for 20 or more patients per shift. 213 Major Barriers to Follow-Up of Emergency Department Patients at Federally Funded Clinics: Metropolitan-Wide Survey Pilot Data Lewis L, Dziuba D/Washington University, St. Louis, MO Background: Previous research has shown follow-up (F/U) rates of 11вЂ“30% for patients referred to a federally qualified health center following an emergency department visit. This research was conducted to identify major barriers to F/U. Study Objectives: Identify major barriers to follow-up at federally qualified health centers (FQHC) for uninsured or underinsured patients seen and discharged from an urban-based ED. Methods: Study Design: Prospective cohort, descriptive, observational Study Setting: A large urban ED with annual volume of 80,000. Participants: All uninsured or underinsured patients seen and discharged from an urban, adult ED during study hours, with no self-identified usual source for outpatient medical care, were English speaking, and had a telephone for F/U, were eligible. Patients were given information regarding the FQHC closest to them for F/U and were asked for a number where they could be reached by phone to answer questions about their clinic appointment. Phone F/U was attempted within a few weeks, with multiple attempts made for up to 2 months. Research assistants used a standardized questionnaire to determine patient demographics and: 1) If the patient followed-up; and 2) If not, what was the major barrier to F/U. We asked all patients who successfully followed up if they had to pay a co-pay. Patients were asked for the single, most important factor to improve access to FQHCs. Descriptive statistics include proportions with 95% confidence intervals. Results: 213 patients were screened and consented to be in the study. Fifteen patients were excluded because they had an alternate source of care. Of 198 remaining subjects, 100 were women (50.5%) and 151 African-Americans (76.3%). Mean age was 35.2 years. We have complete F/U data on 114 patients (49.1%). 57 patients (50%; 95%CI 40.8 вЂ“59.1) followed up to an FQHC. Of the 57 that did not keep their F/U appointment; 54 completed the survey. Transportation was the major identified barrier NП 17 (31.5%; 95%CI 19.1вЂ“ 43.9); followed by feeling better NП10 (18.5%; 95% CI 8.2вЂ“28.9). Other reasons included cost NП8; and lost appointment information NП6. Of the patients who kept their appointment, only 18 (31.6%; 95%CI 19.5вЂ“ 43.7) had a co-pay, and only 8 (14%: 95%CI 5.0 вЂ“23.1) paid more than $15. The most important factor identified to improve access by the 59 respondents to this question was transportation NП20 (33.9%; 95% CI 21.8 вЂ“ 46.0). Cost was an important factor in 10 respondents (17.0%; 95% CI 7.4 вЂ“26.5). Conclusion: F/U rate for patients in this study was higher than in previous reports and may reflect a selection bias in patients able to be followed up by phone, or an effect of knowing they would be contacted about their appointment. Transportation was the major barrier to F/U to an FQHC, followed by cost. Offering transportation and lower cost alternatives would likely increase F/U at FQHCs in this population. 214 Emergency Department Boarding Is Associated With Higher Medication-Related Errors but Fewer Laboratory Errors During the Early Admission Period Liu SW, Chang Y, Weissman J, Griffey R, Hamedani A, Thomas J, Nergui S, Singer S/Massachusetts General Hospital, Boston, MA; University of Massachusetts, Boston, MA; Washington University School of Medicine, St. Louis, MO; Wisconsin University, Madison, WI; Good Samaritan Medical Center, Brockton, MA; Harvard School of Public Health, Boston, MA Study Objectives: As hospitals have become increasingly crowded, more patients have ended up вЂњboardingвЂќ in the emergency department (ED) while awaiting their inpatient beds. Prior studies have not compared the quality of care of boarders and nonboarders. We hypothesized that patients who board or have longer boarding times are more likely to have errors and adverse events during an early admission period than non-boarders or those with shorter boarding times. S66 Annals of Emergency Medicine Methods: This retrospective study utilized data from chart review and administrative databases and employed an explicit/implicit review methodology. Setting: The study took place at two academic, urban hospitals. Participants: All patients with the admitting diagnosis of chest pain, pneumonia and cellulitis between August 2004 and January 2005 were eligible. We excluded patients ПЅ 18 years of age, those admitted directly to the catheterization lab, ПЅ 36 hours, to nonfloors, to precaution rooms and those transferred from other hospitals. The dependent variables were: 1. Adverse events/near misses over the early admission period (24 hours) 2. Errors: Medication errors and process measure errors such as delayed repeat cardiac enzyme labs, late prothrombin time (PTT) level checks, late antibiotic doses, missed home medications over the early admission period. Independent variables were: dichotomous and continous definitions of вЂњboardingвЂќ status as defined respectively by 1) time from bed request to ED departure Пѕ two hours and 2) time between bed request and ED departure. We defined the first 24 hours after this two-hour time point as the early admission period. Biostatistical Analysis: We tested our hypothesis by utilizing individual-level, cross-sectional, multiple logistic regression models, controlling for potential confounders. Results: 2234 patients were initially eligible. After exclusions, our analysis was based on 1668 charts. 450 were nonboarders and 1218 were boarders. There were no significant differences between boarders and nonboarders in terms of sex, age, ethnicity, or adjusted Charlson score, nor differences in adverse events and near misses. Boarding time was associated with higher odds of missing at least 50% of home medications (AOR 1.086 95% CI (1.057вЂ“1.115)) and having a medication error (AOR 1.056 95% CI (1.028 вЂ“1.084)) controlling for age, sex, ethnicity, means of arrival, ESI, shift of arrival, hospital capacity, hospital site, and comorbidities. There was no relationship between boarder status or boarding time with late PTT checks, antibiotic administration and adverse events. Longer boarding times decreased the odds of having a late cardiac enzyme check [AOR 0.927 95% CI (0.887вЂ“ 0.970)]. Conclusion: Longer boarding times are associated with a higher likelihood of medication related errors but a lower likelihood of some lab related errors. Patient who spend more time boarding in the ED may miss home medications more often because EDs are not designed to provide inpatient level of care. However, the finding that patients who board longer do better or no worse in terms of lab checks indicates that not all care provided to patients boarding in the ED is inferior to inpatient management. This may be secondary to resources inherent to each setting. Future studies should examine which processes allow optimal care for boarded patients. 215 A Comparison of Inferior Vena Cava Measurements in Emergency Department Patients With Acute Systolic Versus Diastolic Heart Failure Sen A, Hegg AJ, Strote S, Miller JB/Henry Ford Hospital, Detroit, MI Study Objectives: Measurement of inferior vena cava (IVC) diameter and collapsibility index has been reported to estimate volume status in different cohorts of patients. Our objective was to assess whether IVC diameters and collapsibility index differ among patients presenting to the emergency department (ED) with decompensated diastolic heart failure versus systolic failure. Methods: We analyzed a convenience sample of 70 patients prospectively enrolled in the ED of an inner-city teaching hospital between July 2008 and April 2009. Inclusion criteria were age Пѕ 50 years and the chief complaint of acute dyspnea. Exclusion criteria were mechanical ventilation, trauma, portal hypertension, and recent abdominal surgery. After informed consent was obtained, all patients were assessed with routine clinical evaluation and bedside sonography of the IVC and aorta (Ao) by emergency physicians. Echocardiographic measurements and outcomes were compiled following admission to the hospital. Diastolic dysfunction was defined as symptomatic heart failure with preserved systolic function (ejection fraction Пѕ 50%). The maximum antero-posterior diameter of the IVC was measured sonographically both in inspiration (i) and expiration (e) by M-mode in the subxiphoid area. The difference between the diameters of IVCe and IVCi was regarded as collapsibility, and the collapsibility index was defined as (IVCe вЂ“ IVCi)/IVCe П« 100%. The diameter of the aorta proximal to the celiac trunk was also measured in M-mode, and the IVCe/Ao index was calculated for each patient. Statistical analysis included studentвЂ™s t-test and correlation analysis with test of significance set at pПЅ0.05. Figures are expressed as mean values with standard deviations unless otherwise stated. Results: Of the 70 patients enrolled, we evaluated 31 patients who were diagnosed with decompensated heart failure. One of these patients was excluded from analysis because no estimate of the ejection fraction was present. The mean age of the study cohort was 72 П© 10 years. 71% were males and 90% were African-American. 50% of these patients had echocardiographic evidence of systolic dysfunction and the Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts remaining had diastolic failure. There was a significant difference between the maximum IVC diameter (IVCe) of patients with systolic dysfunction versus patients with diastolic dysfunction (2.35 П© 0.66 cm vs. 1.89 П© 0.47 cm, pП0.04). There was no difference in the collapsibility index between systolic failure and diastolic failure (20.86 П© 15.3% vs. 26.45 П© 20.3%, pП0.4). Differences were also observed in the IVCe/Ao ratios (1.21 П© 0.28 cm vs. 0.99 П© 0.21 cm, pП0.02) between the systolic and diastolic failure cohorts. Conclusion: Among patients diagnosed with decompensated heart failure, IVC diameter is greater in patients with systolic dysfunction than diastolic dysfunction. IVC collapsibility index did not differ between the two groups. 216 Comparison of Bedside Ultrasound and Panorex Radiography in the Diagnosis of a Dental Abscess in the Emergency Department Adhikari S, Blaivas M/University of Nebraska Medical Center, Omaha, NE; Northside Hospital Forsyth, Cuming, GA Study Objectives: Panorex x-rays are often obtained to evaluate patients with suspected dental abscess in the emergency department (ED) to determine if someone needs incision and drainage. But it requires the patient leaving the ED and time to interpret the x-rays which adds a delay to the patient care and disposition in ED. To our knowledge, the utility of bedside ultrasound (US) in diagnosing a dental abscess has never been investigated before. The objective of this study is to compare bedside ultrasound and Panorex radiography in the diagnosis of a dental abscess in ED. Methods: This is a retrospective review of patients presenting to an academic ED with facial pain, swelling and toothache who received a bedside US and a Panorex x-ray for suspected dental abscess. ED US logs were reviewed for the diagnosis of dental abscess. Emergency physician investigators performed bedside US prior to Panorex x-rays. The bedside US examinations were performed using either a Phillips Envisor system or a SonoSite M-Turbo system with a broadband linear array transducer. Both x-rays and US were independently reported. The medical records of these patients were reviewed for history, physical examination findings, additional diagnostic testing, and disposition plan. The US images obtained in ED were subsequently reviewed by another sonologist who is blinded to the study hypothesis, and ED US interpretations. Data are summarized using descriptive statistics. Continuous data are presented as means with standard deviations and dichotomous data are presented as percent frequency of occurrence with 95% confidence intervals. Results: A total of 19 patients (mean age, 40 years П©/ПЄ 13.6 [standard deviation]) were identified over a two-year period. All patients had facial pain, swelling, and tenderness of teeth. No periapical abscess was reported in 6/19 (31% CI 10 вЂ“52%) patients, with which US showed 100% concordance. A radiological diagnosis of periapical abscess was made in 13/19 (68% CI 47вЂ“ 89%) patients. US agreed with Panorex x-ray in 10/13 (76% CI 54 вЂ“99%) cases. In the 3 cases where US disagreed with X-rays, radiographic abnormalities were reported on the opposite side where patient didnвЂ™t have any symptoms. 10 patients were evaluated by dentistry or ENT service in ED and incision and drainage was performed in 9 cases. There is 100% agreement between emergency physician investigator and blinded sonologist US interpretations. Conclusion: Bedside US is non-ionizing, can provide an alternative to Panorex x-rays in the evaluation of dental abscess and improve throughput in the ED. 217 INSPIRED: Instruction of Sonographic Placement of IVs by RNs in the Emergency Department Liteplo AS, Patel P, Huang C, Dipre M, Kimberly H, Noble VE/Massachusetts General Hospital, Boston, MA Study Objectives: Vascular access is a critical aspect of patient care for all hospitalized patients. When standard palpation techniques of peripheral IV placement fail, patients often require alternative methods of vascular access, but these alternatives pose risks to patient safety, can be costly, and utilize valuable resources. Ultrasound has been shown to be a valuable tool in successful placement of peripheral IVs. We hypothesize that emergency nurses can easily learn this technique and successfully and safely use ultrasound to assist them with peripheral IVs after a brief training course taught by emergency physicians experienced in ultrasound. We also seek to identify vein characteristics predictive of failure of IV placement and patient satisfaction with the procedure. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Methods: Emergency physicians with prior experience with ultrasound designed a two-hour training course. Twelve nurses participated in the project. All twelve nurses completed a pre- and post-course survey of their comfort level with ultrasound. Once certified, nurses were able to use the ultrasound to guide IV insertion, after obtaining verbal consent. For each patient enrolled, a datasheet was filled out describing the number of prior blind sticks, the perceived difficulty of the IV placement, vein characteristics (visibility, palpability), and the results of each attempt. Patients were asked if they would prefer an ultrasound-guided IV to a standard IV in the future. Data were entered into a Microsoft Excel spreadsheet and tabulated. This study was institutional review board-approved. Results: Prior to the training, 16% (2/12) of nurses reported they were comfortable with general use of an ultrasound machine, 40% (5/12) were comfortable identifying a vein on ultrasound, and 8% (1/12) were comfortable placing an IV with ultrasound guidance. After the training, 100% (12/12) of nurses were comfortable with all three of these measures. This comfort level persisted at a 1-month follow-up survey. After the course, 100% (12/12) of nurses felt likely to attempt an ultrasound-guided IV when they have a difficult stick patient, and 92% (11/12) felt likely to help a colleague. At one month, these values were both 100%. 120 patients were enrolled. There was an average of 2.6 blind attempts per patient prior to an attempt with ultrasound. The average perceived difficulty of IV before ultrasound guidance was 4.5 on a scale of 1вЂ“5, 5 being most difficult. Nurses successfully punctured a vein in 93% of patients (111/120). An IV was successful 74% of the time (89/120), on the first try in 63% (76/120). Arterial puncture occurred in 2.5% (3/120) of patients. There was no difference between the successful and unsuccessful attempts in vein depth (5.0 vs 5.1 mm) or diameter (3.9 vs 3.8 mm). Of the patients surveyed, 78% (79/101) of patients would prefer an ultrasoundguided IV in the future, 3% (3/101) would not, and 19% (19/101) had no preference. Conclusion: A 2-hour training module taught by physicians is an effective modality for teaching nurses how to use ultrasound for guidance of peripheral IV placement. Nurses are able to achieve IV access in the majority of patients in whom blind sticks have failed, and can do so safely, accurately, and usually on the first attempt. The rate of arterial puncture is very low. Vein depth and diameter do not correlate with likelihood of success. Patients overwhelmingly would prefer ultrasound-guided IVs in the future. 218 Bedside Ultrasound Evaluation of Tendon Injuries Wu TS, Rosenberg M, VanDillen C, Flach F, Simpson C/ Orlando Regional Medical Center, Orlando, FL Study Objectives: For years, subspecialists have utilized musculoskeletal ultrasound during the assessment and diagnosis of potential extremity tendon lacerations. Ultrasound can diagnose full and partial tendon disruptions in a quick and non-invasive manner with sensitivities and specificities approaching 100%. Goaldirected, focused ultrasonography is becoming a mainstay of practice in multiple emergency departments (ED) nationwide, and emergency physicians are learning how to perform basic musculoskeletal scans. We sought to determine if bedside ultrasonography can be used to expedite diagnosis and discharge planning in patients with suspected tendon injuries in the ED. Methods: This was a prospective study conducted at an academic Level 1 trauma center with an annual ED census of approximately 90,000 patients. Patients were eligible for study enrollment if they were at least 16 years of age, and had sustained a closed or open extremity injury that put them at risk for potential tendon injury. Prior to initiation of the study, resident and attending physicians were given a twohour course on how to perform tendon ultrasonography. Enrolled patients underwent a bedside ultrasound evaluation prior to wound irrigation and exploration. For each study participant, the following data were noted: injury location, suspected degree of tendon injury based on physical exam, degree of tendon injury visualized on ultrasound, degree of tendon injury visualized on exploration, time of initial patient encounter, time to diagnosis via ultrasound, and time to disposition based on exploration findings. Ultrasound results were verified against findings seen on wound exploration or MRI. Results: Twenty-one adult patients were prospectively enrolled in the study. There were five finger injuries, seven hand injuries, three forearm injuries, four arm injuries, and two leg injuries. Of the 21 total patients, three patients had partial tendon injuries, four suffered from 100% tendon laceration or rupture, and fourteen had no tendon injury noted on exploration or MRI. Bedside Annals of Emergency Medicine S67 Research Forum Abstracts ultrasound was accurate in estimating the degree of tendon injury in 20 of the 21 cases (sensitivity 100%; specificity 92.9%). In contrast, predictions of suspected tendon injury by physical exam were correct in 16 of the 21 patients (sensitivity 100%; specificity 65%). It took an average of 27 minutes to evaluate the suspected tendon injury using bedside ultrasound. In contrast, tendon evaluation following local anesthesia, irrigation, and open wound exploration took on average 92 minutes to complete. Conclusion: Emergency physicians trained in basic tendon ultrasonography can utilize ultrasound at the bedside to rapidly and accurately evaluate potential tendon lacerations. Bedside ultrasound is more specific than physical exam for detecting tendon lacerations, and takes less time to perform than traditional wound exploration techniques. standardized phantoms (Blue Phantomв„ў, Bothell, WA) in one of 5 randomized positions. Emergency medicine residents and attendings were instructed to evaluate NT location simulating a right internal jugular vein approach. Subjects sequentially scanned the phantoms in randomized order, with each phantom randomized to either SA or LA. An expert observer verified NT location at the time of study. The outcome measure was correct NT position identification. All studies were recorded on SVHS video. Videos were reviewed by investigators. Time was calculated using the SVHS on-screen clock. Time вЂќbeganвЂќ at the first transducer contact with the phantom. Time вЂќendedвЂќ when the transducer was finally removed from the phantom. Analysis using PearsonвЂ™s Chi-square and Agresti-Coull binomial confidence intervals was performed, with significance defined as p ПЅ 0.05. Results: 416 (90%) of 462 times were included. Due to video corruption 46 scans were not included. See Table. Conclusion: The time required to identify the needle tip location was independent of the US transducer orientation and level of training. With increased accuracy in needle tip identification in the long axis, our study further supports using the long axis as a primary technique for ultrasound guided central venous cannulation. 220 How Accurate Is the Last Menstrual Period in Dating a First Trimester Pregnancy? Saul T, Lewiss RE, Del Rios M/St. LukeвЂ™s Roosevelt Hospital, New York, NY 219 Time to Identify Needle Tip Location Is Independent of Ultrasound Transducer Orientation and Physician Level of Training Sierzenski P, Kochert E, Mink JT, Cook D, Nichols WL, Reed III J, Nomura J/ Christiana Care Health Services, Newark, DE Study Objective: To determine the accuracy of last menstrual period (LMP) in determining gestational age and to determine the accuracy of emergency physician performed crown-rump length (CRL) measurement as an estimation of gestational age (GA). Methods: We prospectively enrolled a convenience sample of patients presenting to the emergency department (ED) and thought to be in the first trimester of pregnancy. Study physicians underwent a didactic lecture and hands on focused training in 1st trimester gestational age determination by emergency department ultrasound (EDUS). Ultrasound scans were compared to those performed in the department of radiology as the gold standard. Paired sample t-test was used to determine the correlation between GA by LMP and by EDUS compared to GA as determined by radiology US. Descriptive statistics were used to determine the frequency by which gestational age by LMP and by EDUS had a discrepancy of greater than 7 days and the average discrepancy compared to radiology US. Results: 72 patients have been enrolled. Of these patients 4 did not consent. 68 patients with suspected 1st trimester pregnancy underwent EDUS. Table 1 summarizes our results. Conclusion: An accurate determination of gestational age is important in prioritizing the differential diagnosis and triage of patients as conditions such as ectopic pregnancy present at certain times in gestation. Our data suggests that determining LMP is an inaccurate method of estimating GA when compared with radiology-performed ultrasonography. Bedside ultrasound is more accurate and should be used by emergency physicians to determine GA in patients presenting with suspected 1st trimester pregnancy. Background: Ultrasound (US)-guided central venous access is recommended by national organizations and medical societies. Increased accuracy for вЂќneedle tipвЂќ (NT) identification in a long axis orientation has been demonstrated. Study Objective: To determine if NT identification with US requires more time (seconds) in a long-axis (LA) or a short-axis transducer orientation (SA). Methods: Standard central access introducer needles were placed in 6 S68 Annals of Emergency Medicine Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts 221 Evaluation of Ectopic Pregnancy With Bedside Ultrasound by Emergency Physicians: A MetaAnalysis Stein JC, Wang R, Adler N, Goldstein R, McAlpine I, Won G, Jacoby V, Kohn M/ University of California, San Francisco, CA Study Objectives: Early and accurate recognition of ectopic pregnancy (EP) is essential to avoid morbidity and mortality. Research and clinical practice have demonstrated a clear role for pelvic ultrasound examination in patients at risk for EP. Such evaluations have typically been performed by radiologist or OB/GYN consultants. Several studies have investigated the accuracy of pelvic ultrasound by emergency physicians. These studies have generally shown both high sensitivity and negative predictive value for ruling out EP. It has been demonstrated that this approach is cost effective, and decreases the time patients spend in the ED. However, these accuracy studies have been relatively small with wide confidence intervals around the performance estimates, perpetuating uncertainty regarding the appropriate role of this technology. In order to better assess overall test characteristics of the use of pelvic ultrasound by emergency physicians in the evaluation of EP, we conducted a systematic review and meta-analysis. Methods: A structured search was performed of both MEDLINE and EMBASE from 1966 through August 2008. The search string utilized the following subject terms and text words: вЂњectopic pregnancy,вЂќ вЂњultrasound or ultrasonography or sonography,вЂќ and вЂњemergency.вЂќ The search was limited to human subjects, and included all languages. We conducted online bibliographic searches of abstract submissions to Annals of Emergency Medicine and Academic Emergency Medicine from 1990 through August 2008. Additionally, we searched through the bibliographies of studies that met relevance criteria for further articles on the subject. Two independent reviewers screened all abstracts and subsequent manuscripts for inclusion using the following criteria: 1) original research of female emergency department patients at risk for EP, 2) emergency physician performed and interpreted the initial pelvic ultrasound, 3) a gold standard follow-up criterion (formal radiology or clinical) was used for all patients. Two independent reviewers then extracted data from the included studies, and standardized the testing vocabulary such that a negative study for emergency physician was a definite intrauterine pregnancy (gestational sac plus yolk sac and/or fetal pole). Study quality was assessed utilizing a validated tool for quality assessment of diagnostic accuracy studies (QUADAS). Pooled data was analyzed with a random effects model. Results: The initial search yielded 576 publications. Abstract review yielded 57 with potential relevance. After full manuscript review, final inclusion yielded eight articles and one abstract for a total of 1987 patients (99% agreement, kappa 0.95). Our random effects model of the sensitivity demonstrated homogeneity and showed a pooled estimate of 99.3% (95% CI: 96.5 to 100). The model also demonstrated homogeneity for negative predictive value, with overall estimate of 99.96% (95% CI: 99.6 to 100). For both specificity and positive predictive value, there was significant heterogeneity. Overall, emergency physicians were able to rule out emergency physician in 63% of patients. Conclusions: This systematic review demonstrates that studies of the use of bedside ultrasound performed by emergency physicians consistently demonstrate excellent sensitivity and negative predictive value for ruling out ectopic pregnancy in a wide variety of clinical settings. 222 Nurse Utilization of Ultrasound Guidance for Peripheral IV Placement in the Emergency Department: Does It Change Over Time? Lyon M, Sinex JE, Shiver SA, Bloch A, Flake M/Medical College of Georgia, Augusta, GA Study Objectives: Nurse utilization of ultrasound (US) for peripheral intravenous (PIV) access has been increasing, particularly in academic medical centers. However, little is known about how the frequency of use of this technique changes over time following initial adoption within an institution. Our objective is to describe the utilization of US for PIV access over time in a well-developed nursing based program. Methods: This was a prospective observational trial performed in a Level I academic ED. Nurses, both RN and LPN, trained in US-guided PIV access recorded their use of and indications for the procedure for quality assurance purposes. A 5month sample period in 2008 was compared to a similar 5-month sample period in 2003. The data were evaluated using descriptive techniques. Results: ED volume was comparable between the two study periods (75,000 vs. 78,000, respectively), as was nurse staffing (105.6 vs. 120.4 FTE). During the 2003 time period, 10 nurses were trained (6.4%), and during the 2008 time period 30 nurses had Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ attended training (25%). The 2003 time period yielded 321 US-guided PIV access procedures by 7 nurses (70% of the trained staff ), and the 2008 time period yielded 217 US-guided PIV access procedures by 18 nurses (60% of the trained staff). In the most recent study period, 48.8% of US-guided PIV access procedures were performed by 2 nurses and 89.8% of procedures were performed by 7 nurses. During the 2003 time period, procedures were equally divided among the 7 users. The most common reasons given for using US during either time period were prior failed access (60.4%), need for large bore PIV access for IV contrast or resuscitation (24.4%), or a physical examination consistent with poor venous access (22.6%). Conclusion: US-guided PIV placement by nurses can be described as being performed by a relatively small core cadre of users who employ US relatively frequently, and a larger group who use it rarely. It was further observed that the overall number of procedures did not increase over time, though the number of nurses employing this technique did increase. Further research is needed to define the barriers to implementation of the technique after training. 223 Emergency Department Bedside Ultrasound Measurement of Caval Index as Non-Invasive Determination of Low Central Venous Pressure: A Multi-Center Validation of an Emergency Department Protocol Hansen AV, Medak AJ, Campbell C, Nagdev A, Castillo EM/University of California - San Diego, San Diego, CA; Highland General Hospital, Oakland, CA Study Objectives: An initial study has shown that among critically ill adult emergency department (ED) patients undergoing central venous catheterization, a greater than 50% decrease in the inferior vena cava (IVC) diameter measured by experienced emergency physician sonographers is a good predictor of low central venous pressure (CVP). This is preliminary data from a study that seeks to validate this protocol at an additional center among emergency physician sonographers of varying experience. Methods: Critically ill adult ED patients undergoing central venous catherization were enrolled in a prospective, observational study. Their maximal inspiratory (IVCi) and expiratory (IVCe) IVC diameters were measured by two-dimensional bedside ultrasound completed by emergency medicine residents and attendings of varying ED ultrasound experience. Prior to measurement of a transduced CVP, emergency physician sonographers were also asked to estimate the CVP as Пѕ or ПЅ 8mm Hg by visually estimating respiratory variation of the IVC diameter. The caval index (CI) was calculated as the relative decrease in IVC diameter over one respiratory cycle (IVCeвЂ“IVCi/IVCe). Linear regression was used to assess the association of CVP and CI. The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and 95% confidence intervals of a CI Х† 50% to predict a CVP ПЅ 8 mm Hg were estimated. These characteristics were also estimated for the emergency physician sonographerвЂ™s ability to predict a CVP ПЅ 8 mm Hg based on visual estimation of inspiratory collapse of the IVC. Results: 25 patients have been enrolled; however, 1 patient was excluded as the operator was unable to locate the IVC. 12.5% of operators were second year residents, 41.7% were third year residents, 16.7% were fourth year residents and 29.2% were attending emergency physicians. Of 24 patients, the median age was 56 and 58% were female. Mean time and fluid administered from ultrasound measurement to CVP determination was 18 minutes and 10 mL, respectively. 50% of the patients had had a measured CVP less than 8 mm Hg. The relationship between CI and CVP in an unadjusted linear regression model was вђ¤: ПЄ.12 (95% CI: ПЄ0.23, ПЄ.010). The sensitivity of a CI Х† 50% to predict a CVP ПЅ 8 mm Hg was 60% (24.7вЂ“ 86.3%), specificity was 85.7% (56.2вЂ“97.5%), PPV was 75% (35.6 вЂ“95.5%), NPV was 75% (47.4 вЂ“91.7%). The sensitivity of emergency physician sonographer estimated CVP ПЅ 8 mm Hg to predict an actual CVP ПЅ 8 mm Hg was 90% (54.1вЂ“99.5%), specificity was 78.6% (48.8 вЂ“94.3%), PPV was 75% (42.8 ПЄ93.3%), NPV was 91.6% (59.8 вЂ“99.6%). Conclusions: These preliminary data suggest that a protocol in which emergency physician bedside ultrasound measurement of CI Х† 50% has shown to be a good noninvasive predictor of low CVP may be validated when performed by emergency physician ultrasonographers of varying experience. In particular, clinician estimated CVP ПЅ 8 mm Hg based on bedside ultrasound appears to be a good predictor of a low CVP. Rapid, bedside measurements of CI could be a useful guide in the resuscitative management of critically ill patients. Annals of Emergency Medicine S69 Research Forum Abstracts 224 Teaching the Focused Assessment With Sonography in Trauma Exam: Is an Ultrasound Mannequin Simulator as Good as or Better Than Using Live Models for Practical Training? Damewood S, Cadigan B, Jeanmonod D/Albany Medical Center, Albany, NY; St. LukeвЂ™s Hospital, Bethlehem, PA Study Objective: This study was designed to evaluate the effectiveness of two different вЂњhands-onвЂќ Focused Assessment With Sonography in Trauma (FAST) curricula, a mannequin model with ultrasound simulator and a human model with ultrasound machine, in teaching the skills of both image acquisition and image interpretation of the exam. Methods: This study is a prospective randomized controlled study conducted on a consecutive sample of fourth year medical students enrolled during their required emergency medicine rotation. Fourth year medicals students were chosen as an ultrasound naД±ВЁve population, and were screened to ensure a lack of prior ultrasound training. All study participants received a standardized didactic presentation on the FAST exam, which illustrated both normal and abnormal findings. The students were randomized into two groups for the hands-on intervention. The first group practiced the FAST exam on the Ultrasim (MedSim Ft. Lauderdale, FL), an ultrasound mannequin simulator, set to simulate both positive and negative findings. The second group practiced on normal human subjects. The students were then tested on whether images of pre-recorded FAST exams were positive or negative. After the interpretive test, both groups performed the FAST exam on a standardized normal patient. The students recorded still images representing each of the four views of the traditional FAST exam that they deemed were adequate images. The time required for each participant to complete the FAST exam was recorded. After finishing image acquisition, the students recorded their perceived level of confidence in the quality of images that they acquired. Two blinded investigators with expertise in EM ultrasound scored the acquired images according to a pre-established set of scoring criteria. A third blinded investigator reviewed images if there was a discrepancy in scores. The adequacy of the obtained images, time to acquisition of the images, the studentsвЂ™ levels of confidence in image acquisition, and scores of the interpretive test between the two groups were compared. Results: To date, 56 participants have been enrolled in this study. The adequacy of the obtained images scored out of a possible 24 points was similar between the simulator and human subject groups, with means of 14.8 (95% CI 12.7вЂ“17.0) and 15.2 (95% CI 13.6 вЂ“16.9) (pП0.68) respectively. The median time for the simulator group to record the FAST exam was 223 seconds (IQR 155вЂ“298.5) while the human subjects groupвЂ™s median time was 270 seconds (IQR 202вЂ“310) (pП0.059). The participantsвЂ™ perceived confidence was also similar. The simulator groupвЂ™s median confidence score on a scale of 0 вЂ“10 was 5 (IQR 4.2вЂ“ 6.7) while the human subject groupвЂ™s median score was 4 (IQR 3.7вЂ“5.2) (pП0.213). In regards to the interpretive test, the median score of the simulator group was 84% (IQR 75вЂ“ 89), compared to 78% (IQR 68.5вЂ“ 87.5) (pП0.134) in human subject group. Conclusions: According to our preliminary data set, there was no significant difference between the groups for the measured outcomes of perceived confidence of image adequacy, time to image acquisition, image interpretation, or acquired image adequacy. This data set suggests there is no difference between ultrasound simulators and human subjects in teaching students how to perform and interpret the FAST exam. 225 Should This Stroke Patient Be Transferred? Computed Tomographic Angiography Predicts Use of Tertiary Interventional Services Thomas LE, Goldstein JN, Hakimelahi R, Gonzalez RG/Massachusetts General Hospital, Boston, MA Study Objectives: Many organizations have recommended that primary and comprehensive stroke centers be established to organize stroke care. However, there are no formal guidelines for determining which patients should be transferred to comprehensive stroke centers. A rapidly available prediction tool for advanced interventional services would help community hospitals determine which patients might benefit from transfer. Multislice computed tomographic scanners are widely available in U.S. emergency departments; we hypothesized that the finding of an occlusive thrombus in a proximal cerebral artery on computed tomographic angiography (CTA) would predict use of advanced neurointerventional services. Methods: Consecutive ischemic stroke patients presenting within 24 hours of symptom onset to a single academic emergency department in 2006, and who S70 Annals of Emergency Medicine underwent emergent CTA, were retrospectively reviewed. Proximal cerebral artery occlusions on CTA were defined as distal/terminal (intracranial) internal carotid artery, proximal (M1 or M2) middle cerebral artery, and/or basilar artery. Tertiary care interventions including intra-arterial (IA) thrombolysis, mechanical clot retrieval or removal, and any neurosurgical procedure were captured. Results: During the study period, 283 patients presented within 24 hours of symptom onset, and 207 (73%) received a CTA. 25% of patients received intravenous tissue plasminogen activator, 2.4% received IA thrombolytics, 6.8% received a mechanical intervention, 3.3% underwent surgery, and 52% were admitted to the neuroscience intensive care unit. 72 (35%) showed evidence of a proximal cerebral artery occlusion on CTA, and 22 (11%) received a tertiary neurointervention. Patients with proximal thrombi had higher National Institutes of Health stroke scale scores than those without this finding (17 (IQR 9 вЂ“21) vs. 4 (IQR 2вЂ“9), pПЅ0.0001). In addition, those with proximal thrombi were more likely to receive an intervention (25% vs. 3%, pПЅ0.001). They were more likely to undergo IA thrombolysis (8% vs. 1%, pП0.008), a mechanical intervention (19% vs. 0%, pПЅ0.0001), or admission to the neuroscience ICU (85% vs. 35%, pПЅ0.0001). They were also more likely to suffer in-hospital mortality (30% vs. 6%), and less likely to be discharged home (10% vs. 48%) (pПЅ0.001). Evidence of proximal occlusion on CTA predicts use of IA thrombolysis with sensitivity 86%, specificity 67%, PPV 8% (5вЂ“9%), and NPV 99% (97вЂ“99%). It predicts use of mechanical intervention with sensitivity 100%, specificity 70%, PPV 19%, and NPV 100%. In multivariable logistic regression controlling for age, sex, initial National Institutes of Health Stroke Scale score, and time to presentation, the only independent predictors of interventional services were increasing NIHSS (OR 1.1, 95%CI 1.01вЂ“1.2) and proximal clot on CTA (OR 5.8, 95%CI 1.7вЂ“20). Conclusion: Proximal cerebral artery occlusion on CTA is a sensitive, but not specific, independent predictor of use of advanced neurointerventional services. While not all centers can perform a comprehensive CTA, almost all emergency departments in the US can perform multislice CT scanning with contrast, and have the ability to determine presence of a thrombus in a proximal cerebral artery. CTA may be a valuable tool in determining which stroke patients would benefit from transfer to a center with comprehensive neurointerventional services. 226 Nonaneurysmal Subarachnoid Hemorrhage: Clinical Course and Outcome in Two Distinct Hemorrhage Patterns Gilmer M, Wiliams A, Ray D, Jones JS/Michigan State University College of Human Medicine, Grand Rapids, MI; MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI; MERC/ Michigan State University, Grand Rapids, MI Background: Fifteen percent of spontaneous SAH have a normal cerebral angiogram, which indicates non-aneurysmal SAH (NASAH). In contrast to aneurysmal SAH, patients who have a NASAH have a better prognosis and fewer neurological complications. Two distinct hemorrhage patterns in NASAH have been identified on initial computed tomography (CT): perimesencephalic and diffuse subtypes. The diffuse hemorrhage pattern involves more than the prepontine cisterns and mimics aneurysmal rupture. The perimesencephalic hemorrhage pattern has blood confined to the midbrain cisterns with no evidence of intraventricular and intracerebellar hemorrhage. Study Objectives: To compare the predisposing factors, treatment, and subsequent complications in patients with two different patterns of NASAH. Methods: This retrospective cohort analysis evaluated consecutive adult patients presenting to the emergency department with an admitting diagnosis of SAH. The study took place at two urban U.S. academic medical centers over a six-year study period (2003вЂ“2008). The patients were stratified based on grade at presentation, severity, and pattern of SAH on initial CT of the head into perimesencephalic and diffuse subtypes. The patients were further differentiated based on the development of vasospasm, hydrocephalus and required treatments, and clinical outcomes. Patients were excluded if a causative lesion was discovered subsequently. Chi-square and ANOVA tests were used to compare clinical features among the cohorts examined. Results: A total of 436 patients with subarachnoid hemorrhage were evaluated during the study period; 89 (20%) had no identified source of bleeding (NASAH) and fulfilled the inclusion criteria. Twenty-nine patients were considered to have the perimesencephalic (p-SAH) subtype, while 60 patients fit criteria for the diffuse (dSAH) subtype. There were no significant differences between the two hemorrhage subtypes in age, sex, ethnicity, hypertension, tobacco or alcohol use, or use of anticoagulants. Patients with perimesencephalic hemorrhage had a milder, gradual Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts onset headache and significantly less altered level of consciousness. Patients with dSAH subtype had a higher risk for complications related to SAH with an increased incidence of hydrocephalus (33% vs. 3%, pПЅ.01), symptomatic vasospasm (28% vs. 7%, pП.04) and secondary stroke (15% vs. 0%, pП.07). Ultimately, only 67% of d-SAH patients achieved complete recovery and independent living, compared to 90% of p-SAH patients. Conclusions: Patterns of hemorrhage on the initial CT scan are important prognostic factors for NASAH. The patients that fit strict criteria for perimesencephalic hemorrhage demonstrated a relatively benign course. Patients with a diffuse hemorrhage pattern are at increased risk for hydrocephalus and secondary stroke; they are also less likely to achieve complete recovery and should therefore be cared for with a higher level of surveillance. 227 Examination of Adherence to Evidence-Based Practices and 30-Day Outcomes for Emergency Department Patients Treated for Transient Ischemic Attack Baumann MR, Halberg MJ/Maine Medical Center, Portland, ME Study Objectives: Little evidence regarding outcomes in transient ischemic attack (TIA) patients discharged from the emergency department (ED) or on local adherence to identified best practices in TIA care was available. The purposes of this study were to: 1) evaluate health outcomes in patients treated in the ED for TIA at 48 hours, 7 days, and 30 days, 2) to evaluate compliance with identified best practices in TIA care, and 3) to examine the relationship between ABCD2 score and disposition in TIA patients. Methods: This retrospective health records survey was exempted by the hospital institutional review board. A sample of 50 health records for patients seen in a single academic tertiary care ED with a diagnosis of TIA was randomly selected for review and study inclusion. Demographic characteristics, ABCD2 score, treatment regime, imaging results, and disposition were collected from all records. Examination of the electronic health record for a 30-day period following the initial visit was conducted to determine repeat visits for TIA or stroke at 48 hours, 7 days, and 30 days. Results: In our randomly selected cohort, 28 (56%) patients were admitted to the hospital and 22 (44%) were discharged to home. Eight percent of the study population had a repeat visit for TIA or stroke during the 30-day period following their initial ED visit. Patients admitted on their initial visit returned for TIA or stroke more frequently than their discharged counterparts (10.7% vs. 4.5%, respectively, вђ№2 П 36.255, p П 0.000) and had higher ABCD2 scores (22 vs. 8 with moderate to high risk scores, respectively, вђ№2 П 26.8, p П 0.000). ED workups for TIA compared favorably with identified evidence-based practices: 100% of patients received an electrocardiogram, 98% received brain computed tomography or magnetic resonance imaging, and 86% received carotid imaging. Carotid imaging was performed 100% of the time in admitted patients. Echocardiograms were obtained in 79% of admitted patients versus 0% of discharged patients. The majority of patients (94%) were discharged on anti-platelet medications. Those patients with high and moderate risk ABCD2 scores were admitted to the hospital in 80% and 72% of cases, respectively. This relationship was noted to be statistically significant, r П 0.512, p П 0.000. Conclusions: In this cohort of emergency department patients, 8% of the study population was treated for repeat TIA or stroke within 30 days of the index ED visit. Care for the majority of patients followed identified evidence-based practices. We found ABCD2 scores to be correlated with admission to the hospital and return visits for TIA or stroke. Additional research on the use of the ABCD2 score as a predictor of risk for repeat TIA or stroke is warranted. 228 Cephalgia in Emergency Department Responds to Oxygen Decreasing Time to Relief, Length of Stay, Computed Tomography Utilization, and Need for Pharmacotherapy Veysman BD, Carluccio A, Ohman-Strickland P, Arya R, Ostro B, Merlin MA/ UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ; Umiversity of Medicine and Dentistry of New Jersey-School of Public Health, Piscataway, NJ Study Objectives: Efficacy of high-flow oxygen is documented in cluster headaches, but has not been studied in emergency department (ED) patients with undifferentiated headaches. We hypothesized that an initial ED therapy of high-flow oxygen would produce rapid and significant relief, decrease time to headache resolution, length of stay, ordering of computed tomography (CT) of the head and the need for headache pharmacotherapy. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Methods: Evaluation of patients over 21 was conducted at our academic adult emergency department with an annual census of 58,000. A convenience sample of 59 subjects whose complaints included a headache were approached, of whom 48 consented, met the inclusion criteria and completed the study. Seventeen subjects were randomized to 100% oxygen at 15 L/min for 15 minutes, 14 subjects received high flow air for 15 minutes, and 17 subjects received no intervention prior to standard treatment. Headache intensity was assessed using a 10-point visual analog scale (VAS). Kruskal-Wallis ANOVA test was used to assess differences between treatments for continuous outcomes and PearsonвЂ™s chi-square for binary responses. Results: Times to relief were significantly shorter (pП0.0003) for patients treated with oxygen (medianП40, Inter-quartile range, IQRП11вЂ“ 45) relative to those treated with high flow air (mediansП110, IQRП100 вЂ“180) or nothing (medianП120, IQRП55вЂ“180). Length of stay was also significantly shorter (pП0.016) for patients treated with oxygen (medianП57.5, IQRП40, 196.5) than for those with air (medianП210, IQRП155вЂ“270) or nothing (medianП180, IQRП100 вЂ“210). In addition, CT scans were ordered less frequently (4/17П24% for oxygen, 11/14П79% for air, and 8/17П47% with nothing, p-valueП0.0094); pharmacotherapy used less often (5/17П29% for oxygen, 12/14П86% for air, and 14/17П82% with nothing, p-valueП0.0008); and narcotic therapy used less frequently, although this association was not statistically significant (pП0.21). Headache intensity was also significantly reduced at both 15 minutes and 30 minutes (pПЅ0.0001 and П0.0002), with patients treated with Oxygen realizing greater reductions in VAS scores (medianП41 and 44, IQRП24 вЂ“56 and 24 вЂ“58) than patients treated with air (mediansП9.5 and 7, IQRП0 вЂ“16 and 0 вЂ“10) or nothing (mediansП0 and 7, IQRП0 вЂ“12 and 0 вЂ“16). (Median baseline VAS scores did not differ significantly between treatments with pП0.23.) Conclusion: High-flow oxygen therapy for 15 minutes is an effective treatment for undifferentiated headache in emergency department patients. Initiating oxygen therapy upon arrival to the ED and prior to standard therapy leads to faster headache resolution, decreased use of CT imaging and pharmacotherapy, and shorter length of stay. 229 A Survey of Emergency Physician and Stroke Specialist Beliefs and Expectations Regarding Telestroke Moskowitz A, Chan Y, Bruns J, Levine SR/Mount Sinai School of Medicine, New York, NY Study Objectives: Telestroke, the application of telemedicine to the treatment of acute ischemic stroke (AIS), allows stroke specialists (SS) to remotely examine patients and aid emergency physicians in making treatment decisions. The safety and improved decisionmaking via Telestroke support broader implementation of the technology. We aimed to identify and compare the barriers perceived by SSs and emergency physicians preventing greater Telestroke adoption. Methods: A Likert-style survey was developed based on a literature review and semi-formal focus groups with SSs and emergency physicians. We distributed the survey nationwide using an online survey system to 382 SSs identified during a systemic review of academic stroke physicians at American academic medical centers and from discussions with colleagues, and to 226 emergency physicians attending the 2008 American College of Emergency Physicians (ACEP) national conference. Participants watched a 5-minute video of a Telestroke consult prior to completing the survey to ensure a base level of familiarity with the technology. Results: One hundred and thirty five (35%) of the SSs returned the survey via the online survey system and 226 emergency physicians completed the survey at an ACEP booth set up by one of the authors (AM). The average ages of the emergency physicians and SSs were 40 and 47 respectively (p П ПЅ0.001). The emergency physicians were 73.1% male and the SSs were 79.5% male (p П NS). Fifty-five percent of the emergency physicians were attendings for more than five years as compared to 82% of SSs (p ППЅ0.001). SSs reported being more knowledgeable than emergency physicians about telemedicine generally (pПЅ0.001) and Telestroke specifically (pПЅ0.001). Participants in both specialties agreed that Telestroke has the potential to reduce geographical differences in stroke care and is superior to standard phone consultation. Emergency physicians indicated a stronger belief in the potential of using Telestroke for physician and community stroke education than SSs (pП0.003). On a scale of 1 (Very Significant) to 5 (No Barrier), the greatest barriers perceived by SSs to expand Telestroke implementation were inadequacy of reimbursement (2.0П®1.0) and medical liability (2.3П®1.1,). Emergency physicians reported medical liability (2.3П®1.2) and time and cost of installation (2.4П®1.1) to be the greatest obstacles. Emergency physicians perceived patient preference for physical visits (pПЅ0.001), inability to manage rt-PA side effects (pП0.001), level of Annals of Emergency Medicine S71 Research Forum Abstracts technology (pП0.011), and rt-PA not being widely considered the standard of care for AIS (pП0.017) to be more significant barriers than SSs. SSs found the possibility of increased personal work to be a greater barrier than emergency physicians (pПЅ0.001). Conclusion: SSs and emergency physicians report positive beliefs regarding Telestroke; however, a number of barriers exist to greater implementation. Medical liability needs to be more rigidly defined and Telestroke installation processes streamlined in order to encourage greater Telestroke adoption. Differences between barriers perceived by emergency physicians and SSs need to be addressed and reconciled where possible. 230 Out-of-Hospital Normobaric Oxygen Therapy in Presumptive Acute Stroke Patients: A Preliminary Study Chan Y, Richardson L, Moskowitz A, Katz M, Chason K, Singhal A, Poojary I, Kramer S, Levine SR/Mount Sinai School of Medicine, New York, NY; Massachusetts General Hospital, Boston, MA; New York College of Osteopathic Medicine, Old Westbury, NY Study Objectives: Numerous recent studies demonstrated that normobaric oxygen may significantly reduce cerebral infarct size and extend the reperfusion window after stroke. The New York City (NYC) Regional Emergency Medical Advisory Committee out-of-hospital protocol mandates administration of 10вЂ“15 L/min of 100% O2 via nonrebreather mask to all patients with a presumptive diagnosis of stroke. We examined the frequency, feasibility, and safety of out-of-hospital normobaric oxygen use for acute stroke including those found to have stroke mimics. Methods: We conducted a retrospective review of the out-of-hospital call reports of all patients transported by our (NYC) hospitalвЂ™s ambulances with a presumptive diagnosis of stroke. In total, 366 stroke calls between 2003 and 2008 matched these criteria. Results: The mean age of the patients was 70 (П®15), 61% were female, and the mean time of onset of symptoms was 247 (П®690) minutes. The average on scene time was 25 minutes (П®9) and the average transport time was 5 minutes (П®2). The Cincinnati Pre-Hospital Stroke Scale (CPSS) was documented in 78% of patients. Of the 307 patients (84%) with documentation in the вЂњO 2 therapyвЂќ section of the outof-hospital call reports, 301 (98%) received O 2 therapy. Of those with documented O2 administration by EMS, 248 (83%) received 15L/min 100% O2 via nonrebreather mask, 13 (4%) received 12L/min and 33 (11%) received 10L/min. Three patients (1%) were treated using a bag valve mask and two (ПЅ1%) patients received O 2 via nasal cannula at 4L/min and 6L/min. All patients had repeat out-of-hospital call reports vital signs upon arrival to the emergency department and the means were not significantly different from the initial measurements. With the exception of 1 patient, we found no documented respiratory distress, hypoventation, intubation, or other complications related to normobaric oxygen use in the out-of-hospital phase despite the approximately 30 minute administration of 10 вЂ“15L/min 100% O 2 via non-rebreather mask to most of these patients. For those patients who had two CPSS and/or Glasgow Coma Scale (GCS) assessments, there was no relationship between oxygen administration and change in CPSS or GCS. We reviewed data on the 33 patients with a change in initial and final GCS scores; 28 had received documented oxygen. Twenty-five of these patients had an improvement in GCS, whereas 3 patients had a lower repeat GCS. We found no reported cases of patient/caregiver refusal of, disruption/premature termination of, or logistical/technical difficulty with the delivery of supplemental O2. Conclusion: Most of the presumptive stroke call patients in NYC receive 10 вЂ“15 L/min of 100% O2 via non-rebreather mark in the out-of-hospital setting. The administration of out-of-hospital normobaric oxygen is feasible and appears safe. However, given the relatively small sample size, incomplete clinical record, confounders, and retrospective method, a prospective randomized control trial is necessary to confirm the safety and efficacy of normobaric oxygen in AIS. 231 Predictors of Mortality in Patients Presenting to Emergency Department with Stroke: A Developing Nation Scenario Chandra S, Agarwal D, Surana A, Singh V, Mohan A, Khan MA/All India Institute of Medical Sciences, New Delhi, India; Mayo Clinic, Rochester, MN; Mysore Medical College and Research Institute, Mysore, India Study Objectives: Case fatality rate in stroke in Indian subcontinent is higher compared to Western countries. Risk factors for poor outcome following stroke S72 Annals of Emergency Medicine include age, severity of stroke, low Glasgow Coma Scale, atrial fibrillation, previous stroke, hyperglycemia, fever, urinary incontinence and abnormal breathing. Although mortality in developing countries is higher, we have less knowledge about predictors. Hence, we planned this study to determine the factors predicting inpatient case fatality (ICF) rate for stroke. Methods: This was a hospital-based prospective study on stroke conducted during January 2005 to December 2006 in a teaching hospital catering predominantly to rural population from South. Cohort of stroke patients admitted on two predetermined days of every week to medical emergency ward, were enrolled and followed up till their discharge. ICF rate for this study was taken as mortality occurring before discharge of patient from hospital. Data has been analysed using SPSS version 11.5. Results: 134 patients (65.7% were from rural population, 55.22%-smokers, 46.76%-alcoholics) with mean (SD) age of 53.83П®18.02years [significantly lower in females (mean differenceПЄ9.73years pП0.002)], were admitted and diagnosed to have stroke.87.3% had first episode of stroke and 12.7 had more than one episode of stroke. ICF rate was 26.1%. ICF rate has no relation with age (pП0.516), sex (pП0.460), number of episodes (0.795), underlying hypertension (pП0.905). Odds of diabetics dying were 12 times higher than non-diabetics. Inpatient mortality was also significantly higher in smokers compared with non-smokers (pП0.004), in patients with right-sided compared with left-sided hemiplegia (pП0.029) and who couldnвЂ™t afford computed tomography (CT) scan (pП0.007). Kaplan Meier curve in Image-1 shows the survival following admission to emergency ward. Conclusion: Our study has shown that active smokers, involvement of the right side and non performance of CT were independent predictors of mortality which have not been shown earlier. Also, we found that diabetes mellitis is independent predictors of mortality in stroke, which has been seen in earlier studies too (see graphic). 232 Emergency Department Hyperglycemia as a Predictor of Mortality and Functional Outcome After Intracerebral Hemorrhage by Diabetes Mellitus Status Odufuye AO, Bellolio M, Jain A, Dhillon R, Manivannan V, Gilmore R, Chandra R, Palamari B, Decker W, Stead LG, Yerragondu N/Mayo Medical School, Rochester, MN; Mayo Clinic, Rochester, MN; University of Rochester School of Medicine and Dentistry, Rochester, NY Study Objective: To explore the association between glycemia at presentation and prognosis in intracerebral hemorrhage, and compare between those with and without diabetes mellitus (DM). Methods: This was an observational cohort study with 237 consecutive patients who presented to the emergency department with intracerebral hemorrhage and had blood glucose measurement within 24 hours of presentation. Medical records were reviewed and stroke severity, functional outcome at discharge, and date of death were obtained. Results: Median age was 73 years (IQR 59 вЂ“ 82). There were 123 (51.9%) females. Median blood glucose at presentation was 140 mg/dL (range 61вЂ“ 600 mg/ dL). DM patients had higher glucose levels (median 202 mg/dL for DM versus 133 mg/dL for non-DM, pПЅ0.0001, Wilcoxon test). Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts Among patients without diabetes (non-DM), there was a linear relationship between stroke severity (NIHSS) at presentation and glucose level; the higher the glucose level, the higher NIHSS (worse stroke severity); pПЅ0.0001, R-square 25.7%. There was no significant relationship between blood glucose and stroke severity among diabetic patients; pП0.298, R-square 2.4%. In non-DM patients, hyperglycemia was associated with death within 7 days and within 1 month; pПЅ0.0001. In addition, there was a positive linear relationship between glucose level at presentation and modified Rankin score (mRS) at discharge among non-DM patients; the higher the glucose level, the higher the mRS (worse functional outcome); R-square 22.6%, pПЅ0.0001. Although hyperglycemia was associated with death within 7 days (pП0.034) and within 1 month (pП0.022) in diabetic patients, this association was not as strong as that seen among non-DM patients. However, among diabetic patients, there was no relationship between glucose level at presentation and mRS at discharge; R-square 5.3%, pП0.119. In logistic regression model, after adjustment for stroke severity and age, glucose was an independent predictor of death within 7 days (pПЅ0.0001), death within 1 month (pПЅ0.0001) and poor functional outcome (pПЅ0.0001) in non-DM patients. However, among diabetic patients, glucose was not an independent predictor of death within 7 days (pП0.20), death within 30 days (pП0.20) and functional outcome (pП0.38). Conclusion: Hyperglycemia at presentation was associated with increased 7-day and 1-month mortality regardless of diabetic status in the univariate analyses. However, after adjustment by age and NIHSS, glucose was an independent predictor of death in non-DM patients only. Hyperglycemia at presentation is associated with worse stroke severity at presentation and worse functional outcome at discharge in non-diabetic patients only. 233 Screening Electroencephalograms Are Feasible and Identify Potential Subclinical Seizure Activity in Emergency Department Patients Bastani A, Young E, Hunt-Walch R, Kayyali H/Troy Beaumont Hospital, Troy, MI; Cleveland Medical Devices, Cleveland, OH Background: Seizures account for 1 million emergency department (ED) visits annually. Due to the cost and expertise required to interpret and perform an electroencephalogram (EEG) the majority of hospitals cannot provide EDs with EEG coverage. Supported by the National Institute of Health initiative PA-04-006, a portable, wireless multi-channel EEG device, the Crystal Monitor, was developed to provide emergency physicians access to a screening EEG during the ED visit. The Crystal Monitor generates a 20-minute screening EEG utilizing an abbreviated montage to minimize set-up time. The EEG data is then digitized allowing a neurologist anywhere in the world with Internet access to review the EEG and provide an interpretation. Study Objective: To evaluate the feasibility and utility of screening EEGs on patients presenting to the ED with potential seizure activity. Methods: We conducted a prospective observational study on patients presenting to the Troy Beaumont ED between March 2004, and March 2009. Troy Beaumont is a 279-bed community hospital with a yearly ED census of 70,000 patients. Adult patients (age Пѕ 18 years) with a preliminary diagnosis of syncope, potential partial-complex or generalized seizure disorder, head injury with prolonged symptoms or acute undiagnosed altered mental status were eligible for enrollment. Those patients with a confirmed nonneurologic diagnosis for their presenting complaint were excluded. Eligible patients were then asked to complete an informed consent and had a screening EEG performed by a trained ED research assistant during the ED stay. The EEG data was then password protected and transmitted over the Internet for interpretation by the study neurologist. The emergency physicians were blinded to the result; therefore, neither specific care nor follow-up EEG was mandated by inclusion into the trial. Our primary outcome measures were EEG quality and EEG diagnosis as reported by the study neurologist. EEG Quality was evaluated using the following criteria: 1Пpoor quality/uninterpretable, 2Пfair quality/acceptable, 3П good quality/acceptable or 4Пexcellent quality/acceptable. Descriptive statistics were utilized to analyze the data. Results: A total of 227 patients were enrolled of which 47.6% were female with a mean age of 55.7 years. The indications for a screening EEG were: 1) a witnessed or suspected seizure disorder 68.2% (155/227), 2) syncope 22.9% (52/227), 3) altered mental status 7.5% (17/227), and 4) head injury with prolonged symptoms 1.3% (3/227). EEG quality was acceptable in 92.5% of patients (See Table #1). The EEG interpretation for all acceptable EEGs was: 1) normal in 64.9% (135/208), 2) identified generalized or focal slowing in 23.6% (49/208), and 3) identified epileptogenic foci in 11.5% (24/208) of patients. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Conclusion: Screening electroencephalograms performed in the emergency department are feasible, of acceptable quality, and able to diagnose seizure potential in a significant number of patients. 234 Comparison of Blunt Versus Sharp Spinal Needles Used in the Emergency Department in Rates of Post-Lumbar Puncture Headache Torbati S, Katz D, Silka P, Younessi S/Cedars-Sinai Medical Center, Los Angeles, CA Study Objectives: To compare rates of post-lumbar puncture headache (PLPHA) in patients undergoing a diagnostic lumbar puncture (LP) in the emergency department (ED) with blunt versus sharp spinal needles of the similar size. Methods: This was retrospective review of consecutive series of adult patients undergoing LP in the ED of a quaternary (Level I Trauma) medical center staffed with full time emergency physicians between April 2008 and February 2009. As part of a performance improvement project, physicians were encouraged to use blunt spinal needles and had both 22 g blunt (Gertie MarxВ®) and 22 g sharp (Quinke) needles available in their LP kits. Primary outcome was the incidence of PLPHA in patients having a lumbar puncture with either blunt versus sharp needles. Secondary outcome was LP procedural failure rates defined as the inability to obtain cerebrospinal fluid with use of the first LP needle chosen by the emergency physician. PLPHA was defined as a new or different headache worsened by sitting and standing, improved when supine, which developed within 24 вЂ“72 hours of the LP. Inpatient records were reviewed to determine the presence of PLPHA for admitted patients. Outpatient records and phone follow-up data obtained within 3 weeks of ED visit was used to determine presence of PLPHA for patients discharged home. Fisher test was used to detect differences between the groups. Results: Three hundred seventeen consecutive adult patients, ranging from 18 to 95 years of age, had diagnostic LPs during the study period, 56.8% of whom were female and 43.2% male. The major indications for the LP were to evaluate for meningitis and/or subarrachnoid hemorrhage (94%). Blunt LP needles were used to obtain CSF in 45.4% and sharp needles in 54.6% of the patients. Follow-up was available for 92% of the study group. PLPHA was reported in 4.48% of patients in whom a blunt LP needle was used compared with 11.32% of those with sharp needles (pП.017). Procedural failure rate was 26.3% for the blunt needles versus 9.4% for the sharp needles (pПЅ.0001). Conclusion: Use of blunt LP needles was associated with reduced rates of PLPHA and higher rates of procedural failure compared with sharp LP needles of similar size in an ED setting. The reduced rates of PLPHA with the blunt LP needle support existing literature in non-ED setting recommending its use whenever feasible. 235 Can We Defer a Type and Screen for Pregnant Patients With Vaginal Bleeding Who вЂњKnowвЂќ Their Blood Type? Shah K, Cavallo E, Kurobe A, Paisley J, Newman DH/St. LukeвЂ™s-Roosevelt Hospital, New York, NY Study Objective: Pregnant women with vaginal bleeding often require Type and Screen testing for Rh positivity. We sought to determine if there is a subset of pregnant women presenting to the emergency department who reliably know their blood type and for whom a type and screen could safely be omitted/deferred in the emergency department (ED). Methods: This was a prospective, convenience sample cohort study at 2 associated urban academic centers from Jan 2007 through Jun 2008 with an annual ED census of 150,000 patients. Pregnant patients who had a Type and Screen obtained as part of their ED evaluation and were capable of consent were enrolled by trained research associates working in the ED approximately 16 hours per day during Annals of Emergency Medicine S73 Research Forum Abstracts semester-based time blocks. Subjects completed a standardized data form in the ED prior to the subject being informed of their blood type results. Information requested included demographic information, pregnancy history and whether they knew their blood type by selecting вЂњno,вЂќ вЂњmaybeвЂќ or вЂњyes, definitely.вЂќ Research associates entered the subject data and the laboratory determined blood type into an Access Database. Standard descriptive statistics with 95% confidence intervals were performed. Results: Among the 319 pregnant women enrolled, the mean age was 27.8 (range of 18 to 43), 26.1% had no prior pregnancy, 40.4% were receiving prenatal care and the majority were Hispanic (50.8%). 106/319 (33.2%) subjects reported that вЂњyes, definitelyвЂќ they knew their blood type; 103 (97.2%[.95CIП94.0 вЂ“100%]) identified their correct blood type and 105 (99.1% [.95CIП97.2вЂ“100%]) identified their correct Rh Factor. None of these subjects selected a positive Rh when they were in fact a negative Rh. 49/319 (15.4%) subjects reported вЂњmaybeвЂќ they knew their blood type. 14/49 (28.6%) were incorrect and 6 selected a positive Rh when they were in fact a negative Rh. 26/319 (8.2%) subjects had a negative Rh and none of these subjects thought they had a positive blood type. 17 subjects stated they had a rhogam injection in the past and all had a negative Rh except for 1. Conclusion: Pregnant women reporting that вЂњyes, definitelyвЂќ they knew their blood type are reliable, whereas those reporting вЂњmaybeвЂќ are not. Deferring an expensive and time-consuming Type and Screen test for a subset of pregnant women who вЂњdefinitelyвЂќ know their blood type may be reasonable. 236 An Analysis of Prolonged Length of Stay in a Pediatric Emergency Department Place R, Howell J, Malubay S, Kou M/Inova Fairfax Hospital, Falls Church, VA Study Objective: The past decade has seen increased emphasis placed upon process management and many emergency departments have begun to focus on process times in an effort to improve patient satisfaction. More recently, as fewer emergency departments are responsible for more patient visits, improving throughput efficiency has become a matter of simple survival. One universally compared measure of throughput is average length of stay. However, analysis of aggregate averages fails to highlight the specifics of process inefficiency. In order to accomplish this, we studied patient visits with prolonged throughput times. Methods: Between June 1, 2009 and September 27, 2009, we examined a consecutive, prospective cohort of pediatric patients at a suburban academic, level 1 pediatric trauma center. Time-stamped electronic medical records of all discharged patients with a length of stay (LOS) exceeding 6 hours were manually reviewed. LOS was defined as the time between arrival and discharge from the department. Admitted patients were excluded. Demographic data including diagnosis, physician provider, process intervals, and diagnostic studies were evaluated. Predetermined criteria defining physician inefficiency included: time between decisions or clinical events (90 minutes), delayed disposition (60 minutes after all clinical data or treatment completed), serial workup (secondary studies ordered after first round completed), decisions that could have been made earlier. Results: Average discharge LOS for 7199 seen during the study period was 163 minutes. One hundred sixty-seven patients (2.3%: 95% CI 2.0 вЂ“2.7%) required more than 360 minutes to be discharged from the emergency department. The door-to-doc interval was greater than 60 minutes in 56 (36%: 95% CI 29 вЂ“ 44%) cases, while arrival to triage was greater than 30 minutes in only 11 (6%: 95% CI 4 вЂ“12%) cases. Inefficiencies in care provided by the ED attendings contributed to prolonged patient stays in 110 (66%: 95% CI 32вЂ“ 47%) cases: delayed in decisionmaking (15%), decisions that could have been made earlier (22%), delayed disposition after completed evaluation (27%), serial workup (32%). Only 34 (20%: 95% CI 15вЂ“27) of prolonged LOS could be attributed to legitimate observation. Consultant delays of greater than 2 hours were found in 14% of cases. When normalized for patient volume, the individual rate of prolonged LOS between different attendings ranged from 0.6% to 8.8%. The single most important patient-related factor was a chief complaint of abdominal pain in 59 (35%: 95% CI 26 вЂ“ 45%). Conclusion: Excessive department throughput times can be objectively linked to physician behavior. Most cases have some component of delayed decisionmaking, serial evaluation, or inefficient response to clinical information. Significantly variability exists between different physicians. Patients with abdominal pain comprise a disproportionate number of prolonged stays. S74 Annals of Emergency Medicine 237 Supplemented Triage and Rapid Treatment in the Emergency Department White BA, Brown DF, Sinclair J, Chang Y, Carignan S, McIntyre JA, Biddinger PD/ Massachusetts General Hospital, Boston, MA Background: Emergency department (ED) crowding is a well-recognized problem locally and nationally, and the burden of capacity constraints is predicted to worsen in the future. Multiple studies have demonstrated the negative effect of hospital and ED crowding on patient care metrics, including delayed care, increased diversion rates, and increasing numbers of patients who leave the ED without complete assessment. In 2006, the Institute of Medicine called for improved operations management tools to be employed as a part of the solution, although it is not yet clear which solutions will be most effective. Study Objective: The studyвЂ™s main goal was to assess the effect of a single intervention, namely a physician-led screening program (START) on standard performance measures of an urban, academic tertiary care emergency department. The START program complemented a triage nurse with an ED attending physician who initiated a diagnostic workup within one hour of patient arrival and selectively triaged patients to the most appropriate areas of the ED. These performance measures were quantified using standard operational metrics. Methods: This before-and-after cohort study compared performance measures over two 3-month periods (SeptemberвЂ“November 2007 and SeptemberвЂ“November 2008). The 3-month identical blocks were chosen to avoid any seasonal effect. Data from an electronic patient tracking system (EDIS) were queried over 12982 patients in the pre-intervention period, and 14254 patients in the post-intervention period. The primary outcomes included: 1) the overall patient length of stay, 2) the length of stay for discharged patients (ie, not admitted to inpatient service), and 3) the percentage of patients who left without complete assessment (LWCA). Wilcoxon rank sum tests and Chi-squared tests were used to compare the differences between the two groups. Results: In the post-intervention period, median overall ED LOS was decreased by 28 minutes (8%, 360 minutes pre-intervention, 332 minutes post-intervention, pПЅ0.001). Median length of stay for patients discharged from the ED decreased by 23 minutes (7%, 318 minutes pre-intervention, 295 minutes post intervention, pПЅ0.001). LWCA was decreased by 1.7% (4.1% pre-intervention, 2.4 % post intervention, pПЅ0.001). Conclusions: In this before-and-after study, a physician-led screening program was associated with a 28-minute decrease in overall ED length of stay, despite an increase in ED patient volume. Over the period studied, this equates to an increased ED bed capacity of 73 bed-hours per day. In addition, ED LOS for discharged patients was decreased by 7%. Finally, the proportion of patients who LWCA was reduced by 1.7 %, or almost half. Since there were no other significant and identifiable operation changes in the ED between these two intake periods, it appears that this START intervention effected these improvements. 238 An Analysis of Emergency Department Observation Units Impact on Patient Satisfaction Scores Chandra A, Harrison D, Boardwine A, Villani J, Gerardo C, Hocker M, Limkakeng A/Duke University Medical Center, Durham, NC Background: Emergency department observation unit (EDOUs) have been touted to be more efficient, help with crowding, and save money. Hospitals measure patient satisfaction through Press Ganey surveys. The impact of an EDOU on patient satisfaction has not been reported to date. We hypothesize that an EDOU will have a positive impact on patient satisfaction results as measured by Press Ganey surveys. Methods: This is a retrospective observational analysis of Press Ganey scores collected for 8 quarters before the opening of a 13-bed EDOU in January 2002 and compared to 6 quarters post-EDOU opening at a tertiary care, academic, urban hospital. The facility, physician staffing, nursing, and wait times all remained the same during this period. Mean values and a 95% CI are reported and statistical significance is calculated using a T-test. Significance is defined as a p-value ПЅ 0.05. Results: The mean overall Press Ganey scores pre-EDOU was 75.2 (CI95 74.2вЂ“ 76.2) and post-EDOU was 78.2(CI95 75.4 вЂ“ 81) which is statistically significant (pП0.02). The mean EDOU score was 9% higher than the overall score. PostEDOU, 8 of 9 scoring categories increased (Table 1). Other than physician scores, all other mean values were higher among the post-EDOU subcategories. Conclusion: The introduction of an EDOU appears to be associated with a statistically significant improvement in patient satisfaction scores as reported by Press Ganey. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts вЂ«ШЎвЂ¬Statistically significant. 239 The Impact of Emergency Department Boarding on Hospital Revenues Pines JM, Fieldston E, Hollander JE, Isserman JA, Lorch SA, Reilly PM, Terwiesch C, Heckman JD/University of Pennsylvania, Philadelphia, PA; ChildrenвЂ™s Hospital of Philadelphia, Philadelphia, PA; Wharton School of Business, Philadelphia, PA Study Objective: Patients admitted to hospitals through the emergency department (ED) are often required to board for long periods in the ED after admission. This practice is associated with negative patient outcomes including higher death rates. Concerns have been raised that this practice is profitable. We studied how a вЂњno-boardingвЂќ policy would have affected hospital revenues in a single, urban, academic hospital during FY07 (July 1, 2006 вЂ“June 30, 2007). Methods: We performed a retrospective study and built a financial model using real hospital revenue data from a single hospital in FY07 with 55K annual visits, and 725 inpatient beds. The primary outcome was total net revenue, which was calculated as actual net revenue plus potential gains from a вЂњno-boardingвЂќ policy: completed evaluations in 90% of left-without-being seen (LWBS) patients, additional patients received without trauma and medical diversion, minus potential losses from вЂњno boardingвЂќ: a reduction in non-ED admissions (elective and transfer) with fewer hospital days available given bed demand by ED admissions. Non-ED admissions were excluded if they did not directly compete with the ED for inpatient beds (psychiatry, newborn nursery, obstetrics, rehabilitation). We assumed that LWBS patients had the same admission rate as those who stayed (26%), a constant arrival and admission rate for trauma activations (0.3 per hour, 59%) and medical ambulance patients (2.2 per hour, 40%) based on actual data during the study period. Sensitivity analyses were performed to assess how changing the allowable boarding time to 2 hours and the expected admission rate for LWBS to 10% affected revenue calculations. Results: Data were analyzed from 42,041 ED outpatient visits (with 3,159 leftwithout-being seen [7.5%], 14,039 ED admissions, and 18,192 non-ED admissions. ED admissions accounted for 75,240 hospital-days while non-ED admissions accounted for 111,825 hospital days. There were 5,213 ED boarding days during FY07. Median boarding time was 7.7 hours (IQR 4.9 вЂ“11.3). In the base model, potential gains from revenues from a вЂњno-boardingвЂќ boarding were $13,003,394 and potential losses were $(48,593,292). The potential net revenue from вЂњno-boardingвЂќ was a loss of $(35,589,898). When boarding was defined at 2-hours after bed request, net revenue loss was $(31,215,847). When the LWBS admission rate was 10%, net losses from boarding were $ (26,097,443) and $ (21,723,392) at 0 and 2-hour boarding times, respectively. Conclusion: A вЂњno-boardingвЂќ policy would have resulted in $22вЂ“36 million less in net revenue during FY07 in our hospital, depending on the definition of boarding and the expected admission rate for LWBS patients. 240 Primary and Specialty Care Follow-Up for Uninsured Emergency Department Patients Ginde AA, Talley BE, Trent SA, Raja AS, Sullivan AF, Camargo Jr CA/University of Colorado Denver School of Medicine, Aurora, CO; Denver Health Medical Center, Denver, CO; Brigham and WomenвЂ™s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA Study Objectives: Patients often need urgent outpatient primary or specialty care follow-up after their emergency department (ED) visits, but access is particularly Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ difficult for uninsured patients. Systems of ED referrals to primary and specialty care may differ depending on the type of care required; the extent and factors associated with these differences are unknown. In this study, we sought to characterize primary and specialty care follow-up options for uninsured ED patients in Colorado and to evaluate differences in these options based on ED characteristics. Methods: We mailed a survey to physician or nurse directors of all 74 EDs in Colorado during January to April 2009 and collected data on ED characteristics, supplemented by the 2007 National Emergency Department Inventories (NEDI)USA (www.emnet-usa.org). Outpatient primary care follow-up was assessed by the following question: вЂњWhere does your ED typically refer uninsured ED patients for urgent (ПЅ2 weeks) primary care follow-up after the ED visit (eg, new onset type 2 diabetes stable for discharge)?вЂќ Specialty care follow-up was assessed by: вЂњWhere does your ED typically refer uninsured ED patients for urgent (ПЅ2 weeks) specialty follow-up after the ED visit (eg, orthopedics for fracture needing outpatient surgical care)?вЂќ Using multiple choice responses, the follow-up options were classified as private physician or clinic affiliated within the same hospital; public clinic or university hospital; or no referral system/policy. Data analysis included chi-square test to compare differences in follow-up options by ED characteristics. Results: We received complete responses from 62 (84%) EDs. Referral to private physicians or clinics at the same hospital was 40 (65%) EDs for primary care and 45 (73%) for specialty care. Referral to a public clinic or university hospital only was endorsed by 16 (26%) EDs for primary care and 8 (13%) for specialty care, and 6 (10%) and 9 (15%) had no referral system for primary and specialty care, respectively. The following factors were associated with higher reported access to primary care follow-up at the same hospital: lower visit volume (79% for EDs with ПЅ1 patient per hour vs. 45% for Х†3 patients per hour; pП0.02), rural area (79% vs. 63% for urban areas; pП0.04), and possibly critical access hospital status (77% vs. 58%; pП0.12). Conversely, higher visit volume (95% vs. 54%; pПЅ0.01), urban (88% vs. 54%; pПЅ0.01), and non-critical access hospitals (83% vs. 55%; pП0.02) had greater access to specialty follow-up at the same hospital. Rates of hospital admission and uninsured patients seen were not significantly associated with availability of either primary or specialty care follow-up options. Conclusion: Referral patterns for uninsured patients differed by ED characteristics in Colorado, and some reported having no referral system. Smaller, rural EDs had higher ability to refer within their own hospital for primary care but lower for specialty care. These data may have important implications in access to timely follow-up care for uninsured ED patients, and future studies will correlate observed differences in ED referral systems with actual patient access to care. 241 A Multifaceted Quality Improvement Program Improves Hand Hygiene Compliance in the Emergency Department Schuur J, Crim H, Pandya D, Rosborough S, Venkatesh A, Villarreal R, Pallin D/ Brigham and WomenвЂ™s Hospital, Boston, MA Study Objectives: Proper hand hygiene (HH) is a key measure for preventing health care-associated infections; however, health care staff often do not perform proper HH. There is little evidence about which quality improvement (QI) techniques are effective at improving HH compliance in the emergency department (ED). We aimed to determine if a two-stage QI project would improve ED HH. Specifically, we aimed to assess the impact of a HH educational campaign with regular real-time feedback on HH compliance. Methods: Observational HH data was collected prospectively, at an urban, level one academic ED with 57,000 annual visits from Feb-08 onward by the hospital infection control department. The HH QI initiative began with multidisciplinary team meetings in June-08. Initially, the team identified and addressed barriers to HH compliance, such as an inadequate number of disinfectant dispensers and frequently empty dispensers. In Sept-08 the HH project was publicly introduced with multiple educational efforts and an ED-wide staff awareness campaign. In Jan-09 daily ED auditing with feedback was added. Auditing and feedback consisted of a research assistant performing direct observation of all ED health care workers every weekday. At the end of each direct observation session, the observer reported summary performance data by provider group to staff. Attending physicians and charge nurses were asked to discuss the results at rounds. A weekly email detailing the ED staff performance on HH was distributed and ED leadership championed HH at regular meetings. We compared HH rates across the three periods of the project: PRE (2вЂ“5/2008), EDUCATION (6вЂ“12/2008), and AUDIT (1вЂ“4/2009) and between provider types (MD/PA, nurse, nursing aide, non-clinical staff) using chisquares tests and Cochran-Mantel-Haenszel test for trend. Results: Over 15 months of the project, 2016 HH observations were collected Annals of Emergency Medicine S75 Research Forum Abstracts (154 PRE, 293 EDUCATION, 1569 AUDIT). Prior to the QI campaign (PRE), HH compliance was 36% (95% CI 29%вЂ“ 44%). During the educational period of the project (EDUCATION), HH compliance was 68% (95% CI 63%вЂ“73%). During the audit period HH compliance was 88% (95% CI 86%вЂ“90%). There was a significant increase in performance across the three periods overall (P ПЅ.0001) and a 20% absolute increase in HH compliance between the EDUCATION and AUDIT phases (95% CI 14%вЂ“26%). All provider groups showed significant improvement over the QI project: MDs/PAs improved by 48% (95% CI 34 вЂ“ 62%), nurses by 56% (95% CI 45вЂ“ 68%), nursing techs by 43% (95% CI 24 вЂ“ 62%) and non-clinical staff by 63% (95% CI 39 вЂ“ 87%). Conclusion: A two-stage HH QI project that utilized an educational campaign and audit and feedback significantly improved ED HH compliance. Each project stage provided a distinct increase in HH compliance supporting the use of several QI techniques when devising a HH improvement strategy. Audit and feedback with active support from departmental leadership appear to increase HH compliance above and beyond less direct QI techniques. 242 Validating an Emergency Medicine-Specific Tool to Estimate Cognitive Impairment Birkhahn R, Briigs WM, Bove J, Datillo PA, Arkun A, Parekh A, Gaeta TJ/New York Methodist Hospital, Brooklyn, NY Study Objectives: Long work hours, demanding schedules, and sleep deprivation have long been associated with residency training; existence of sleepiness and fatigue can result in decreased cognitive performance, impaired memory and focus, inflexibility, and errors. Our goal was to adapt and validate an existing cognitive assessment tool that could be used with emergency medicine residents to assess the cognitive effects of resident fatigue. Methods: Testing was conducted using faculty medical students associated with an emergency medicine residency training program. We developed a computer-based interactive test with two elements from the Walter Reed Performance Assessment Battery: (1) number memory test: a series of digits is shown and then recalled forwards and then backwards; (2) the addition and subtraction tasks give two-digit numbers to be added and subtracted. To this, we added a 15-question ACLS quiz for rhythm and ECG recognition and response, which was developed locally using a Delphi panel of attending physicians. Three minutes per task were allotted for each element of the battery. To assess the measureвЂ™s variability and understanding we tested the new scale on separate cohorts of students and attending physicians. Serial testing was conducted to establish learning interaction, extinction, and optimal testing strategies. Reaction times and number of correct answers for each element, and intra- and inter-individual variance of results, were measured. Results: Seventeen students and 11 attending physicians completed multiple trials (n П 79). In a test of extinction mean scores and reaction times did not change with increasing trials per individual (pП0.33), except in the ACLS quiz portion where improvements (in both correct answers and reaction times) which suggested that at least 2 trials were needed to train the physicians (pП0.02). There were no differences in variability in scores due to number of trials nor in whether the individual was a student or attending (pП0.31). Mean scores were: 7.0 correct forward digits, 5.9 backward, 13 correct additions and subtractions, 13 correct ACLS questions for attendings and 8 for students. Conclusions: The cognitive battery performed as expected; it was quick and easy to administer and showed little variability between individuals. Baseline reaction S76 Annals of Emergency Medicine times and accuracy scores were stable and can serve as reference for comparing scores received while fatigued. It is important to control for the improvements (learning curve) in the ACLS portion of the battery; thus to gauge the effect of fatigue, at least two trials per individual should be run. The addition of an ACLS question bank to create a novel test battery appears promising as an EM-specific tool to estimate cognitive impairment. The ability to reliably and quickly measure impairment is an important step in limiting the effects of resident fatigue. 243 The Use of an Expeditor and Its Impact on Emergency Department Length of Stay Handel DA, Ma OJ, Workman J, McConnell KJ/Oregon Health & Science University, Portland, OR Study Objectives: It is believed that the use of an individual whose primary role is to help with patient flow will decrease emergency department (ED) lengths of stay (LOS) and improve patient satisfaction. This pilot program in our ED used a group of paramedics who were trained to initiate ED care, assist with patient admission process, and facilitate discharges. The objective of this study was to measure how the role of an вЂњexpeditorвЂќ affected LOS. Methods: This was a pre-post observational study. Inclusion criteria were ED patients: age Пѕ 21 years, non-ambulance arrival, and wait Пѕ 5 minutes. The implementation of the expeditor role began on 12/15/08 at a level 1 trauma and academic medical center with an annual census of 40,000 visits. The position was a modification of the role of a paramedic already working in the ED and did not entail additional personnel. The expeditor was on duty from 1300-0100 daily, historically the busiest time in the ED. We evaluated the change in LOS for admitted patients and patients discharged home, with November 2008 acting as the pre-intervention period and January 2009 acting as the post-intervention period. We assessed the effect of the expeditor using multiple linear regression. Variables in the analysis included: daily census, patient age, triage acuity, the use of triage scripting notification of wait times, the total number of hours of boarding that occurred while waiting for inpatients beds during a day, and individual bed wait times. A day was used as the smallest unit of comparison. Results: A total of 1,809 patients were included in the analysis. There was no significant change in LOS for patients discharged home. However, the LOS for admitted patients decreased by 12.69 minutes (pП0.000) after the implementation of the expeditor. Other variables associated with LOS included the use of scripting at triage to notify patients of wait times, the wait times for beds for admitted patients, and the number of hours of boarding. Conclusion: The use of an expeditor improved the LOS for admitted patients but not for discharged patients. This points to the positive impact that these individuals have on improving the flow of higher acuity patients through the ED to inpatient beds. Whether or not this amount of time is clinically significant remains to be seen, and further analysis is needed to see if this trend continues over a longer period of time. 244 Environmental Predictors of Hand Hygiene Compliance in the Emergency Department Venkatesh A, Pallin D, Crim H, Pandya D, Rosborough S, Villarreal R, Schuur J/ Brigham and WomenвЂ™s Hospital, Boston, MA Study Objective: Health care worker (HCW) hand hygiene (HH) prevents health care-associated infections, and studies show that environmental factors such as room visibility and availability of handwashing stations affect HH compliance. Little is known about how the unique emergency department (ED) work environment affects HH compliance. We aimed to determine the predictive value of HH opportunity characteristics, ED layout, and ED crowding on HH. Methods: Observational HH data was collected prospectively at an urban, level one academic ED with approximately 57,000 annual visits. A trained research assistant directly observed HH in the ED in accordance with regulatory standards. HH compliance was defined as use of alcohol handrub or standard handwashing before and after contact with each patient or patient environment. A standardized data collection instrument was used to collect HH opportunity characteristics, ED layout, and ED crowding data. HH opportunity characteristics included glove use, HCW type, and room entry/exit. Predefined ED layout variables included ED unit (ED unit vs. observation unit [OBS]), room visibility (high vs. low), and bed location (private room vs. hallway). ED crowding variables included total ED census, proximate ED unit census, and waiting room census. Chi square tests were used to compare differences in HH based on categorical variables. The T-test was used to Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts compare continuous ED crowding variables with HH compliance. Multivariate logistic regression was used to adjust for multiple environmental and behavioral predictive variables. Results: A total of 1475 HH opportunities were available for analysis with overall HH compliance of 88.2%. Reduced HH compliance was significantly associated with glove use (84.9% vs. 89.2%, pП0.03), OBS unit location (80.1 vs 89.5%, pП0.0002), and high visibility rooms (86.2% vs. 91.3%, pП0.003). A significant difference was demonstrated when comparing HH across health care provider types: MD (93.5%), nurse (88.0%), nurseвЂ™s assistant (84.7%) and other HCW (75.6%), pПЅ0.001. No significant bivariate difference in HH compliance was demonstrated between room entry and exit, hallway location, or any ED crowding variable. After adjustment for all covariates, OBS unit location (OR: 0.43, 95%CI: 0.23, 0.82), high visibility room location (OR: 0.64, 95%CI: 0.45, 0.93), and hallway location (OR: 0.59, 95%CI: 0.34, 0.99) were significantly associated with lower HH compliance. Conclusions: ED specific work environment characteristics such as hallway bed location or OBS unit location impacted HH compliance, while other environmental markers such as ED crowding were not associated with HH compliance. Individual EDs should consider what local work environment barriers exist to effective ED HH. 245 Should the Deeply Comatose Trauma Patient Be Intubated by EMS? Irvin CB, Walters J, Sills R/St. John Hospital and Medical Center, Detroit, MI Background: Previous studies have suggested increased mortality in trauma patients intubated in the field. These studies have included heterogeneous populations (GCS scores ПЅ9). Deeply comatose patients (Scene GCSП3) may comprise a population most likely to benefit from intubation in the field. No previous study has evaluated the effects of intubation on the outcome of this sickest population. Study Objective: To compare the outcome of Scene Intubated and Not Scene Intubated trauma patients in deep coma (GCSП3). Methods: Using the National Trauma Data Base (V. 6.2), all trauma patients with вЂњLegitimateвЂќ (not intubated/sedated) initial scene GCS scoreП3 were analyzed. Variables extracted included: Age, ISS score, Scene GCS scoreП3, ED GCS score, Arrival ED intubation status, ED first systolic blood pressure, discharge status (alive or dead), and Abbreviated injury score (AIS) for Head. Patients arriving in ED with no blood pressure, or given paralytics or sedatives were excluded. Data was then analyzed using logistic regression. Results: There were 11109 patients with Legitimate GCS scene П3 analyzed, and only 23% (2538/11109) were scene intubated. The mortality rate for the Not Intubated patients was 35% (ISSП24), and 62% (ISSП31) for the Scene Intubated patients (p3). Regardless of arrival ED GCS, those Scene Intubated were still more likely to die (ED GCSП3, Scene Intubated mortality П67% compared to Not Intubated mortality of 49% (p3, Scene Intubated mortalityП 36%, compared to Not Intubated mortality of 14% (pПЅ.001)). Of patients with recorded Head AIS scores of 3вЂ“ 6 (serious, severe, critical, unsurvivable), those Scene Intubated had a mortality of 68% (979/1464) and those Not Intubated had a mortality rate of 46% (1789/3844),pПЅ.001. Using Logistic regression and controlling for the slightly higher ISS score in those Scene Intubated, Scene Intubated patients were twice as likely to die if their GCS remained at 3 in the ED (ORП2.03) and more than 3 times as likely to die (ORП3.48) if the ED GCS was Пѕ3 (ie, they improved en route). Conclusion: Even severely comatose trauma patients have a much higher mortality rate when Scene Intubated, versus those Not Scene Intubated. Although the exact reasons for this remain unclear, these results suggest re-evaluation of current policies for EMS intubation at the scene in these severely traumatized patients. 246 Admission Rates for Walk-In Patients Differ Between Suburban and Urban Emergency Departments While Admission Rates for Emergency Medical Services Arrivals Show No Significant Difference Matthews P, Nichols WL, Durie C, McGinnis-Hainsworth D, Hypes S, Reed III J, Schofer J, Megargel R/Christiana Care Health Services, Newark, DE; State of Delaware Office of Emergency Medical Services, Dover, DE Study Objectives: Patients in an urban environment may utilize emergency departments (ED) differently than patients in a suburban environment. Previous Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ research has demonstrated that significant differences exist among the percentage of patients admitted dependent upon their mode of arrival to the ED. The purpose of this study was to further investigate the admission rates of suburban versus urban hospitals based on patient mode of arrival. The modes of arrival that were investigated include walk-in patients, Basic Life Support (BLS) transports, and Advanced Life Support (ALS) transports. Methods: We used a retrospective cohort design. Data were collected from the EDs of a suburban level I trauma center and an urban level IV trauma center in the same health care system. These hospitals are located 14 miles apart and see a cumulative annual volume of approximately 150,000 ED patients. The StateвЂ™s out-ofhospital system is a two-tier structure with BLS and ALS. Patients presenting to the ED from the first Wednesday of alternating months (January, March, May, July, September, and November) in 2007 were reviewed. Medical record numbers and ED patient tracking systems were used to determine patient disposition. Confidence intervals were determined using the Agresti-Coull binomial method and p-values were determined using PearsonвЂ™s chi-squared. Results: A total of 2,438 ED encounters were reviewed. See Table for results. Conclusion: Walk-in patients at the suburban ED required admission twice as often as in the urban ED. No significant differences in suburban ED admission rates between BLS or ALS transports existed when compared to the urban ED. This suggests that urban patients are more likely to seek non emergent care from an ED than their suburban counterparts. Patients activating emergency medical services had similar rates of admission in these suburban and urban hospitals. 247 Baseline Carboxyhemoglobin Levels in Firefighters Using the Masimo Rainbow SET Rad-57 Pulse COOximeter Black A, Muniz J, Benitez FL, Burkhalter L, Isaacs M, Luber SD, Pepe PE, Velez LI/University of Texas Southwestern Medical Center, Dallas, TX Background: Carbon monoxide (CO) has been the leading cause of acute poisoning death in the United States for the last 100 years. It is a potential hazard to firefighters while engaging in fire ground activities. CO toxicity may present with nonspecific signs and symptoms. Until recently, the only way to reliably diagnose CO poisoning was using co-oximetry. With the introduction of the Masimo Rad-57, testing for CO can now be performed rapidly and non-invasively, allowing for prompt screening and treatment. To date, no data has been published regarding baseline carboxyhemoglobin (COHb) levels in professional firefighters. Study Objectives: To determine baseline COHb levels in professional firefighters while not engaging in fire ground operations, inquiring about risk factors associated to increased levels of COHb in this вЂњhigh riskвЂќ population. Methods: Professional firefighters (FFs) in the BioTel EMS system were voluntarily enrolled in the study. Using a new product in the market (Masimo Rainbow SET Rad-57 Pulse CO-Oximetry) a non-invasive finger probe measurement of COHb was obtained in the participants. The device was applied to the individualвЂ™s fingertip, and a measurement for COHb was recorded for each hand. A standardized survey form was used to collect individual data regarding potential CO exposure sources, such as cigarette smoking, exposure to exhaust fumes, and recent firefighting operations. Results: A total of 857 professional FFs were enrolled. The average time working as a FF is 18 years. The COHb average in the right hand was 1.41% and for the left hand was 1.28%; pПЅ0.05. For the following group comparisons, the average right hand value was used. Smokers (nП132; 16%) had a mean COHb of 1.68% (95% CI: 1.32вЂ“2.04) while non-smokers (nП735) had a mean COHb: 1.36% (95% CI: 1.23вЂ“1.48); pП0.057. FFs who fought a fire ПЅ72 hrs prior to measurement (nП113) had a mean COHb of 1.66% (95% CI: 1.33вЂ“2.00) while those who fought fire Пѕ72 hrs prior (nП683) had a mean COHb of 1.37% (95% CI: 1.24 вЂ“1.51); pП0.119. Annals of Emergency Medicine S77 Research Forum Abstracts Conclusion: Baseline COHb levels were not elevated in the FFs of this large urban EMS system. There was no statistically significant difference in baseline levels between smokers and non-smokers; nor between FFs who fought a fire less than 72 hours prior to measurement and those who did not. The device is easy to use and was well received by the FFs. More out-of hospital studies are required to determine how this technology can best be applied as a out-of-hospital screening tool for individuals with potential CO poisoning. 248 Predictors of Ambulance Use for Emergency Department Patients Over 45 With Chest Pain Meisel ZF, Branas C, Pines JM/University of Pennsylvania, Philadelphia, PA Study Objectives: Chest pain in patients over the age of 45 may indicate the presence of an urgent condition such as acute coronary syndrome (ACS). Transport by Emergency Medical Services (EMS) has been demonstrated to be associated with improved processes and outcomes for patients with ACS. Only half of patients with acute myocardial infarction (AMI) are transported to the hospital by ambulance. However, the predictors of ambulance arrival for patients who present to emergency departments (EDs) with chest pain have not been described. We sought to determine the impact of race, sex, location, and insurance status on the usage of ambulance care for transport to the ED for patients over age 45 with chest pain. Methods: We performed a retrospective analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2004 вЂ“2006, an annual probability sample of US ED visits. Primary outcome was arrival by ambulance. Included were patients over age 45 and for whom вЂњchest pain and related symptomsвЂќ was identified as a reason for visit according to the Visit Classification for Ambulatory Care (RVC). Excluded were visits from patients who reside in a nursing home or other institution since these characteristics are associated with both insurance status and mode of arrival. We used logistic regression to determine the impact of race, sex, insurance status, and urban hospital location (metropolitan statistical are [MSA]) on mode of arrival. Results: From 2004 вЂ“2006, there were 17,384 visits representing 57.2 million (99% CI 53вЂ“ 62 million) patient visits for patients over 45 with chest pain. Mean age was 74, 80% white, 15% black, and 57% female. 6,002 (35%) of visits arrived by ambulance. In the multivariable analysis, we adjusted for race, sex, age, MSA, triage urgency, and insurance type. Male sex (OR 0.85 [99%CI 0.76 вЂ“ 0.93]), lack of insurance (self pay or charity care; OR 0.73 [99% CI 0.55вЂ“ 0.98]) and private insurance (OR 0.59 [99%CI 0.51вЂ“ 0.68]) were associated with decreased odds of ambulance use. The following characteristics were associated with increased odds of ambulance arrival: urban location (OR 1.7 [95% CI 1.3вЂ“2.2]), Medicaid (OR 1.4 [95% CI 1.2вЂ“1.6]) and Medicare (OR 1.2 [99%CI 1.1вЂ“1.3]). Race was not associated with differences in ambulance use. Conclusions: Male sex, lack of any insurance, possession of private insurance, and non-urban location are associated with lower rates of ambulance care as a means of transport to the emergency department for patients over 45 with chest pain. 249 Type of Insurance Is Associated With Ambulance Use for Transport to Emergency Departments in the United States Meisel ZF, Branas C, Pines JM/University of Pennsylvania, Philadelphia, PA Study Objectives: Utilization of emergency department (ED) care has been associated with insurance type but not lack of insurance. The relationship between insurance status and ambulance use for transport to EDs has not been fully explored. Unnecessary ambulance use for patients with non-acute conditions has been described; however, the relationship between insurance status and ambulance use for low acuity ED visits has not been. We determined the impact of insurance status on the ambulance use for transport among general ED visits and low acuity ED visits using a nationwide sample. Methods: We performed a retrospective analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2004 вЂ“2006, an annual probability sample of US ED visits. Primary outcome was arrival by ambulance. The primary independent variable was the expected source of payment. Included were all ED visits in the sample. Excluded were visits in patients who reside in nursing homes or other institutions since these patients use ambulance transport almost exclusively. S78 Annals of Emergency Medicine We used logistic regression to assess the association between expected payment source and ambulance transport. We repeated these methods for a low-acuity subgroup which was defined as patient visits which did not result in a hospital admission or transfer and which were assigned to the longest acceptable time to be seen by a physician (2вЂ“24 hours). Results: From 2004 вЂ“2006, there were 101,131 visits representing 320 million ED visits (99%CI 300 вЂ“355 million). Mean age was 35, 24% black, 72% white, and 54% female. 14,505 (15%) of visits arrived by ambulance, representing 46 million (99% CI 42вЂ“51 million) transports. In the univariate analysis, increased odds of ambulance transport was associated with expected use of any health insurance (OR 1.17 [95%CI 1.08 вЂ“1.27]) and Medicare (OR 3.09 [95%CI 2.9 вЂ“3.3]). Medicaid was associated with decreased odds of ambulance use (OR 0.77 [95%CI .71вЂ“.85]) In multivariable analysis, after adjusting for race, sex, age, urban location, triage urgency, and insurance type, the following characteristics were statically associated with ambulance arrival: Medicare (OR 1.28 [95% CI 1.16 вЂ“1.40]) and Medicaid (1.21 [95% CI 1.11вЂ“1.32]). In the adjusted low acuity subgroup only private insurance was associated with decreased odds of ambulance use when compared to all other expected paytypes (OR 0.69 [95%CI .55вЂ“.88]). Race, sex and lack of insurance were not associated with ambulance use in either the whole cohort or the low acuity subgroup. Conclusions: Insurance type is associated with ambulance use among general and low-acuity ED patient visits while lack of insurance, race, or sex are not. 250 Collaborative to Decrease Ambulance Diversion: The California ED Diversion Project Castillo EM, Vilke GM, Williams M, Turner P, Boyle J, Chan TC/University of California, San Diego, San Diego, CA; The Abaris Group, Walnut Creek, CA Study Objectives: Ambulance diversion has become a national problem that affects more than half of all emergency departments (EDs). The California ED Diversion Project (CEDDP) was a state-wide initiative to reduce diversion in four regions of the state by implementing ED, hospital and county emergency medical services (EMS) measures to address ED crowding and ambulance diversion regionally. The objective of this study is to assess the impact of CEDDP collaborative on ED ambulance diversion rates. Methods: This is a pre/post study investigating ED diversion rates in four regions of California before and after CEDDP over a two-year period. As part the CEDDP collaborative, EDs and hospitals instituted best practices to improved patient flow, including input, throughput and output measures; EMS agencies also enacted regionwide diversion mitigation strategies and efforts. Monthly ED diversion data were collected prospectively from hospital EDs and EMS agencies after initiation of CEDDP, and compared with historical ED diversion data the year prior to CEDDP. Data were also compared month-to-month to address anticipated seasonal changes. Comparisons were made using a paired t-test. Means, standard deviations (SD), and point estimates with associated confidence intervals are presented. Analysis was performed using SPSS version 16.0. Results: During the study period, there were a total of 31,735 diversion hours in the four CEDDP study regions, with 17,618 during the pre-CEDDP period and 14,117 in the post-initiation period. The monthly average of ambulance diversion decreased from 1468 hours (SDП390.6) to 1176 hours (SDП605.8) resulting in a significant decrease (difference of 292 hours; 95% CIП99, 484; pП0.007). There was a decrease in diversion hours for every month-to-month comparison except January and February (increases of 1% and 14.6%, respectively). Conclusion: By instituting regional ED, hospital and EMS agency patient flow and mitigation strategies, the CEDDP collaborative appeared to significantly reduce ambulance diversion hours in four large geographic regions. Continued communication and emphasis on diversion are likely needed to sustain these decreases. 251 Pharmacist Implementation in the Emergency Department Hong AL, Brozick A, Lam S, Parris M, Paine M, Flowers PW/Memorial Hermann Katy Hospital, Katy, TX; Memorial Hermann Hospital System, Houston, TX Background: Due to a recent increase in emergency department (ED) patients and The Joint CommissionвЂ™s National Patient Safety Goals requirement to Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts вЂњaccurately and completely reconcile medications across the continuum of care,вЂќ an opportunity for an ED pharmacist was offered. Additionally, Centers for Medicare and Medicaid Services (CMS) identify core measures as a means to measure effective evidence-based medicine. Thus, the ED pharmacistвЂ™s primary goal was to facilitate home medication reconciliation (HMR) and to identify core measures patients to assist in medication selection. Study Objective: The purpose of implementing a pharmacist in the ED was to conduct medication reconciliation, to identify core measure patients, and to provide consultative services, which included recommending evidence-based medication selection, identifying medication allergies, counseling patients on medication compliance, and answering drug information questions to reduce potential medication errors. Method: During a three-month pilot program (March - May 2008), the pharmacist worked in the ED Monday through Friday from 1:00-9:00p.m. Due to the impact shown through monthly documented interventions and peak ED visit times, approval was obtained for seven-day coverage from 2:30-11:00p.m. The ED is set in a 127-bed non-profit hospital 20 miles west of Houston, Texas serving both an urban and rural population. The ED averages greater than 3,300 visits on a monthly basis. Admission from the ED accounts for greater than 55% of all hospital admissions. The ED pharmacist was responsible for completing HMR for all patients who were admitted from the ED. The admitting team was responsible for medication reconciliation for patients not seen by the pharmacist. The ED pharmacist assisted in identifying possible core measure patients and recommended evidence-based therapy. Results: The post-audit pilot period data showed 100% completion for HMR obtained by the pharmacist. The ED pharmacist completed more than 50% of HMR for all hospital admissions, and documented at least 300 interventions monthly. The five major intervention categories documented were drug information (21.5%), medication recommendation (21.4%), patient care (15.3%), error prevention (14.7%), and core measures identified (12%). From September 2008 through January 2009, the ED pharmacist completed 2209 HMR, prevented 299 errors, and provided 436 medication recommendations to ED physicians. Conclusion: This study suggests the ED pharmacist improved compliance with Joint Commission National Patient Safety Goals. The ED pharmacist provides safe and effective care to patients by helping avoid medication errors and assisting health care providers to make informative medication selections through evidence-based medicine. This study validates the value of a pharmacist as an integral member of the ED health care team. 252 Provider Impression of Cervical Spine Injury and Its Effects on Quality of Out-of-Hospital Immobilization Techniques Dailey M, Prunty H, Frisch A, Martin T, Osborne B, Blank F, Barus R, Fitzgerald T/Albany Medical Center, Albany, NY; University of Pittsburgh Medical Center, Pittsburgh, PA; Baystate Medical Center, Spingfield, MA Study Objective: Out-of-hospital trauma care frequently includes the application of a cervical collar, yet little evidence currently exists about the quality of cervical collar placement. The study objective is to assess the quality of cervical collar application on immobilized patients arriving via ambulance (EMS) to the emergency department (ED) and to see if there is a correlation with provider impression of severity of mechanism of injury (MOI), provider likelihood for injury, or heightened risk (NEXUS criteria). Methods: A cross sectional observational study was performed at two tertiary care academic medical centers. A convenience sample of non-critically ill, immobilized patients, who had a cervical collar applied by EMS were enrolled. Out-of-hospital providers were surveyed about patientвЂ™s presentation and exam, as well as likelihood of cervical spine injury and the severity of the MOI. Each subjectвЂ™s cervical collar was evaluated based upon standardized manufacturer specifications for appropriate application including: size, proper assembly, tightness, head position, and chin location relative to the chin rest. Results: Of 190 subjects enrolled, EMS considered high likelihood for neck injury in 125 patients, although they considered 143 to have significant MOI. Thirty patients arrived immobilized with neither significant MOI nor high likelihood of injury. Of the patients with high likelihood of cervical spine injury, 29 (23%) had collars applied correctly, and of the patients with significant mechanism, 36 (25%) were applied correctly. One of the objective NEXUS Criteria (midline c-spine tenderness, intoxication, level of alertness, focal neurologic deficit, painful distracting Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ injury) was present in 138 patients, with 40 (29%) of the collars correctly applied. There was no statistical difference found in rate of correctly applied collars, including severity of mechanism of injury or NEXUS criteria (PП0.6). Notably, of the 136 patients with incorrectly applied collars, 30 arrived with an adjustable collar unlocked and 3 arrived with a collar placed upside down. Conclusions: This study demonstrates that many patients are being transported to the ED with improperly applied cervical collars, regardless of provider suspicion of injury, severity of mechanism of injury or objective physical examination criteria. While we cannot comment on the outcomes of these patients, EMS agencies must maintain an active quality improvement process to assure that out-of-hospital providers are applying cervical collars correctly. 253 The C.I.N. Study: Is Contrast-Induced Nephropathy a Problem in High-Risk Emergency Department Patients? Su M, Soohoo D, Lukin M, Patel S, Zhang S, OвЂ™Donnell MB, Messina J, Ward M/North Shore University Hospital, Manhasset, NY Study Objectives: 1)To determine the incidence of contrast-induced nephropathy (CIN) in high-risk emergency department patients receiving IV contrast. 2)To determine which comorbid risk factors (RF) are associated with the development of CIN. Methods: A retrospective chart review study was performed at a suburban academic university-affiliated ED with over 72,000 visits per year. Charts were reviewed for patients over an 18-month period. CIN was defined as 1) a proportional rise of 25% or 2) 0.5 mg/dL increase in serum creatinine level 48 hours after contrast exposure 3) a decrease in glomerular filtration rate (GFR) from a normal level above 90ml/min/1.73m^2 to a level below 60ml/min/1.73m^2 48 hours after contrast exposure. Inclusion criteria: Patients Пѕ17 years of age presenting to the ED who received either an abdominal, head or chest CT scan with IV contrast and were admitted to the hospital. The following RFs for CIN were examined: hematocritПЅ39% for men or ПЅ36% for women, renal disease, proteinuria, prior renal surgery, diabetes, congestive heart failure (CHF), hypertension (HTN) or gout. Exclusion criteria: Age ПЅ18 yrs old or incomplete data. Statistical Analysis: Estimated population midpoints and 95% confidence intervals (CI) were obtained for sensitivity and specificity for each HRF. Descriptive statistics and univariate analyses using the chi-square test or FisherвЂ™s exact test as deemed appropriate for the above categorical variables was used to compare patients with CIN as compared to patients without CIN. Those factors that appeared to be associated with CIN in the univariate analyses (pПЅ0.10) were included in a logistic regression model. Backwards selection was used to remove variables which did not significantly contribute to each of the models. Descriptive statistics and student t-tests were completed for relevant data collected between groups with and without CIN. Results: 70 subjects were enrolled, 51% male. Analysis was not completed for CIN definitions 2 and 3 due to insufficient data. Sensitivity and specificity reported respectively for the following high risk factors: gout, 25.00% (CI:4.4564.42) and 98.38% (CI:90.17-99.92), HTN, 87.50% (CI:46.68-99.34) and 29.03% (CI:18.55-42.13), CHF, 25.00% (CI:4.45-64.42) and 88.71% (CI: 77.51-94.96), diabetes, 25.00% (CI:4.45-64.42) and 72.58% (CI:59.56-82.78), prior renal surgery, 0.00% (CI:0.00-40.23) and 96.77% (CI:87.83-99.44), proteinuria, 25.00% (CI:4.45-64.42) and 82.26% (CI:70.05-90.40), renal disease, 12.50% (CI:0.66-53.32) and 93.55% (CI:83.50-97.91), low hematocrit, 75.00% (CI:35.58-95.55) and 48.39% (CI:35.66-61.32). Comparing patients with CIN vs. patients without CIN, there was a significant difference in patients who had a history of gout (pПЅ0.0327). Reported mean arterial pressure (MAP) of patients without CIN was 95.9 mmHg (CI:90.0-100.9) vs. 110.0 mmHg (CI: 99.7-120.3) for patients with CIN. Conclusion: Incidence of CIN was 11.43% (CI:5.41-21.82), 2.86% (CI: 0.50-10.86), 1.43% (CI:0.07-8.77) for each definition respectively. Patients with gout are twenty times more likely to have CIN (ORП20.3, 95% confidence interval: 1.6 to 258.5) compared to patients without CIN (pПЅ0.0202). Baseline MAP was also found to be significant between subjects who developed CIN (pПЅ0.0455). A past medical history of gout and HTN appear to be the only significant RFs for CIN. Annals of Emergency Medicine S79 Research Forum Abstracts 254 Epidemiology of Out-of-Hospital Emergencies in Andhra Pradesh, India, 2007 Mahadevan SV, Strehlow MC, Emergency Management and Research Institue (EMRI)/Stanford University School of Medicine, Palo Alto, CA Study Objectives: EMRI (Emergency Management and Research Institute) began emergency medical services (EMS) in the state of Andhra Pradesh (population 80 million) on August 15th, 2005. Unlike other Indian ambulance services, which are typically hospital-based and urban, EMRI provides centralized EMS to the entire state. This study describes the epidemiology of EMRIвЂ™s ambulance transports during 2007. Methods: A retrospective analysis of the EMRI call center database and all available PCRs (patient care records) was performed for patients with medical emergencies transported by EMRI between January 1st and December 31st, 2007. Results: In 2007, EMRI received 8,342,063 telephone calls and responded to 437,613 emergencies (medical/police/fire), of which 414,613 (94%) were medical. Call center database records and all available PCRs (173,520) were analyzed. 57% of patients were male and 43% female. 7.8% were pediatric (ages Х…17) and 7.3% were geriatric (age Х†65). 79% of medical emergencies were from rural areas and 21% from urban areas. The mean response time (call-scene) for all transports was 20.0 minutes: 14.5 minutes for urban areas and 21.1 minutes for rural areas. For urban areas, the most common classifiable emergencies were vehicular trauma (46%), non-vehicular trauma (8%), pregnancy-related (8%), cardiac (5%), respiratory (4%), and poisoning/ overdose (4%). For rural areas, the most frequent emergencies were vehicular trauma (28%), pregnancy-related (21%), abdominal pain (7%), poisoning/overdose (7%), non-vehicular trauma (6%) and cardiac (4%) and respiratory (4%). The most common emergency occurring in men was vehicular trauma (47%); in women, pregnancy-related (42%). Out-of-hospital treatments rendered included oxygen (43%), local wound care (29%), IV fluids (18%) and splints (6%). Conclusion: This epidemiologic study of Indian EMS, the largest on record, describes important considerations of patients requiring out-of-hospital emergency care in India. This valuable data will help guide health care development and resource utilization, preventative public heath measures, and EMS expansion in India. 255 The Outcome of Out-of-Hospital Cardiopulmonary Arrest in the Over 85-Year-Old Japanese Population Taken to the Emergency Department. Umezawa K, Branch J, Yamagami H, Ofuchi H, Ohta B, Uchida Y, Kitahara H/ Shounan Kamakura General Hospital, Kamakura, Japan; Shonan Kamakura General Hospital, Kamakura, Japan; Chigasaki Tokusyuukai Medical Center, Chigasaki, Japan Study Objectives: Out-of-hospital cardiopulmonary arrest (CPA) in the elderly (above 85 years old) has tended to increase particularly because of the increase of the elderly population. The long-term prognosis following cardiopulmonary resuscitation (CPR) in this selected population has recently been called into question. We considered the outcome of out-of-hospital cardiopulmonary arrest in a selected elderly population over 85 years of age taken to two local emergency departments. We also identified the grade of the doctor overseeing the patient and whether this reflected on the eventual treatment administered and survival of this population. Methods: This study was retrospective looking at the pooled results from two local community hospitals. Only patients over the age of 85 having suffered out-ofhospital cardiac arrest were included in this study. 211 patients were selected between January 2005 and November 2008 inclusive. We assessed the total time of the advanced cardiac life support (ACLS), the rate of successful resuscitation and the outcome attributed to the staff administering the treatment. Results: The incidence of out-of-hospital CPA was 78.2% at the patientвЂ™s home and 17.5% at nursing homes. The rate of bystander CPR was 21.8%. Electrocardiographic findings in the emergency department was 75.8% asystole, 22.7% pulseless electrical activity and 1.4% ventricular fibrillation and ventricular tachycardia. Successful resuscitation was 24.6% and вЂњdo not attempt resuscitationвЂќ following successful resuscitation was 88.5%. The mean time of ACLS was 23.9 minutes by junior doctor and 22.0 minutes staff doctors respectively. The rate of successful resuscitation was 24.6% and 24.7% for patients treated by junior doctors and senior doctors respectively, and the mean length of stay was 1.9 days and 2.6 days respectively. Conclusion: The time of CPR was shorter when carried out by senior doctors compared to junior doctors although the initial outcome of survival was unchanged. If the resuscitation was successful but the family did not wish for continuation of S80 Annals of Emergency Medicine advanced life support, all of those patients subsequently died. In view of the results of this study, we recommend that the elderly population consider making a Living Will to incorporate an advanced directive to avoid invasive and futile treatment in the event of a sudden cardiac arrest. 256 Hospitalizations of Older Human Immunodeficiency Virus Patients in the United States From 2000-2006 Tadros A, Shaver E, Davis S/West Virginia University, Morgantown, WV Background: There are increasing cases of human immunodeficiency virus (HIV) patients who are 50 and older, but the unique characteristics of these patients compared to younger adults are not well described. Study Objective: We sought to estimate the number of hospitalizations of older adults with HIV (age Х† 50) in the United States (US) from 2000-2006 and compare selected clinical and demographic features of this population to younger adult (age 19-49) patients. Methods: This was a retrospective cohort study using seven years (2000-2006) of data in the Nationwide Inpatient Sample (NIS). The NIS is a stratified, multi-stage sample designed to provide national estimates of hospitalizations in the US. It contains approximately 8 million hospital discharges in each data year. Clinical Classifications Software (CCS) was used to identify HIV patients. Cases were selected if a CCS П 5 (вЂњHIV InfectionвЂќ) was present in any of the CCS discharge diagnoses for each patient. The following comparisons between younger and older adults were made: sex, number of admissions, hospital charges and procedures, and primary diagnoses. SAS-Callable SUDAAN software was used to produce unbiased standard errors. Results: From 2000-2006 there were an estimated 1,664,823 hospitalizations of adults with HIV in the US with the emergency department as the admission source in 66.22% of these cases. Most of these cases (67.14%) were hospitalized in teaching hospitals located in urban areas. Almost one-quarter of these hospitalizations (394,965) were by older adults. Admissions for older patients almost doubled from 2000 (42,732) to 2006 (80,139), while younger adults had similar admission rates (188,544 versus 183,049). Older adults were more likely to be male (73.11%; 95% CI 71.54-74.43) compared to younger adults (64.24; 62.84-65.61), and were significantly more likely to die during hospitalization (5.58%; 5.29-5.90 versus 3.69%; 3.55-3.84, respectively). The following primary discharge diagnoses were among the most common in both age groups: pneumonia (not tuberculosis), substance-related mental disorders, and skin and subcutaneous tissue infections. Other top primary diagnoses included affective disorders and alcohol-related mental disorders in younger adults, and congestive heart failure (non-hypertensive) and implant or graft complication in older adults. The top 5 principal procedures for both groups included alcohol and drug rehabilitation, vascular catheterization, and blood transfusion. Common procedures for the older group also included hemodialysis and intubation/mechanical ventilation, and for the younger group included lumbar puncture and bronchoscopy. Older adults had a significantly higher average hospital charge compared to younger adults ($32,868; 95% CI 30,766-34,970 versus $27,514; 95% CI 25,832-29,197, respectively). Conclusions: HIV patients at least 50 years of age accounted for almost 400,000 hospitalizations in the US from 2000-2006. They were more likely to be male and die during hospitalization compared to younger adults infected with HIV. Psychiatric and substance abuse disorders were common diagnoses in both age groups, as were skin and subcutaneous infections. Admissions for older HIV patients almost doubled during the study period and future studies should examine whether this is due to aging of the HIV population or new infections in this age group. 257 Cognitive Impairment and Comprehension of Emergency Department Discharge Instructions in Older Patients Bryce SN, Han JH, Kripalani S, Schnelle J, Storrow A, Ely EW/Vanderbilt University School of Medicine, Nashville, TN Study Objectives: Cognitive impairment (dementia and delirium) is common in older emergency department (ED) patients, yet its effect on patient comprehension of ED discharge instructions is unknown. We sought to determine how cognitive impairment affects comprehension of discharge instructions in older ED patients. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts Methods: This was a cross-sectional survey study conducted at a single ED located in an academic, tertiary care level 1 trauma center. English-speaking patients aged 65 years and older who were discharged from the ED were included. Patients were excluded if they had resided in a nursing home, had severe dementia, or were previously enrolled. A trained research assistant administered an open-ended survey designed to evaluate patientsвЂ™ comprehension of their discharge instructions in the following domains: discharge diagnosis, medications prescribed by the emergency physician, instructions to return to the ED, and follow-up. Each domain was rated by two reviewers blinded to each otherвЂ™s rating and to the patientвЂ™s cognitive status. A 5-point scale ranging from 1 (no understanding) to 5 (complete understanding) was used to compare the patientвЂ™s response to the survey with the patientвЂ™s discharge instructions located in the electronic medical record. The reviewersвЂ™ ratings were averaged for final analysis. Cognitive impairment was defined as the presence of delirium (as measured by the Confusion Assessment Method for the Intensive Care Unit) or dementia (as measured by the Mini-Mental State examination, Information Questionnaire on Cognitive Decline in the Elderly, or as documented in the medical record). Comparisons between the cognitively impaired and non-cognitively impaired groups were performed using the Wilcoxon Rank Sum Test. A p-value ПЅ 0.05 was considered statistically significant. Results: A total of 114 patients were enrolled. Median (IQR) age was 73 (69, 81) years old. 67 (58.8%) were females, 28 (24.6%) were non-white, and 61 (53.8%) had cognitive impairment. Level of comprehension ratings for each discharge instruction domain can be seen in Table 1. Patients who were cognitively impaired were significantly less likely to understand their discharge diagnosis, instructions to return to the ED, and follow-up instructions. No significant difference in comprehension of medications prescribed was observed between the 2 groups. Conclusions: Older ED patients with cognitive impairment exhibited lower comprehension of discharge instructions compared to patients without cognitive impairment, especially in the domains of their diagnosis, reasons for returning to the ED, and follow-up instructions. Level of understanding ratings are expressed in median (interquartile ranges). history, and evaluation of the following: social support, medications, vision, postural blood pressure, cognition, continence, footwear, gait and balance. Upon identifying the risk factors of fall, appropriate advice, immediate intervention and onward referrals were rendered accordingly. Patients were followed up at 3, 6, 9 and 12 months through telephone call. A research assistant obtained basic and instrumental activities of daily living (ADL) scores and number of subsequent falls. ED re-attendances and hospitalizations were obtained though electronic medical records. Patients were compared against historical controls collected between 7th April to 15th June 2008, based on the same criteria above, who received standard ED care. Results: There were 179 in the control and 89 patients in the intervention group. There was no difference in baseline characteristics (age, sex, baseline functional scores and injuries) between the two groups. Seventy-one (79.%) of patients in the intervention group required falls risk-factor modification. Only 6 (6.7%) patients did not need any intervention, while 12 (13.5%) refused intervention. Forty-five (51%) patients within the intervention group fell indoors and 29% experienced difficulties in getting up after the fall. Common fall risk factors found included improper footwear (69%), visual impairment (48%), gait (25%) and balance (28%) disturbance. At 3 months, there were only a small number of fallers in each group: 11 (6.9%) in the controls and 7 (8.5%) in the intervention group. There was a reduction in ED reattendance (21.7% vs 19.1%) and hospitalization (14.3% vs 10.1%). However, none of these three-month variables were statistically significant. Conclusions: The results of this study provide insight to the common risk factors for falls in the elderly so that preventive and appropriate intervention can be made. Early results, although not significant, are encouraging: there is a trend towards reduced ED reattendance and hospitalisation rates. We look forward to follow-up results at 6, 9 and 12 months. 259 Occult Cognitive Impairment in Admitted Older Emergency Department Patients Is Not Identified by Admitting Services Heidt JW, Carpenter CR/Washington University in St. Louis, St. Louis, MO *Only the 54 (47.4%) patients who received prescriptions were used in this analysis. 258 Preliminary Results of a Multidisciplinary Falls Evaluation Program for Elderly Fallers Presenting to the Emergency Department Wong EM, Foo C/Tan Tock Seng Hospital, Singapore, Singapore Background: A fall in an elderly is a sentinel event. It may be a harbinger to future falls, which may result in injury, immobility, fear of falling, functional decline, and even death. In a busy emergency department (ED), there is a tendency to focus on the patientвЂ™s physical injury. However, if the culprit fall risk factors are not addressed, the patient is at risk of falling again. Study Objective: In this study, we provide a multidisciplinary assessment of elderly fallers presenting to the ED. The objective is to identify risk factors for future falls so that appropriate intervention may be provided to reduce further falls, ED reattendance and hospitalisations. Methods: This is a prospective study taking place in Tan Tock Seng HospitalвЂ™s ED from June 16, 2008 to September 18, 2008. Patients 60 years and above who presented to the ED with a fall, and were able to ambulate before and after the fall were recruited. Excluded were nursing home residents, those who are already on follow-up with a geriatrician, patients with cognitive impairment unable to give consent, and patients who refused to participate. Intervention involved assessment by an emergency doctor, an emergency nurse trained in geriatric care, and a physiotherapist. Assessment included a detailed falls Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Study Objectives: Unrecognized cognitive impairment can adversely impact older adult outcomes in emergency medicine (EM). Admitted patients with occult cognitive dysfunction may be recognized more often than discharged subsets, either by EM staff or inpatient services. Our objectives were to compare the nurse and physician EM and inpatient physician documented identification of potential cognitive impairment in older adults. Methods: A prospective, cross-sectional convenience sampling was conducted at one urban medical center emergency department (ED). Eligible subjects were consenting English-speaking patients over age 65 years who had not received potentially sedating medications including anti-emetics, sedative-hypnotics, or narcotic-analgesia prior to criterion standard testing. Research assistants obtained a Mini Mental Status Exam (MMSE) on each subject. Two investigators, blinded to the MMSE result, later conducted an electronic chart review of the emergency nurse and physician note along with the inpatient physician admission and discharge notes to identify any documentation of confusion, disorientation, memory deficits, or potential cognitive dysfunction. Reliability was assessed with kappa analysis, while proportions were compared with вђ№2 tests. Results: Over 5 months, 251 subjects were enrolled. Of these, 47% were male with mean age 76-years and 55% were African-American with illness severity stratified by Emergency Severity Index 32% B and 66% C. Admitted subjects were 58% of the cohort. Cognitive dysfunction (MMSE Х… 23) was identified in 35% of the total cohort and 39% of the admitted subset. Two investigator chart review reliability for emergency or inpatient physician documentation of dementia was good (вђ¬П0.724 for PMH, 0.597 for emergency physician note, and 0.688 for inpatient physician note), but only fair for nursing documentation (вђ¬ П 0.404). Past medical history documented dementia in 4%, failing to identify 86% of those with an abnormal MMSE during their ED evaluation. Emergency nurses and physicians noted no cognitive abnormalities among 84% and 72%, respectively of those with an abnormal MMSE. Inpatient physicians did not document any cognitive abnormality in 60% of those with an impaired MMSE. Conclusion: Occult cognitive dysfunction is prevalent in admitted and discharged ED patients. Emergency nurses and physicians fail to document recognition Annals of Emergency Medicine S81 Research Forum Abstracts of this geriatric syndrome. Inpatient physicians rarely identify cognitive impairment missed by the ED. 260 Geriatric Syndrome Screening in Emergency Medicine: A Geriatric Technician Acceptability Analysis Carpenter CR, Griffey RT, Stark S, Coopersmith CM, Gage BF/Washington University in St. Louis, St. Louis, MO Study Objectives: Older adults routinely face social isolation and economic stressors concurrently with increasing frailty and co-morbid burden, often presenting atypically with multiple confounding processes. The demographic imperative facing 21st century health care will challenge emergency medicine (EM) to heighten evidence-based surveillance and focused interventions on a historically unprecedented geriatric population. Our objectives were to evaluate emergency physician and nurse acceptance of non-nurse, non-physician screening for geriatric syndromes. Methods: This was a single-center emergency department (ED) survey of EM attending physicians and nurses following a pilot screening project. Geriatric screeners were paid medical student research assistants evaluating consenting ED patients over age 65 for cognitive dysfunction, fall risk, or functional decline. Potential patient subjects were only approached after approval of the treating physician. Screening results were not communicated to nurse or physician staff since this pilot project was a feasibility trial and not an interventional trial. The anonymous survey was completed after eight months of screening and evaluated perceptions about the geriatric screener feasibility and barriers to implementation. In addition, respondents reported their current practice for screening older adults using ED validated tools for prognosis, fall risk, dementia, visual and hearing impairment, polypharmacy, functional status, and immunizations. Results: The survey was completed by 72% of physicians and 33% of nurses. Less than 25% of physicians routinely screen for any geriatric syndromes. Nurses evaluate for fall-risk significantly more often than physicians (97% vs. 24%, pПЅ0.001), but no other significant differences were noted in ongoing screening efforts. The majority of nurses (85%; 95% CI 73%-97%) and physicians (71%; 95% CI 52%-91%) identified geriatric screener assistants as beneficial to patients without impeding ED throughput. Few physicians or nurses identified any barriers to ancillary screeners evaluating for occult geriatric syndromes. Conclusion: Most nurses and physicians are not currently screening for any geriatric syndromes. Dedicated geriatric screeners are perceived by nurses and physicians as beneficial to patients with the potential to improve patient safety and clinical outcomes. 261 Restraint Use in the Elderly Emergency Department Patient Swickhamer C, Colvig C, Chan SB/Resurrection Medical Center, Chicago, IL Study Objectives: The elderly frequently suffer from altered mental status and other medical conditions requiring physical and/or chemical restraint for patient and staff safety in the emergency department (ED). This study examine outcomes of physically restrained ED elders. Methods: Two-year retrospective study from an urban community teaching hospital ED. Included were patients 65 years and older, physically restrained in the ED, requiring inpatient hospitalization. Data included age, sex, restraints indications, restraint type, restraint length, adverse outcomes, ED discharge diagnosis, ED disposition, hospital length of stay and disposition. Results: Eighty-three patients reviewed over 2 years. 56.6% were nursing home residents. 86.7% had medical indications for restraints. 32.5% (27/83) were admitted from the ED to the ICU. 42.2% (35/83) received both chemical restraints and physical restraints. The median number of medications upon patient arrival was 8.0, and three patients were on a medication which could adversely interact with chemical restraint medication. The mean length of stay (LOS) in the hospital was 7.2 days (SD: 5.7 days). 10 patients expired, 14 went home, and 59 to a nursing facility (8 with new behavioral medications). Of the 36 patients originally from home, only 11 (30.6%) were discharged home. There were no outcome differences between patients with both chemical and physical restraints and patients with physical restraints alone. S82 Annals of Emergency Medicine Conclusion: In this 2-year retrospective study, elderly patients placed on physical restraints in the ED were most often medically ill with high severity and likely to required both physical and chemical restraints. Chemical restraints may be contraindicated in some patients secondary to prior medications. Elderly patients from home who require physical restraints in the ED are unlikely to return home. 262 Yield of Head Computed Tomography in the Alcohol-Intoxicated Patient Shah K, Godbout B, Kwon A, Newman D, Wiener D/St. LukeвЂ™s-Roosevelt Hospital, New York, NY Study Objective: We aimed to determine the yield of positive cranial computed tomography (CT) findings in alcohol-intoxicated patients presenting to the emergency department. Our secondary aim was to determine if elderly patients were more likely to have an intracranial injury. Methods: An electronic chart review was performed at our inner city, academic institution with an annual census of 165,000 patients and a 3-year emergency medicine residency program. All patients with either a chief complaint or diagnosis of alcohol intoxication who had a head CT performed in the emergency department between the dates of January 2004 and December 2007 were identified. Specific, pre-determined data elements such as demographics, CT scan results and disposition were extracted by 2 trained, hypothesis-blinded extractors using a pre-formatted data form. вЂњPositiveвЂќ head CT was defined as evidence of any type of intracranial hemorrhage. вЂњElderlyвЂќ was defined a priori as greater than or equal to 60 years of age. Standard statistical methods including chi-square calculations were utilized for data analysis and group comparisons (head CT yield between older and younger patients). Results: There were a total of 2,673 subjects (82% male) with alcohol intoxication and a head CT scan performed over our 4-year study period. A total of 50 (1.9%) subjects had a positive head CT with a mean age of 51 (range from 20 to 84) and 92% male predominance. Comparing elderly subjects (nП555) with those ПЅ 60 years of age (nП2118), the yield of positive head CT was 2.70% (.95CIП1.44.1%) versus 1.65% (.95CIП1.1-2.2%), respectively. Conclusion: The yield of positive head CT among alcohol-intoxicated patients was 1.9%. Although CT scan of elderly patients had a higher yield than those less than 60 years of age (2.7% vs. 1.7%), the difference was not statistically significant. 263 Assessing Three-Month Fall Risk for Geriatric Emergency Department Patients Carpenter CR, DesPain RW, Keeling TN, Rothenberger MP, Shah MP/ Washington University in St. Louis, St. Louis, MO Study Objectives: Older adult falls are a leading cause of injury often precipitating rapid functional decline. Emergency department (ED)-initiated falls prevention reduces subsequent fall-related morbidity, but limited resources necessitate a focus on high-risk subsets. Recent synopses have suggested specific clinical predictors lacking external validation in the ED. The objective of this study was to validate previously reported risk-factors for geriatric falls in ED patients. Methods: A prospective observational study was conducted at one urban medical center ED. Eligible subjects were consenting English-speaking patients over age 65 years who had not received potentially sedating medications including anti-emetics, sedative-hypnotics, or narcotic-analgesia prior to prognostic variable testing. Variables assessed included self-reported dementia or ParkinsonвЂ™s; prior falls within the last month or year; recent prolonged bed confinement; phenothiazine, benzodiazepine, anti-depressant, antihypertensive, or narcotic analgesic use; bedside functional tests (chair stand, tandem gait); Mini Mental Status Exam cognitive assessment; residual stroke deficits; fear of falling; the Identification of Seniors at Risk and the Triage Risk Screening Tools. The primary outcome was reported falls at three-month phone follow-up using a pretested script. Secondary outcomes included injurious falls and ED recidivism. Proportions were compared with вђ№2 tests. Results: Over 9 months, 158 subjects were enrolled with three-month followup. Of these, 58% were female with mean age 77 years and 54% were AfricanAmerican. Admitted subjects were 54% of the cohort. Cognitive dysfunction Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts (MMSE Х… 23) was identified in 29% although dementia history was only selfreported in 4%. Falls in the preceding year were reported by 41%. Recommended bedside functional tests could not be performed in 49% of subjects. Falls within three months were reported in 17% (95% CI 12%-24%), while fall-related injuries were reported in 6.3% and ED recidivism in 43.7%. Univariate analysis identified only two-risk factors as significant: previous falls within one-month (pПЅ0.001) or one-year (p П 0.002). Conclusion: Previous and future falls are prevalent among older ED patients. Recommended functional bedside tests are impractical for half such patients and are not significantly associated with self-reported three-month falls. Previously suggested outpatient and inpatient fall risk factors fail to identify geriatric patients with self-reported falls. ED-specific fall risk factors are need to identify high-risk subsets. 264 Has Grandma Been Drinking? Irvin CB, Kott I, Abuel V/St. John Hospital and Medical Center, Detroit, MI Background: Seniors suffering trauma have a worse prognosis than younger victims. Seniors may already be challenged (with slower response times, visual challenges, etc) and the compounding effect of alcohol may contribute to even greater mortality. No previous studies have evaluated the frequency of alcohol ingestion in elderly trauma patients, or the effects on outcome when seniors are intoxicated. Study Objective: To determine the proportion of elderly trauma victims with alcohol ingestion, compared to younger victims, and evaluate if alcohol presence is associated with worse outcome. Methods: Using the National Trauma Data Bank (version 6.1), the following variables were retrospectively analyzed in ACCESS: Age (Пѕ 64 (Seniors), 40-64 (MidAge), and 18-39 (Young), Injury Severity Score (ISS), Alcohol present, Length of Stay (LOS), and Discharge status (alive vs dead). Cases with missing data were excluded. Results: Of the 404,559 cases with complete data, 16% were Seniors, 35% were MidAge, and 50% were Young. Seniors were more likely to die with a mortality rate of 9.3%, compared to MidAge of 4.7% and Young of 3.9%, pПЅ.01. Alcohol presence was reported in 9.2% seniors, 31% MidAge, and 37% Young, pПЅ.01. Seniors with alcohol had an increased mortality (11%) compared to Seniors without alcohol (9%, pПЅ.01), MidAge with alcohol had an increased mortality (5%) compared to MidAge without alcohol (4%, pПЅ.01). The Young mortality did not change with presence of alcohol (pП.4). Alcohol presence was also associated with increased LOS ((approximately 1 day in all age groups, pПЅ.01), and ISS (2 point increase in ISS in all age groups, pПЅ.01). Conclusion: Alcohol presence in trauma patients decreases with age, but when present, is associated with increased ISS, and LOS. Almost 10% of traumatized seniors will have alcohol present. Additionally, when alcohol is present, seniors have a higher ISS score and higher mortality. Injury prevention programs for seniors need to address alcohol consumption as this may contribute to increased death in trauma. 265 Guided Medication Dosing for Elderly Emergency Department Patients Using a Real-Time, Computerized Decision Support Tool Griffey RT, Lo HG, Burdick E, Keohane C, Bates DW/Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO; University of Pennsylvania, Philadelphia, PA; Brigham and WomenвЂ™s Hospital, Division of General Medicine, Boston, MA; Brigham and WomenвЂ™s Hospital, Harvard Medical School, Boston, MA Study Objective: The elderly account for an increasing number of emergency department (ED) visits, hospital admissions, and 1/3 of all prescribed medications. Age-related differences in physiology and a high prescription rate make the elderly more susceptible to adverse events including falls, hip fracture, intracranial hemorrhage, gastrointestinal bleeding, oversedation, and altered mentation. It is known that a number of common medications whose standard dosages for otherwise healthy adults are potentially harmful in the elderly. Recently, the use of real-time, computerized decision support tools in conjunction with computerized order entry (CPOE) systems has been shown to improve medication ordering and impact patient safety in elderly patients in the inpatient setting. We implemented a similar intervention in the ED to study its Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ impact on physician ordering behavior and adverse drug events in elderly emergency patients. Methods: This study took place in an academic, urban emergency department (ED) exclusively using CPOE. This was a prospective trial of 4 consecutive 6week blocks where the decision support tool was alternately inactive вЂњOFFвЂќ (periods 1 and 3) or active вЂњONвЂќ (periods 2 and 4). This was followed by chart review for a sample of patients in each block using previously described explicit chart review methodology to identify adverse drug events. When active, the application made adjusted default dosing or alternate medication recommendations in patients Пѕ64 who were ordered selected benzodiazepines, opiates, non-steroidal anti-inflammatory drugs (NSAIDs) or sedative-hypnotics identified by a multidisciplinary expert panel as potentially harmful in the elderly (based on modified Beers list). Physicians could accept or reject recommendations. Outcome measures compared ON and OFF periods for: (1) % agreement with recommended dosing (overall and broken down by drug and class) for the initial order, and (2) rate of adverse drug events. Data analysis was performed using t tests for continuous variables and chi-square test for discrete data. Results: There were 2419 orders among 1356 unique patients making 1548 total visits. There were no differences between cohort demographics including race, age, and sex. Overall agreement with recommended dosing was low, with a greater percentage of initial orders consistent with recommendations during the ON (31.4%) vs. OFF (23.0%) periods both overall (pП0.03) and for each drug class: benzodiazepines (pП.03), opiates (pП0.04) and NSAIDs (pП.0009) (sedative hypnotics had too few orders for reliable analysis). The pattern of agreement followed the activation status of the decision support tool. With overall agreement increased from periods 1 to 2 (pП.03), decreasing nonsignificantly from period 2-3 (pП.06) and increasing from period 3-4 (pПЅ.0001). Chart reviews were performed in 223 patients (16%) with no significant difference found in the rate of adverse events during ON vs. OFF periods. Conclusion: Real-time computerized decision support improved physician ordering behavior consistent with recommendations for adjusted medication dosing in the elderly, though overall agreement rates were low. This effect appears to be dependent on the application being live. There was no clear effect on adverse event rate in this study which was underpowered to detect a significant change. 266 Do Non-English-Speaking Patients With an Admitting Diagnosis of Pneumonia Experience a Systematic Delay in Time to Antibiotics? Green JP, Garg N, Berger T/New York Hospital Queens, Flushing, NY; Jacobi Medical Center, Bronx, NY Study Objective: To determine whether non-English-speaking (nEs) patients with an admitting diagnosis of pneumonia experience a systematic delay in time to first antibiotics. Methods: A retrospective chart review was performed at an urban teaching hospital for all adult patients admitted from the emergency department with a diagnosis of pneumonia during a 6-month period (8/1/2007-1/31/2008). Primary language spoken, demographics, time from arrival to chest x-ray and arrival to antibiotics were collected. Compliance with institutional goals for arrival to first antibiotics ПЅ 4 hours were reviewed. Mann Whitney U was used for continuous and chi-square for categorical data. Results: 391 patients were admitted from the emergency department for pneumonia during the 6-month period. 147(37.6%) patients were nEs. Mean age was 71.2 years, 51% were female. 377(96.4%) patients received antibiotics less than 4 hours from arrival. Median time to chest x-ray for English vs. nEs patients was 71.0 min [95% CI 64.0-80.0] vs. 76.0 min [64.0 to 86.7], pП0.61. Median time to first antibiotic for English vs. nEs patients was 65.0 min [95% CI 57.0-75.9] vs. 74.0 min [95% CI 59.6 to 83.0], pП0.64. Compliance with institutional goals for time to first antibiotic for English vs. nEs patients was 3.6% [95% CI 1.1 to 6.1] vs. 4.5% [95%CI 0.9 to 8.1] min, pП0.89. Conclusion: There was no evidence of a systematic delay in time to chest x-ray or time to first antibiotic for non-English-speaking patients in this population. Limitations included a retrospective design and small sample size. Annals of Emergency Medicine S83 Research Forum Abstracts 267 Emergency Department Nurse Workloads and Their Contributors Rabin E, Koita J, Salaam O, Richardson L/Mount Sinai School of Medicine, New York, NY Study Objectives: As evidence mounts that larger patient-to-nurse ratios (PT:Ns) lead to patient morbidity and possibly mortality, over 20 states have developed safe nurse staffing laws. It is unclear if, and how, many of the laws will apply to emergency departments (EDs), where nurses are subject to growing and unpredictable patient volumes. Laws that only limit inpatient PT:N could worsen ED PT:N by increasing boarding. Existing research has not focused on ED nursing workloads or suggested strategies to effectively limit them. We seek to quantify the magnitude and variability of ED PT:N and to identify factors in Asplin et alвЂ™s input-throughput-output ED crowding model that most affect ED PT:N. Methods: Data on non-critical adult patients were collected prospectively in a large urban public ED during randomly selected 8- and 12-hour shifts between June and September 2008. Every two hours the following were recorded: number of patients triaged over the previous 2 hours (input factor), patients awaiting physician evaluation or radiology study (throughput factors), boarders (output factor) and total number of patients and nurses. PT:N values were derived for each observation. A mixed linear analytical model accounting for correlation of temporal clusters of data points was used to identify significant contributors to PT:N. Results: Data were collected at 115 points in time during 20 shifts. Average PT:N was 5.6 patients per nurse (min 2.2, max 10.3, var 2.8). PT:N was greater than 6 in 34.7% of cases. Significant contributors to PT:N included triaged patients (вђ¤ 0.013 PПЅ0.0001), patients awaiting physician (вђ¤ 0.127 PПЅ0.0001) and boarders (вђ¤ 0.061 PП0.0016). Patients awaiting radiology studies did not contribute significantly (вђ¤ 0.052, PП0.139). Conclusion: ED nurses frequently carry more than six patients, the number often cited as the threshold for inpatient floor safety. Increases in ED crowding input, throughput and output factors were significantly associated with greater ED nurse workloads; strategies to limit any of these may decrease ED PT:N. Legislative proposals for safe nursing standards and strategies to decrease crowding should consider the effects on ED nursesвЂ™ workloads. 268 Change in Acuity of Emergency Department Visits After Massachusetts Health Care Reform Smulowitz PB, Baugh CW, Schuur JD, Liu SW, Lipton RB, Wharam JF, Landon BE/Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Womens Hospital and Massachusetts General Hospital, Boston, MA; Brigham and Womens Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA; Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA Study Objectives: Between October 1, 2006 and December 31, 2007 Massachusetts enrolled 439,000 individuals in health insurance products during the implementation of its landmark near universal health care legislation. This reform serves as a natural experiment with which to study the impact of health reform on changes in emergency department (ED) use. Our objective was to determine the relationship between health care reform in Massachusetts and ED use for low- and high-acuity conditions for the population of patients who were previously in government subsidized insurance or uninsured. A secondary objective was to determine if a significant increase in total visits among all patients was observed. Since access to health care depends on more than just insurance status, we hypothesized that the rate of ED visits for low acuity conditions would not decrease after the reform. Methods: This retrospective pre-post study utilized data from administrative databases at three urban tertiary care teaching hospitals. The baseline period was from January 1st, 2006 to September 30th, 2006 and the comparison study period was January 1st, 2008 to September 30th, 2008. We limited the analysis to include those groups most affected by the health reform law, which were patients covered by government subsidized insurance (ie, Medicaid, Free Care Pool and Commonwealth Care) and the uninsured. Acuity of visits was determined using a modification of BillingsвЂ™ Emergency Department Algorithm. This modified algorithm clusters ICD-9 discharge codes into low, intermediate, and high acuity visits. We used chi square tests to compare the proportion of low and high acuity ED visits before and after the health reform implementation period. S84 Annals of Emergency Medicine Results: Total visits increased from 169,665 to 190,465 (p ПЅ .05) after the reform period for all types of patients. There was no significant difference in the pre- and post-reform ED visit rate for low acuity visits among patients who were previously in government subsidized insurance or uninsured at two of the hospitals (30.90% versus 29.24%, p П 0.12, and 33.82% versus 35.41% p П 0.10, respectively). However, at the third hospital, a significant increase was observed (34.22% versus 39.50%, p ПЅ .05). There was no significant change in the proportion of high acuity visits observed for patients with any type of payer. Conclusion: Massachusetts health care reform was temporally associated with an increase in the volume of ED visits at 3 urban teaching hospitals. None of the institutions demonstrated a decrease in low acuity visits in the time period following health care reform. While this 3 site pre-post analysis is limited by its design, it suggests that increased insurance coverage will not lead to an immediate reduction in ED visits. 269 The Impact of Declining Emergency Department Subspecialty Availability Ladde J, Bullard T, Papa L/Orlando Regional Medical Center, Orlando, FL Background: The availability of emergency specialty services is a significant problem. Reasons cited include poor reimbursement, legal repercussions, and disruptive on-call scheduling. The impact is particularly important for centers that continue to provide these services. Study Objective: This study compared the availability of emergency specialty services during two discrete time points to assess the impact of declining emergency services. Methods: This cross-sectional study used 2003 and 2007 Florida State Registry transfer data to compare availability of emergency specialty services per capita per 100,00 populations. Specialties examined included: burns, emergency medicine, ear nose and throat, general surgery, hyperbarics, neurology, neurosurgery, obstetrics, ophthalmology, oral and maxillofacial surgery, orthopedics, pediatrics, plastic, thoracic surgery, trauma, urology, and vascular surgery. Data are expressed as per capita per 100,000 population. Results: The actual demand for specialty services from 2003 to 2007 did not change significantly (pП0.97). However, overall, the total number of emergency specialty services available per capita per 100,000 population declined from 52.4 (SD55.4) in 2003 to 36.6 (SD21.1) in 2007 (pП0.042). In particular, emergency medicine and trauma services declined from 3.4 (SD2.8) to 2.2 (SD1.8) per capita per 100,000 population respectively (pПЅ0.001). The number of surgical specialties (such as cardiovascular, general, neurosurgery, oro-maxillofacial, plastic, thoracic, vascular and burns) available per capita per 100,000 population declined from 11.8 (SD14.1) in 2003 to 7.7 (SD4.5) in 2007 (pП0.033). The specialties with the most significant decreases in services from 2003 to 2007 included trauma, burn, and oromaxillofacial surgery. Conclusion: This study underscores the dramatic statewide shortage in ED coverage for critical subspecialties and how the burden of these reductions has been shifted to those still providing services. Further studies to evaluate the impact these shortages create and how to alleviate the problem are needed. 270 The Impact of Health Care Reform in Massachusetts on Emergency Department Use by Uninsured and Publicly Subsidized Individuals Smulowitz PB, Adelman L, Lipton R, Burke L, Weiner S, Sayah A, Baugh CW, Burke MC, Landon BE/Beth Israel Deaconess Medical Center, Boston, MA; Tufts Medical Center, Boston, MA; Cambridge Health Alliance, Cambridge, MA; Massachusetts General Hospital, Boston, MA; Milford Regional Medical Center, Milford, MA; Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, MA Study Objectives: Massachusetts enrolled 439,000 individuals in health insurance plans during implementation of its landmark near-universal health care legislation. From a population who was previously uninsured or part of the Free Care Pool, 169,000 individuals were enrolled in a publicly subsidized program (Commonwealth Care), and 76,000 individuals were enrolled in Medicaid (Masshealth). Our objective was to determine if health care reform was associated with a change in the rate of use of the ED by those patients most directly impacted by the health reform legislation. Methods: This was a retrospective pre-post study set using ED utilization data from 6 hospitals in Massachusetts (3 tertiary care teaching hospitals and 3 Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts community hospitals). The baseline period was January 1 - September 30, 2006. The comparison period after the implementation of health care reform was January 1 - September 30, 2008. We first measured the total volume of ED visits in the before and after periods. We then measured the percent of total visits in each period that were either uninsured or in publicly subsidized programs. The study group during the baseline period consisted of visits by individuals who were Self Pay, Free Care, or in Masshealth. The study group during the comparison period consisted of visits by individuals who were either in Self Pay, Free Care, in Masshealth, or the newly created Commonwealth Care group. We used chisquare testing to compare the frequency of visits in these groups before and after the implementation of health reform. Results: In 2006 there were 179,557 total ED visits and 195,635 total visits in 2008. (p ПЅ .05) In the study group for 2006 there were 62,210 visits, accounting for 34.6% of total ED visits. A significant decrease was found in 2008 compared to 2006 (p ПЅ .05), where there were 60,383 visits in the study group, or 30.9% of total ED visits. This is mainly a consequence of a reduction in the number of ED visits by self pay and free care patients. Patients enrolled in Commonwealth Care accounted for 2.6% of the population in Massachusetts and 3.0% of all ED visits in these hospitals in 2008. Conclusion: Health care reform, for the hospitals in this study, was associated with a decrease in the frequency of ED visits by patients who were either uninsured or insured by publicly subsidized programs. There was, however, a significant increase in overall ED visits during this time period. The results suggest that the uninsured are not the primary cause of increasing ED volumes. This preliminary study highlights some important trends in ED use after health care reform in Massachusetts. This study was limited by the relatively small number of hospitals in the sample though it includes both large teaching hospitals and community hospitals. 271 Accidents Waiting to Happen: Decreasing Access to Emergency Departments in Rural Areas in the U.S., 2001-2005 Hsia RY, Shen Y/University of California at San Francisco, San Francisco, CA; Naval Postgraduate School, Monterey, CA Study Objectives: The Institute of Medicine and other public health institutions have voiced growing unease that there could be systemic disparities in access to traditionally underserved patients. One important indicator is the availability of critical services, such as those of emergency services, especially in rural areas. The objective of this study is to determine if access to emergency departments (EDs), as defined by geographic proximity, has increased or decreased in rural areas for specific sub-populations over time between 2001 and 2005. Methods: We obtained characteristics of communities using zip code level data from the 2000 Census and further supplemented this dataset with longitude and latitude coordinates of each zip code and hospital, and calculated the distance between each community to the nearest ED. We extracted data regarding ED availability between 2001-2005 from the American Hospital Association (AHA) Annual Surveys. Our unit of analysis was community as defined by zip code. Our key variables of interest were the proportion of underserved populations in each zip code by the following categories: race/ethnicity (black, Hispanic), economically disadvantaged (poor, near poor, and unemployed), and elderly (greater than 65 years of age). We controlled for population, county, and hospital (and hospital market) characteristics. We used multivariable regression with STATA to determine odds that distance to the nearest ED increased between 2001 and 2005. Results: A total of 9,754 zip codes were included in our sample, with an estimated population size of 37.8 million. Between 2001 and 2005, access to the nearest ED deteriorated for 7% of zip codes, equivalent to 3.1 million people. Two groups experienced a deterioration in access: areas with high shares of Hispanic population (2.72 times more likely to have decreased access to ED, pПЅ0.01), and those with medium and high shares of families below poverty (1.81 and 1.8 times more likely to face decreased access to ED, pПЅ0.01, pПЅ0.05, respectively). Conclusion: We find that there has been a decline in proximity to the nearest ED for rural communities, and that this decline in access is not evenly distributed. These findings of this study have serious implications regarding the continued evolution of access to emergency departments for certain populations. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 272 Are Public Hospitals More Efficient in Providing Health Care? Roberts RR, Rodrigo Y, Kampe LM, Bowman SH, Ahmad I/Stroger Hospital of Cook County, Chicago, IL; St. MathewвЂ™s University, Grand Cayman, Cayman Islands; Cermak Health Care System, Chicago, IL Study Objectives: It is often remarked that public teaching hospitals operated less efficiently than private or not-for-profit hospitals. Our study objective was to determine the efficiency of ten public hospitals compared to the national average. A second objective was to determine the relative costs for medical care in states with dense urban populations versus more rural states. Methods: The Resource Based Relative Value Scale (RBRVS) was used to determine the total output for ten public hospitals in 2005. We measured total hospital admissions, hospital inpatient days, ambulatory and ED visits, and inpatient and ambulatory surgeries and multiplied the totals by their Relative Value Units (RVUs). This total output was divided by the total number of full-time equivalent employees (FTEs) to determine the facility efficiency. The same procedure was used to determine the total output and efficiency of the U.S. hospital system as a whole in 2005. For all RBRVS we used the median value within each health care output category. Because ambulatory care relative to inpatient care varied greatly between facilities, a sensitivity analysis was performed. The highest and lowest RVUs for a clinic visit were substituted for the average while all other services were scaled to the clinic visit RVU. We also performed total measurements while sequentially excluding ambulatory surgery and clinic visits and excluding national physician office FTEs. Finally, a preliminary examination of the relative medical and business costs for densely populated states - New York and Massachusetts - versus the more rural Alabama and Nebraska was conducted. Results: In the base case, the ten public hospitals achieved 252.9 RVUs per FTE compared to 244.5 RVUs for the national total. In the sensitivity analysis using varied ambulatory RVUвЂ™s, public hospitals provided 743.9 RVUs compared to 578.6 for national facilities when using the lowest clinic RVU. When using the highest clinic RVU, public hospitals provided 163.2 compared to 168.1 for national RVU. In the rest of the analyses, the public hospitals had more RVUs per FTE than the national Annals of Emergency Medicine S85 Research Forum Abstracts average. The geographical regions varied greatly in the hourly wage for hospital professionals such as nurses with the highest rate in Boston, MA at $36.95 vs. $24.29 in Lincoln. This was also true for infrastructure costs: $38.0 per square foot in New York, $33.1 in Massachusetts versus $17.4 and $19.3 in Alabama and Nebraska, respectively. In contrast, the total spent on pharmaceuticals as a proportion of total health care was 29% higher in Nebraska compared to Massachusetts. Higher cost for prescription drugs was confirmed by calling a national pharmacy in each state. Conclusion: Using the RBRVS to value health care outputs, ten urban public hospitals provided more health care units per FTE than the national average. All of our public hospitals were in densely populated urban areas, are often crowded and therefore may benefit from the efficiency of scale. Our preliminary work to determine how geographical area affects hospital costs suggests that areas with low wage, salary and real estate costs appear to pay similary or higher costs for pharmaceuticals- in total and by individual prescription. This paradox may need examination as a cause of health disparity and could impact the national cost-effectiveness for new pharmaceuticals that save money by reducing health care encounters. 273 Association Between Emergency Department Crowding on the Appropriateness of Resuscitation Room Utilization: An Expert Panel Study in a Single Emergency Center Kim J, Choi H, Shin S, Kim D, Cha W/Seoul National University Hospital, Seoul, Republic of Korea Study Objectives: The aim of this study was to evaluate the appropriateness of resuscitation room utilization and find their association with emergency department (ED) crowding. Methods: This study was carried out from July 1, 2008 to August 31, 2008 in a single regional emergency center (level 1 center). Targets were patients with age of 15 years or older. Patients who died on arrival (DOA) were excluded. The decision of putting patients into the resuscitation room was done by doctors, nurses or paramedics or even by out-of-hospital caregivers. There was no written protocol for entering the resuscitation room. The disposition of resuscitation patients were made after they were clinically stabilized or died. The data of these patients were recorded to the resuscitation room registry by emergency nurse specialists. Collected data were physiologic parameters, diagnoses, interventions, clinical results, and time variables. Three emergency physicians reviewed every case independently afterward. They categorized each case as appropriate, over-utilization, or delayed-utilization. Agreements were made if at least two of the physicians agreed on a same category. Calculation of visits per hour was regarded as crowding index. We categorized the included hours into quartiles according to the calculated hourly visits. Results: Total of 145 patients was included. 64.8% was male and mean age was 60.7 (57.8 - 63.6) years. 26 (17.9%) of these were discharged from the ED, 98 (67.6%) were admitted, 9 (6.2%) were transferred to another facility, and 11 (7.6%) died in the ED. Overall hospital mortality was 37 (25.5%). The panel decided that utilization of the resuscitation room was appropriate for 88 (60.7%) of patients, overutilized for 39 (26.9%), and delayed-utilized for 18 (12.4%). When compared by the crowding factor, the hourly visits, there was significant association. The rate of appropriate utilization was 100% when there were less than two visits per hour, 75% when two or three visits per hour, 61.2% when four to six visits per hour, and 54.8% when more than 7 visits per hour (pПЅ0.05). Conclusion: The resuscitation room was utilized appropriately only for 60.7% of all cases. The rate of appropriate utilization showed negative association with crowding state of the ED. 274 Multi-Center Study of Left Without Treatment Rates From Emergency Departments Serving a Large Metropolitan Region Lev R, Castillo EM, Vilke GM, Chan TC/Scripps Mercy Hospital, San Diego, CA; University of California, San Diego, San Diego, CA Study Objectives: Emergency department (ED) crowding is a growing problem that threatens the safety net function of EDs nationwide. ED patients who leave without treatment (LWOT, without being seen by a physician or against medical advice) may represent a significant problem of the health care safety net of a community. The objective of this study was to investigate the association between ED S86 Annals of Emergency Medicine crowding and throughput on LWOT rates in EDs serving a large metropolitan region. Methods: Design: Multi-center observational study as part of a county-wide ED crowding initiative and annual summit. Setting: All 19 EDs serving a large metropolitan area of 2.7 million people. Participants: All patients seen in the 19 EDs during a 1-year period (July 1, 2007-June 30, 2008). Data was collected from each ED on patient volume, ED beds, LOS for admitted and discharged patients, payor mix, admission and psychiatric patient hold rates, specialty service availability, and LWOT rates. EDs were stratified by size and capacity as either small (ПЅ20 beds) or large (Пѕ20 beds). Differences in means, standard deviations (SD), parameter estimates and associated 95% confidence intervals [CI] are reported. The association between LWOT and LOS was assessed using unadjusted linear regression. Differences in LWOT and LOS measures by ED size were compared using t-tests. Data analysis was conducted using a statistical software program (SPSS 16). Results: During the one-year study period, there were 893,000 ED patient visits for the region cumulatively at the 19 EDs, which varied in size from 8 to 89 beds. Mean annual census for each ED varied from 10,944 to 100,764 visits and monthly patient volume/bed varied from 94 to 344 patients/bed. The mean LOS was 6.0 hours (SDП1.8) for admitted patients and 3.3 hours (SDП0.8) for discharged patients. The mean LWOT rate was 3.2% (SDП2.0) with a range of 1 to 8%. Ten EDs had Пѕ20 beds (52.6%) and nine ПЅ20 beds (47.4%). Small EDs had significantly lower LWOT rates and means LOSs (LWOT differenceП2.6%, CIП1.1, 4.1, pП0.002; LOS admit difference П1.6 hours, CIП0.02, 3.1, pП0.048; and LOS for discharged patients difference П1.0 hours, CIП0.4, 1.6, pП0.002). The relationship between LOS discharged patients and LWOT in an unadjusted linear regression model was вђ¤: 2.07 (95% CI: 1.33, 2.81). There was an increase of 1% in the LWOT rate for each 2.1 hour increase in LOS for discharged patients. Conclusion: In a regional study of all EDs serving a large metropolitan area, LWOT rate was associated with ED size and LOS, with a progressive increase in LWOT rate with longer ED LOS for discharged patients. 275 A Classification System for Emergency Departments: Massachusetts, 2008 Camargo Jr CA, Ginde AA, Handel DA, Keadey MT, Raja AS, Rogers J, Sullivan AF, Espinola JA/Massachusetts General Hospital, Boston, MA; University of Colorado Denver School of Medicine, Aurora, CO; Oregon Health & Science University Hospital, Portland, OR; Emory University Hospital, Atlanta, GA; Brigham & WomenвЂ™s Hospital, Boston, MA; Monroe County Hospital, Forsyth, GA Study Objectives: A standard national approach to the classification of emergency departments (EDs) is вЂњessential for the optimal allocation of resources and provision of critical information to an informed publicвЂќ (2006 Institute of Medicine report on the вЂњFuture of Emergency CareвЂќ). To inform future nation-wide efforts, we applied a capabilities-based classification to Massachusetts (MA) EDs. Methods: We mailed a survey to all ED directors in MA, excluding federal hospitals; 85% (nП63) responded. Questions were designed to classify EDs into 5 tiers: Level 1 EDs offer continuous (24/7) on-site physician coverage and consults in medicine, surgery, orthopedics, obstetrics/gynecology, pediatrics, and anesthesia in ПЅ30 minutes with specialty consults (cardiology, neurosurgery, and neurology) in ПЅ1 hour; Level 2 EDs have a physician on-site 24/7 and consults in ПЅ1 hour; Level 3 EDs have a physician on-site 24/7 and consults are not available in ПЅ1 hour; Level 4 EDs are open 24/7 with a physician available to the ED from within hospital and variable consult availability; and Level 5 EDs are open 24/7 with a physician available to the ED from outside the hospital. Data analyses used chi square, FisherвЂ™s exact, and Kruskal-Wallis tests. Results: In 2008, 11% of MA EDs were Level 1, 33% Level 2, 56% Level 3, and 0% were Level 4 or 5. Level 1, 2 and 3 EDs differed in median annual visits (52k [IQR 4786k], 54k [IQR 42-67k], 28k [IQR 20-46k], respectively; pППЅ0.001) and other factors: staffing (e.g., median # of full-time ED attendings: 20 (IQR 12-35), 16 (IQR 12-20), 10 (IQR 7-14); pПЅ0.001), resources (eg, presence of a dedicated CT scanner in 86, 38, 9%; pПЅ0.001), and acuity (eg, admission rates: 25% (IQR 23-33%), 19% (IQR 15-20%), 15% (IQR 11-18%); pПЅ0.001). Crowding was a concern at all levels, with most ED directors stating that they were either вЂњatвЂќ or вЂњoverвЂќ capacity (100, 95, 81%; pП0.30) and provided care for patients in the hallway (100, 86, 54%; pП0.08). Nevertheless, EDs differed by report of вЂњboardingвЂќ patients for Пѕ2 hours while waiting for inpatient beds to become available (100, 100, 74%; pП0.02). Conclusion: By investigating the basic characteristics of MA EDs, we were able to classify EDs. The levels identify potential gaps in available services but also highlight Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts the challenges shared by MA EDs. Data from other states would provide important state comparisons. This project provides a framework for developing a future nationwide ED classification system. 276 Nurse-Operated Ultrasound for Difficult Intravenous Access: A Randomized Trial River G, Hebig A, McAlpine I, Stein J/UCSF School of Medicine, San Francisco, CA; Stanford University, Palo Alto, CA Study Objectives: We sought to compare ultrasonographically versus nonultrasonographically guided peripheral intravenous access performed by emergency nurses on emergency department patients with difficult intravenous access. Methods: We conducted a prospective, randomized control trial at an academic, tertiary care hospital. Nurses were trained in ultrasound guidance for peripheral intravenous access, and were allowed to practice using ultrasound for several months before commencing the study. Patients with difficult intravenous access, defined as those who had two prior unsuccessful cannulation attempts by nursing staff, were randomized to 2 groups: (1) intravenous access obtained through an ultrasonographically guided technique or (2) intravenous access obtained through non-ultrasonographically guided methods. Outcomes measured included success rate, total number of cannulation attempts, time to successful intravenous access, and both patient and nurse satisfactions on a Likert scale. Groups were compared using Wilcoxon rank-sum test for non-normal data. Results: During the study period, 47 patients were randomized in the trial: 26 to the ultrasound group and 21 to the control group. The ultrasound group had 87% cannulation success while the control group had 72% success (difference of 15%, Chi2 PП0.237.) In the ultrasound and control groups, respectively, an average of 1.5 and 2.0 further intravenous attempts were required before successful cannulation (mean difference of 0.5 attempts, 95% CI -.07-1.03, PП0.09.) Average time to cannulation in the ultrasound group was 26 minutes compared to 22 minutes in the control group (mean difference 4 minutes, 95% CI-7.43-14.9, PП0.50). Patients in the ultrasound group had average Likert satisfaction score of 4.2 compared with 3.4 for the control group (average increase of 0.8 in the ultrasound group, 95% CI -.371.8, PП0.184) while nurses in the ultrasound group recorded an average satisfaction of 4.5 compared to 2.7 in the control group (average difference of 1.8, 95% CI .922.55, PП0.0001). Conclusion: This small study was not able to demonstrate that nursing ultrasound leads to improvement in success rate or number of attempts required to place intravenous lines in patients with difficult intravenous access. It is possible that with a larger study, the difference in success would become clinically significant. It is unlikely, however, that a larger study would produce a relevant improvement in the number of cannulation attempts or time to cannulation based on the confidence intervals of our study. 277 Teaching Focused Obstetric Ultrasound to Midwives in Rural Zambia Kimberly H, Murray A, Mennicke M, Ngoma B, Chisanga C, Ngoma E, Tyer-Viola L, Ahn R, Liteplo A, Burke T, Noble VE/Massachusetts General Hospital, Boston, MA; Royal Infirmary Edinburgh, Edinburgh, United Kingdom; Brigham and WomenвЂ™s Hospital, Boston, MA; Kapiri-Mposhi District Hospital, Kapiri, Zambia; Nkole Rural Health Center, Nkole, Zambia Study Objectives: There is increasing interest in using point-of-care ultrasound in developing countries with limited access to imaging diagnostics. We developed a focused obstetric ultrasound training program for midwives in a rural health district in Zambia. Our objectives were to assess the ability of midwives to learn basic obstetric ultrasound and to evaluate whether the use of ultrasound changed the clinical management of patients. Methods: Twenty-one nurse midwives from 3 rural sites in the Central District of Zambia underwent focused obstetric ultrasound training. The training was carried out by three emergency ultrasound-trained physicians over a 6-month period from October 2008 to March 2009. The initial instruction involved 2 hours of interactive teaching and 3 weeks of supervised hands-on scanning. This was followed up at 2 and 6 months with 2- and 3-week periods of evaluation and hands-on scanning. Midwives were trained to identify the following fetal pulse rate (FHR), fetal presentation, placental location, number of gestations and gestational age. All scans and data sheets were reviewed by the study physicians. Midwives were evaluated for their ability to operate the machine, and to acquire and interpret images. Results: Four hundred forty-one scans were performed by 21 midwives over a Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 6-month period. The mean number of scans per midwife was 21 (range 1 - 170). The majority of scans were performed in the second and third trimester and 182 (41%) were supervised by the study physicians. Some of the findings included non-vertex presentation 76 (17%), multiple gestations 30 (7%), no FHR 10 (2%) and low lying placenta 3 (ПЅ1%). In 73 of the 441 scans (16.5%) the ultrasound findings prompted a change in patient management. These changes included repeat ultrasound 26 (36%), increased antenatal visits 17 (23%), referral to provincial hospital 13 (18%), advised delivery in clinic 5 (7%), and other 12 (16%). To measure ultrasound ability and skill retention, 7 of the midwives were evaluated with a 14-question observed structured clinical exam (OSCE) 2 months after their initial training and then again at 6 months. Under direct observation, they were assessed in their abilities to operate the machine and to acquire and identify basic obstetric ultrasound findings as detailed above. The OSCE demonstrated an overall improvement in the midwivesвЂ™ scanning abilities over the time studied with mean scores at 2 and 6 months of 9.7 (69%) and 11.6 (83%) respectively. Conclusion: Midwives in rural Zambia can be trained to use a portable ultrasound machine to perform basic obstetric ultrasound including identifying multiple gestations, calculating fetal pulse rate and identifying fetal presentation. The skills learned improved over the 6-month study period. Introduction of ultrasound machines caused a change in clinical management in 16.5% of the patients scanned by the midwives. More data is necessary to assess the sustainability of the skills learned and to determine whether the introduction of ultrasound can ultimately improve obstetric care in rural Zambia. 278 Comparative Extravasation Rates of 1.75-Inch and 2.5-Inch Ultrasound-Guided Peripheral Vascular Catheters Bauman MJ, Nomura JT, Schofer JM, Resurreccion D, Toulson K, Reed III J, Sierzenski P/Christiana Care Health System, Newark, DE Study Objectives: We compared the extravasation rates of 1.75-inch (4.5cm) and 2.5-inch (6.4 cm) intravenous catheters (IVs) used for ultrasound (US)-guided peripheral venous access. We also calculated the minimum length of catheter required in the vein to minimize extravasation. Methods: Twenty-two subjects were randomized to receive a 1.75-inch or 2.5inch 18-gauge IV for US-guided peripheral vascular access in the emergency department (ED). The IVs were assessed for extravasation hourly for 4 hours and then every 4 hours for up to 12 hours or until the subject left the ED. Subjects admitted to the hospital had a 24- and 48-hour chart review for a new IV start as an indication of initial IV failure. The distance from skin surface to the edge of target vein was also recorded. Assuming a 45o angle of the needle track to the skin, the length of catheter in the vein was calculated. Data are presented with standard deviation and were analyzed using StudentвЂ™s t-test and PearsonвЂ™s chi-square. Results: The 1.75-inch IVs extravasated at a significantly higher rate than the 2.5-inch IVs, 50% (6/12) versus 10% (1/10), p П 0.045. The mean depth of the target vein was not significantly different for 1.75-inch and 2.5-inch IVs, 0.94 cm (П©/- 0.42 cm) vs. 0.98 cm (П©/- 0.52 cm) respectively, p П 0.839. The mean length of catheter in the vein was significantly shorter for 1.75-inch catheters than for 2.5inch catheters, 3.2 cm (П©/- 0.6 cm) versus 5.0 cm (П©/- 0.7cm), pП 0.001. The mean length of catheter in the vessel was also significantly shorter in the extravasated group than the not extravasated group, 3.15 cm (П®0.95) vs. 4.38 cm (П® 0.98), pП0.012. The 1.75-inch IVs that extravasated trended towards a shorter amount of catheter in the vessel than those that did not extravasate, 2.9 cm (П©/- 0.6 cm) versus 3.5 cm (П©/0.4 cm), pП 0.053. The mean time to extravasation for the 1.75-inch IVs was 2.0 hours (П©/- 1.1 hours). The one extravasation on the 2.5-inch catheter group occurred at 36.3 hours. Conclusion: 1.75-inch IVs extravasate more often than 2.5-inch IVs when used for US-guided peripheral venous access. A length of catheter in the vessel of greater than 3.5 cm is recommended for US-guided peripheral venous access. 279 Optic Nerve Sheath Ultrasound for the Evaluation of Children With Suspected Ventriculo-Peritoneal Shunt Failure Hall MK, Sabbaj A, Spiro D, Meckler GD/Oregon Health & Science University, Portland, OR Background: Ventriculo-peritoneal shunts (VPS) are the most common neurosurgical procedure in children. Up to 80% of VPS fail in the first 10 years. Annals of Emergency Medicine S87 Research Forum Abstracts Symptoms and signs of VPS failure are non-specific and insensitive, and current standard of care includes radiologic neuro-imaging (NI) such as CT, MRI and plain films. NI is expensive, time consuming, and exposes children to ionizing radiation. Moreover, NI remains insensitive in up to 1/3 of shunt failures. Recently, optic nerve sheath diameter (ONSD) has been proposed as a safe and efficient surrogate for elevated intracranial pressure (ICP) and may be a useful screening tool in children with suspected VPS failure. Study Objectives: 1. Determine the utility of ONSD in predicting clinical VPS failure. 2. Determine the feasibility of ONSD in the emergency department (ED). Methods: Prospective, single blinded observational study of children 6 months to 18 years presenting to an urban tertiary childrenвЂ™s ED with suspected VPS failure. The primary outcome measure was surgical shunt revision. The experimental variable was mean ONSD in mm, measured 3mm posterior to the optic disc. Additional variables included demographics, past medical history, symptoms, signs, and standard imaging results as well as parental prediction of shunt failure. Results: ONSD was completed in 36 patients, of whom 16 had VPS failure. The mean age was 10 years (range 6 months to 18 years), and 46% were male. Using agebased upper limits for ONSD of 40 mm for infants ПЅ 1 and 45mm for older children, the sensitivity of ONSD was 61% and the specificity was 17%. Traditional NI, and clinical symptoms and signs were equally unreliable (see table 1). Parental prediction of shunt failure had a sensitivity of 100% and a specificity of 21%. Conclusion: Though feasible in the ED, ONSD is neither sensitive nor specific as a screening tool for suspect VPS failure in children. Table 1: Traditional Neuro-imaging in VPS Failure 280 Comparison of Web- Versus Classroom-Based Basic Ultrasound and Extended Focused Assessment With Sonography for Trauma Training in Two European Hospitals Platz E, Goldflam K, Mennicke M, Parisini E, Christ M, Hohenstein C/Brigham and WomenвЂ™s Hospital, Boston, MA; Harvard School of Public Health, Boston, MA; Klinikum Nuremberg, Nuremberg, Germany; Klinikum Kempten OberallgГ¤u, Kempten, Germany Study Objectives: Training practicing physicians in new skills presents a major challenge both in the United States and in countries where emergency medicine is an emerging specialty. Because classroom-based training is associated with higher costs and less flexibility we sought to evaluate whether it is superior to blended learning, in the format of Web-based lectures combined with a hands-on workshop, and whether it results in better knowledge retention of basic ultrasound techniques and the EFAST (Extended Focused Assessment with Sonography for Trauma). Methods: Physicians from various specialties practicing in two German emergency departments were enrolled and randomized into two didactic groups. The classroom group attended traditional lectures, while the Web group watched narrated lectures online. Identical slides were used for both groups. All participants completed the same Web-based 29-item multiple choice test before and after their didactic sessions, as well as a second post-test eight weeks after the practical training. After completion of the first post-test, both groups participated in hands-on EFAST training. A control group of physicians also completed the pre-test and first post-test without receiving any didactic intervention or practical training. Given the longitudinal nature of the data and the balanced study design, an analysis of the response profiles in the two study groups was carried out to assess the significance of differences in mean score patterns. Results: Fifty-five subjects participated in the study. 63.6% subjects were male, S88 Annals of Emergency Medicine 79.6% were resident physicians and 9.3% had no prior ultrasound training. Both the classroom (nП19) and Web group (nП23) showed significant improvement in scores between the pre- and post-test 1 (75.9% vs. 93.9% and 77.8% vs. 92.5%, p ПЅ 0.001), as well as similar retention of knowledge after eight weeks in the post-test 2 (88.6% and 88.9%, p П 0.72). There was no statistically significant difference in mean score profile between the two groups, suggesting comparable efficacy of the Web-based lectures as an educational method (pП0.572). The control group (nП13) did not show any significant change in test scores for pre- and post-test 1 (83.3% and 82.8%, p П 0.88), indicating that there was no learning effect without intervention. There was no difference between the Web and classroom group in access to ultrasound machines or number of patients scanned by the participants after completion of the course. Both groups rated their enjoyment of the course, their perception of its effectiveness and their comfort with ultrasound use after the didactic training similarly. Conclusion: Blended learning provides the opportunity to teach practicing physicians through a combination of Web-based lectures and practical workshops, potentially allowing for lower cost and greater flexibility than with classroom instruction. Our data suggest that Web-based didactic training of basic ultrasound techniques and the EFAST is comparable to traditional classroom lectures and results in similar knowledge retention. 281 Impact of Image Processing on the Pleural Sliding Sign Holm M, Reardon R, Caroon L/Hennepin County Medical Center, Minneapolis, MN Study Objective: Sonographic identification of pleural sliding is a quick and simple means to rule out pneumothorax in any critically ill patient. Ultrasound is much more sensitive than physical exam or chest radiography for detecting pneumothorax. Evaluation for pneumothorax is now a routine part of the FAST (Focused Assessment with Sonography for Trauma) exam. We noticed that it is often easier to identify pleural sliding using older ultrasound equipment. Modern ultrasound machines use several image processing features to improve image quality, and all of these features are typically activated during a FAST exam. We evaluated the combined effect of tissue harmonics, SonoMB (spatial compounding) and SonoHD processing on the identification of pleural sliding. Methods: This was a prospective study in which twenty-five physicians (residents and faculty) were asked to evaluate for pleural sliding in a healthy 70 Kg male. Physicians had variable ultrasound experience but all had some experience using the pleural sliding sign in a clinical setting. Using a SonoSite M-Turbo with a C60x 5-2 MHz curved array transducer (SonoSite, Inc. Bothel, WA) each physician scanned the right side of the volunteerвЂ™s chest in the 3rd to 4th intercostal space in the midclavicular line. Each physician was asked to look for pleural sliding with the image processing features in two different configurations. First, with tissue harmonics, SonoMB and SonoHD activated, then with all three of these features deactivated. Physicians were then asked if it was easier to see pleural sliding with all of these features on or off, or if it made no difference. Physicians were not blinded to the configuration of the machines. Results: 23/25 physicians (92%) thought it was easier to see pleural sliding with all image processing features deactivated, 1/25 thought it was easier to see pleural sliding with all image processing features activated and 1/25 saw no difference (pПЅ 0.001). Conclusion: Some processing features that improve abdominal and cardiac imaging make it more difficult to recognize pleural sliding. To our knowledge, this is the first study of the impact of image processing on the pleural sliding sign. More research is needed to determine optimum image processing configurations for each part of the FAST exam. 282 Correlation of Bedside Ultrasound Measurement of the Respiratory Variation of Internal Jugular Venous Diameter With Invasive Central Venous Pressure Measurement in Patients With Severe Sepsis Bigler JB, Berkeley RP, Puchala G/University of Nevada School of Medicine, Las Vegas, NV; University of Nevada, Las Vegas, NV Background: Identifying patients with severe sepsis and initiating prompt resuscitation via early goal-directed therapy (EGDT) guidelines continues to be a Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts challenge in many emergency departments (EDs). This study evaluated the collapsibility or distensibility of the internal jugular (IJ) vein and its correlation with central venous pressure (CVP), a key end-point of resuscitation in EGDT. The study hypothesis was that bedside ultrasound can be utilized to identify volume underresuscitated patients, with CVP ПЅ8 as per EGDT guidelines, prior to the initiation of invasive CVP monitoring. Study Objective: To evaluate the correlation of the respiratory variability of internal jugular venous diameter, measured by bedside ultrasound, compared with invasively measured central venous pressure. Methods: This was an institutional review board-approved prospective clinical study, utilizing convenience sampling, of adult patients (age Х†18 years) who presented to an academic, urban ED with 70,000 patient visits per year. Inclusion criteria consisted of ED patients with Х†2 systematic inflammatory response syndrome criteria and a suspected or identified source of infection, who required central venous access for resuscitation and CVP monitoring per a standardized institutional EGDT management protocol for severe sepsis. Bedside ultrasound was utilized to measure the maximal internal height and width of the IJ vein, followed by the minimal height and width with respiratory variation, at the time of central venous catheter insertion; measurements were repeated Х†45 minutes later. Patients were supine while ultrasound was performed by emergency medicine residents and/or attendings. Images were paused and measured, followed by printing of hard copies for data analysis. All physicians involved in the study had previously received training in the method of IJ measurement by the lead investigator. Clinical variables recorded included the corresponding vital signs at the time of each IJ measurement, CVP and ScvO2 immediately following measurement, the concomitant use of vasopressors and/or sedatives, volume of crystalloid infused prior to each measurement, and comorbidities. Formulae utilized for calculation of the IJ collapsibility or distensibility were: Collapsibility Index П [((Max Height П© Max Width)/2) - ((Min Height П© Min Width)/2)] / ((Max Height П© Max Width)/2). Distensibility Index П [((Max Height П© Max Width)/2) - ((Min Height П© Min Width)/2)] / ((Min Height П© Min Width)/2). Results: We enrolled 17 patients; 2 were excluded due to incomplete data. The mean (П®SEM) age was 48 (4.4) years, and 11/15 (73%) were male. 50% had significant comorbidities. Initial mean (П®SEM) lactate was 2.9 (0.59) mmol/L. Initial median (95% CI) CVP was 10.2 (8.65,11.8) mmHg and initial median collapsibility/ distensibility index was 0.068 (П®SEM П 0.124); range П (0.01-3.0). Primary measure: The Pearson correlation coefficient (95% CI) was ПЄ0.306 (0.061,-0.593), r-squared П 0.094. Limitations: Small study size, convenience sampling, inter-rater reliability was not measured. Conclusion: There is a fair to moderate correlation between IJ collapsibility/distensibility index and measured CVP. If this relationship is validated with a larger prospective study, this may have the potential to positively impact severe sepsis management via non-invasive identification of low CVP. 283 Utility of Bedside Biliary Ultrasound in the Evaluation of Emergency Department Patients With Isolated Epigastric Pain Adhikari S, Morrison D, Zeger W, Chandwani D, Krueger A/University of Nebraska Medical Center, Omaha, NE; Detroit Medical Center, Detroit, MI; Loma Linda University Medical Center, Loma Linda, CA Study Objectives: A biliary ultrasound is not routinely performed on patients presenting with isolated epigastric pain to emergency department (ED). Some of these patients are initially misdiagnosed with gastritis, gastroesophageal reflux disease and peptic ulcer disease only to return later to be diagnosed with cholelithiasis or cholecystitis after a more complete evaluation. The objective of this study is to determine the utility of bedside biliary ultrasound (US) in the evaluation of ED patients presenting with isolated epigastric pain. Methods: This is an institutional review board-approved prospective observational study of adult patients presenting to two academic EDs with isolated epigastric pain. Patients with history of gallstones, cholecystectomy, gastrointestinal bleeding and chronic abdominal pain were excluded. Patients were enrolled if an emergency physician other than the study investigator determined that patient had isolated epigastric pain and tenderness. emergency physician investigators who were not involved in the clinical care of these patients performed bedside biliary US using either a GE Logiq or Philips Envisor system with a 5-2 MHz curvilinear probe. The US images obtained in ED were subsequently reviewed by another sonologist who is blinded to the study hypothesis, ED US interpretations and other clinical Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ information. History, physical examination findings, laboratory results, additional diagnostic tests, and disposition data were obtained from the treating emergency physician and ED chart. Descriptive statistics are used to analyze the data. Continuous data are presented as means with standard deviations and dichotomous data are presented as percent frequency of occurrence with 95% confidence intervals. Results: A total of 33 patients (female-25, male-8) were enrolled. The mean age of the patients was 36 years П©/- 14.9 (SD). 15/33 (45% CI 28-62%) reported similar symptoms in the past. 22/33 (67% CI 50-82%) had associated vomiting. All subjects had isolated epigastric tenderness. Gallstones were found in 9/33 (27% CI 12-42%) on bedside US. Three of these patients had sonographic signs of chloecystitis. All 9 patients had normal liver function tests and only 2 had leucocytosis. The treating emergency physicianвЂ™s initial evaluation didnвЂ™t include an US in 6/9 (67% CI 3697%) patients with cholelithiasis on bedside US. Three of these 6 patients were hospitalized. All 9 patients were initially given GI cocktail by the treating emergency physician. There is 100% agreement between emergency physician investigator and blinded sonologist US interpretations. Conclusion: Bedside biliary ultrasound detected gallstones in almost one-third of our ED patients with isolated epigastric pain. It can avoid misdiagnosis and expedite management in these patients. 284 Intra-Articular Foreign Body Evaluation: Ultrasound versus Fluoroscopy Illston B, Lyon M, Caudell MJ, DiCarlo J/Medical College of Georgia, Augusta, GA Study Objectives: In out-of-hospital settings, evaluating for soft tissue foreign bodies can be challenging with management options consisting of delayed removal or local surgical exploration. However, when an intra-articular foreign body (FB) is suspected, transfer to a hospital setting is often required for radiographic evaluation. Ultrasound (US) evaluation may allow for determination if joint involvement is present, possibly eliminating or delaying transfer. Our objective is to evaluate the effectiveness of bedside US in accurately determining the absence of an intra-articular FB in comparison to fluoroscopy and computerized tomography (CT). Methods: This was a prospective blinded study to determine the utility of US and fluoroscopy to detect intra-articular FB. The largest joint in a skin-on chicken quarter (thigh-leg) was the target for the FB insertion. A single spine from a freshly harvested Uni sea urchin was introduced through the skin of the chicken, directed towards the joint. The spines were very fragile, and introduction caused the spine to break leaving no evidence of the location of insertion. As a result, the investigator was unable to determine the final position of the spinous tip. Each chicken quarter was evaluated for the presence of an intra-articular foreign body by 3 methods: bedside US, fluoroscopy, and CT. A separate investigator performed each modality and was blinded to the otherвЂ™s results. US evaluation was performed by an emergency physician with hospital credentials for emergency US using a SonoSite MicroMaxx US machine with a linear probe. Fluoroscopy was performed by a second emergency physician using a GE series 9600 fluoroscopy system. There was no time limit for the evaluation of the chicken quarter by either fluoroscopy or US. Using a GE Lightspeed VCT2 scanner, 0.625 mm slices (joint protocol) were acquired to evaluate the location of the foreign body. If the FB violated the joint capsule, then the interpreting radiologist classified the FB as intra-articular. Descriptive statistics were used to report the accuracy of each modality for the detection of intra-articular foreign body. All values are reported with a 95% confidence interval. Results: Six of the 10 trials resulted in the spine penetrating the joint capsule. Ultrasound detected 9 of the 10 foreign bodies. There was one false positive result for joint penetration yielding a sensitivity, specificity and negative predictive value for detecting the intra-articular foreign body of 100% (72.6, 100%), 75.0% (40.7, 75.0%), 100% (54.3, 100%) respectively. Fluoroscopy detected all 10 foreign bodies, but had one false positive result for joint penetration yielding a sensitivity, specificity and positive predictive value of 100% (76.8, 100%), 75.0% (40.1, 75.0%), 100% (53.5, 100%) respectively. The false positive result of both US and fluoroscopy occurred with the same foreign body. Conclusion: CT remains the gold standard for FB joint penetration. However, US may prove to be a valuable tool in identifying out-of-hospital joint penetration, thereby reducing unnecessary delay in treatment or hospital transfer. Annals of Emergency Medicine S89 Research Forum Abstracts 285 The Significance of Peripheral White Blood Cell Count in Cases of Acute Otitis Media in Children Between 2 to 17 Years of Age Nibhanipudi Sr KV, Hassan Jr G/NY Medical College Metropolitan Hospital Center, New York, NY Background: AOM is a common clinical condition frequently encountered in pediatric emergency department. Watchful waiting has been advocated in recent years for the treatment of uncomplicated AOM in children less than 2 years. In our study we like to evaluate WBC count as an objective parameter to make the decision of treating AOM with antibiotics. Study Objective: To determine whether peripheral white blood cell count (WBC count) may help/aids making treatment decisions in children with uncomplicated acute otitis media (AOM). Methods and Materials: Children with a clinical diagnosis of AOM between the ages of 2 and 17 years of age were included in the study after obtaining the informed consent from their parents and also signed assent form from children Пѕ6 years of age. All patients were subjected to a venepuncture and a complete blood count (CBC) with differential was performed. Pain was assessed using Pain Analog Scale as developed by the New York City Health and Hospitals Corporation. Patients with a WBC count Пѕ15,000 were given amoxicillin. Patients with WBC counts ПЅ15,000 were not given any antibiotics but were given analgesic ear drops. Patients in both groups were given either acetaminophen or ibuprofen for pain relief/or fever reduction in the appropriate dosages. The parents were instructed for a follow-up appointment on 3rd day and were reevaluated both clinically and also for pain using the same pain analog scale. Children who did not receive antibiotics initially and still have otalgia using the pain analog scale antibiotics were prescribed and those already receiving antibiotics were considered for change of antibiotic regimen. Pain relief is the primary parameter of the study. Results: A total of 100 patients were enrolled in the study. Seven patients with WBC counts Пѕ15,000 were given antibiotics. Six out of 7, the pain resolved completely. (0 pain score on day 3). One out of the 7 patients (14%) treated with antibiotics had a score of 8 on day 1 and pain remained at 4 on day 3. His antibiotics was changed to augmentin. 93 out of 100 patients had WBC counts ПЅ15,000, and were not given antibiotics initially. Ninety out of 93 patients had significant improvement in pain severity which came down to 0 on day 3. Three patients out of 93 (3.2%) did not have significant pain relief on day 3. All these 3 patients were given amoxacillin. Comparison of the proportions between the groups was analyzed using Fishers Exact test. Conclusions: The outcome of our study with an objective parameter (WBC count) could help physicians to treat AOM appropriately by avoiding the unnecessary use of antibiotics without causing significant complication from the disease. This could also reduce the adverse effects of antibiotics as well as the increasing bacterial resistance to common antibiotics. Table 1 Table 2 S90 Annals of Emergency Medicine 286 Evaluation of Emergency Medicine Discharge Instructions in Pediatric Head Injury Sarsfield MJ, Callahan JM, Grant WD, Morley EJ/SUNY Upstate Medical University, Syracuse, NY; ChildrenвЂ™s Hospital of Philadelphia, Philadelphia, PA Study Objectives: Pediatric head injury is a common occurrence. There is mounting evidence that patients require removal from sports and play to help speed recovery and limit the morbidity from their initial injury. The objective of this study was to determine how often discharge instructions given to children who had sustained head injuries included information regarding activity restrictions, activity time constraints, and specifics of follow-up care. Methods: A retrospective chart review of patients aged 2-18 years evaluated and treated for head injury during a 4-month period at a tertiary care center, level 1 trauma center which sees approximately 14,000 pediatric patients per year. Included were those children seen, evaluated, and diagnosed with any of the following: mild head injury, concussion, minor head trauma, or mild traumatic brain injury. Subjects were excluded if there was a positive acute CT finding (other than findings of a simple linear skull fracture) related to the head injury or if the subject required admission. Data was collected using a structured data extraction form. Percentages were compared for significance using Chi-Square. The study was approved by the institutional review board and HIPAA offices. Results: A total of 204 patients met eligibility. Among these patients 95.1% received instruction to follow-up with a physician, 82.8% received anticipatory guidance regarding expected symptoms, 15.2% received specific restriction time from sports, and 21.5% were removed from sports. One-hundred and thirteen (113) patients were determined to have sustained a concussion from the chart review. Patients with sports-related concussion were significantly more likely to receive discharge with return-to-sports restrictions (chi square П 11.225, p ПЅ0.008) and instructions to remove the child from play (Chi square П 9.781, p ПЅ 0.004) than patients with motor vehicle crash or other types mechanisms of injury. Conclusion: Children sustaining head injury were inadequately instructed to restrict athletic activities upon discharge. This is particularly true for patients who sustain a concussion from non-sports-related activity. 287 Does Insurance Status Make a Difference in Pediatric Trauma Patients? Irvin CB, Hakmeh W, Fox JM/St. John Hospital and Medical Center, Detroit, MI Background: A recent study in Archives of Surgery found that uninsured trauma patients had a higher mortality. One limitation of this study is that uninsured patients may also have chronic health problems, and may generally be in poorer health, predisposing them to worse outcomes after trauma. Children tend to be healthier with less chronic health problems when compared to adults. This study sought to determine if the trend of increased mortality in uninsured patients was also true in the pediatric population. Study Objective: To compare the outcome of Insured an Uninsured pediatric trauma patients. Methods: Using the National Trauma Data Bank (v6.2), the following variables were extracted: Age (age 1-18), Payment type, First Systolic Blood pressure, emergency department Glasgow Coma Score, ED disposition, Injury Severity Score (ISS), Length of Stay (LOS), ICU days, and discharge status. Insurance was divided into BlueCross-BlueShield (BCBS), Uninsured (self pay, charity), or Other (Medicaid, HMO, Medicare, government, Auto Insurance, etc). Results: Of the 156,848 patients in the study, 13% were uninsured, 6% were BCBS, and 66% had Other insurance. Uninsured had a higher mortality overall (2.8% compared to BCBS at 1.3% or Other at 1.4%, pПЅ.001). Additionally, when a sicker subset of patients was evaluated (GCS 3-13), the mortality rate for uninsured was 21.4% (542/2537) compared to BCBS at 10.9% (120/1101) and Other at 11.9% (1407/11812), pПЅ.001. For patients with GCS 3-13, the ISS scores were lower in the uninsured group (20.2) compared to BCBS (22.1), pПЅ.001. In the population of GCS 3-13, Uninsured had shorter LOS (6.4 days) compared to BCBS (9.9 days) and Other (9.0 days), pПЅ.001. In the GCS 3-13, Uninsured also had less ICU days (3.9 days) compared to BCBS (5.5 days) and Other (5.5 days), pПЅ001. The statistical trend of lower ISS with higher mortality and lower LOS and ICU days for Uninsured compared to BCBS or Other persisted in the total group (all GCS scores) and also in the GCS scores of 14-15. Conclusion: Mortality disparity exists for uninsured pediatric trauma patients. Although Uninsured pediatric patients have lower ISS scores, they have higher Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts mortality, shorter LOS, and less ICU care. Although the exact reasons for this disparity are unclear, efforts to provide health insurance for all children may be one means to address this disparity. 288 A Rise in Emergency Department Visits of Pediatric Patients for Renal Colic From 1999-2008 Kairam N, Allegra JR, Eskin B/Morristown Memorial Hospital, Morristown, NJ Study Objective: Renal colic is predominantly a disease of adults with only occasional cases occurring in the pediatric population. A recent report from a single hospital showed a rise in the number of children with renal colic. Our objective was to confirm this in a large multihospital database of emergency department (ED) visits. Methods: Design: Retrospective cohort. Setting: Consecutive pediatric patients (age less than 18 years) with the ICD-9 diagnosis of вЂњrenal colic, calculus kidney, calculus ureter, urinary calculus, or uretheral calculusвЂќ seen by emergency physicians in 29 urban, suburban and rural EDs in New Jersey and New York between 1/1/1999 and 12/31/2008. We analyzed the number of renal colic visits as a percent of total ED pediatric visits in yearly intervals using the Student t test and performed a regression analysis. Alpha was set at 0.05. Results: The database contained 6,497,458 total ED visits of which 1,312,487 (20%) were pediatric visits. Of these, 1028 (0.078%) were for renal colic. The median age was 16 years (inter quartile range: 13 years - 17 years) and 61% were female. The percentage of ED pediatric visits for renal colic increased from 0.050% in 1999 to 0.089% in 2008, an increase of 78% (95% CI: 31% to 224%, p ПЅ0.003). The correlation coefficient for this upward trend was R2 П 0.63 (pПЅ0.007). Conclusion: We found a marked increase in ED pediatric visits for renal colic over the past decade. This may reflect a real increase in the incidence of renal colic in the pediatric population or an increased use of imaging modalities for abdominal and flank pain. 289 Ultrasound Assessment of Dehydration in Children With Gastroenteritis Levine AC, Shah S, Noble VE, Epino H/Brigham and WomenвЂ™s Hospital, Boston, MA; Alameda County Medical Center, Oakland, CA; Massachusetts General Hospital, Boston, MA Study Objectives: Acute gastroenteritis remains a major cause of morbidity and mortality in children around the world, accounting for 1.8 million deaths annually in children under five years of age, or roughly 17% of all child deaths. While oral rehydration solution (ORS) has been shown to be an effective, safe, and inexpensive method of treating children with mild to moderate dehydration, IV fluids are required to treat children with severe dehydration. The World Health Organization (WHO) recommends using four clinical signs to determine the severity of dehydration, however, prior studies have found that these signs lack adequate sensitivity, specificity, and reliability. We attempt to determine whether ultrasound assessment of the inferior vena cava (IVC) to aorta ratio can be used to determine the severity of dehydration in children presenting with acute gastroenteritis, and whether it performs better than the WHO criteria. Methods: We enrolled a prospective cohort of children under 15 years of age presenting with diarrhea or vomiting to three rural hospitals in Rwanda. Upon arrival, study coordinators consented the parent of all eligible children and performed an ultrasound of the IVC and aorta. Children were also assessed clinically by a second clinician using the standard criteria recommended by WHO. All children were weighed on admission to the hospital and then rehydrated according to standard Rwandan Ministry of Health protocols. Patients were weighed again just prior to discharge, and a percent weight change of greater than 10% was considered the gold standard for severe dehydration, according to the standard practice in the pediatric literature. We used ROC curves to determine the maximum sensitivity and specificity for the IVC to aorta ratio compared to our gold standard. We also determined the sensitivity and specificity of the WHO criteria compared to the same standard. Results: 28 children were enrolled in an initial pilot study, of which 25 have complete data available. The median age for children enrolled in the study was 9 months (range 1 - 42 months). 60% (15/25) of patients enrolled were male and 20% (5/25) had severe dehydration according to our gold standard. We found the WHO criteria to have a sensitivity of 80% (95% CI: 45-100%), a specificity of 55% (95% CI: 33-77%), a LR positive of 1.8 (95% CI: 0.9-3.4), and a LR negative of 0.36 (95% CI: 0.06-2.2) for detecting severe dehydration. In comparison, ultrasound of the IVC to aorta ratio had a sensitivity of 80% (95% CI: 45-100%), a specificity of Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 75% (95% CI: 56-94%), a LR positive of 3.2 (95% CI: 1.3-7.7), and a LR negative of 0.27 (95% CI: 0.05-1.6). Conclusion: In a prospective cohort of children presenting to three separate developing world hospitals with symptoms of acute gastroenteritis, we found ultrasound of the IVC to aorta ratio to have similar sensitivity and better specificity than the WHO criteria for assessing the severity of dehydration. While this pilot study remains too small to draw definitive conclusions, we expect our larger, upcoming study of 260 children will produce similar results. If ultrasound is found to be an accurate and reliable tool for determining severity of dehydration in children with gastroenteritis, it could be used to improve triage for children presenting to hospitals in both the developed and developing world, which in turn could translate into reduced morbidity and safer, more cost-effective care for patients. 290 A Teaspoon of Medication: How Much Is Really in It? Mir M, Palta A, Eden A, Kondamudi N/Wycoff Heights Hospital, Brooklyn, NY; The Brooklyn Hospital Center, Brooklyn, NY Study Objectives: Dosing errors are by far the most common type of medication errors in pediatrics and are attributed to calculation errors, illegible handwriting, and inability of some caregivers to understand instructions. Language barriers play a major role in the occurrence of dosing errors. It is common practice to prescribe liquid medications in teaspoonfuls rather than the actual quantity in milliliters. Our hypothesis is that the вЂњunderstandingвЂќ of the volume per teaspoonful may be variable in our caregivers of children, contributing to dosing errors. Our objectives were to determine the prevalence of teaspoon use and knowledge of medication volumes in them among caregivers and health care personnel. Methods: A survey questionnaire was mailed to 400 randomly selected pediatricians (Brooklyn/Queens area) and 100 area pharmacists. Another questionnaire (English and Spanish) was administered to a convenience sample of 398 caretakers at the pediatric unit/ED (nП245) and an affiliated private office (nП153). The same questionnaire was then administered to a convenience sample of health care workers (nurses and resident physicians; nП64).One hundred caretakers were asked to bring a teaspoon used for administration of medication to their children from their homes and volume of these was measured. Statistical analysis was done using SPSS for Windows, version 11.0. Results: A total of 148 pediatricians responded to the survey (response rateП37%) despite three mailings. Prescription of medications by teaspoonfuls was reported in 45%, prescription using milliliters in 42%, and 13% used both. Of the 100 mailings to the area pharmacists, 55% responded (response rateП55%) of whom 93% recommend medication dosing in units of teaspoonfuls. Survey of care givers revealed that 31% of English-speaking responders used teaspoons for medication administration compared to 43% of Spanish-speaking responders (pП0.025). Only 55% of English-speaking caregivers knew that 5ml equaled a teaspoon compared to 59% in the Spanish-speaking group (pПNS). Correct identification of a teaspoon among a set of various spoons occurred in 43% of English-speaking responders and only 23% of Spanish-speaking responders(pППЅ0.01). Among the health care personnel, 47% reported use of teaspoon for medication administration. Caregivers brought out a total of 53 spoons used at home for medication measurement and only three teaspoons measured to be 5ml. Conclusion: A large proportion of health care providers still recommended use of teaspoonfuls to administer liquid medication, despite TJC recommendation to use milliliters. Most caregivers used teaspoons for dosing medication and most teaspoons had inaccurate volumes when measured. 291 Spectrum of Bacterial Pathogens Seen in a Community Pediatric Emergency Department Kondamudi N, Bai H, Thumalapalli M, Rawstron S/The Brooklyn Hospital Center, Brooklyn, NY Study Objectives: To determine the spectrum of bacterial pathogens encountered in a pediatric emergency department (PED) of a community hospital. Methods: The study was conducted in a community hospital PED with 16,000 annual visits. All cultures sent for patients ПЅ 18 years to the microbiology lab from the PED between Jan 1, 2005 and June 30, 2006 (18 months) were identified. Medical records of these patients were reviewed to extract demographic and clinical data, lab findings, initial and final diagnosis and recorded into a database. The culture system used for aerobic and anaerobic culture was BD Bactec 9240 (Bacton & Dockinson Company) and the sensitivity tests system used were from BioMerieux, Annals of Emergency Medicine S91 Research Forum Abstracts Inc. VITEK GNS-106 was used for Gram-Positive susceptibility and GNS-128 was used for Gram-Negative susceptibility.SPSS for window 16.0 was used for statistical analysisПЅbr . Results: The total number of cultures sent was 519 from 23562 PED visits for a rate of 2.2%. The overall rate of performance of blood, urine and throat culture was 0.7% each (nП163, 164, 160 respectively). The most common age group was 4-12 year group, mostly for throat cultures (41%, nП165), followed by the 3 month to 3 year group, mostly blood and urine cultures (31%, nП125). Cerebrospinal fluid cultures were done in only 0.02% cases (nП13). The positive culture rate for blood was 9% (14/163; for urine was 21% (35/164;) and for throat was 21% (35/160). There was significant association in performance of blood culture with age 3 years (pПѕ0.05). The most common organisms identified in blood were contaminants (7), Staph aureus in 4,and Strep Pneumoniae in three cultures. The most common organism in the urine was E.coli (nП23), which was resistant to ampicillin (16/23 П 70%), amp/sulbactam (10/23, 45%) and cotrimoxazole (13/23, 56%). S. aureus, Klebsiella sp., Enterobacter sp., P. aeruginosa had 100% resistant rates to ampicillin. The prevalence of MRSA in this survey was 14%. The most common organism identified was group A streptococci in throat cultures. There were 5 contaminated blood cultures for a 4.3% contamination rate. Conclusions: The performance of cultures in this study was low compared to the published literature, representing underutilization. Contamination rate exceeded true bacterial growth among blood cultures indicating low prevalence rates of bacteremia. urinary tract infection is much more prevalent than bacteremia and the identified urinary pathogens are usually resistant to ampicillin. Knowledge of local prevalence of bacterial pathogens and their sensitivity will aid in more appropriate selection of antibiotic therapy. 292 Perceptions and Practices of Fever: Survey for Parents With Febrile Child Visiting Pediatric Emergency Department Kim D, Lee Y, Lee J, Jeong J, Kim J, Choi M/Seoul National University Hospital, Seoul, Republic of Korea Study Objectives: Fever is one of the most common presenting complaints for pediatric emergency department (ED) visits. Previous studies showed that fever phobia, exaggerated concerns about fever, is common among parents. Our object is to evaluate parentsвЂ™ perceptions and patterns of management for fever in their child. Methods: During the 2 months of 2008, we conducted a questionnaire survey among 746 parents of children visiting to ED because of fever. The main outcome results were answers to questions about variable aspects of the knowledge, perception and management of fever. Results: Most participants were college-educated and lived in an urban area. Two thirds of participants were female (mean age 34.7 years). Twenty eight percent of the parents considered temperatures less than 38.0В°C to be вЂњfever.вЂќ Seventy-eight parents (10.5%) believed that, left untreated, temperature could rise to over 42.0В°C. Most common concerns about refractory fever in their child were febrile seizure (35.5%) and brain damage (39.5%). Four hundred fifty-five parents (60.7%) said that they would check their childвЂ™s temperature ПЅ30 min when their child had a fever. Surprisingly, 66.2% of parents said that they would awaken their child to take an antipyretic. ParentsвЂ™ experiences of alternating uses of antipyretics were common (32.7%) and frequently were done without medical advices. About a half of parents (46.0%) said that they usually decide the dosage of antipyretics according to the doctorвЂ™s advice. Parents were worried about the harmful effects of antipyretics; the development of tolerance (41.9%) and dependency to drugs (39.7%). Conclusion: Many parents who visited the ED with a febrile child had a poor understanding of fever. There is a big need for systematic educational efforts to reduce fever phobia and to use antipyretics adequately. 293 Respiratory Distress Assessment Instrument as a Predictor of Hospital Admission and Severity in Children With Bronchiolitis Dhillon RK, Bellolio M, Wickremasinghe AC, Anderson JL/Mayo Clinic, Rochester, MN Study Objectives: To investigate the relationship between Respiratory Distress Assessment Instrument (RDAI) score and treatment administered in infants presenting to a pediatric emergency department (ED) with acute bronchiolitis and S92 Annals of Emergency Medicine clinical severity as graded by the RDAI. To investigate the relationship between the RDAI score and disposition from the pediatric ED. Methods: This is an ongoing prospective cohort study of previously healthy infants aged 0 to 23 months who present to a tertiary care ED with acute bronchiolitis, defined as first time wheezing associated with cough, coryza and respiratory distress. Infants with previously diagnosed heart or lung disease, or recent (ПЅ6 hours) albuterol or epinephrine treatment are excluded. Data collected includes a prospectively evaluated RDAI score, demographics, medical history and vital signs (oxygen saturation, respiratory rate, ETCO2, pulse rate). Data are captured every 5 seconds. Discharged patients are being followed by phone 2 weeks after ED discharge. Results: Twenty-two patients have been enrolled until date, with a median age 6.4 months (IQR 3.4-11), 64% males, 91% Caucasian, and 27.3% had history of premature birth. The median RDAI score at presentation was 6 (IQR 5-9). None of the patients had past medical history of recurrent respiratory tract infections, multiple births or airway abnormalities such as tracheomalacia. Smoking in the home was prevalent in 23% of the study population and 46% attended day care. Bronchodilators had been given to 32% of the patients and corticosteroids to 9% prior to ED presentation. There was no significant relationship between oxygen saturation on arrival and initial RDAI score (R-square 35.3%, pП0.16). There was no significant relationship between the ETCO2 measured on arrival to ED and initial RDAI (R-square 6.5%, pП0.399). Children on steroid therapy had higher initial RDAI scores (median 9.5 for those on steroids vs 6 for those not on steroids). This difference was clinically significant, however, not statistically significant (pП0.199). There was no relationship between admission RDAI score and admission to the hospital (pП0.819). There was a significant relationship between post bronchodilator RDAI score and admission to the hospital. Children with higher scores were more likely to be admitted (pП0.047). Conclusion: The RDAI score after bronchodilator treatment is a predictor of hospital admission. Patients on chronic steroids have higher RDAI scores which reflect more severe clinical presentation with bronchiolitis. 294 The Effects of Skin Pigmentation on the Detection of Genital Injury From Sexual Assault: A Population-Based Study Rechtin C, Rossman L, Jones JS, Wynn B/MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI; YWCA West Central Michigan Nurse Examiner Program, Grand Rapids, MI Background: Little is known about the role of race on the prevalence of genital injury following rape or sexual assault. A recent study suggested that individuals with darker skin may be at a disadvantage for injury identification with the current examination strategies (direct visualization, contrast media, colposcopy), and color awareness may be an important component of the sexual assault forensic examination. Study Objective: To investigate the role of skin pigmentation in the visual identification of genital injury following rape in women 13 years and older. Methods: This retrospective cohort trial evaluated consecutive female patients presenting to a community-based Nurse Examiner Program (NEP) during a 10-year study period. Sexual assault victims presenting directly to four downtown emergency departments are routinely referred to the NEP for evaluation after triage and initial assessment. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medical-legal examinations using colposcopy with nuclear staining. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification form. For the purposes of this study, injury was defined as any tissue trauma visible on inspection which was then subsequently classified using the TEARS classification (tears, ecchymoses, abrasions, redness, and swelling) system. Primary outcome of interest was the documentation of physical injuries from sexual assault in whites versus backs living in the same urban community. Chi-square and ANOVA tests were used to compare anogenital findings in victims examined. Results: Case files of 2234 patients were reviewed; 83% were white and 17% were black. The two cohorts were comparable in terms of age, marital status, type of sexual assault, alcohol and drug use, known assailant, and time to physical exam. Whites had a greater prevalence of documented non-genital (39% vs. 26%, pПЅ.001), as well as anogenital injuries (64% vs. 54%, pПЅ.001). The localized pattern of anogenital injuries was similar in both cohorts; typically involving the fossa navicularis, followed by the posterior fourchette, labia and hymen. The most common type of injury in all patients was lacerations; however, whites had a greater incidence of documented erythema (32% vs. 23%, pПЅ.001). Conclusions: Despite the use of colposcopy with nuclear staining and digital Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts imaging, forensic examiners in this community-based study consistently documented fewer anogenital injuries in black women. These findings suggest that individuals with darker skin may be at a disadvantage for injury identification with current forensic examination techniques. 295 What Happens at the 72-Hour Mark? Physical Findings in Sexual Assault Cases When Victims Delay Reporting Burger C, Olson M, Dykstra D, Jones JS, Rossman L/Michigan State University College of Human Medicine, Grand Rapids, MI; MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, MI; YWCA West Central Michigan Nurse Examiner Program, Grand Rapids, MI Background: Most of the literature regarding anogenital injuries resulting from sexual assault is limited to victims examined within a 24-48 hour time frame. As a result, a 72-hour post-assault window is usually suggested as the maximum time interval for documentation of anogenital injuries. Study Objectives: To analyze the frequency, location and types of anogenital trauma in sexual assault victims as a function of the victimвЂ™s age and the time interval between the assault and the forensic examination. A secondary objective was to analyze demographic factors that may be associated with a delay in forensic examination in adolescent (ages 13-19 years) and adult victims (Пѕ19 years old). Methods: This retrospective cohort trial evaluated consecutive female patients presenting to a community-based Nurse Examiner Program (NEP) during a 10-year study period. Sexual assault victims presenting directly to four downtown emergency departments are routinely referred to the NEP for evaluation after triage and initial assessment. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medical-legal examinations. The patients were stratified based on age (adolescent vs. adult) and the time interval between the assault and the forensic examination. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification form. Chi-square and ANOVA tests were used to compare clinical features among separate cohorts. Results: A total of 2799 cases met the inclusion criteria of the study; 28% (776) delayed seeking medical care for at least 24 hours following the assault. Victims who delayed seeking medical examination were younger (20.7 vs. 23.6 years, p ПЅ.001), more likely to be assaulted by a known acquaintance or family member (86% vs. 79%, pПЅ.001), and were less likely to report the assault to police (64% vs. 84%, pПЅ.001). The frequency of anogenital lacerations and abrasions decreased from 71% at less than 24 hours to 28% at greater than 96 hours after the assault (pПЅ.001). Out of the total study population, 43% (1192) were 19 years of age or younger. Adolescent victims who delayed seeking medical care were more likely to report more alcohol or drug use prior to the assault (58% vs. 47%, PПЅ.001). Across all time periods adolescents had a consistently higher frequency of genital injuries compared to adults, but in both populations documented anogenital injuries steadily decreased each day after the assault by approximately 8% (95% CI, 6% to 10%). At the 72hour mark, 50% of adolescents and 38% of adult victims had documented anogenital injuries. Conclusions: Twenty-eight percent of adult women and 33% of adolescent victims presented to an urban sexual assault clinic more than 24 hours after their assault. The frequency and types of anogenital injuries vary significantly depending on timing of the forensic examination. Approximately half of young women had injuries documented 72 hours after a sexual assault. 296 Early Treatment of Hypertonic Saline and Arginine Is Important in Restoration of T Cell Dysfunction Choi S, Hong Y, Cho H, Yun Y, Kim J, Moon S, Han C, Shin J, Kim S, Cho Y/ Korea University Guro Hispital, Seoul, Republic of Korea; Korea University Anam Hospital, Seoul, Republic of Korea; Korea university Guro Hispital, Seoul, Republic of Korea; Korea University Ansan Hospital, Ansan, Kyounggi-do, Republic of Korea Study Objectives: Immunological suppression is a well-recognized consequence of trauma and hemorrhagic shock and contributes to infectious complications, ultimately leading to sepsis and multi-system organ failure. Several mechanisms of post-traumatic immune impairment, including T cell dysfunction, have been proposed. T cell dysfunction after traumatic stress is characterized by a decrease in T cell proliferation. The addition of prostaglandin E2 (PGE2), which depressed immune function after hemorrhage and trauma, to T cells decreases T cell proliferation and Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ that Hypertonic saline (HS) restores PGE2-induced T cell suppression. Besides, arginine is essential in restoring T cell proliferation by HS. Therefore, we are to know if there is any differences in T cell proliferation according to the concentration of arginine, if HS restores PGE2-induced T cell suppression in 80uM of arginine, clinically relevant since serum arginine concentration, and whether HS restoration of T cell dysfunction is dependent on the injection time of HS. Methods: Jurkat cells were cultured in 0uM, 40uM, 80uM, 400uM, 800uM, 1600uM arginine media, final concentration of 2.5 П« 106 cell/ml. Cell proliferation was measured. Jurkat cells were cultured in 80uM arginine media, clinically relevant since serum arginine concentration. Cell proliferation was detemined in both PGE2 stimulated and HS treated group by the MTT cell proliferation assay and arginase activity were measured. Besides, according to treated time of HS, cell proliferation was measured. Results: Increased concentration of arginine media increased MTT cell proliferation. In 80uM of arginine, which concentration in the serum of human, HS did not restore Jurkat cell proliferation suppressed by PGE2 as measured by MTT cell proliferation assay. In 1.14mM arginine media, HS restore PGE2 suppressed Jurkat cell proliferation to normal. However, HS could not restore Jurkat cell suppressed by PGE2 in case of 2 hour after adding PGE2. Conclusion: Jurkat cell proliferation was increased by the increase of arginine concentration. And, in order to restore PGE2-suppressed Jurkat cell proliferation, HS must be added quickly and also require proper amount of arginine. 297 Injury Patterns Are Different for Older and Younger Patients in Equestrian Accidents Bilaniuk JW, Gage AM, Adams JM, Siegel BK, Cockburn MI, DiFazio LT, Allegra JR/Morristown Memorial Hospital, Morristown, NJ Study Objective: Horseback riding has been identified as a higher-risk activity than motorcycle riding, football and skiing. There has been little research of injuries associated with equestrian accidents. Examining injury patterns may give clues for prevention of injuries. We hypothesized that there are different patterns of injury for older and younger patients in equestrian accidents. Methods: Design: Retrospective cohort. Setting: Level two trauma center in suburban northern New Jersey. Population: Consecutive visits from January 1, 2004 to Dec. 31, 2007. Protocol: We searched the trauma registry and the E- codes from the hospital information system to identify patients with equestrian injuries. We grouped injuries into categories based on regions of the body. We a priori chose to compare patients less than 50 years with those greater or equal to 50 years. Chi-square was used to test for statistical significance with alpha set at ПЅ 0.005 using the Bonferroni correction for multiple comparisons. Results: Of 277,000 visits in the database, 285 patients (0.1%) had equestrian injuries. The median age was 30 years (inter quartile range 14 - 50 years) with 27% Пѕ 50 years. Female comprised 84%. The 2 most common injuries as a percentage of injured patients for each age group were: Пѕ 50 years - rib fractures (23%) and T-L-S spine fractures (18%) and ПЅ 50 years - concussion (22%) and upper extremity fractures (16%). Comparing the 2 groups we found: statistically significant greater percentages in the older population for rib fractures 23% vs. 5% (p П 0.00001) and spinal fractures 18% vs. 6% (pП0.004). There were no statistically significant differences for other injuries between the 2 age groups. Conclusions: We found different patterns of injuries associated with equestrian accidents for older and younger patients. There were a statistically significant greater percentage of rib and spinal fractures for ages Пѕ 50. Older horseback riders may benefit from steps to prevent osteoporosis and by using chest protector vests. 298 Admission Fibrin Degradation Product Level Predicts the Need for Massive Transfusion and Mortality in Adult Blunt Trauma Patients Maekawa K, Hirayama S, Uemura S, Nara S, Mori K, Asai Y/Sapporo Medical University, Sapporo, Japan Study Objectives: When a large volume of coagulum generates in body cavity after blunt trauma, secondary fibrinolysis occurs and the serum level of fibrin degradation product (FDP) elevates immediately. Acute trauma coagulopathy associated with massive transfusion (MT) and mortality is characterized by anticoagulation and hyperfibrinolysis. On the hypothesis the admission FDP level correlates with the volume of coagulum and hyperfibrinolysis, we evaluated whether the admission FDP level is predictive of the need for MT and mortality in adult blunt trauma patients. Annals of Emergency Medicine S93 Research Forum Abstracts Methods: A retrospective study was done on blunt trauma patients Пѕ/П18 years old, referred to a single tertiary care center at the university hospital over a 2-year period. Baseline demographic data (age, sex), physiological variables on admission (respiratory rate (RR), systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score), hematological variables on admission (hemoglobin (Hgb), platelet counts (Plt), fibrinogen (Fbg), antithrombin (AT), FDP), Revised Trauma Score (RTS), Injury Severity Score (ISS), time interval from injury to ED were collected. These hematological variables were examined in relation to the need for MT and mortality. MT was defined as transfusion volume Пѕ/П10 units packed red blood cells in 24 hours of hospitalization. Multiple logistic regression analysis were used to determine level of significance. Receiver-operator characteristic (ROC) curve analysis was used to evaluate predictive factors. Results: From 1/06-12/07, 157 eligible patients were admitted to the ICU after injury. Multiple logistic regression to control for the effect of possible confounding variable (age, sex, RR, systolic BP, GCS score, RTS, ISS, time interval) found FDP to be an independent predictor of the need of MT (adjusted odds ratio 1.01, 95%CI 1.01-1.02). ROC analysis showed an area under the curve of 0.76 (95%CI 0.67 0.84) and identified FDP value Пѕ106 вђ®g/dL as an optimal cut-off point, with a negative predictive value of 88%. A similar multiple logistic analysis found FDP to be an independent predictor of mortality (adjusted odds ratio 1.02, 95%CI 1.01-1.03). ROC analysis showed an area under the curve of 0.84 (95%CI 0.77 - 0.92) and identified FDP value Пѕ89 вђ®g/dL as an optimal cut-off point, with a negative predictive value of 93%. Conclusion: An admission FDP level is predictive of the need for MT and mortality in adult blunt trauma patients. Because it is easily obtainable, it may become a preferable and practical marker for early identifying severely injured patients likely to require MT. 299 Can Coagulation Markers on Arrival Predict Neurological Outcome in Patients With Traumatic Brain Injury? Shimizu T, Takahashi I, Morishita Y, Kamoshida H, Onishi S, Naito Y, Oshiro A, Henzan N, Mizuno H, Ozaki Y/Teine Keijinkai Hospital, Sapporo, Japan Study Objectives: Several studies have suggested a correlation between neurological outcome after traumatic brain injury and coagulation test results at initial evaluation. There is, however, presently no test established for clinical use. This study is a retrospective observational study designed to identify commonly used diagnostic tests that can help predict neurological outcomes of patients with traumatic brain injury. Methods: 183 patients (126 men and 57 women; mean age 60 years, range 0-94) with an Abbreviated Injury Score (AIS) Пѕ or П 3 in the head and AIS score ПЅ 3 elsewhere in the body were included in the study. We reviewed the international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen (Fib), fibrinogen degradation products (FDP), and platelet count (Plt) of all subjects. Neurological outcome was assessed by using the Pittsburgh Cerebral Performance Category (CPC) score. We defined CPC 1-2 as the favorable outcome group and CPC 3-5 as the poor outcome group. INR, aPTT, Fib, FDP, and Plt were compared across the respective groups. Statistical significance was accepted at pПЅ0.05. Results: 116 of 183 patients (63.4%) were discharged with favorable neurological outcome. INR, aPTT, and FDP were significantly higher and Plt was significantly lower in patients in the poor outcome group as determined by the Mann-Whitney U test. Multiple logistic regression and ROC curves of each serum marker revealed FDP to be most statistically significant for prediction of poor neurologic outcome. Using an FDP cutoff value of 80mcg/ml, the sensitivity and specificity were 53% and 86% respectively and the positive likelihood ratio was 3.8. Conclusion: Of the coagulation markers we measured, FDP demonstrated the most statistically significant correlation with poor neurological outcome in traumatic brain injury patients. The cutoff of FDP should be 80mcg/ml as this has a reasonably good specificity of 86%. A prospective cohort study with larger sample size could validate and warrant the usefulness of this diagnostic test. 300 Fishing-Related Infections in the United States Krieg C, Samlan SR, Chan SB/Resurrection Medical Center, Chicago, IL these type of injuries in the literature and almost no studies reviewing subsequent post-injury infections or use of prophylactic antibiotics. The objective of this study is to provide evidence of infections associated with puncture wounds, lacerations, or foreign body from fish or fishhooks. Methods: The National Electronic Injury Surveillance System (NEISS) was queried for all fishing-related injuries between 2002 and 2006. Data abstracted include age, sex, type and location of injuries, whether related to fish hooks or other fish wounds. All cases were reviewed for evidence of infections related to the fishing injuries. Results: There were 6661 cases reported over five years, 70.0% were caused by fish hooks, 2.5% caused by fish bites, and 27.5% other injuries related to fishing. There were 38/4662 (0.8%) infection associated with fish hooks and32/165(19.4%) infections associated with fish wounds. 70.0% of the infections involved the hand or fingers. Conclusion: The incidence of infections related to fishhooks is less than 1% while the incidence of infections related to fish wounds is much higher. We believe that by demonstrating this low risk of infection, we offer evidence that no prophylactic antibiotics are required in fishhook injuries. We also show that the rate of infection by fish wound injuries is higher and it would be advantageous to consider the administration of prophylactic antibiotics involving fish wound injuries. 301 The Effect of the Repeal of the Pennsylvania Helmet Law on the Severity of Head and Neck Injuries Sustained in Motorcycle Accidents Mersky A, Eberhardt M, Overfield P, Melanson S, Stoltzfus J, Prestosh J/St. LukeвЂ™s Hospital, Bethelehem, PA Study Objectives: Previous studies have shown helmets to prevent brain injuries in motorcycle crashes. Although not substantiated, opponents to helmet laws have cited increased risk of neck injuries while wearing helmets as one reason to repeal helmet laws. In September 2003 Pennsylvania weakened its motorcycle helmet law, requiring only inexperienced riders and those under the age of 21 to wear helmets. We analyzed data to determine if fatalities as well as head and neck injuries have been affected by the change to this law. Methods: Utilizing data obtained from the Pennsylvania Trauma Systems Foundation State Registry (PTSF) and the Pennsylvania Department of Transportation (PenDOT), we retrospectively analyzed fatalities, head and neck injuries caused by motorcycle crashes. We compared data from the period prior to the weakening of the law (August 2000 to August 2003) (PRE) and immediately after the change was enacted (October 2003 to October 2006) (POST). In addition in the POST period, we analyzed the affects of the change in the helmet law on the presence of severe head injuries in MCAs. Chi square and Bonferroni statistical analysis were used to analyze the data. Results: In the POST period, 1465 more individuals were admitted to trauma centers than during the PRE period (4229 vs 2764) as a result of MCA. The percentage of theses patients that were known to be wearing helmets decreased from 89.3% PRE (2309/2585) to 57.2% POST (2295/4014) pПЅ .0001. The absolute number of fatalities due to motorcycle crashes both at the scene of the accident (451 PRE vs 537 POST) and in trauma centers (152 PRE vs 210 POST) increased in the POST period but the percentage of deaths did not change (PRE 4% (451/10,731), 5.5% (152/2764) vs POST 4% (537/12,955), 5% (210/4229)) (p П .83, pП .33). Of the individuals who died in the POST period, the percentage of deaths that occurred in the unhelmeted (UH)patients was greater than helmeted (H) patients ( H 4.4% 101/2295 vs UH 6% 103/1719; pП .02). Serious head injuries, defined as AIS scores 3 to 6, occurred more frequently in the POST period than in the PRE (PRE 21% 581/2764 vs POST 25.5% 1080/4229) (pПЅ .0001) and within the POST period UH patients were more likely to experience a serious head injury than H patients (H 18.3% 420/2295 vs. UH 36.4% 625/1719). In addition, the number of patients who sustained serious neck injuries, defined as fractures of C1 - C7, were greater in the POST period (PRE 2.7% 75/2764 vs POST 4% 171/4229; pП.003). Conclusion: While the use of a helmet does not appear to decrease the percentage of deaths from motorcycle accidents, it does decrease the number of serious head injuries. This data also supports the use of helmets to prevent neck injuries although further study is needed. 302 Characteristics of Fragment Wounds in a Combat Setting Givens ML/Carl R Darnall Army Medical Center, Fort Hood, TX Study Objectives: Fishing injuries are a common injury seen everyday in clinics and emergency departments around the world. These injuries consist of lacerations, puncture wounds, and retained foreign bodies. There is very limited reporting of S94 Annals of Emergency Medicine Study Objectives: Fragment wounds are a common injury in combat settings and many of these fragments are left in place. There is currently no literature which Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts describes the outcomes of patients with retained fragments. The purpose of this study was to describe the outcomes of combat zone inflicted penetrating wounds with retained fragments after treatment in a combat support hospital. Methods: An institutional review board-approved prospective observational study was performed involving United States Military patients who presented to the combat support hospital in Baghdad, Iraq with retained fragments from combat injury. Unstable patients or patients with emergent injuries requiring operative intervention were excluded. Patients were enrolled in the emergency department and one week and one month follow-up was obtained by phone or email. Results: Seventy-four patients were enrolled (ages 19-48, 71 men and 3 women). Forty-nine fragment injuries were due to improvised explosive devices (IEDs), 9 from mortars, 7 from gunshot wounds (GSWs), 4 from rockets, 2 from grenades and 1 unidentified. Twenty-eight patients had fragments less than 0.5cm, 21 with fragments 0.5-1.0cm and 17 with fragments Пѕ1.0cm (8 not described). Sixty-seven patients received antibiotics in the ED. Of the 7 patients who did not receive antibiotics in the ED, only 2 did not receive antibiotics on admission or prescribed at discharge. The average pain score at presentation was 8. One-week follow-up was obtained on 49/74 patients (66%). All but one patient saw a health care provider for follow-up. Twenty-seven (55%) patients described redness at the injury site one week after injury, 4 reported fever, and 20 patients (40%) described pus or discharge from the wound. The average pain score at one week was 5. Thirty-five (71%) patients had limitations on their activity at one week. One-month follow-up was obtained on 37/ 74 (50%) patients. The average pain score at one month was 3. Nineteen of the 37 (51%) patients described activity limitation at one month post injury. Eighteen of the 37 patient followed up at one month felt their injury was cosmetically disfiguring. One patient had his fragment removed between the one-week and one-month followup. Conclusion: This study found that pain, redness and wound discharge are common one week post injury. For many patients pain may persist and activity limitation may be present even at 6 months post injury. While the data was not robust enough to determine predictors of infections, ongoing pain, or function loss; this study offers some insight into what the anticipated clinical course for fragment wounds may involve. Further research needs to be done to determine predictors of outcomes and further define the proper care of patients with retained fragments. 303 An Analysis of Emergency Department Revisit Rates Based on Patient Satisfaction Scores Yang A, Liu J, Merlin M/UMDNJ-Robert Wood Johnson, New Brunswick, NJ; UMDNJ-CINJ, New Brunswick, NJ Study Objectives: The objective is to determine correlation between patient satisfaction scores and return visit rates to the emergency department (ED). The null hypothesis is: patients who have higher satisfaction scores will have higher return visit rates. Methods: The study was conducted at a regional emergency department that served and urban and suburban population. The study hospital was one of five hospitals in a tem mile radius. All patients that were discharged from the emergency department were sent a questionnaire about their emergency department experience within 2 days of their visit. The patients were asked to score their satisfaction on a scale of one to five with: ED environment, Nurses, Doctors, Family issues, Ancillary staff, Clerical staff, Personal issues, and overall ED experience. All patients 21 years and older who were treated in the ED and discharged were included. Patients that were admitted to the hospital and patients younger than 21 were excluded. The ED re-visits of patients who had completed the surveys were collected for a period of one year following the initial visit. Results: 313 surveys were collected during the study period. 104 of these patients returned to the ED over the following year with 194 individual re-visits. A test for goodness of fit yielded a deviance value/DF of 2.0835. A Poisson regression model was used for analysis. Results of the data analysis are shown in the table. Conclusion: Almost none of the parameters measured in the patient satisfaction survey had any statistically significant correlation with ED patient re-visits. Only the personal issues category had a statistically significant correlation with ED revisits. Our findings call into question the validity of improving patient satisfaction as a means to increase return visits and revenue. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 304 The Use of Scripting at Triage and Its Impact on Elopements Handel DA, Daya M, York J, Larson E, McConnell KJ/Oregon Health & Science University, Portland, OR Study Objectives: Prior studies have demonstrated that scripting that lets the patient know their expected waiting time at triage have improved patient satisfaction, and elopements (also known as left without being seen) have been proposed as one possible measure of patient satisfaction. The purpose of this study is to measure the impact of scripting language at triage on the rates of elopements, controlling for patient volume and other potential confounding variables. Methods: All patients 21 years of age and older who presented to the triage window in the ED waiting room (not by ambulance), waited greater than 5 minutes, and were not immediately brought back were included in the analysis. The study setting is an academic, level 1 trauma center with approximately 40,000 visits a year. This was a pre and post intervention study with, the same three-month period (November-January) used for comparison purposes. The triage nurses were trained to notify patients of the wait time. The wait time provided was the longest time for a patient waiting at that moment in the waiting room. A button was created in the electronic health record to track that scripting was provided after implementation of the plan. For those patients who did not have the button clicked, it was assumed they had not received the information. After the implementation of triage scripting, a onemonth washout period was excluded (October 2008) allowing comparison of November 2007-January 2008 (pre-scripting period), with November 2008-January 2009 (post scripting period). A multiple logistic regression model was used to control for confounding factors such as daily patient volume, patient age, length of stay (LOS) for admitted and discharged patients, weekend vs. weekday visits, and triage acuity using the Emergency Severity Index scale. Results: 7,201 patients were included in this analysis. 2.5% of patients who received the scripting eloped (45/1,782), compared to 4.7% (266/5,612) who did not. Based on univariate analysis, this difference was statistically significant (pП0.000). However, the use of scripting was not found to have a significant impact on whether or not patients eloped prior to evaluation (pП-.375) when adjusting for confounding factors in the regression model. Significant confounders in the model include the daily census, patient age, triage acuity, LOS for admitted and discharged patients, and weekday visits. Conclusion: The use of triage scripting was not found to significantly reduce the rates of elopement in patients stable enough to be placed in the ED waiting room. Further longitudinal data comparison are warranted to see if any impact on elopement rates can be detected and to evaluate impact on other outcome measures such as patient satisfaction scores. 305 Reliability of Emergency Severity Index Version 4 Choi M, Kim J, Choi H, Lee J, Shin S, Kim D, Ro Y/Seoul National University Hospital, Seoul, Republic of Korea Study Objectives: The aim of this study is to test the reliability of Emergency Severity Index 4 (ESI-4) in different setting, Korea from North America. We also tried to evaluate the effect of implementing the ESI-4 and its effect on self-efficacy. Methods: This study was carried out from August 1, 2008 to August 31, 2008 in a single regional emergency center (level 1 center). Target patients for the validation were those who visited the center with age of 15 years or older. The study for effect of ESI-4 had been done for 5 days from January 12, 2009. The collection of the ESI-4 data was done by triage nurses. These nurses had finished the standardized course and had gone through multiple conferences with emergency physicians about clinical cases regarding the ESI-4. The convenience sampling method Annals of Emergency Medicine S95 Research Forum Abstracts was used to select participants. Four research nurses and one third year resident scored the ESI-4 to the selected patients as references, independently. We calculated the weighted kappa between the triage nurses and research nurses, and between triage nurses and the emergency resident to evaluate the consistency of the ESI-4. We also measured internal consistency of the ESI according to their clinical experience. We took a survey, which consisted of 13 questions for implementation effect and 5 questions for self-efficacy. The results of the survey were analyzed by three groups according to their clinical experience (junior group versus senior group). Results: Total of 2,982 patients visited the emergency center during the study period. We enrolled 478 (16.2%) patients to evaluate the ESI-4 between triage nurses and research nurses, and another 442 (14.8%) patients for triage nurses and the emergency resident. The weighted kappa was 0.49 (0.39-0.55), and 0.47 (0.39-0.55), respectively. Triage nurses were divided into two groups by their clinical experience (3 years), the weighted kappa was 0.47 (0.35-0.58) for the junior group, and 0.50 (0.410.59) for the senior group. The analysis of survey showed relatively high scores on вЂњFaster intervention for high-priority patients,вЂќ and вЂњHigher accuracy of triageвЂќ after implementing the ESI4. The longer clinical experience they had, the higher self-efficacy was scored. Conclusion: For validating the ESI-4, moderate level of reliability was measured among nurses and between nurses and an emergency physician in a Korean single ED. Analysis of the effect of the ESI-4 showed similar effects for each group, but higher self-efficacy for more experience group. 306 Video Technologies in Emergency Health Research in Assessing Quality of Care: A Study of Trauma Resuscitation Milestones Sen A, Hu P, Mackenzie C, Xiao Y, Dutton R/Henry Ford Hospital, Detroit, MI; R Adams Cowley Shock Trauma Center, Baltimore, MD Study Objective: Studies have demonstrated that trauma resuscitation times are predictive of patient outcome and increased delays were detrimental to patient care. Use of video technologies in emergency research is a novel way of identifying system roadblocks and ensuring quality of care and efficiency. We assessed resuscitation times, milestones and factors which influence golden hour trauma patient care in the emergency department (ED). Methods: Following institutional review board-approval, video-recorded images were retrospectively analysed over a 4-week period, in 145 patients presenting with major trauma. Time to CT scan, conventional x-rays, Lodox Statscan, endotracheal intubation (ETI), insertion of chest tubes, central venous access was measured from time of patient admission. Multivariate analysis was performed to account for the influence of diurnal and on-call teams, patient census, Injury Severity Score (ISS) and the effect of patient GCS on time to resuscitation milestones. Statistical analysis was conducted using JMP SAS (SAS Institute, Cary, NC, USA). Results: Our video analysis of trauma resuscitation showed 100% compliance with time to CT within 2 hrs in patients with GCSПЅП13. Reduced GCS and high ISS were strongly predictive of time to CT and ETI in a multivariate regression analysis (pПЅ0.001). Use of Lodox Imaging, low ED census was associated with significantly reduced resuscitation times (pПЅ0.05). Conclusions: Video recording has the advantages of providing accurate times to interventions that are not hindered by poor documentation or the memory of those involved. It can be a useful tool in resuscitation quality evaluation and identify variances in process flow helping in addressing inefficiencies in emergency care. 307 Customer Service and Communication Training Initiative for Emergency Physicians Improves Patient Satisfaction Despite Crowding in the Emergency Department Katz GR, Schwaab J, Pestrue J, Moseley MG, Caterino J/The Ohio State University, Columbus, OH Study Objectives: To evaluate the effect of a physician-oriented customer service and communication training program on emergency department (ED) patient satisfaction in a crowded ED. Methods: A retrospective cohort study was conducted at this university ED with an emergency medicine residency program. In preparation, three faculty physicians attended a health care-oriented customer service training program offered by The Disney Institute. Using this knowledge base and incorporating industry best practices, these physicians developed a customer service training program for S96 Annals of Emergency Medicine widespread implementation in an academic ED. All faculty and resident physicians either participated in the program during allotted conference periods or watched a video of the program, resulting in 4 hours of customer service lectures annually. The curriculum focused on the use of communication tools, such as scripted responses and personalized provider information cards, and the importance of consistent caregiver messages with respect to patient care plan and anticipated waiting and testing times. An outside speaker was recruited to increase the perception of credibility and value of customer service training; however, the curriculum was directed by previously trained faculty physicians. The effectiveness of this program was assessed by evaluating trends in patient satisfaction scores post-intervention. Results: Sixty-six resident and faculty physicians participated in the customer service training program in 2007 and again in 2008. During the study period the annual ED census exceeded 58,000 visits, hours of diversion averaged over 740 per year, and the вЂњLeft Without Being SeenвЂќ rate was 4.7%. Patient satisfaction was measured using a one-to-ten scale in a variety of domains. Analysis of 2,972 patient satisfaction surveys collected before and after the intervention revealed significant improvement in patient perceptions. Overall satisfaction with the ED experience improved from 58.4% of patients rating their experience a 9 or 10 in the fiscal year ending June 30th 2006 to 65.5% for the year ending June 30th, 2008 (pП.001). The primary driver of satisfaction was communication, accounting for 29.7% of the change in overall satisfaction. Additionally, care provided by physicians accounted for 23.6%. Post-intervention satisfaction scores also showed significant improvement in вЂњsatisfaction with physicianвЂќ (69.6% vs. 74.7%, pП.002), вЂњsatisfaction with communicationвЂќ (64.9% vs. 69.7%, pП.005), and вЂњphysician courtesy and respectвЂќ (75.8% vs. 79.0%, pП.023). Conclusion: Despite ED crowding, which is purported to be a service dissatisfier, physicians can improve patient satisfaction and impact the perception of the care they provide with customer service-oriented communication tools. 308 A Lean-Based Triage Redesign Process Improves Door-to-Room Times and Decreases Number of Patients at Triage Farley H, Hines D, Ross E, Massucci JL, Alders V, Reed J, Sweeney T, Jasani N, Reese CL/Christiana Care Health Systems, Newark, DE Study Objective: To determine if a Lean-based triage redesign process improves the mean door-to-room time of Emergency Severity Index (ESI) 4 and 5 patients and decreases the mean number of these patients waiting at triage. Methods: A prospective analytic cohort study of ESI 4 and 5 patients presenting to an academic emergency department (ED) with an annual volume Пѕ100,000 was conducted in 2008. All ESI 4 and 5 patients presenting to the ED during the study period were included. The mean door to room time was calculated for each of the following time periods: 2300-0700, 0700-1500, and 1500-2300. The number of ESI 4 and 5 patients waiting to be seen at triage was collected on an hourly basis by an electronic patient tracking system and means were calculated for each of the same time periods. Utilizing Lean principles to reduce non-value-added activities in patient care, a triage redesign process was progressively implemented from May-August, 2008. The mean door-to-room time and the mean number of ESI 4 and 5 patients at triage were compared before (1/1/08-4/30/08) and after (9/1/08-12/31/08) the intervention using StudentвЂ™s t-test, with a p-value of Х… 0.05 considered significant. Results: 28,446 pre-intervention patient visits and 32,099 post-intervention patient visits were analyzed. There was a significant improvement in door-to-room time overall (64.2 vs. 43.5 min, pПЅ0.001), from 2300-0700 (72.6 vs. 41.8 min, pПЅ0.001), 0700-1500 (48.2 vs. 38.4 min, pПЅ0.001), and 1500-2300 (77.4 vs. 50 min, pПЅ0.001). There was also a significant decrease in the mean number of ESI 4 and 5 patients waiting at triage overall (4.2 vs. 2.9, pПЅ0.001), from 2300-0700 (3.9 vs 2.6, pПЅ0.001), and from 1500-2300 (6.7 vs. 4.9, pПЅ0.001). There was no significant difference observed from 0700-1500 (2.6 vs. 2.2, pП0.179). Conclusion: Implementation of a Lean-based triage redesign effort resulted in a significant decrease in the mean door-to-room time, as well as in the mean number of ESI 4 and 5 patients waiting at triage. 309 Validation of Modified Emergency Severity Index Version 4 Lee J, Choi H, Shin S, Kim D, Ro Y/Seoul National University Hospital, Seoul, Republic of Korea Study Objectives: Emergency Severity Index (ESI) has been used widely in US, which categorize the emergency patients according to acuity and need for resources to Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts manage them. To make successful triage, trained providers should decide on the basis of their experience. To increase inter-rater reliability, we modified ESI and tested its validity. Methods: This study was done in an urban teaching hospital emergency department (ED), which has about 45000 annual visit. Triage nurses were trained and implemented from July to September in 2008. Data were collected from electronic medical record, which include all components to be needed for ESI and ED results from November to December in 2008 for more than 15 years old patients. To compare with original ESI, we modified it as followings; M1: Level three with mildly abnormal vital sign (HRПѕ100, RRПѕ20) is automatically categorized as level two. M2: Level three with severely abnormal vital sign (HRПЅП40, HRПѕП120, RRПЅП10, RRПѕП25) is automatically categorized as level two. M3: Level three with abnormal vital sign (HRПЅП40, HRПѕП120, RRПЅП10, RRПѕП25) is automatically categorized as level 2. If number of expected resources is over than three, one to two, and zero, the cases are categorized as level three, level two and level one, respectively. Validity was compared using the area under the receiver operating characteristic curve (AUC) and 95% confidence interval (95% CI) to predict the outcome, which defined as hospital death, intensive care (admission to intensive care unit or hospital death). Results: Total number of patients was 5,478 (male 51.4%. mean age 53.3П® 18.2). Of these, mortality was 1.6%. The distribution by original ESI was level one (2.70%), level two (13.16%), level three (74.66%), level four (8.63%), and level five (0.84%). In M1, M2, and M3, proportions were changed to 32.69%, 15.20%, 15.20% for level two, 55.11%, 72.21, 54.78% for level three, 8.65%, 8.65%, 26.58% for level four, respectively. The AUCs of original ESI, M1, M2, and M3 for mortality was 0.822 (95% CI, 0.772Пі0.872), 0.848 (95% CI, 0.808Пі0.889), 0.829 (95% CI, 0.779Пі0.879), and 0.845 (95% CI, 0.801Пі0.889), respectively. The AUCs of original ESI, M1, M2, and M3 for intensive care was 0.830 (95% CI, 0.806Пі0.854), 0.827 (95% CI, 0.794Пі0.840), 0.817 (95% CI, 0.803Пі0.851), and 0.830 (95% CI, 0.806Пі0.854), respectively. There was no significant difference among original ESI and modified ESIs. Conclusion: More objective decisionmaking tools, modified ESIs showed very similar performance to predict outcomes compared to original ESI. 310 Impact of Mandated Nurse-Patient Ratios on Time to Antibiotic Administration in the Emergency Department Chan TC, Vilke GM, Killeen JP, Guss DA, Marshall J, Edward CM/University of California, San Diego, San Diego, CA Study Objectives: Mandated nurse-patient ratios (NPRs) are gaining attention as a means of improving the quality of health care. The impact of NPRs in the emergency department (ED) where patient acuity and census fluctuate are unclear. Our study objective was to assess the effect of mandated NPRs on ED patient care. Our null hypothesis was that NPRs would have no impact on timeliness of patient care, specifically time to antibiotic administration for pneumonia patients. Methods: Design: Multi-center prospective observational study on the effects of mandated NPRs. Setting: Two EDs, an academic, urban center and suburban, community hospital, with combined census 61,000. Participants: All patients seen in the EDs for a 12-month period (January 2008 through December 2008) following implementation of State-mandated NPRs. We developed an automated electronic tracking system to track changing patient acuity and staffing, and to calculate realtime NPRs every 10 minutes. вЂњOut of ratioвЂќ (OOR) was defined as a patient whose ED nurse had patient responsibilities greater than current State-mandated NPRs for more than 20 minutes of care time. Patient data collected included real-time patient acuity, diagnosis, length of stay, NPR status of the nurse, and physician order-toadministration time for antibiotics. ED data included daily census, admissions and overall NPR compliance. Log-linear regression models were used to assess the effect of NPR status on medication administration time after controlling for ED census, admission rate and acuity. Beta coefficients and associated with 95% confidence intervals [CI] are reported. Results: Overall, during the study period in both EDs, 92.5% of patients were cared for by ED staff while вЂњIn-RatioвЂќ (IR) and 7.5% were cared for when staff was OOR. More patients had nurse staff OOR when admitted to an inpatient service (11.1%) compared to discharged (6.6%). A total of 5,318 (9.3%) patients received antibiotics during their ED stay, of which 5.8% were diagnosed with pneumonia. Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Medication administration time (physician order-to-administration) was 24 minutes (IQRП11, 49) for all patients who received antibiotics. Time to antibiotic administration was 24 minutes (IQRП11, 49) when nurse staff was IR, and 29 minutes (IQRП 15, 60) when OOR. For patients diagnosed with pneumonia, time to antibiotics was 28 minutes (IQRП14, 54) overall, 27.5 minutes (IQRП14, 53) when IR, and 30 minutes (IQRП15, 71) when OOR. Using log-linear regression, after controlling for patient acuity at time of triage, hospital, and census at time of ED admission, there was no significant difference in terms of time to antibiotics overall or for patients diagnosed with pneumonia (8.2%, [CI ПЄ4.9 to 21.3%], pП0.221 overall and ПЄ16.0%, [CI ПЄ66.2 to 34.2%], pП0.531). Conclusion: In this study, NPR status did not significantly impact timeliness of antibiotic administration (order-to-administration time) for ED patients, including those treated for pneumonia. 311 Care Plan Program Reduces the Number of Visits for High-utilizing Psychiatric Patients in the Emergency Department Abello A, Brieger B, Ziebell C, Dear K, Milling Jr T, King B/University Medical Center at Brackenridge, Austin, TX Background: A small number of patients representing a significant demand on emergency department (ED) services present regularly for a variety of reasons, including psychiatric or behavioral complaints and lack of access to other services. The care plan program was created in 2001 as a database of ED high-utilizers and patients of concern, as identified by ED staff and reviewed and approved by program administrators. Care plans were generated and discussed with the patients and visual cues inform providers of care plan availability. This program has been implemented to improve their care and mitigate local ED strain. Study Objectives: To determine whether enrollment in the care plan program reduces the frequency of ED visits for high-utilizing psychiatric patients, whether patients utilized other appropriate avenues of psychiatric treatment in lieu of ED visits, and to identify which psychiatric conditions or demographic groups respond most favorably in terms of compliance and better treatment pattern outcomes. Methods: A list of medical record numbers was assembled by searching the program database and ED registration databases for adult patients initially enrolled between the dates of 11/1/06 and 10/31/07. Inclusion criteria were occurrence of a psychiatric ICD9 code in their medical record or a care plan code of 1 or 2, implying a serious psychiatric disorder causing harmful behavior. Additional data was acquired using an indigent care tracking database and electronic medical records. Variables collected from these sources were analyzed to identify changes before and after program enrollment. Results: Forty-eight patients were chosen for the cohort. The median age was 38.5 [19-63; SDП11.3], non-normal distribution. The cohort was 24% uninsured, and 23% had unpaid medical bills or related collection agency debt; 43.5% were enrolled in federal insurance coverage (Medicaid/Medicare), while only 13% of the cohort received coverage from the local county insurance program; and another 13% were privately insured. During the visit immediately prior to High Alert Program enrollment 25% of patients reported pain without injury on presentation, and an additional 11.4% presented specifically with chest pain, while only 20.5% were given a psychiatric chief complaint and an additional 7% presented with poisoning/ overdose. There was a significant reduction in the number of visits to the ED from the year prior to program enrollment to the year following enrollment (8.9 prior to 5.9 post, pПЅ0.05). There was also an increase in psychiatric hospital visits (2% prior to 25% post, pПЅ0.05). Patients with uninsured financial status were found to be more likely to respond to enrollment with a reduction in visits (pПЅ0.05). Conclusion: An alert program that identifies ED high-utilizers with psychiatric conditions and creates a care plan reduces visits and leads to more appropriate use of other resources. 312 Patient Satisfaction Is Associated With Clinical Quality and Hospital Outcomes in Acute Myocardial Infarction Glickman S, Boulding W, Manary M, Staelin R, Cairns C, Schulman K/University of North Carolina, Chapel Hill, NC; Duke University, Durham, NC Background: Many hospitals now routinely utilize patient satisfaction surveys instruments and data to assess the quality of their care. Despite their popularity, it is unclear whether patient satisfaction data provides any useful information about the Annals of Emergency Medicine S97 Research Forum Abstracts medically related quality of hospital care (ie, the performance of evidence-based treatments) or if it provides independent information on the overall quality of patient care above that obtained from the more accepted clinical performance measures. Study Objectives: To determine 1) whether patient satisfaction data is associated with the quality of cardiac care, as measured by adherence to evidence-based guidelines; and 2) whether patient satisfaction data is an independent predictor of a hospitalвЂ™s risk-adjusted inpatient mortality rate. Methods: Clinical processes of care and patient outcomes for patients with acute non-ST segment elevation myocardial infarction were obtained from the CRUSADE registry. Patient satisfaction data for cardiac admissions were obtained from patient surveys administered by a large corporate provider of satisfaction data. Pairwise Pearson product moment correlation coefficients and weighted least squares linear regression were used to evaluate the association of hospital patient satisfaction scores with clinical quality with hospital risk adjusted in-patient mortality rates. Results: Twenty-five hospitals (203 hospital quarterly observations), comprising 3,562 completed patient satisfaction surveys and clinical data on 6,411 patients in the CRUSADE registry were included in the analysis. Higher hospital-level patient satisfaction scores were positively correlated with adherence to evidence-based treatments for acute myocardial infarction. (RП0.20, pПЅ0.01 for a composite measure of 6 acute measures including aspirin and beta blocker at arrival, EKG within 10 minutes, heparin use, glycoprotein IIb/IIIa inhibitor use, and cardiac catheterization within 48 hours). Higher hospital-level satisfaction scores were associated with lower inpatient mortality (RП-0.19, pПЅ0.01). In multivariable analysis, after controlling for a hospitalвЂ™s clinical performance, patient satisfaction was an independent predictor of inpatient mortality (pП0.02). A 10% absolute increase in a hospitalвЂ™s average patient satisfaction score was associated with a 37.7% relative reduction in hospital risk-adjusted mortality. Conclusion: PatientsвЂ™ assessments of their care may provide important, independent information to consumers and hospital managers about the overall quality of emergency department and hospital care for acute myocardial infarction. 313 Effect of IV Deferoxamine on Burn Wound Progression Lim T, Lin F, Taira BR, Singer AJ, McClain SA, Clark RA/Stony Brook University, Stony Brook, NY Study Objectives: We have previously shown that pretreatment with curcumin reduces burn wound progression in a rat comb burn model. While the exact mechanism of curcumin is unknown, some have proposed that it acts as an iron chelator, reducing free oxygen radical generation that can lead to cell injury. Deferoxamine is an iron-chelating agent used in the treatment of acute iron intoxication and chronic iron overload. We hypothesized that treatment of burns with IV deferoxamine would reduce the conversion of the burn zone of stasis to full necrosis. Methods: Design - Randomized controlled experiment. Subjects - 15 SpragueDawley rats. Interventions - Two burns were created on each animalвЂ™s dorsum using a brass comb with four rectangular prongs preheated in boiling water and applied for 30 seconds resulting in four rectangular 10 x 20 mm full thickness burns separated by three 5 x 20 mm unburned interspaces (zone of ischemia). The interspaces represent the zone of stasis and left untreated most progress to necrosis over 1-3 days. Animals were randomized to receive one of three doses of deferoxamine or vehicle one hour and 24 hours after injury. Outcomes - Wounds were observed at 7 days after injury for visual evidence of necrosis in the unburned interspaces. Full thickness biopsies from the interspaces were evaluated with hematoxylin and eosin staining 7 days after injury for evidence of necrosis. Data Analysis - The percentage of interspaces that progressed to necrosis were compared with вЊѕ2 tests. Results: Thirty comb burns with 90 unburned interspaces were created and distributed between control, three doses of deferoxamine, and vehicle. The number of interspaces that progressed to full thickness necrosis were 27/33 (0.82) in the control group, 15/18 (0.83) in the low dose (10mg/kg), 12/18 (0.67) in the intermediate dose (30 mg/kg), and 13/18 (0.72) in the high dose (100mg/kg) treatment groups. When compared to controls, there was no significant difference in the percentage of interspaces undergoing necrosis in the low, intermediate, and high dose treatment groups respectively (pП 0.892, 0.228, 0.426). Conclusion: Treatment with IV deferoxamine has not reduced the percentage of unburned skin interspaces that progress to full necrosis in a rat comb burn model. S98 Annals of Emergency Medicine 314 Effect of IV Pentoxifylline on Burn Wound Progression Lim T, Taira BR, Singer AJ, Lin F, McClain SA, Clark RA/Stony Brook University, Stony Brook, NY Study Objectives: Cutaneous burns are dynamic injuries with a central zone of necrosis surrounded by a zone of ischemia. Progression of this ischemic zone to full necrosis over the days following injury is due in part to free oxygen radicals and impaired perfusion due to vasoconstriction and micro-thrombosis. Pentoxifylline (PTX) is synthetic xanthine derivative that has been shown to have anti-platelet and anticoagulant activities, decrease blood viscosity and inhibit thrombus formation. We hypothesized that treatment of burns with PTX would reduce the conversion of the ischemic zone to full necrosis. Methods: Design - Randomized controlled experiment. Subjects - Eighteen Sprague-Dawley rats. Interventions - Two burns were created on each animalвЂ™s dorsum using a brass comb with four rectangular prongs preheated in boiling water and applied for 30 seconds resulting in four rectangular 10 x 20 mm full thickness burns separated by three 5 x 20 mm unburned interspaces (zone of ischemia). Left untreated, most interspaces undergo necrosis within 1-3 days. Animals were randomized to receive one of three doses of PTX or vehicle 1 hour and 24 hours after injury. Outcomes - Wounds were observed at 7 days after injury for visual evidence of necrosis in the unburned interspaces. Full thickness biopsies from the interspaces were evaluated with hematoxylin and eosin staining 7 days after injury for evidence of necrosis. Data Analysis - The percentages of interspaces that progressed to necrosis were compared among groups with вЊѕ2 tests. Results: Thirty-six comb burns with 108 unburned interspaces were created and distributed between control, 3 doses of PTX and vehicle. The number of interspaces that progressed to full thickness necrosis was 27/33 (0.82) in the control group, 15/24 (0.63) in the low dose (4mg/kg), 21/24 (0.88) in the intermediate dose (8 mg/kg), and 22/24 (0.92) in the high dose (12mg/kg) treatment groups. When compared to controls, there were no significant differences in percentage necrosis in the low, intermediate and high dose treatment groups respectively (pП 0.102, 0.557, 0.291). Conclusion: Treatment with IV PTX does not reduce the percentage of unburned skin interspaces that progress to full necrosis in a rat comb burn model. 315 Catecholamines in Simulated Arrest Scenarios Lundin EJ, Dawes DM, Ho JD, Ryan FJ, Miner JR/University of Louisville, Louisville, KY; Hennepin County Medical Center, Minneapolis, MN; Lab Corp, Phoenix, AZ Study Objectives: The mechanisms of death in many arrest-related deaths are unclear. Law enforcement devices or tactics are often scrutinized in these unexplained cases. Unexplained arrest-related deaths have occurred after the use of electronic control devices. The primary concern has been direct cardiac arrhythmias induced by the delivered charge. Some authors have opined that the temporal relationship between electronic control device use and arrest-related deaths may be related to an acute stress cardiomyopathy induced by high circulating catecholamines, rather than an immediate electrically induced arrhythmia. In this study, we compared the stress response during several simulated use of force encounters. Methods: This was a prospective, observational study of human subjects. The subjects were a convenience sample of law enforcements officers receiving a training exposure or TASER employees. Subjects were randomized to one of five groups: 1) a 150 meter sprint, simulating flight from law enforcement officers, 2) 45 seconds of hitting and kicking a heavy bag, simulating physical combat with law enforcement officers, 3) a 10-second TASER X26 exposure, 4) a K-9 training exercise of approximately 30 seconds, and 5) an oleoresin capsicum (O.C.) exposure to the face. Subjects had an intravenous catheter placed by a physician or paramedic prior to the test. Baseline catecholamines (epinephrine, norepinephrine, dopamine, and total) were drawn at that time. Subjects then participated in their assigned task. Catecholamines were drawn immediately (within 30 seconds) after the task and every 2 minutes for 10 minutes. Results: Sixty subjects completed the testing. The median age was 35 (range 19 to 67), 85% were male, and the median body mass index was 27.8. For total catecholamines, there was no difference between the groups at baseline and the median pre-task was 474 (range 241 to 1348, IQR 296 to 824). Immediately after the task, the highest median was the heavy bag group at 3621 (range 1359 to 11669, IQR 3177 to 4891). The next highest Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts was the sprint group at 2070 (range 1466 to 3606, IQR 1794 to 2518). The K-9 group was next at 1503 (range 803 to 2001, IQR 1299 to 1642). The TASER group and O.C. groups were last at 1038 (range 653 to 1363, IQR 955 to 1089) and 1032 (range 545 to 1233, IQR 736 to 1085). These differences persisted for all time points. Fractionated results followed the same pattern. Conclusions: The comparison of use of force encounters demonstrated that the TASER X26 was one of the least activating of catecholamines while the simulated combat was one of the most activating of catecholamines. The authors recommend further study in this area to assist law enforcements officers in determining the best tactics and devices to utilize in arrest scenarios that have higher likelihood of being associated with an arrest-related death. 316 Visualization of Intraosseous Flow Paths by Angiography, Computed Tomography and Vital Dye Techniques De Lorenzo RA, Rubal BJ, Ward JA, Jordan BS, Hanson CE, Holbrook-Emmons VL, Medina JS/Brooke Army Medical Center, Fort Sam Houston, TX; Brooke Army Medical Center, San Antonio, TX Study Objective: Visualization of intraosseous flow paths by angiography, computed tomography and vital dye techniques. Background: Understanding the dynamic flow characteristics of intraosseous (IO) infusions is important to understanding the nature of drug and fluid delivery using this route. We employed angiography and selective ante mortem and post mortem contrast computed tomography (CT) to define IO venous conduits, late intramedullary flow phenomena, and extraosseous extravasation. Methods: Twenty-seven IO sites (NП36) (EZ-IO 9001 AD, Vidacare, San Antonio, TX) were established in 4 female swine (Sus scrofa, 39.6 П® 1.7 Kg) in the proximal tibia, distal femur, distal humerus, sternum, proximal ulna and proximal tibia under fluoroscopic guidance. The adequacy of IO needle placement was determined by withdrawal of medullary blood and/or infusion of normal saline. Following Пѕ 2 hours of hemodynamic recording from each IO site, IO flow was assessed by cine angiography at 30 frames per second (OEC, Medical Systems Inc, Salt Lake City, UT) using high flow Х†3ml/sec Х†150 psi, Mark V power injector, MedRAD, Pittsburgh, PA) or low flow (gravity flow at 55cm or slow hand infusion) contrast infusion (Iohexol, 300mg/ml, GE Health care, Princeton, NJ). CT angiography was performed in two animals antemortem and in two animals postmortem. 5-10cc of tissue marking dye (TMD-5, TBS, Durham, NC) was infused post mortem at IO sites for visualization of extravasations and medullary flow. Representative bone samples were demineralized with 17% HCL and longitudinally sectioned for direct correlate with angiography. Results: Adequate IO placement was achieved in 90% of attempts. Failures were identified by extraosseous extravasation of contrast agent. Evidence of local contrast infiltration of cancellous regions near the IO site was observed in all successfully placed IO needles. Low pressure contrast infusions revealed a web of venous channels that drained to a single nutrient foramen with needle placement within the diaphysis. However, IO placement near the metaphysis (nП3) or within epiphysis (nП1) revealed multiple outflow channels. The number of outflow foramen could not be determined at 4 sites. Retrograde medullary filling (flow away from nutrient foramen) was consistently observed with high contrast flow rates often with a late sudden expansion of venous channels. Antemortem and post mortem CT or vital dye infusion confirmed the presence retrograde venous perfusion within the IO compartment. Conclusions: In this animal model of an immature skeleton, observations of retrograde contrast flow within the intraosseous compartment suggest that nutrient foramen may offer significant resistance at high flow rates during intraosseous infusion. 317 A Manometric Method for Evaluating Flow Dynamics and Thrombus Burden of Intraosseous Devices: Theory and Application Rubal BJ, Ward JA, Jordan BS, Hanson CE, Medina JS, Holbrook-Emmons VL, De Lorenzo RA/Brooke Army Medical Center, Fort Sam Houston, TX Study Objective: It is well recognized that intraosseous (IO) devices provide the benefit of rapid vascular access in cases of trauma, hemorrhage and cardiopulmonary resuscitation when intravascular access cannot be achieved. In spite of the impact of a new generation of IO devices for out-of-hospital care and battlefield injuries, few methods are available for investigating IO perfusion dynamics. This study provides Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ the theory and applications for a novel method for assessing IO compartment flow dynamics and resistances that should prove useful for elucidating IO fluid- and pharmaco-dynamics and failures. Methods: A manometer is a fluid-filled tube used to directly measure compartment pressures by the height of a fluid column. When a saline-filled manometer is attached to an IO access port, the fluid in the manometer discharges until manometer pressure equals pressure within the marrow compartment. These changes in pressure were modeled by a three parameter exponential decay model (Pman П Po e-bt П© Pbone). Where Pman П the height of the manometer column during discharge into the IO compartment, Po П initial height of the manometer fluid column, b П decay constant, t П time in minutes, and Pbone П the height of manomometer column when equilibrated with pressures in the IO compartment. Because the manometer is of uniform diameter, changes in manometer height with time also represent calibrated fluid flow into the I/O compartment. The decay constant (b) may be used as an index of outflow resistance and outflow and inflow resistances can be calculated given central venous pressure and arterial pressure, respectively. In this study, manometer discharge pressures were recorded from the proximal tibia (EZ-IO 9001 AD, Vidacare, San Antonio, TX) using a 55cm x 2mm saline-filled manometer (Cardinal Health, Dublin, OH) from 4 female swine (Sus scrofa, 39.6 П® 1.7 Kg) under general anesthesia. Results: Under baseline conditions, aortic blood pressure was 83/52 mmHg (mean П 64 mmHg) and mean central venous pressure was 3 mmHg. An excellent fit (R2 П 0.999, PПЅ0.001) was noted with the three parameter model. In series of observations, the initial decay constant with saline discharge through the manometer was (bП 0.0008), following a 3cc saline flush IO flow improved (bП0.003). Further improvement was observed with a 3 cc heparin flush (b П 0.040), and with a heparin flush followed by the infusion of heparin saline through the manometer (b П 0.200). IO thrombus depressed the decay constant and increased IO outflow resistance. Conclusions: These data suggest that manometer discharge pressures may prove useful in assessing the flow dynamics of the IO compartment and in characterizing the time course of IO failures. Preliminary results at low infusion pressures (ПЅ55cm saline) followed by heparin infusion suggest that IO flow is influenced by the activation of the clotting cascade. Furthermore, results suggest that a heparin challenge following standard IO infusion protocols may prove useful for assessing intraosseous thrombus burden. 318 Fetuin Protects Mice Against Lethal Sepsis by Modulating Bacterial Endotoxin-Induced HMGB1 Release and Autophagy Wang H, Lam L, Li W, Ashok M, Zhu S, Ward MF, Li J, Yang H, Tracey K, Sama A/North Shore University Hospital, Manhasset, NY Background: The pathogenesis of sepsis is complex, but in part mediated by bacterial endotoxin, which stimulates macrophages to release early (eg, TNF, IL-1) and late (eg, HMGB1) pro-inflammatory mediators. Various inflammatory stimuli (eg, endotoxin, cytokines, and oxidative stress) similarly induce autophagy, a catabolic degradation process responsible for eliminating damaged cytoplasmic components during infection. A negative acute phase protein, fetuin (fetus protein in Greek), was recently characterized as a negative regulator of inflammation by opsonizing cationic anti-inflammatory molecules (eg, spermine). Study Objectives: To further elucidate the role of fetuin in lethal experimental sepsis. Methods: We examined its effects on endotoxin-induced HMGB1 release and autophagy in vitro, and determined whether administration of exogenous fetuin protects mice against lethal experimental sepsis (induced by cecal ligation and puncture, CLP) in vivo. Results: In vitro, fetuin (25 - 100 microgram/ml) effectively inhibited endotoxin-induced (100 ng/ml) HMGB1 release (by 60-90%), but enhanced endotoxin-induced autophagy in macrophage cultures. In vivo, intraperitoneal administration of fetuin (100 mg/kg, once daily, for three days) beginning at П© 24 hour post CLP, significantly increased animal survival rates from 40% (in saline vehicle group, N П 22 mice/ group) to 90% (in fetuin group, N П 22 mice/group, P ПЅ 0.05). Conclusion: Fetuin occupies a protective role in experimental sepsis by attenuating a late mediator of lethal systemic inflammation. Annals of Emergency Medicine S99 Research Forum Abstracts 319 Intracranial Constructive Interference of Low Frequency Ultrasound: An In-Vitro Pilot Study of Parameter Dependence Smith DA, Shaw III GJ/University of Cincinnati, Cincinnati, OH Study Objectives: The only FDA-approved therapy for acute ischemic stroke is the administration of recombinant tissue plasminogen activator (rt-PA). However, this therapy has a 6.4% rate of intracranial hemorrhage leading to interest in other adjunctive therapies such as ultrasound-enhanced thrombolysis (UET). UET was recently studied in several clinical trials, whereby ultrasound (US) is applied to the skull of the stroke patient exposing the clot to US while administering rt-PA therapy. In a trial of 2 MHz UET was shown to increase vessel recanalization in acute ischemic stroke patients, and there was a trend towards improved neurologic outcome at 3 months. A trial of 300 kHz UET resulted in a significant increase in the intracranial hemorrhage rate (Пі25%), with no improvement in patient outcome. Ultrasound is altered by the skull; the incident wave passes through the temporal bone and is attenuated. The pulse then travels to the opposite side, and reflects from the inner table adding to the incident pulse. This phenomenon is called вЂњconstructive interference,вЂќ and may lead to larger pressures than expected from attenuation alone. In a previous work, it was shown that 120 kHz ultrasound pressure amplitude is reduced by 23% by the temporal bone. It is desirable to minimize the acoustic pressure in UET-based therapies, as high amplitudes can cause substantial bioeffects; such bioeffects may explain the results of the 300 kHz UET study. In this work, we measure the acoustic field of 120 kHz ultrasound within a human skull for various ultrasound parameters. We hypothesized that constructive interference within the skull occurs at 120 kHz, resulting in larger pressure amplitudes than would be expected by attenuation alone by the temporal bone. Methods: A skull with the top removed was degassed and placed in a water tank filled with deionized distilled water. A custom-made 120 kHz transducer (Sonic Concepts, Bothell, WA), was used to generate the ultrasound, and oriented such that the ultrasound was incident normal to the temporal bone. A hydrophone (Reson TC4308) was placed in a computer-controlled 3 axis positioning system, and the acoustic pressure field mapped as a function of position within the skull, and in the вЂњfree fieldвЂќ configuration. The ultrasound parameters used were: a duty cycle (DC) of 50% or 80%, a pulse repetition frequency (PRF) of 1.6, 5.4 or 8 kHz, and a peak to peak pressure amplitude (Pp-p) of 0.23 or 0.33 MPa. Two measurements were made for each setting, and the primary parameter of interest was the ratio R of the largest Pp-p in the skull and the largest вЂњfree fieldвЂќ Pp-p for the same parameters. Data are presented as means with standard deviations. Results: Overall, the average R for all ultrasound treatments was 92П®4%; larger than the value of 77% that would result from temporal bone attenuation. Increasing PRF, which would increase constructive interference, increased R from 87П®2% to 94П®1% for PRF values of 1.6 and 8 kHz respectively. There was no obvious dependence of R on the remaining parameters. Conclusions: Constructive interference of 120 kHz ultrasound within the skull increases the pressure amplitude to a greater degree than would be predicted from attenuation of the signal through the temporal bone. The interaction of ultrasound and the skull is complex, and much work is needed to optimize UET-based therapies while minimizing potential bioeffects. 320 0.62) for brightness, and 4.57 (SD 0.73) for contrast. All residents reported a score of 5 for anatomical identification. Of 326 patients with USG guided CVC, 186 were eligible and incidence rate for post CVC local/systemic infection was 0%. 16 patients received post CVC prophylactic antibiotics. The average hospital infection rate post CVC was 7.56% over 2 years. The cost of equipment/CVC was $2.80 compared to existing estimates of $22 for prevalent techniques. Conclusion: The use of TegadermВ®, and povidone iodine antiseptic solution, is a cheap, reproducible, technique for maintaining asepsis during guided CVC. The adaptability of TegadermВ® to most probe types makes it potentially universally applicable for all USG guided procedures. Asepsis in Ultrasound-Guided Central Venous Access: A New Technique Subhan I, Jain A, Joshi M/Apollo Health City, Hyderabad, India; University of Rochester, Rochester, NY Study Objective: Development of a new cost-effective technique for maintaining asepsis during ultrasound (USG)-guided central venous catheterization (CVC). Methods: A 2-operator technique for aseptic precautions during USG-guided CVC was developed using sterile self-adhesive plastic (TegadermВ® 10x12 cm), and povidone iodine solution. To gauge coherence, a 5-point Likert scale questionnaire for comparing 4 pairs of images (each pair comprising images obtained using standard gel and the new technique) was answered by 30 emergency medicine residents. Following this patients undergoing USG-guided CVC with the new technique from Jun/07-May/08 were prospectively followed for 4 days. Patients ПЅ15 years, undergoing re-catheterization, receiving oral/intravenous antibiotics prior to procedure, with sepsis prior to CVC; catheter removal, death or discharge within 4 days, were excluded. Post-CVC infection criteria were pre-defined. Results: Mean Likert scores were 4.73 (SD 0.45) for image coherence, 4.9 (SD S100 Annals of Emergency Medicine 321 Out-of-Hospital Critical Care ProvidersвЂ™ Retention of Ultrasound Skills for Diagnosis of Pneumothoraces: A Nine-Month Follow-Up Lyon M, Walton P, Bloch A, Shiver SA/Medical College of Georgia, Augusta, GA Study Objectives: A prior study demonstrated that out-of-hospital critical care providers (PHCP) can accurately determine the presence or absence of sonographic sliding lung sign (SLS) for the diagnosis of pneumothorax (PTX). Our objective is to determine the PHCPвЂ™s accuracy to detect the SLS after 9 months of clinical usage. Methods: This was a blinded randomized observational trial assessing the ability Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts of PHCPs to identify SLS with ultrasound (US). After training in the use of US for the diagnosis of PTX, the PHCPs, were allowed to use the technique during aeromedical transport for patient care. After a 9-month period of clinical usage, the PHCPs were reevaluated using the same cadaveric model used in the prior training. No further instruction was given concerning the technique. Participants used a SonoSite 180 PLUS machine with a microconvex transducer in clinical practice and in evaluation of the cadaveric model. A fresh warmed cadaver was used as a model for demonstrating the presence or absence of the SLS. With ventilation and endotracheal intubation, the pleural movements of the cadaver result in the appearance of the SLS. With esophageal intubation, no pleural movement and no SLS are seen with ventilation. This model has been validated in other research projects. The cadavers were randomly intubated in the trachea (SLS) or in the esophagus (no SLS) as determined by a random number generator. The intubations were accomplished using direct laryngoscopy and fiber optic confirmation when necessary. Participants were excluded from the room during the intubations, and the cadaver was completely covered except for the chest area, thus blinding the participant to the location of intubation. Each trial consisted of evaluation of the right hemithorax for the presence or absence of the SLS. The participants were isolated from one another during the data collection process, with each participant evaluating the cadaver independently. No time limits were placed on the participants performing the US. Both M-mode and Doppler US were also available for use at the participantвЂ™s discretion. Results: Eight PHCP enrolled in the original study (4 RN and 4 CCEMT-P). With 16 trials displaying no SLS and 32 displaying SLS, the presence or absence of the SLS was correctly identified in 46 of the 48 trials for a sensitivity and specificity of 96.9% (95% CI, 89.6%, 99.1%) and 93.8% (93%, 79.3%) respectively. At the 9month follow-up study, 7 of the original PHCP were employed by the aeromedical service, and all agreed to participate in the study. All reported clinical usage of US for detection of SLS, but at a rate of less than 1 occurrence/month. The presence or absence of the SLS was correctly identified in all 56 trials with 28 trials each showing SLS or no SLS. The sensitivity was 100% (95% CI, 93.6%, 100%) and the specificity was 100% (95% CI, 93.6%, 100%). Conclusion: While complex diagnostic applications using US may not become part of the critical care transporterвЂ™s skills in the near future, this study shows that all members of a critical care transport team are able to retain this valuable skill with varying amounts of clinical use over a nine-month period. 322 Rate and Outcome of First Trimester Indeterminate Pelvic Ultrasounds in an Urban Emergency Department Phillips C, Bendeck K, Layman K, Milzman D, Antonis M/Washington Hospital Center, Washington, DC Study Objectives: To determine the rate of indeterminate pelvic ultrasounds on pregnant patients by emergency department (ED) providers in an urban ED and outcome if follow-up was done as instructed. Methods: Design: A retrospective review of a prospectively collected Azyxxi database (Smith and Feied; Redmond, Washington Microsoft). All patients found to have a positive urine pregnancy and/or a serum quantitative beta human chorionic gonadotropin (BHCG) level Пѕ5 between March 1, 2009 and March 31, 2009 and had a pelvic ultrasound by the emergency physician were included in the study. The charts were reviewed by the blinded (other data) author for record of ultrasound findings, BHCG level, discharge diagnosis, and any repeat visits to the ED. Ultrasound findings were defined as intrauterine pregnancy (IUP) seen (yolk sac П©/fetal pole seen in the uterus), fetal demise, molar pregnancy, definite ectopic or indeterminate (anything other than the above). Setting: A 901-bed, community teaching and Level I trauma hospital with 84,000 ED visits annually staffed by ED attendings and emergency medicine residents. Type of Participants: Consecutive ED patients with a positive urine or blood pregnancy test and an ultrasound performed by the ED provider. Results: Over the month included in the study, we found 103 pregnant patients with an ultrasound performed by the ED provider. Thirty-six of the ultrasounds (35%) were indeterminate. 19/36 (53%) had another study by an OB attending and eight of those patients had a definitive ultrasound including IUP (4), blighted ovum (2), fetal demise (1), and twin IUP (1). In the remaining 28 patients, definitive diagnosis was made on the first visit in 11 by clinical exam and history including spontaneous abortion (8) and ectopic pregnancy (3). There was also one patient admitted with pyelonephritis with no definitive ultrasound finding. Sixteen remaining patients were instructed to follow up in 48 hours in the ED. Of those, 7 never returned (43.8%). Nine patients did return Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ as instructed and were diagnosed with spontaneous abortion or fetal demise (4 or 44.4%), IUP (4 or 44.4%) or ectopic pregnancy (1 or 11.1%). Of note, a total of 4 of 36 (11.1%) patients with an indeterminate ultrasound by the ED provider were diagnosed with ectopic pregnancy on first or second visit. Conclusion: Ectopic pregnancy occurs in 2% of all pregnancies, and is the diagnosis to be excluded in the ED in a pregnant woman presenting with pain and/or bleeding. Most patients had definitive diagnosis by the ED ultrasound (65%) without OB involvement. Of the remaining patients with an ED ultrasound read as indeterminate, 55% were still able to be diagnosed in one visit by OB ultrasound or clinical exam. Ultimately 16 of 103 (15.5%) patients were told to follow up in the ED for repeat testing. Our patients did not follow those instructions 43.8% of the time, which points to a systemic problem. Of those who did follow the instructions, 1 of 9 or 11.1% had ectopic pregnancy diagnosed. Limitations of the study included small sample size as most patients had a definitive ultrasound or diagnosis clinically. Also, lacking the follow-up on almost half of patients points to a need for a better follow-up system and also further study on a prospective basis for clarification of what happens to patients with indeterminate ultrasound findings in the ED. 323 Technical and Interpretive Error Rates for the Focused Assessment With Sonography in Trauma Exam Montoya AM, Gaspari RJ, Mendoza M, Resop D/University of Massachusetts Medical School, Worcester, MA Background: Integrating ultrasound into clinical practice requires that emergency physicians possess an understanding of the images required to make an informed decision, the technical skills to acquire an interpretable image, and the cognitive skills necessary to interpret that image. Prior studies of ultrasound education have failed to separate these different cognitive processes. It has been unclear which types of errors are more common when learning emergency ultrasound, and therefore what areas should be emphasized in training. Methods: We conducted a retrospective analysis of prospectively collected data on Focused Assessment with Sonography for Trauma (FAST) exams performed by emergency medicine residents, fellows and attending physicians from June 2007 to August 2008. The data was collected at an urban, academic medical center with approximately 85,000 patient visits per year. All ultrasound studies performed in the emergency department were recorded on DVD and reviewed by one of three emergency physicians with extensive experience in emergency ultrasound. The acquired images were scored for overall technical quality and for the inclusion of all required views. Technique was graded using an 8-point scale of image quality with a score of 1 being regarded as uninterpretable and a score of 8 being technically perfect images with all required landmarks. Results: A total of 2962 FAST exams were performed during the course of this study. Of these studies, 9% were positive for the presence of free fluid. Interpretative error was observed in 192 (6%) cases. There were 62 (2%) studies mistakenly interpreted as negative by the physician performing the scan. The most frequently misinterpreted view was the right upper quadrant (RUQ), which accounted for 32% of the false negative readings. 130 (4%) studies were misinterpreted as being positive. Errors of interpretation decreased as the experience of the physician performing the scan increased. Physicians that had previously performed less than 25 FAST exams accounted for 16 (26%) false negative interpretative errors. Those with 26-50 prior exams also committed 16 errors (26%) while those with 51-75 and 76-100 prior exams committed 8 (13%) errors each. The most difficult view to acquire was the left upper quadrant (LUQ) with 632 (36%) individual technical errors. All four required quadrants were included 91% of the time with the supra-pubic (SP) view being omitted most frequently (14%). Physicians that performed more FAST exams committed fewer technical errors. Those that had completed 1-25 FAST exams committed 12% of the observed technical errors, 26-50 scans accounted for 9%, 51-75 scans 6%, and 76-100 4%. The most common technical score was a 6 (excellent technique on most views), which accounted for 25% of all the studies, followed by 20% with a score of 7 (excellent technique on all views), and 16% with 8 (perfect technique). Conclusion: Some views of the FAST exam are more difficult to acquire and interpret than others. The SP view was most commonly missed, the LUQ view was the most difficult to image and the RUQ view was the most difficult to interpret. As expected, the number of errors decreased as the number of scans performed by the physician increased. Education of the FAST exam should stress acquisition skills and interpretive skills independently. Annals of Emergency Medicine S101 Research Forum Abstracts 324 The Significance of the Wall Echo Shadow Triad on Ultrasonography in Emergency Department Patients Singla A, Gupta S, Garg N, Bharati A, Chun P/New York Hospital Queens, Flushing, NY Study Objective: The wall-echo-shadow (WES) triad results from visualization of the gallbladder wall, echoes from gallstones located immediately beneath the wall, and posterior acoustic shadows. It represents a large stone or multiple small stones filling the lumen of the gallbladder. The presence of a WES triad has been reported to suggest the diagnosis of cholecystitis, but this has yet to be proven. The objective of this study is to determine if the presence of a WES sign on gallbladder ultrasound (US) carries an increased risk of infection, obstruction, or other complications. Methods: This is a retrospective, cross-sectional, observational study. The subjects were a convenience sample of patients who received a right upper quadrant abdominal US in an urban, Level I emergency department (ED) with Пѕ100,000 annual visits from 1/ 2006 to 3/2009. The investigators were US trained registered diagnostic medical sonographer-eligible or registered diagnostic medical sonographer-certified emergency physicians. All 3,701 biliary US performed in the ED in that time period were reviewed by the investigators and all patients with the WES triad were identified and then confirmed by a registered diagnostic medical sonographer-certified emergency sonographer. A chart review was then performed. Lab values, vital signs, admission information, patient demographic information, intraoperative findings, pathology results, and revisits to the emergency department for symptoms related to biliary disease were documented for patients identified with the WES triad. Analysis was performed utilizing a logistical regression model. Results: Of 3, 701 US exams reviewed, 55 patients were identified to have the WES sign. Thirty-eight of the 55 patients with a WES sign were admitted for surgery. All of these admitted patients (100%) had abnormal intraoperative findings and pathology reports: including acute cholecystitis, chronic cholecystitis, significant adhesions or scarring secondary to ongoing inflammation, cystic duct stone, common bile duct stone and cholecystoduodenal fistula. Of the 17 discharged patients, 8 patients had a repeat visits due to biliary disease. Patients with the WES triad were more likely to be admitted based on age pП0.034, OR 1.030 (95% CI 1.002-1.058) and elevated white blood cell count pП0.018, OR 1.41 (95% CI 1.062-1.878). No other patient demographic, lab, vital sign, or ultrasound factors achieved significance. Conclusion: Ultrasound of the gallbladder is a common procedure performed in the emergency department. The significance of the WES triad has been hypothesized, but not yet proven. We found that a large percentage of patients with the WES triad on ultrasound have acute and chronic cholecystitis. Factors that support admission include age and elevated white cell count. This suggests that the presence of a WES sign may be a clinically significant finding for inpatient surgical evaluation and treatment of gallbladder infection. 325 Access to Immediate Bedside Ultrasound in the Emergency Department Talley B, Ginde A, Raja A, Sullivan A, Camargo Jr C/Denver Health Medical Center, Denver, CO; University of Colorado Denver School of Medicine, Aurora, CO; Brigham and WomanвЂ™s Hospital, Boston, MA; Massachusetts General Hospital, Boston, MA Study Objectives: The use of bedside emergency department (ED) ultrasound has become increasingly important for emergency physicians because of its ability to provide rapid and real-time information to assist in clinical decisionmaking and patient care, including trauma assessment and central line placement. In this study, we sought to evaluate differences in the availability of bedside ultrasound based on basic ED characteristics (eg, annual visit volume) and on physician staffing. Methods: We surveyed physician or nurse directors of all 74 EDs in the state of Colorado between January and April of 2009 and included supplemental data from the 2007 National Emergency Department Inventories (NEDI)-USA (www.emnet-usa.org). We assessed access to bedside ED ultrasound by the following question: вЂњIs bedside ultrasound available immediately in the ED?вЂќ ED characteristics included ED visit volume, location in an urban or rural area, hospital admission rate, total emergency physician full-time equivalents (FTEs), and proportion of emergency physicians who were board-prepared or board-certified (BC) by the American Board of Emergency Medicine, American Osteopathic Board of Emergency Medicine, or the American Board of Pediatrics. Data analysis used chi-square test to compare differences in access to bedside ED ultrasound by ED characteristics and physician staffing. Results: We received complete responses from 62 (84%) EDs. Immediate access to S102 Annals of Emergency Medicine bedside ultrasound was available in 42 (68%) EDs. The following ED characteristics were associated with greater reported access to bedside ultrasound: higher visit volume (100% for EDs with Х†3 patients per hour vs. 43% for ПЅ1 patient per hour; pПЅ0.001) and urban location (85% vs 46% for rural areas; pП0.001). The following ED staffing factors were associated with higher reported access to bedside ultrasound: greater number of emergency physicians (100% for EDs with Пѕ10 emergency physician FTEs vs 41% for EDs with 0-4 emergency physician FTEs; pПЅ0.001) and the percentage of board certified/board prepared emergency physicians (97% for EDs with Пѕ75% of emergency BP/BC physicians vs 37% for EDs with 0-24% emergency medicine BP/BC physicians; pПЅ0.001). Hospital admission rates were not significantly associated with access to ED bedside ultrasound. Conclusion: Immediate access to ED bedside ultrasound was available in 68% of Colorado EDs with significant differences according to basic ED characteristics and physician staffing. Smaller, rural EDs and those staffed by fewer emergency BP/BC physicians had less access to immediate ED bedside ultrasound. Given the proven utility of bedside ultrasound in the evaluation and treatment of ED patients, the observed differences in access should encourage emergency medicine educators and administrators to focus on the diffusion of bedside ultrasound into both small and rural EDs. 326 Ultrasound of the Inferior Vena Cava Can Assess Volume Status in Pediatric Patients Ayvazyan S, Dickman E, Likourezos A, Wu S, Hannan H, Fromm C, Marshall J/ Maimonides Medical Center, Brooklyn, NY Study Objective: Although approximately 9% of patients presenting to a pediatric emergency department (ED) are dehydrated, there is no reliable method to measure objectively the degree of intravascular dehydration. Respiratory changes in inferior vena cava (IVC) diameter have been shown to predict volume status in adults. Previous research has demonstrated correlation between IVC diameter and volume status in children undergoing hemodialysis. Other studies have shown that IVC diameter in children can be sonographically measured rapidly and accurately by emergency physicians. If we can establish that IVC diameter predicts volume status in dehydrated children, this tool could assist the emergency physician in rapid diagnosis and prompt resuscitation without the need to wait for blood or urine tests. In this study we use the вЂњdehydrated patientвЂќ as a model for hypovolemia, with the idea that the data could ultimately be used in the setting of any hypovolemic state. We aim to evaluate whether ultrasound of the pediatric IVC can be used to reliably assess volume status. Methods: This is a prospective cohort study. Pediatric ED patients ranging in age from 1 to 41 months were assessed by a pediatric emergency physician and stratified as either clinically euvolemic or hypovolemic. After consent was obtained, one of three emergency medicine residents performed trans-abdominal sonographic measurements of the IVC diameter. Measurements of the IVC diameter just caudal to the insertion of the hepatic veins were obtained in a longitudinal orientation. Results: 75 pediatric ED patients were enrolled in the study; 63 hydrated patients (Group 1) and 12 dehydrated patients (Group 2). There were no statistically significant demographic differences between the groups (age, PП0.132; sex, PП0.206; weight, PП0.217). There was a statistically significant difference with regards to pulse rate (group 1: median pulse rate П 128.5 beats/minute (range: 92 to 178) and Group 2: 145.0 beats/minute [(range: 114 to 184); PПЅ.05]. Sonographycally, Group 1 had statistically significant higher median longitudinal IVC maximum and minimum diameters, and showed a trend toward a greater difference in diameter between the maximum and minimum, as compared to Group 2: Maximum П 64mm vs. 38mm, PПЅ.001; Minimum П 45mm vs. 32mm, PПЅ.05; with a median difference П 20mm vs. 12mm, PП.095 respectively. In addition, 0% of Group 1 demonstrated IVC collapse during inspiration whereas 25% of Group 2 showed complete collapse of the IVC during inspiration (PПЅ.005); in other words complete IVC collapse during inspiration was seen only in the dehydrated patients. Conclusion: Maximum and minimum IVC diameters, as measured during respiration by bedside ED ultrasonography, were lower in clinically dehydrated pediatric patients. Moreover, sonographic visualization of a collapsed IVC may rapidly and reliably predict dehydration status. 327 Correlation of вђ¤-hCG and Ultrasound Diagnosis of Ectopic Pregnancy in the Emergency Department Bloch AJ, Lyon M, Humphries F, Stoeber J, Shiver S/MCG, Augusta, GA Study Objective: Women with ectopic pregnancies tend to have lower вђ¤-hCG levels than women with intrauterine pregnancies (IUP). Transvaginal ultrasound is capable of detecting IUPs when вђ¤-hCG levels are Пѕ1500 mIU/mL, the so-called Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts discriminatory zone. When serum вђ¤-hCG levels are ПЅ1500 mIU/mL and no IUP is detected, the possibility of an ectopic pregnancy or an early IUP exists. Because of the discriminatory zone, emergency physicians often opt not to perform ultrasound on patients whose вђ¤-hCG level is ПЅ1500 mIU/mL. Many ectopic pregnancies, however, are detected by emergency transvaginal ultrasound with вђ¤-hCG levels ПЅ1500 mIU/ mL. The frequency of detection of ectopic pregnancy at levels ПЅ1500 mIU/mL has not been established. Our objective is to determine this frequency. Methods: A retrospective chart review at an academic center with emergency physicians trained and credentialed in transvaginal ultrasound was performed. Charts with discharge diagnosis of ectopic pregnancy, miscarriage, pregnancy, abdominal pain, and vaginal bleeding were reviewed. Inclusion criteria were positive pregnancy with вђ¤-hCG and ultrasound performed in the emergency department at the time of the visit. There were no exclusion criteria. Ectopic pregnancy was defined by sonographic criteria and discharge diagnosis of ectopic pregnancy. Ultrasounds performed by emergency physicians as well as radiology or Obstetrics-Gynecology (OB) were included. The вђ¤-hCG level at which an ectopic pregnancy was diagnosed was recorded and analyzed. Results: From Oct 2007 until Sept 2008, 859 charts were identified and reviewed. Data was recorded on a standardized data sheet, with 20% of charts reviewed by two individuals for verification of concordance. Out of these charts, 176 patients met inclusion criteria. Of the 176 patients, 11 ectopic pregnancies were identified; representing 6.3% of the total pregnancies. Emergency physicians diagnosed 8 of the 11 ectopics by emergency ultrasound. Three of the 11 ectopics were diagnosed by ultrasounds performed by OB. вђ¤-hCGвЂ™s for the ectopics ranged from 456 - 68,138 mIU/mL. Two ectopic pregnancies were diagnosed with a вђ¤hCG ПЅ 500; one between 500-1000 and none between 1000-1500. Overall, 27% of the ectopic pregnancies diagnosed by emergency transvaginal ultrasound had вђ¤hCGвЂ™s ПЅ1000 mIU/ml. Conclusion: Our initial data confirms that ectopic pregnancies can be diagnosed at вђ¤-hCG levels much less than 1500 mIU/mL by emergency ultrasound. Therefore, вђ¤-hCG levels should not be used to determine the need for an emergency transvaginal ultrasound in a patient at risk for an ectopic pregnancy. Since 27% of the ectopic pregnancies diagnosed in our sample had a вђ¤-hCG ПЅ1000 mIU/mL, emergency transvaginal ultrasound should be performed regardless of вђ¤-hCG level in any pregnant woman with suspicion of an ectopic pregnancy. 328 Thromboembolic Events During Venous Compression Ultrasound of the Lower Extremity in Patients With Deep Venous Thrombosis patients were excluded from the analysis due to missing data. Interobserver agreement among chart reviewers was high (k П 0.90). DVT was identified in 363 (15%, CI 13-16%) patients. Common femoral vein was most commonly involved (77%, CI 72-81%). 45/363 (12%, CI 9-15%) were noted to have chronic DVT. No thromboembolic events occurred from compression ultrasound in patients with DVT. All patients with acute DVT were discharged on anticoagulation therapy. Conclusions: There was no evidence of thromboembolic events from venous compression ultrasound in our study. Risk of pulmonary embolism from compression ultrasound is extremely low. 329 Bedside Urinary Bladder Duplex Ultrasonography for the Detection of Obstructing Ureteral Calculi in the Emergency Department Summers S, Fox J, Chin E, Patel B, Shahin G/University of California, Irvine Medical Center, Orange, CA Study Objective: To determine the test characteristics of emergency department (ED) bedside urinary bladder ultrasonography for the diagnosis of obstructing ureteral calculus. Methods: We conducted a prospective observational pilot study on a convenience sample of adult ED patients with suspected renal colic. All patients received duplex urinary bladder ultrasound (CDBU) at the bedside. Non-clinician research assistants were trained how to perform CDBU during two 30-minute sessions. CDBU consisted of counting the number of ureteral jets emanating from each ureterovesicle junction (UVJ) over a 4-min period. The total jet frequency (TJF) was defined as the total number of jets counted from each UVJ over 4 minutes. The relative jet frequency (RJF) was defined as the number of bladder jets on the symptomatic side divided by the TJF. RJF Х… 35% was considered an abnormal test. Patients were excluded if they had an empty bladder on ultrasound or if the TJF was Х… 3. CDBU was compared to computed tomography (CT) urogram for the diagnosis of obstructing ureteral calculus. The ultrasound operator was blinded to CT results. Results: 17 patients were enrolled, and 5 were excluded. The test characteristics of CDBU were as follows: sensitivity 87.5% (95% CI 0.68-0.88), specificity 100% (95% CI 0.62-1), positive predictive value 100% (95% CI 0.78-1), and negative predictive value 80% (0.49-0.8). Both patients with a ureteral calculus Х† 10 mm had an RJF of 0%. Conclusions: CDBU may be a useful bedside diagnostic test for the detection of obstructing ureteral calculus. Adhikari S, Zeger W, Frrokaj I, Blaivas M/University of Nebraska Medical Center, Omaha, NE; Northside Hospital Forsyth, Cuming, GA Study Objectives: Emergency physicians are increasingly utilizing venous compression ultrasound in the evaluation of lower extremity for deep venous thrombosis (DVT). Focused compression ultrasound has proven to be highly sensitive and specific for identifying DVT. Few case reports have been published describing the occurrence of pulmonary embolism caused by dislodging a DVT during compression ultrasound. To our knowledge, no prior studies investigated the risk of thromboembolic events during venous compression ultrasound. The objective of this study is to determine the risk of thromboembolic events during compression ultrasound in patients with DVT. Methods: This was a retrospective review of all emergency department (ED) patients who underwent venous compression ultrasound of the lower extremity for evaluation of DVT over a 6-year period. This study took place at an academic urban ED with an annual census of 48,000 visits. The ultrasound protocol included Bmode and Doppler color flow analysis of deep veins of lower extremity along with compression of common femoral, superficial femoral, deep femoral, popliteal, posterior tibial, peroneal, and greater saphenous veins. Three chart reviewers performed data collection using a standardized data extraction form. A systematic review of medical records was accomplished for patients diagnosed with DVT. Presence of any one of these clinical features is used to identify a thromboembolic event: new onset or worsening shortness of breath, chest pain, palpitations, syncope, hypotension, hypoxia and death within 24 hours after compression ultrasound. Descriptive statistics are used to analyze the data. Continuous data are presented as means with standard deviations and dichotomous data are presented as percent frequency of occurrence with 95% confidence intervals. Interobserver agreement among chart reviewers was assessed by kappa analysis. Results: A total of 2451 patients (female-1595, male-856) were identified over a six-year period. The mean age of the patients was 60 years П©/- 19 (SD). Three Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 330 Antibiotic Prescription by Emergency and ICU Physicians in Patients Admitted to the Intensive Care Unit With the Diagnosis of Septic Shock Capp R, Brown D/Massachusetts General Hospital, Boston, MA Study Objectives: International guidelines recommend that appropriate antibiotics should be administered within an hour of recognition of septic shock. Antibiotic choice should be broad spectrum, based on clinical presentation and local Annals of Emergency Medicine S103 Research Forum Abstracts hospital/community microorganisms susceptibility patterns (MSP). A recent study has shown significant decrease in survival rate in patients diagnosed with septic shock who were not treated with appropriate antibiotics. Here, we evaluated the appropriateness of accuracy of antibiotic ordering by emergency physicians and ICU doctors for patients with septic shock. Methods: Retrospective study looking at all ICU admissions (577) from Nov 1, 2006 to April 01, 2007. All charts were reviewed in order to determine whether they met specific criteria for septic shock as described by the 1991 Society of Critical Care Medicine Consensus Statement on Sepsis Definitions. 84 patients were identified. Appropriate antibiotic regimens were defined as those which complied with Infectious Diseases Society of America guidelines. Final culture data results were used in order to identify appropriate antibiotic coverage. Results: The mean age was 67; 70% were male. 84 patients were pan-cultured. 67 cultures were positive (80%) and provided MSP for appropriate treatment within 48 hours of admission. Initial choice of antibiotics made in the ED covered offending microorganism in 53% of patients. Antibiotic choices were changed within 2 hours of admission to the ICU approximately 67% of time and covered 53% patients correctly. These changes usually provided broader gram negative coverage with use of ceftazidime and cefepime. Conclusion: For patients presenting with septic shock, most are pan-cultured in the ED prior to initiation of antibiotics. Initial ED antibiotic selection covered the offending microorganism in less than 2/3 of septic shock cases. Antibiotic choices were changed within two hours of arrival to the ICU in 67% of the cases. However, these changes did not improve overall coverage of organisms, despite the broader gram negative coverage with cefepime and ceftazidime. This occurred mostly because the organisms not covered were found to be ESBL gram negatives, cephalosporin resistant pseudomonas, fungi, or vancomysin-resistant enterococci. Given we are covering only less than 2/3 of microorganisms, perhaps we should consider using broader coverage antibiotics, such as linezolid/meropenem in the ED in patients presenting with septic shock. 331 Prospective Randomized Trial of TrimethoprimSulfamethoxazole vs Placebo on 30-Day Recurrence Rates for Uncomplicated Skin Abscesses in Patients at Risk for CommunityAcquired Methicillin-Resistant Staphylococcus Aureus Infection: An Interim Analysis Schmitz GR, Pitotti R, Olderog C, Livengood T, Williams J/Wilford Hall Medical Center, San Antonio, TX; Brooks Army Medical Center, San Antonio, TX Study Objectives: Community-acquired methicillin-resistant Staphylococcus aureus (cMRSA) skin and soft tissue infections are becoming increasingly prevalent in the patient population in the emergency department. Currently, conflicting data exist on the utility of antibiotics to treat uncomplicated cMRSA abscesses. No previous studies have investigated the recurrence rates of abscesses after antibiotics. The primary outcome was to determine whether administration of trimethoprimsulfamethoxazole, in addition to incision and drainage, may prevent recurrence of abscesses at 30 days. A subset analysis was performed to evaluate patients who were MRSA positive and patients with abscesses with overlying cellulitis. Methods: The study is a double blinded, randomized controlled trial on trimethoprim-sulfamethoxazole vs placebo on immunocompetent patients ages 18-65 with uncomplicated cutaneous abscesses requiring incision and drainage. It is a multicenter trial conducted at Wilford Hall Medical Center and Brooks Army Medical Center. All patients received incision and drainage and were randomized to receive either one week of trimethoprim-sulfamethoxazole or matched placebo. Exclusion criteria included patients who were immunocompromised, allergic to sulfa, pregnant or breast feeeding, and any patient who had been hospitalized in the previous month or received antibiotics one week before presentation. Patients with perirectal abscesses or other complicated abscesses with fistulas or tracks requiring surgical evaluation were excluded. At the end of 30 days the patients were contacted by investigators, who were blinded to the study groups, and asked whether or not they had formed a new abscess. Recurrence was defined as a new abscess in the same or different location requiring additional incision and drainage or treatment. Results: One hundred eleven patients were enrolled and 30-day recurrence data is available for 58 patients at interim analysis. 33 patients had been randomized to placebo and 25 patients were randomized to trimethoprim-sulfamethoxazole. There was a significant difference between recurrence rates in patients on placebo (33%, with 95% confidence interval of 17 to 49%) vs. patients on trimethoprimsulfamethoxazole (8%, with a 95% confidence interval of ПЄ3 to 11%). (pПЅ.006). S104 Annals of Emergency Medicine The MRSA prevalence rate was 54%. Of the subset of 29 patients who were MRSA positive, 17 patients received placebo and 12 received trimethoprimsulfamethoxazole. There was a trend towards recurrence patients on placebo (29%) vs patients on trimethoprim-sulfamethoxazole (8%), but this difference was not statistically significant because of small sample size. (pП0.168). There were 42 patients with abscesses and overlying cellulitis. Of the subset with surrounding cellulitis, 23 patients received placebo and 19 received trimethoprimsulfamethoxazole. A significant difference of recurrence was detected in patients on placebo (30%) vs. patients on trimethoprim-sulfamethoxazole (5%). (pПЅ0.039). Conclusion: Our preliminary data suggests that trimethoprim-sulfamethoxazole, in addition to incision and drainage, may have some benefit in the prevention of recurrence of uncomplicated abscesses. 332 A Survey of Provider Opinions Regarding Implementing Rapid HIV Testing in the Emergency Department of a Safety Net Hospital Schechter-Perkins E, Murray K, St. George J, Mitchell P/Boston University School of Medicine, Boston, MA; Massachusetts General Hospital Institute of Health Professions, Boston, MA Background: It is estimated that 1 in 4 HIV-positive people in the United States are unaware of their positive status. Centers for Disease Control and Prevention (CDC) in November 2006 changed their recommendations to advise more widespread HIV testing, including the adoption of screening programs at all points of contact with the health care system. Despite the revised guidelines and the availability of rapid HIV testing, implementation of HIV screening in emergency departments (EDs) is not widespread. Study Objectives: To determine ED personnel awareness of the 2006 CDC recommendations regarding HIV testing, perception of HIV as a problem among ED patients, and elucidate how these factors and others impact attitudes towards implementing HIV testing in the ED. Methods: This study was a cross-sectional survey conducted in 2009 of ED nurses and physicians at Boston Medical Center. This ED sees approximately 130,000 patient visits per year and is the main safety net care provider in Boston. ED staff were asked to complete a 10-question, anonymous survey regarding their attitudes toward rapid HIV testing in the ED. Likert scale responses were analyzed by dichotomizing into (strongly) agree and neutral/(strongly) disagree. The relationship between ED position and CDC recommendation familiarity, perception of HIV as a major problem, and attitudes regarding HIV testing in the ED were assessed using chi square statistics. Potential barriers were identified by multiple choice answers and qualitative responses. Results: The survey was completed by 124/132 (94%) of staff members, including 60 MDs, 61 RNs, and 3 that did not identify position. The majority of respondents, 115/124 (93%) agree HIV is a major problem in the patient population, but only 55/124 (44%) report familiarity with the 2006 CDC recommendations. MDs v RNs somewhat or strongly agree with: HIV is a major problem in this population (96% v 88% pП0.16); universal ED HIV testing should be offered (58% v 31% pП0.003); testing should be offered only when clinically indicated (88% v 75% pП0.06); testing should be offered only for high risk patients (78% v 54% pП0.01); testing should be offered by physicians (59% v 38% pП0.02); testing should be offered by nurses (63% v 31% pПЅ0.001); testing should be offered by counselors (93% v 77% pП0.01). There was not a significant relationship between familiarity with CDC guidelines and attitude toward implementing HIV screening (pП.27). At least one barrier was identified by 56% of respondents. Reported barriers include: confidentiality concerns, cost, patient flow and lack of follow-up. Conclusion: Concern for HIV in the ED population was reported to be high while knowledge about CDC testing recommendation was limited. Attitudes about HIV testing differed significantly between MDs and RNs across most questions. Further research should explore overcoming barriers to opposition, particularly among nurses, to widespread ED HIV testing, despite reported concern about HIV in this population. 333 Screening Strategies for Early Identification of Spine Infections in Patients Presenting to Emergency Departments With Severe Back or Neck Pain Shroyer SR, Mehta S/Greater San Antonio Emergency Physicians, San Antonio, TX Study Objectives: Spinal epidural abscess (SEA) is an intraspinal infection that is typically not detected by physicians until the classic triad of symptoms is evident; Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ Research Forum Abstracts however, this is only present in 8-13% of cases. Numerous studies have quantified how poor physician judgment alone is at detecting SEA (0-26% sensitivity). Delay in recognition of SEA occurs frequently, resulting in disease progression which may subsequently lead to permanent paralysis, sepsis, meningitis and death in a tragic number of these cases. The primary objective in this series was to identify clinical strategy(s) for the early identification of patients at risk for spine infections. Methods: Eighty-seven patients presenting to a community ED with severe back or neck pain were evaluated for potential spine infections using data gathered prospectively on a standardized data collection form. A combination of three clinical strategies were used to identify spine infections using four variables which included: fever (or recent history of fever), spine infection risk factors, progressive neurologic deficit and C-reactive protein. All patients not undergoing imaging were followed up by telephone, medical records or primary physician contact for up to six months. The primary outcome measure was the presence of any of the following spine pathology: SEA, vertebral osteomyelitis, paravertebral abscess, paraspinous pyomyositis, psoas pyomyositis, discitis, septic facet or spinal metastasis being diagnosed within 24 hours of presentation to the emergency department. Results: There was a 29% (25/87) prevalence of spinal infections in our patient population. Three strategies were found that more accurately evaluate patients who present to the ED with back or neck pain from spine infection. The first strategy mandated a C-reactive protein if the patient with severe spine pain had any risk factors for spine infection. If the C-reactive protein was 50mg/L or greater then an MRI was required; this strategy was moderately sensitive and specific (88% sensitive; CI, 70-96% and 84% specific; CI, 73-91%) for diagnosing spine infections. The second strategy utilized a risk stratification tool, SIRCH (Spine Infection Risk Calculation Heuristic). It detected 96% (CI, 81-99%) of spine infections and had a specificity of 71% (CI, 59-81%). This strategy resulted in more MRI orders (42 out of 87) than the former strategy (32 out of 87). A third strategy effectively ruled out spine infection without any lab testing or imaging. Patients who presented with all negative variables in SIRCH (ie, no spine infection risk factors, no fever, no history of fever and no progressive neurologic deficit) (12 out of 87) required no C-reactive protein or imaging. The negative predictive value of this last strategy was 98% (CI, 89%-99%). Conclusion: The use of either of the first 2 strategies as well as the rule-out strategy (SIRCH negative) in patients presenting to the ED with severe spine pain are likely to detect spine infection earlier and more accurately. Early detection will likely improve morbidity and mortality in patients with spine infection. 334 A Two-Year Experience of Patients Receiving NonOccupational Post-Exposure Prophylaxis Against HIV in a NYC Emergency Department Egan D, Urbina A, Galatowitsch P/St. LukeвЂ™s Roosevelt Hospital Center, New York, NY; St. VincentвЂ™s Catholic Medical Center, New York, NY Study Objectives: To identify key characteristics of patients presenting to a NYC emergency department for non-occupational post-exposure prophylaxis (nPEP) against HIV. Methods: The study was conducted in a NYC ED located in a section of Manhattan with a high prevalence of HIV infection. We conducted a retrospective chart review of ED visits between 12/04 and 12/06 of patients presenting with ICD9 codes that would identify possible HIV exposures. Patients eligible for nPEP were identified, and data were abstracted from the electronic medical record. Statistical analyses included frequencies, вђ№2 and ANOVA models. Results: A total of 179 patients were identified, of whom 55.6% were men. The risk partner was also male in 87% of cases. The most common exposures were with partners of unknown HIV status: unprotected receptive vaginal intercourse with ejaculation (13.9%), followed by the same with unknown ejaculation (12.2%), and unprotected receptive anal intercourse with ejaculation (8.3%). More than 70% of patients were 37 or younger, with the largest percentage between 23 and 27 years of age (32.2%). Caucasians made up 63.9% of patients followed next by Hispanics (12.8%). nPEP was offered in 96.1% of cases. Almost all patients (97.6%) with medical insurance accepted treatment compared with only 85% of uninsured patients (вђ№2 П30.864; dfП10; pП.001). Notably, while non-whites were significantly less likely to be insured 46% vs. 34% (вђ№2 П13.77; dfП5; pП.017) than whites, this difference did not influence rates of nPEP acceptance. Almost 1/3 of patients presented within 1-5 hours of exposure (32%). A total of 17.5% of patients presented after 36 hours of exposure (NYS guideline for initiation of nPEP) and 2.3% presented after 72 hours (CDC guideline). Victims of sexual assault (39% of study population) presented more rapidly for nPEP than non-victims: 12-17 hours vs. 18- Volume пњµпњґ, пќ®пќЇ. пњі : September пњІпњ°пњ°пњ№ 23 hours (fП5.04; pП.026). Patients who reported an HIV-positive partner delayed their presentation to the ED compared with partners of unknown status: 18-23 hours vs. 12-17 hours (fП3.862, pП.05). Patients with insurance presented sooner to the ED than uninsured patients, 18-23 hours vs. 12-17 hours (fП6.82, pП.01). Conclusion: In our ED, men presented slightly more frequently than women. There appears to be an association between sexual assault, partner HIV status, if known, and insurance status with time to presentation. Many patients presented beyond NYS-recommended treatment times. These data suggest community education and public health efforts on safer sex practices and access to timely nPEP may be targeted to specific populations. In areas of high HIV prevalence, patients frequently present past the ideal 2-hour window, and EDs should establish nPEP protocols to minimize intradepartmental delays of first medication dose administration. 335 Double-Blind, Randomized, Controlled Multi-Center Trial of Antibiotic Treatment for Uncomplicated Skin Abscesses in Patients at Risk for CommunityAcquired Methicillin-Resistant Staphylococcus aureus Infection: An Interim Analysis Olderog CK, Schmitz G, Pitotti R, Williams J, Huebner K, Livengood T, Ritz B/ Brooke Army Medical Center, San Antonio, TX; Wilford Hall Medical Center, San Antonio, TX; Darnell Army Medical Center, Killeen, TX Study Objective: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is emerging as a major cause of skin and soft tissue infections. The role of antibiotics in the treatment of these infections is debated and has not been adequately studied. We evaluated treatment failure at seven days of skin abscesses treated with incision and drainage plus placebo versus incision and drainage plus sulfamethoxazole/trimethoprim. Methods: Patients between 18-65 years old with skin abscesses were prospectively enrolled at a three different military academic emergency departments in Texas. Exclusion criteria included pregnancy, sulfa allergy, antibiotics in the last seven days, diabetes, and immunocompromise-including HIV. Abscesses were excluded if they were facial or perirectal. Patients were randomized to receive incision and drainage plus placebo or incision and drainage plus a 7 day course of sulfamethoxazole/trimethoprim. Physicians were blinded on patient re-evaluation at day three and seven. Treatment failure was defined as need to start antibiotics based on the discretion of the treating physician. P values were calculated using the Pearson Chi-squared Test. Results: 111 patients were enrolled. 85 patients completed the 7-day re-check (76.5%). 12/46 (26%) of patients randomized to receive placebo failed treatment at 7 days. 6/39 (15%) of patients randomized to receive sulfamethoxazole/trimethoprim failed treatment at 7 days (pП0.229). There were 44 patients in the subset of CA-MRSA patients. 9/20 (45%) on placebo failed treatment and 6/24 (25%) on sulfamethoxazole/trimethoprim failed treatment (pП0.163). In the subset of 61 patients with cellulitis, 10/30 (33%) on placebo failed treatment while 6/31 (19%) on sulfamethoxazole/trimethoprim failed therapy (pП0.215). Conclusion: There is no significant diff