test

2nd

Annual SAEM Great Plains Regional

Research Forum

Saturday, September 10, 2011

Farrell Learning and Teaching Center at Washington University in St. Louis

School of Medicine

SAEM Great Plains Regional Research Forum

Schedule of Events

Time Event Location

7:00am - 7:45am Continental Breakfast FTLC 2nd

Floor

7:45am - 8:00am Welcome Moore Auditorium (1st floor)

8:00am - 9:00am Keynote Address

John Younger, MD, University of Michigan

Moore Auditorium (1st floor)

9:10am - 10:45am Oral Presentation Session 1 (Abstracts #1-9) Moore Auditorium (1st floor)

9:10am - 10:45am Lightning Oral Presentation Session 1 (Abstracts #10-24 ) Holden Auditorium (FTLC 1st Floor)

10:45am – 11:00am Break

11:00am – 12:00am Oral Presentation Session 2 (Abstracts #25-30) Moore Auditorium (1st floor)

12:00pm - 12:30pm Lunch (pick up and bring to next event) FTLC 2nd

Floor lobby

12:00pm – 5:00pm SimWars Competition Holden Auditorium (FTLC 1st Floor)

12:30pm – 1:30pm Keynote Address

Past SAEM President Jeffrey Kline, MD

Moore Auditorium (1st floor)

1:30pm – 3:30pm Resident and Medical Student Breakout Sessions FTLC 213A and 213B

1:40pm – 3:00pm Lightning Oral Presentation Session 2 (Abstracts #31-45) Moore Auditorium (1st floor)

3:00pm – 4:20pm Poster Presentations (Abstracts #46-78) FTLC 210 and 211

4:30pm – 5:00pm Awards and Closing Remarks Moore Auditorium (1st floor)

Detailed Schedule of Events

7:00am - 7:45am, Breakfast

Continental breakfast will be available in the 2nd

floor lobby of the Farrell Teaching and Learning Center.

7:45am – 8:00am, Welcome and Opening Remarks, Moore Auditorium

8:00am – 9:00am, Keynote Address, Moore Auditorium

John Younger, MD, University of Michigan

9:10am - 10:45am, Oral Presentation Session 1, Moore Auditorium

Moderator – Larry Lewis MD, Washington University in St. Louis

1. ISAR and TRST Do Not Predict Short-Term Adverse Outcomes in Geriatric Patients. Steven Abboud1 and

Christopher Carpenter2.

1Saint Louis University School of Medicine, St. Louis, MO;

2Washington University

School of Medicine, St. Louis, MO

2. Usefulness of Pediatric Lactic Acid Screening in the Emergency Department. Antonio Cummings, Loren Reed,

Jennifer Carroll, Stephen Markwell, Jarrod Wall and Myto Duong. Southern Illinois University, Springfield, IL

3. Waiting is Frustrating: A Comparison of the Emergency Severity Index to the Australasian Triage Scale for

Psychiatric Patient Assessment. Andrew S Deutsch1, Leslie Zun

2, LaVonne Downey

3 and Trena Burke

2.

1Rosalind Franklin University of Medicine and Science / Chicago Medical School, North Chicago, IL;

2Mt. Sinai

Hospital Emergency Department, Chicago, IL; 3Roosevelt University, Chicago, IL

4. The Effect of Cognitive Dysfunction and Health Literacy on Patient Comprehension of ED Care among Geriatric

Patients. Jessie Hu1, Owais Nadeem

1, and Christopher R. Carpenter

2.

1Saint Louis University School of

Medicine, St. Louis, MO; 2Washington University School of Medicine, St. Louis, MO

5. Comparing Emergency Medicine Practices for Central Venous Catheter Placement to Existing ICU Checklists. Rob

Klemisch and Daniel L Theodoro. Washington University School of Medicine in St. Louis, St. Louis, MO

6. Improved Interpretation of Coagulase Negative Staphylococcal Blood Culture Results Using Limited Genomic

Resequencing. Ashley Satorius, Adriana Rivera, Marika Raff, Duane Newton and John Younger. University

of Michigan, Ann Arbor, MI

7. Evaluating Quality of Life in Cognitively Impaired Geriatric Patients in the Emergency Department. Lila S. Wahidi

and Christopher R. Carpenter. Washington University School of Medicine in St. Louis, St. Louis, MO

8. Patients With Suicide Ideation Presenting To The Emergency Department: A New Characterization Of Mortality

And Outcomes. David Milzman, Hahn Soe-Lin, Laura Baldassari, Han Huang and Nick Echevarria.

Georgetown University School of Medicine, Washington, DC

9. Comparing Urine Acetoacetate Values With Serum 3-beta-hydroxybutyrate Values In Pregnant Women With

Nausea And Vomiting In The Emergency Department. Ian T Ferguson and Michael Mullins. Washington

University in St. Louis, St. Louis, MO

9:10am – 10:45am, Lightning Oral Presentation Session 1, Holden Auditorium

Moderator – Chris Holthaus MD, Washington University in St. Louis

10. Do Admission Check Sheets Improve Compliance with Pneumonia Core Measures? Andrew Abbeg, Sr., Steven

Lorber, Preeti Dalawari and Stacy Revelle. St Louis University Hospital, St Louis, MO

11. Grip Strength as a Brief Diagnostic Test for Frailty and Pre-Frailty in Geriatric Emergency Department Patients.

Grant M. Fischer and Christopher R. Carpenter. Washington University in St. Louis School of Medicine, St.

Louis, MO

12. Are They Working? The Effects Of UI And Community-Based Interventions On Thursday Night Binge Drinking.

Nicholas J Edwards and Michael Takacs. University of Iowa Carver College of Medicine, Iowa City, IA

13. Short QTc in Emergency Department Patients. Stacey House, Peta-Gay Laird and S. Eliza Halcomb.

Washington University in St. Louis, St. Louis, MO

14. Data Based on All-terrain Vehicle (ATV) Crash Site Informs Rural Health and Safety Policy. Gerene M Denning,

Kari Harland, Kevin Kremer, Charles Jennissen and Christopher Buresh. University of Iowa, Iowa City, IA

15. A Comparison of Two Hospital Electronic Medical Record Systems and Their Effects on the Relationship Between

Physician Charting and Patient Contact. John Shabosky, Jonathan dela Cruz and Matthew Albrecht. Southern

Illinois University School of Medicine, Springfield, IL

16. A Mobile Lightly-embalmed Cadaver Lab: A Possible Model For Training Rural Providers. Wesley Zeger1, Paul

Travis2, Michael Wadman

1, Carol Lomneth

1, Sara Keim

1 and Stephanie Vandermuelen

1.

1UNMC, Omaha, NE;

2Creighton University, Omaha, NE

17. Utilization Of Computed Tomography In Blunt Trauma: When Is Thoracic And Lumbar Imaging Warranted?

Aalap Mehta, Laurie Byrne, Vicki Moran and Eric Armbrecht. St. Louis University, St. Louis, MO

18. Changing Presentation Rates For Mtbi (Concussion) And Changing Imaging Rates. Han Huang1, Nick

Echevarria1, David Milzman

1, Carla Tilchin

1 and Ronny Song

2.

1Georgetown University School of Medicine,

Bethesda, MD; 2Georgetown University, Bethesda, MD

19. Validity of the Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) Instrument As

Predictors for Mortality, ED Revisits, Hospital Admission, Nursing Home Admission, and Functional Decline in

Cognitively Normal and Cognitively Impaired Geriatric ED Patients. Dan Feng, Sophia Li and Christopher R

Carpenter. Washington University School of Medicine, St Louis, MO

20. Diagnostic Accuracy of Various Health Literacy Screening Tools in the Emergency Department. Andrew Melson,

Christopher Carpenter and Richard Griffey. Washington University in St. Louis School of Medicine, Saint

Louis, MO

21. "What Did You Say?” Noise: Does It Distract From Patient Care In The Emergency Department? Laurie E Byrne,

Peter Anaradian and Preeti Dalawari. St. Louis University, St. Louis, MO

22. Undiagnosed Mental Illness in Children and Adolescents in the Emergency Department. Yanika Wolfe and

Dane M. Doctor. Rosalind Franklin University/Chicago Medical School, North Chicago, IL

23. A Comparison of Diversion and No Diversion and the Effect on patient Safety and Outcomes in the Emergency

Department. Eman Spaulding, Laurie Byrne, Eric Armbrecht and Collin Jackson. Saint Louis University,

Saint Louis, MO

24. Impact Of Presence Of Third Molars On Mandible Fractures Following Facial Trauma. David Milzman1, David

Weiner2 and Ryan Murray

1.

1Georgetown University School of Medicine, Washington, DC;

2Georgetown

University School of Medicine, Bethesda, MD

11:00am – 12:00 pm, Oral Presentation Session 2, Moore Auditorium

Moderator – Dan Theodoro MD, Washington University in St. Louis

25. Mild Cognitive Impairment: A Pilot Study To Evaluate The Montreal Cognitive Assessment Screening Tool For

Use In Urban Aging African Americans Who Present To The Emergency Department. Kanika A Turner and

Christopher R Carpenter. Washington University School of Medicine, St. Louis, MO

26. Cardioprotection by Endogenous Fibroblast Growth Factor 2 in Cardiac Ischemia-Reperfusion Injury In Vivo.

Stacey L House, Carla Weinheimer, Attila Kovacs and David Ornitz. Washington University in St. Louis, St.

Louis, MO

27. The Correlation between Health Literacy and Numeracy in the Emergency Department. Andrew Melson,


Louis, MO

28. Cost-Benefit Analysis of Specialized Screeners in the Emergency Department and of Memory and Aging Project

Satellite Intervention. Charlene W Lai1 and Christopher R Carpenter

2.

1Saint Louis University School of

Medicine, St. Louis, MO; 2Washington University School of Medicine in St. Louis, St. Louis, MO

29. Ultrasound Simulation Training: Location of Central Venous Catheter Guide Wire Position. Melissa Thomas1,

Charles Schmier2 and Michael Wadman

1.

1University of Nebraska Medical Center, Omaha, NE;

2University of

Arizona Medical Center, Tucson, AZ

30. Application of Lean Principles of the Toyota Production System Lead to Greatly Improved Door to Needle Times.

Matthew Rudy1, Andria L Ford

1, Jennifer A. Williams

2, Naim Khoury

1, Tomoko Sampson

1, Craig McCammon

2,

Shawn O'Connor1, Jin-Moo Lee

1 and Peter Panagos

1.

1Washington University, Saint Louis, MO;

2Barnes Jewish

Hospital, Saint Louis, MO

12:00pm - 12:30pm Lunch

Pick up lunch in 2nd

floor lobby and take to your next event.

12:00pm - 4:00pm Medical Student SimWars Competition, Holden Auditorium

SimWars is a national competition pitting teams against each other solving cases using medical simulators. Midwest

Regional SAEM takes a new twist on SimWars by tailoring it for medical students. This first ever Medical Student

SimWars consists of two pools of 3 teams facing each other in a round-robin format. The winner of each pool will

then face off in the finals where the first Medical Student SimWars Champion will be crowned.

12:30pm – 1:30pm, Keynote Address, Moore Auditorium

Jeffrey Kline, MD, Past President of SAEM, Carolinas Medical Center

1:30pm – 3:30pm Medical Student and Resident Breakout Session, FTLC 213A and 213B

1:30pm-1:45 pm – Welcome and Introduction

Nathan Deal, MD, President of EMRA

1:45pm-2:30pm – Post Residency EM Subspecialty and Academic Career Options

Panel discussion of subspecialty fellowship training and various academic career options. Panelists include:

Stacey House, MD, PhD, Washington University in St. Louis – Research Careers

Preeti Delawari, MD, MSPH, St. Louis University - Research Careers

Evan Schwarz, MD, Washington University in St. Louis – Toxicology

William Gilmore, MD, Washington University in St. Louis – EMS

Brian Wessman, MD, Washington University in St. Louis – Critical Care

2:30pm-3:30pm – Starting a Career in Academic Emergency Medicine

Douglas Char, MD, Washington University in St. Louis

1:40pm – 3:00 pm, Lightning Oral Presentation Session 2, Moore Auditorium

Moderator – Michael Mullins MD, Washington University in St. Louis

31. Impact Of Teaching Life Saving Procedures To First Year Medical Students. Michael Ybarra, Ryan Murray,

David Weiner and David Milzman. Georgetown University School of Medicine, Bethesda, MD

32. Association of Falls with Sarcopenia and Frailty in Older Adults Presenting to The Emergency Department. Denis

T.K. Balaban, Steven Abboud, BS, Stephanie Chang, BS, Dan Feng, BS, Grant M. Fischer, BS, Jessie Hu, BS,

Charlene Lai, BA, Sophia Li, BS, Owais Nadeem, Ross Passo, Taylor Real, Kanika Taylor, BS, Lila Wahidi,

Christopher R. Carpenter, MD, MS

33. Impact Of Airline Flight On Professional Athletes Following Minor Traumatic Brain Injury (mtbi) In Terms Of

Total Games Missed Due To Injury. David Milzman1, Jeremy Altman

2, Matt Milzman

2, Chris Fleury

2 and Carla

Tilchin3.

1Georgetown University School of Medicine, Bethesda, MD;

2Georgetown University, Bethesda,

DC;3Bates college, Bethesda, ME

34. Can Ambulances Be Triaged To Urgent Care Centers Based On Chief Complaint? Tina Khosla, Joseph Delucia,

Ting Zhang and William Terrin. St. Louis University Hospital, St. Louis, MO

35. A Cost Benefit Analysis Of Ultrasound Programs For Central Venous Cannulation. Daniel L Theodoro.

Washington University School of Medicine in St. Louis, St. Louis, MO

36. Airway Management at a Regional Trauma Center: An Analysis of Resident Experience. Jordan Sullivan and

James McClay. University of Nebraska Medical Center, Omaha, NE

37. A Comparison of 3 Forms of Procedural Sedation for the Reduction of Dislocated Total Hip Arthroplasty. Scott

Burdette, Jonathan dela Cruz, Donald Sullivan, Eric Varboncouer, Daniel O'Keefe, Joe Milbrandt, Myto

Duong, Steven Scaife, David Griffen and Khaled Saleh. Southern Illinois University School of Medicine,

Springfield, IL

38. Knowledge of Alcohol Impairment in Boaters. Maria L Scarbrough and Preeti Dalawari. St. Louis University, St.

Louis, MO

39. Got Wheels?--Adolescent Exposure to ATVs and Their Driving Practices. Charles A Jennissen1, Denning Gerene

1,

Hoogerwerf Pam1, Peck Jeffrey

2 and Wetgen Kristel

1.

1University of Iowa Hospitals and Clinics, Iowa City, IA;

2U.S. Army Corps of Engineers, Iowa City, IA

40. Feasibility of Using Health Literacy Screening Tools in an Urban Emergency Department. Andrew Melson,


Louis, MO

41. Frequency and Mortality of Non-Contiguous Spine Fractures with CT Scan Use. Vijai Chauhan1, Neelaysh

Vukkadala2, Howard Place

1, Laura Sicking

1, Lauren Segelhorst

1, Eric Armbrecht

2, Camelia Guild

2 and Preeti

Dalawari1.

1Saint Louis University SOM, Saint Louis, MO;

2Saint Louis University, Saint Louis, MO

42. Self-rated Health As A Predictor Of Emergency Department Recidivism And Functional Decline Among Geriatric

Patients. Stephanie K Chang1 and Christopher R Carpenter

2.

1St. Louis University, St. Louis, MO;

2Washington


43. Stroke Volume Changes in ED Patients with Shock Undergoing Serial Passive Leg Raising and Fluid Challenges.

Stephanie Charshafian1, Ashley Janssen

1, Christopher Holthaus

1, Brian Fuller

1, Kevin Williams

1, Enyo

Ablordeppey1, Brian Wessman

1, Daniel Theodoro

1, Ronald Chang

1, Jennifer Williams

2, Thomas Ahrens

2 and

Richard Hotchkiss1.

1Washington University in St Louis, St Louis, MO;

2Barnes-Jewish Hospital, St Louis, MO

44. Seeking a Functional Definition of Drug-Seeking Behavior. Benjamin Scallon, Mark Graber, Azeemuddin Ahmed,

Kari Harland and Gerene Denning. University of Iowa, Iowa City, IA.

45. Disposition Variability For Patients with Chest Pain Among Emergency Department Physicians. David J

Gresback and Michael D Zwank. Regions Hospital, Saint Paul, MN

3:00pm - 4:00pm, Poster Presentations, FTLC 210 and 211

46. Characterization Of On-road ATV Crashes In Iowa From 2002-2009. Kevin Kremer, Gerene Denning, PhD and

Christopher Buresh, MD. University of Iowa, Iowa City, IA

47. Differences In Perception About Access To Care Between Patients Who Choose An Urban Academic Emergency

Department Over A Community-based Student-run Free Clinic For Non-urgent Care. Matthew Dettmer1,

Cerrone Cohen2, Edward Jauch

3, Kit N Simpson

3, Brenda Walker

3, Wanda Gonsalves

3, Kathryn Koval

3, Joshua

Gray3 and Steven Saef

3.

1Washington University Medical Center/Barnes-Jewish Hospital, St. Louis, MO;

2UC

Davis Health System, Sacramento, CA; 3Medical University of South Carolina, Charleston, SC

48. Preliminary Report On Factors Associated With Inadequate Or Uninterpretable Cervical Spine Radiographs And

Need For Ct In Cervical Spine Trauma. Richard Griffey, Betty Chen and Steven Katz. Barnes-

Jewish/Washington University in St. Louis, Saint Louis, MO

49. All Terrain Vehicle (ATV) Crash Fatality Surveillance through Press Clipping. Gretchen McCall and Charles

Jennissen, MD. University of Iowa, Iowa City, IA

50. A Quality Curriculum: A Novel Approach To Addressing The ACGME Core Competencies. Jonathan dela Cruz,

Antonio Cummings, James Waymack, David Griffen and Christopher McDowell. Southern Illinois University

School of Medicine, Springfield, IL

51. Emergency Department Interruptions in the Age of Electronic Health Records. Matthew Albrecht, Jonathan dela

Cruz and John Shabosky. Southern Illinois University School of Medicine, Springfield, IL

52. Ct Scanning Practice In Minor Pediatric Head Injury At A Community Emergency Department. Myto Duong,

Varshita Pande and Joseph Milbrandt. Southern Illinois University, Springfield, IL

53. Comparison Of Interpreters In Emergency Medicine: Video Conference Vs. In-person. Yanika Wolfe1, Leslie

Zun2, LaVonne Downey

3 and Trena Burke

4.

1Rosalind Franklin University/Chicago Medical School, North

Chicago, IL; 2Mount Sinai Hospital Emergency Department, Chicago, IL;

3Roosevelt University, Chicago, IL;

4Mount Sinai Hospital Emergency Medicine, Chicago, IL

54. Impact Of The Use Of A Standardized Order Set For Asthma Patients In The Emergency Department. Daniel D

Ofori1, Leslie Zun

1 and LaVonne Downey

2.

1Rosalind Franklin University of Medicine and Sciences, North

Chicago, IL; 2Roosevelt University, Chicago, IL

55. Same Patient. Same Overdose. Different Treatment. Different Outcome. Jon B Cole1, Heather Ellsworth

2 and

Samuel J Stellpflug2.

1Hennepin Regional Poison Center, Minneapolis, MN;

2Regions Hospital, St. Paul, MN

56. Effect of Protocol Implementation on Emergency Department Observation Unit Length of Stay and Charges.

Adam E Stenger, Robert Poirier and Jennifer Wiler. Washington University, St. Louis, MO

57. Retrospective Study of Underage Drinking and Emergency Department (ED) Visits: Before and After the 21

Ordinance. Christopher R Peterson and Michael Takacs. University of Iowa, Iowa City, IA

58. A Retrospective Review of the Use and Safety of Sedation for Agitated Patients with Hepatic Encephalopathy in the

Emergency Department. Jason West1 and Vijai Chauhan

2.

1Albert Einstein School of Medicine,

Jacobi/Montefiore Hospitals, Bronx, NY; 2Saint Louis University School of Medicine, St. Louis, MO

59. A Cost Comparison of Fomepizole and Hemodialysis in the Treatment of Methanol and Ethylene Glycol Toxicity.

Heather Ellsworth, Kristin M Engebretsen, Lisa M Hlavenka, Andy K Kim, Jon B Cole, Carson R Harris and

Samuel J Stellpflug. Regions Hospital, St. Paul, MN

60. Equestrian Helmet Use in Horse Organization Promotional Material. Charles A Jennissen1 and Suleimaan

Waheed2.


2University of Iowa, Iowa City, IA

61. Facilitators of Evidence-Based Pediatric Pain Management in Emergency Departments: Similarities and

Differences Between Rural and Urban Hospitals. Charles A Jennissen1, Sarah Wente

2, Charmaine Kleiber

2 and

Ryoko Furukawa2.


2University of Iowa College of

Nursing, Iowa City, IA

62. Characterization of Clinical Rotations in Three and Four Year Emergency Medicine Residency Training

Programs. Kenneth D Grosz, Robert Muelleman, Lance Hoffman and Michael Wadman. University of

Nebraska Medical Center, Omaha, NE

63. Let The Good Times Roll: Computer Modeling to Investigate Risk of ATV Rollover While Turning. Charles A

Jennissen1, Gerene Denning

1, John Steffen

2, Jonathon Marsico

2, Thomas Schnell

2 and Daniel McGehee

2.


2University of Iowa College of Engineering, Iowa City,

IA

64. A Picture’s Worth a Thousand Words: Utilizing Social Media to Better Understand ATV Crash Mechanisms.

Morgan Price1, Gerene Denning

2 and Charles A Jennissen

2.

1University of Iowa Emergency Department, Iowa

City, IA;2University of Iowa Hospitals and Clinics, Iowa City, IA

65. Complications of Extremity Computed Tomography Angiogram Completed in Emergency Department. Emily

Tilzer and Vijai Chauhan. Saint Louis University Hospital, Saint Louis, MO

66. Safety Depictions on Primetime TV: Lack of Seat belts and Helmets. David Milzman. Georgetown University

School of Medicine, Bethesda, MD

67. Agreement Between Physician and CT Scan in High Energy Mechanism Stable Trauma Patients. Michael D

Zwank1, Eric A Gross

2, Mary J Hughes

3, David J Castle

3, Amanda C Miller

3, William P Hughes

3 and Christopher

P Anderson4.

1Regions Hospital, Saint Paul, MN;

2Hennepin County Medical Center, Minneapolis,

MN;3Michigan State University, East Lansing, MI;

4Healthpartners Research Foundation, Bloomington, MN

68. Padding the Slider Transfer Board and Patient Comfort in the Emergency Department. Jerome R Walker1,

Christopher P Anderson2 and Michael D Zwank

1.


2Healthpartners Research

Foundation, Bloomington, MN

69. The Utility of Computed Tomography in the Diagnosis of Renal Colic in the Emergency Department. Michael D

Zwank1, David J Gresback

1 and Benjamin M Ho

2.


2University of Wisconsin,

Madison, WI

70. The True Impact Of A Left Vs. A Right Shift In Assessing A White Blood Cell Count: Bacterial Viral And The True

Infectious Source. David Milzman1, Anchal Ghai

1, Jenika Ferritti-gallon

2 and Stephan Chang

1.

1Georgetown

University School of Medicine, Bethesda, DC; 2Georgetown University, Washington, DC

71. Pre-Arrest Characteristics and Use of Advance Directives among Out-of-Hospital Cardiac Arrest Victims. David

Milzman1, Erwin Wang

2 and Han Huang

3.

1Georgetown University School of Medicine, Bethesda,

MD;2Georgetown University School of Medicine, Bethesda, DC;

3Georgetown University School of Medicine,

Washington, DC

72. Comparison of Data Collection Using Real Time Observers to Subsequent Review of Video Data for Airway

Management Research. James Miner, Megan Terrebonne, Robert Reardon and John McGill. Hennepin

County Medical Center, Minneapolis, MN

73. Correlation Between Exercise Levels and Medical School Board Scores. Vijai Chauhan and Sean Cavanaugh.

Saint Louis University SOM, Saint Louis, MO

74. Pain Medication Delivery In The Ed For Extremity Fractures: Correlation Of Prescribers' And Patients' Gender

And Ethnicity. David Milzman1, Valerie Huckabee

1, Bill Dirkes

1, Julie Vieth

2 and Collier Wright

1.

1Georgetown

University School of Medicine, Washington, DC; 2Georgetown U / Georgetown WHC EM Residency,

Washington, DC

75. Protein Expression Of M2 Receptor In Atria And Ventricles Of Sham Rats. Elizabeth M Spartz, Huiyin Tu, T. Paul

Tran and Yu-Long Li. University of Nebraska Medical Center, Omaha, NE

76. Rates of Selected Procedures and High-Acuity Diagnoses in Urban and Rural Emergency Departments. James

Waymack, Steve Markwell and Ted Clark. Southern Illinois University, Springfield, IL.

77. Do Alcohol-Related Emergency Department (ED) Visits Mirror Police Data? A Retrospective Study. Greg Pelc,

Michael Takacs and Hans House. University of Iowa, Iowa City, IA

78. Acute Disaster Response: Lessons Learned from a Small-scale Event. Kathy Lehman-Huskamp and Anthony

Scalzo. Southern Illinois University, Springfield, IL; Saint Louis University, Saint Louis, MO

4:30pm – 5:00pm, Awards and Closing Remarks, Moore Auditorium.

Oral Presentation Session 1

9:10am-10:45am

1. ISAR and TRST Do Not Predict Short-Term Adverse

Outcomes in Geriatric Patients

Steven Abboud1 and Christopher Carpenter2. 1Saint Louis University

School of Medicine, St. Louis, MO; 2Washington University School

of Medicine, St. Louis, MO

Background: Acute exacerbations of chronic illnesses cause the

geriatric adult to seek emergency medicine care at constantly

increasing numbers. These patients often have complex medical

problems that require more time and care from emergency

department (ED) staff to treat which strain available resources.

Mechanisms to focus finite resources on higher risk subsets would be

of great value in this setting. Two instruments, the Identification of

Seniors at Risk (ISAR) and Triage Risk Screening Tool (TRST) have

been created to stratify seniors at higher risk for adverse outcomes

such as death, institutionalization, functional decline, and ED revisit.

Because both instruments have validity limited to the institutions they

were created at, the National Institutes of Health has prioritized

research of ISAR and TRST.

Objectives: To validate and compare the prognostic accuracy of the

ISAR and TRST for the composite outcome of one-month ED revisit,

institutionalization, death, and functional decline.

Methods: This was a prospective, observational cohort study of

consenting English speaking patients ≥ 65yrs old presenting to the

Barnes Jewish Hospital ED in St. Louis MO between June 1 and July

31 2011. Patients ≥ 65 years old that did not live in a nursing home or

> 30 miles from the hospital were screened using ISAR and TRST.

Patient follow up was at 30 days post screening. Patients were

evaluated for a correlation between ISAR and TRST score and the

composite outcomes of 1) unscheduled ED visit or hospital admission

2) institutionalization, defined as admission to a nursing home or

chronic care hospital or assisted living facility 3) death 4) functional

decline defined as ≥ 3 point decline on 28 point OARS ADL.

Results: Among the 168 patients, the mean age was 74 years, 43.1%

were men, and 62% were African American. Overall predictive

values were summarized using ROC curves that yielded AUCs of

0.702 and 0.641 for ISAR and TRST respectively.

Conclusion: In the validation of both ISAR and TRST we found that

both tests have poor predictive value for composite outcomes of ED

revisit, institutionalization, death, and functional decline as indicated

by unremarkable positive or negative LR‟s and the high proportion of

patients identified as high risk. Future trials should evaluate these

outcomes at 3 months and include ROC curves for each individual

outcome.

2. Usefulness of Pediatric Lactic Acid Screening in the

Emergency Department

Antonio Cummings, Loren Reed, Jennifer Carroll, Stephen

Markwell, Jarrod Wall and Myto Duong. Southern Illinois

University, Springfield, IL

Background: The benefits of lactic acid (LA) assays for adults in the

emergency department (ED) are well known. LA has been used to

monitor hydration status, acid base anomalies and in early goal

directed therapy for sepsis. In pediatric patients, however, LA

screening is not well established. In 2010, our ED initiated a sepsis

protocol in which LA was drawn concurrently with blood cultures.

Objectives: The objective of this study was to determine the

usefulness of ED LA levels in a select group of pediatric patients,

assessing correlation with illness severity, laboratory tests, admission

rates and outcome.

Methods: A retrospective chart review included 158 patients </=2

years old who had features of sepsis and had LA level (mmole/L)

drawn from June 2010 to June 2011. This was performed in a

community ED with 18000 annual pediatric visits. Data collected

included: vitals, labs, cultures, length of stay, admission, and return

to ED within 3 days. Descriptive statistics were examined for

variables of interest and analyzed for relevance. Pearson correlation

coefficients were used to examine relationships between continuous

variables. To further assess the impact of having an elevated LA,

patients were dichotomized into those falling above or below 75th

percentile LA level. T-tests were used to compare LA groups based

on age, temperature, pulse, respiratory rate (RR), white blood cell

(WBC), bicarbonate level, creatinine, blood urea nitrogen, and

platelet count. P<0.05 was considered significant.

Results: Mean LA was 2.26 with a standard deviation of 1.34. A

statistically significant correlation was found between LA level and

RR, WBC, platelet count, and rate of admission. An inverse

relationship was found between LA level and age and temperature.

Admitted patients on average had a LA level of 2.65 and those not

admitted 1.97 (p<0.05). There was one death (11 months old who

was ventilator dependent and was discharged home without returning

within 72 hours, but died 24 days later).

Conclusion: While patients with LA levels >2.7 (at or above the 75th

percentile), were significantly younger, had higher RR, WBC‟s,

platelets and were more likely to be admitted, the mean values for

these variables were not clinically important (e.g. RR 42 and WBC

13.8 in a 9 month old is not abnormal). The usefulness of LA levels,

obtained in the ED for suspicion of sepsis in children, could be

predictive of hospitalization.

3. Waiting is Frustrating: A Comparison of the Emergency

Severity Index to the Australasian Triage Scale for Psychiatric

Patient Assessment

Andrew S Deutsch1, Leslie Zun2, LaVonne Downey3 and Trena

Burke2. 1Rosalind Franklin University of Medicine and Science /

Chicago Medical School, North Chicago, IL; 2Mt. Sinai Hospital

Emergency Department, Chicago, IL; 3Roosevelt University,

Chicago, IL

Background: Psychiatric Emergency Department (ED) visits are

increasing each year, yet there is a lack of mental health descriptors

in the Emergency Severity Index (ESI) triage scale, diminishing the

triage staff‟s ability to properly assess psychiatric patients. The

Australasian Triage Scale (ATS) includes mental health descriptors

and has been shown to increase the competence and confidence of

triage staff.

Objectives: The objective of this study is to compare the Emergency

Nurses Association (ENA) 5-tier ESI to the ATS to determine which

better evaluates a psychiatric patient‟s need for intervention.

Methods: This was a prospective cohort study consisting of a

convenience sample of 58 medically stable consenting adults who

presented with a psychiatric complaint to the level 1 trauma ED in

one urban community teaching hospital during an 8 week period. As

approved by the IRB, subjects were triaged according to the ESI

system by the triage nurse. A second triage assessment was

conducted by a research fellow using the ATS, which included

observed and reported elements. Following admission to the ED, a

Richmond Agitation Sedation Scale (RASS) score was assigned, and

a psychiatric self-assessment was completed by each subject to

determine the degree of distress and anxiety.

Results: A majority of the subjects (&gt 50%) were single, African

American, and admitted with a throughput time over 4 hours. A

significant correlation was identified between ATS and RASS scores

(p = 0.035): however, no correlation was identified between RASS

and the ESI. ATS scores predicted 6 psychiatric self-assessment

questions that had to do with level of agitation, violence, and self

harm (p &lt 0.05). The ESI ranked a majority (&gt 60%) of subjects

as a 3-urgent and only predicted patients‟ intent on hurting

themselves (p = 0.024).

Conclusion: The ESI only correlates with determining risk of harm

to one‟s self, while the ATS was shown to be reliable and valid in

assessing RASS and 6 core questions that determine risk of harm to

self and others. Further, the ATS provided a more even distribution

of triage scores, thus more appropriately coordinating patient

throughput time and providing a more meaningful ranking than the

ESI.

4. The Effect of Cognitive Dysfunction and Health Literacy on

Patient Comprehension of ED Care among Geriatric Patients

Jessie Hu1, Owais Nadeem

1, and Christopher R. Carpenter

2. Saint

Louis University School of Medicine, St. Louis, MO; 2Washington

University School of Medicine, St. Louis, MO

Background: The rate of geriatric patients in the ED has been

steadily increasing over the past several years, and this trend is

expected to continue with the aging baby-boomers. Approximately

one third of older patients who are discharged will return to the ED

within 14 days, with 90% presenting with the same problem that

prompted the first visit, making it essential to identify factors which

contribute to this population‟s high rates of unnecessary recidivism.

Objectives: The objective of this study is to assess the effect of

cognitive dysfunction and health literacy on comprehension of

Emergency Department (ED) encounter among geriatric adults in

four domains: (1) diagnosis, (2) tests and treatments in the ED, (3)

prescriptions and follow-up recommendations, and (4) return

instructions.

Methods: We conducted a cross sectional study on patients over the

age of 65. Thirteen research assistants (RA) screened consecutive

patients from June 1, 2011 to July 31, 2011 at the Barnes Jewish

Hospital ED. Exclusion criteria included failure to consent, residence

more than 30 miles away, residence in a nursing home, and non-

English speakers. The SBT, BAS, and cAD8 questionnaires were

administered to assess cognitive function and the REALM-SF was

used to assess health literacy. At the time of discharge, patients were

also asked to rate their subjective understanding of their ED

encounter for all four domains of ED care.

Results: We enrolled 165 patients. Around 47% of the patients

perceived low comprehension in at least 1 domain of ED visit.

Geriatric patients seemed to most often misunderstand elements of

their ED care, such as tests and treatments received. Greater cognitive

dysfunction was moderately correlated with self-rated lack of

understanding of elements of ED care (Spearman r= -.393; P < .01).

Health literacy had a statistically significant effect (P < .001) on

comprehension of ED care as well. When stratified by level of health

literacy, 81% of patients with less than 9th grade reading level

expressed a lack of understanding in this domain, whereas only 23%

of patients with greater than 9th grade reading level perceived this

lack of understanding.

Conclusion: Cognitive dysfunction and low health literacy in

patients are significantly correlated with lower self-perceived

comprehension of ED care.

5. Comparing Emergency Medicine Practices for Central Venous

Catheter Placement to Existing ICU Checklists

Rob Klemisch and Daniel L Theodoro. Washington University

School of Medicine in St. Louis, St. Louis, MO

Background: The incidence of Central Venous Catheter (CVC)

insertion is increasing in the Emergency Department (ED). Checklists

for CVC placement have been shown to increase adherence to best

practices and reduce central line associated blood stream infections.

Though multiple checklists have been published for use in the

Intensive Care Unit (ICU), none has been tailored to the ED.

Objectives: Perform a pilot study to assess ED utilization of well

accepted CVC checklists and determine adherence to specific

checklist elements related to infection control.

Methods: This was a convenience sample of CVC insertions in an

urban Level I trauma ED performed between June and August 2011.

CVC insertions by ED physicians were captured by an independent,

trained observer on staggered shifts including days, evenings, and

overnights. “Crash” CVC insertions (defined as placed under

imminent life or death conditions) were excluded. Observed ED CVC

placements were compared to elements of four non-ED checklists.

We used descriptive statistics to identify areas of high and low

adherence.

Results: The CVC “bundle” was used by 19 of 19 operators (100%,

95%CI 0.83 to 1) and in 19 of 19 (100%, 95%CI 0.83 to 1) cases the

included checklist was discarded. No operator completed all elements

on any of the four checklists. Sterile gloves were used in 19 of 19

insertions (100%, 95%CI 0.83 to 1), sedation or local anesthetic was

used in 18 of 18 (100%, 95%CI 0.83 to 1), and maintenance of a

sterile field throughout the procedure was observed in 17 of 17

(100%, 95%CI 0.82 to 1). Operators wore caps and masks during 16

of 19 insertions (84%, 95%CI 0.62 to 0.94) and gowns during 18 of

19 insertions (95%, 95%CI 0.75 to 0.99). In 9 of 19 insertions (47%,

95%CI 0.27 to 0.68) patients were not draped from head to toe, 8 of

18 insertion sites (44% 95%CI 0.25 to 0.66) were not scrubbed for a

full 30 seconds, 7 of 17 (41% 95%CI 0.21 to 0.64) operators did not

clamp all unused lumens, and in 9 of 16 insertions Trendelenburg

position was not used (56%, 95%CI 0.33 to 0.77).

Conclusion: This small pilot study demonstrated that ED physicians

have not adopted CVC checklists. In addition, adherence to some

aspects of established checklist practices are poor. Outcomes of ED

central lines may benefit from an ED developed, structured checklist.

6. Improved Interpretation of Coagulase Negative Staphylococcal

Blood Culture Results Using Limited Genomic Resequencing

Ashley Satorius, Adriana Rivera, Marika Raff, Duane Newton and

John Younger. University of Michigan, Ann Arbor, MI

Background: Coagulase-negative staphylococci are the most

common cause of catheter and implanted device infection. They are

also the most common cause of false positive blood cultures. Thus,

patients from whose blood these organisms are recovered often face

mandatory hospitalization and broad spectrum antibiotics until the

clinical significance of the culture can be determined (usually days).

Improved means of discriminating pathogenic from contaminating

organisms are greatly needed.

Objectives: We examined the utility of limited genetic sequencing of

bacterial isolates using multilocus sequence typing (MLST) to

discriminate between known pathogenic blood culture isolates of S.

epidermidis and isolates recovered from skin.

Methods: Ten blood culture isolates from patients meeting CDC

criteria for clinically significant S. epidermidis bacteremia and ten

isolates from the skin of healthy volunteers were studied. MLST was

performed by sequencing ~ 400 bp regions of 7 genes (arc, aroE, gtR,

mutS, pyr, tpiA, and yqiL). Genetic variability at these sites was

compared to an international database (www.sepidermidis.mlst.net)

and each strain was then categorized into a genotype on the basis of

known genetic variation. The ability of the gene sequences to

correctly classify strains was quantified using the support vector

machine function in the statistical package R. 1,000 bootstrap

resamples were performed to generate confidence bounds around the

accuracy estimates.

Results: Between strain variability was considerable, with yqiL

being most variable (6 alleles) and tpiA being least (1 allele). The

mutS gene, responsible for DNA repair in S. epidermidis, showed

almost complete separation between pathogenic and commensal

strains. When the 7 genes were used in a joint model, they correctly

predicted bacterial strain type with 90% accuracy (IQR 85, 95%).

Conclusion: Multilocus sequence typing shows excellent early

promise as a means of distinguishing contaminant versus truly

pathogenic isolates of S. epidermidis from clinical samples. Near-

term future goals will involve developing more rapid means of

sequencing and enrolling a larger cohort to verify assay performance.

7. Evaluating Quality of Life in Cognitively Impaired Geriatric

Patients in the Emergency Department

Lila S. Wahidi and Christopher R. Carpenter. Washington University

School of Medicine in St. Louis, St. Louis, MO

Background: An aging population has resulted in a rising prevalence

of age-related conditions, such as cognitive dysfunction, which can

affect one's quality of life (QOL). It is important to study geriatric

QOL in the emergency department (ED) to guide medical care in the

ED and after discharge.

Objectives: To determine correlations between cognitive dysfunction

and geriatric patient QOL ratings in an ED setting and to investigate

the ability of cognitively impaired patients to rate their QOL by

comparing self-ratings to those of a caregiver.

Methods: In this prospective, cross-sectional study at one urban

academic medical center, trained researchers collected patients'

responses on the Short Blessed Test (SBT) and the Quality of Life-

Alzheimer's Disease (QOL-AD) Subject Report. Caregivers

completed the QOL-AD Caregiver Report. Consenting subjects were

non-critically ill, English-speaking, community-dwelling adults over

65 years. Spearman rho coefficient and Wilcoxon signed-rank test

evaluated relationships between patient and caregiver QOL-AD

scores with regard to the patients' level of cognition.

Results: Patient QOL ratings were obtained from 60 patient-

caregiver pairs. QOL evaluations by patients and caregivers were

more highly correlated in patients of normal cognition. Mean total

QOL scores were lower for cognitively impaired patients than

patients of normal cognition. The difference between mean total QOL

scores for patients and caregivers was greater for patients of

abnormal cognition.

Conclusion: Fewer significant correlations for cognitively impaired

patients and their caregivers can explained by several reasons

including patient lack of insight, denial of impairment, adaptation to

the condition, or the fact that cognitive impairment may not

negatively impact quality of life. Understanding patient QOL is

important for referral to multidisciplinary programs with the goal of

reducing preventable hospitalizations and ED recidivism.

QOL-AD

Patients of Normal SBT (n=27) Patients of Abnormal SBT (n=33)

Wilcoxon Patient Ratings

Caregiver Ratings

Spearman coefficient

Patient Ratings

Caregiver Ratings

Spearman coefficient

Mean (SD) Mean (SD) rho p Mean (SD) Mean (SD) rho p p

Physical health Energy Mood

Living situation Memory Family Marriage Friends Self as a whole Ability to do chores Ability to do things

for fun Money Life as a whole Total Score

2.41 (1.01) 2.41 (1.01) 2.96 (0.90) 3.52 (0.75) 2.93 (0.96) 3.41 (0.69) 3.52 (0.58)

3.44 (0.58) 3.22 (0.51) 2.81 (1.14) 3.04 (1.02) 3.19 (1.00) 3.48 (0.58) 40.33 (7.66)

2.41 (0.97) 2.67 (0.88) 2.63 (1.08) 3.41 (0.84) 3.04 (0.81) 3.37 (0.79) 3.22 (0.93)

3.33 (0.73) 3.04 (0.90) 2.81 (1.21) 2.96 (1.02) 3.26 (0.98) 3.44 (0.75) 39.59 (9.07)

0.766 0.757 0.813 0.288 0.253 0.230 0.550

0.379 0.348 0.513 0.173 0.255 0.414 0.677

0.000 0.000 0.000 0.145 0.204 0.249 0.003

0.051 0.076 0.006 0.388 0.200 0.032 0.000

2.39 (0.97) 2.06 (1.00) 2.12 (0.93) 2.70 (0.88) 2.24 (0.87) 2.91 (0.95) 3.33 (0.89)

2.97 (0.92) 2.76 (1.03) 2.55 (1.03) 2.64 (1.06) 2.36 (1.08) 2.97 (0.85) 34.00 (8.60)

2.06 (0.86) 2.30 (1.02) 1.97 (0.88) 3.03 (0.81) 2.21 (0.74) 3.00 (0.87) 3.03 (0.88)

3.06 (0.75) 2.70 (0.88) 1.97 (0.88) 2.18 (0.81) 2.48 (0.76) 2.88 (0.74) 32.88 (7.17)

0.287 0.356 0.517 0.066 0.299 -0.017 0.349

0.044 0.292 0.269 0.169 0.309 0.149 0.351

0.106 0.042 0.002 0.715 0.091 0.926 0.047

0.808 0.099 0.129 0.348 0.080 0.406 0.045

0.012 0.120 0.531 0.174 0.686 0.127 0.059

0.175 0.128 0.256 0.812 0.276 0.071 0.112

8. Patients With Suicide Ideation Presenting To The Emergency

Department: A New Characterization Of Mortality And

Outcomes.

David Milzman, Hahn Soe-Lin, Laura Baldassari, Han Huang and

Nick Echevarria. Georgetown University School of Medicine,

Washington, DC

Background: Psychiatric patients exhibit increased suicide risk

shortly after discharge, but little is known about the fate of patients

who are discharged after presentation with Suicidal Ideation (SI). In

the U.S. there is furthermore a lack of supporting documentation for

outcomes following admits from Emergency Department (ED)

presentations for SI.

Objectives: To determine if patients who present to the ED with

Suicidal Ideation are at increased risk for death by suicide than those

patients presenting with other acute complaints.

Methods: Setting: urban hospital, 950 patient beds, ED with 80,000

annual visits

•Retrospective data collection using Azyxxi data record developed by

Smith and Feeid (Microsoft, Redmond WA)

•Patients included presented with triage complaint or ED diagnosis of

suicide or spelling variants between 2002-2007.

•Cohort of 3742 patient records (SI Cohort) screened against Social

Security Death Registry (http://ssdi.rootsweb.com/cgi-bin/ssdi.cgi) to

obtain mortality statistics.

•Subcohort of 108 patients with a positive match for death on the

SSNDR (Death Cohort) was identified and sociodemographics and

co-morbidities were characterized.

•True suicides as primary cause of death were then ruled in by cross-

referencing of this subcohort with the District of Columbia‟s Medical

Examiners Office

Results: 3,625 pts with SI presented to the ED during the study

period over 5 years accounting for 53,217 ED visits with a mean of

13.4 visits for SI alone (95%CI: 10/5-17.1) with an overall mortality

rate of 4.8%. for all comers in the ED population. The mean time to

death for the 122 deaths in the suicide group was 2.9 years from the

initial suicide ideation visits. for all suicidal patients, there was a

mean of 11 visits and an average of 5.1 years from first ED visit( all

cause) till death for those that died in the study period. 50% of the

death cohort were found to abuse alcohol and/or substances and 32%

were HIV positive. Only 10% of those that died during the study

period were determined to have died from OD or self -inflicted

wounds; this results in an overall true suicide rate of 0.5 percent for

the entire suicidal patient presenting to the ED.

Conclusion: SI is still a serious problem, However; the deaths for

these patients presenting to the ED do not come at any increased rate

in this preliminary study.

9. Comparing Urine Acetoacetate Values With Serum 3-beta-

hydroxybutyrate Values In Pregnant Women With Nausea And

Vomiting In The Emergency Department.

Ian T Ferguson and Michael Mullins. Washington University in St.

Louis, St. Louis, MO

Background: Nausea and vomiting affect upwards of 80% of

pregnant women and are frequent causes of emergency department

visits. The ED physician must distinguish between uncomplicated

nausea/vomiting (“morning sickness”) and hyperemesis gravidarum

(HG) because this affects treatments decisions, including type and

quantity of IV fluids, and length of stay.

Objectives: Our aim of this study was to determine whether

fingerstick 3-beta-hydroxybutryrate (BHB) predicts ketonuria in

pregnant women with nausea and vomiting.

Methods: We enrolled 77 pregnant women who presented to the

Barnes-Jewish Emergency Department with complaints of

nausea/vomiting. All procedures were completed under IRB

approval. Exclusion criteria were: 38.3°C or altered mental status,

prisoners, and >1 liter of IV fluid before screening. All subjects had a

fingerstick BHB test, with results reported in increments of 0.1

mmol/L. Urine ketone results were made available once reported as

part of standard of care and varied from 0 (trace) to +4 values.

Results: We constructed a contingency table and receiver-operating

curve for comparing the BHB values to those urine ketone values for

each patient. We used a cut-off urine ketone value of +3 or +4 to

sufficiently indicate severe nausea/vomiting or hyperemesis as these

values necessitate aggressive fluid management to reduce ketonemia

and improve ketone urine clearance.

Mean BHB was 0.435 mmol/L and median urine was +1 for the

cohort as a whole. The ROC gives an area under the curve of .94. The

sensitivity and specificity for a fingerstick test of >.4 mmol/L are

85% and 94% respectively. The PPV is .88 and the NPV is .92. The

positive likelihood ratio is 14 and the negative likelihood ratio is .16.

Conclusion: Fingerstick BHB provides a rapid and reliable

diagnostic tool to correlate ketonemia (3-beta-hydroxybutyrate)

levels with ketonuria (acetoacetate) levels in pregnant women with

nausea/vomiting. Fingerstick BHB results may be obtained earlier in

the course of care than urine samples and as a result, may increase

triage efficacy, lower length of stay times, and positively affect

patient outcomes in an emergency department setting.

Lightning Oral Presentation Session 1

9:10am-10:45am

10. Do Admission Check Sheets Improve Compliance with

Pneumonia Core Measures?

Andrew Abbeg, Sr., Steven Lorber, Preeti Dalawari and Stacy

Revelle. St Louis University Hospital, St Louis, MO

Background: The Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) includes antibiotics given within 6 hours of

arrival to the emergency department (ED) for patients diagnosed with

pneumonia as a performance measure. The Center for Medicaid and

Medicare Services (CMS) uses this as one of its core measures to

continue funding to hospitals; a 97% compliance rate is expected.

However, atypical pneumonia presentations may cause a delay in

antibiotic treatment and will be considered an outlier if an

explanation of the delay is not given.

Objectives: The objective of this study was to assess the monthly

compliance rate with this measure before and after the institution of a

checklist.

Methods: This was a review of aggregate data of ED pneumonia

compliance for public reporting at an academic tertiary center. A

preliminary data analysis compared 8 months before and 4 months

after the checklist was instituted in March 2010 (final analysis will

include 8 months post checklist). The checklist, developed by the

institutional pneumonia committee, enables physicians to indicate

typical versus atypical presentation, time to antibiotics, and

explanations for delays in treatment. A t test for independent samples

was used to analyze differences in compliance rate between groups.

Results: There were 143 reportable pneumonia cases in the

preliminary time period; 88 (62%) prior to checklist and

55 (38%) after. After the institution of the checklist all pneumonia

patients received timely antibiotics with 100% average monthly

compliance compared to before checklist of 94.1% (p value <0.027).

Conclusion: The preliminary data suggests that using a pneumonia

checklist is one way that an emergency department can improve

compliance with the time to antibiotic CMS core measure.

11. Grip Strength as a Brief Diagnostic Test for Frailty and Pre-

Frailty in Geriatric Emergency Department Patients

Grant M. Fischer and Christopher R. Carpenter. Washington

University in St. Louis School of Medicine, St. Louis, MO

Background: Linda Fried et al.‟s well-established definition of

frailty classifies geriatric adults as frail if they meet 3 of the

following 5 criteria: unintentional weight loss, exhaustion, low grip

strength, slow walking speed, and low physical activity level. It

categorizes them as pre-frail if they meet 1 or 2 of these criteria. ED-

case finding for frailty could offer opportunities for intervention. A

brief, effective tool for identifying frailty must be developed in order

for frailty-specific ED-case finding to be possible.

Objectives: The purpose of this study was to determine if grip

strength could serve as a brief diagnostic test for frailty and/or pre-

frailty in geriatric ED patients.

Methods: An observational, cross-sectional study was conducted on

a consecutive sample of eligible subjects at the ED of Barnes-Jewish

Hospital (BJH). Eligible subjects included consenting English-

speaking, community-dwelling patients at least age 65 years who

presented to BJH‟s ED from June 1, 2011 to July 31, 2011 and did

not reside over 30 miles from BJH. Trained geriatric technicians

evaluated subjects for adherence to all of the Fried criteria except

walking speed. For data analysis, subjects were considered frail if

they had unintentionally lost at least 10 lbs in the year prior to testing,

felt exhausted in the week prior to testing, and were found to have a

low physical activity level (as determined by the Stanford Brief

Activity Survey). They were classified as pre-frail if they tested

positive for 1 or 2 of these criteria. Grip strength values, measured by

a JAMAR® Plus Hand Dynamometer, were adjusted for age and

height based upon population norms for each gender. The diagnostic

test characteristics of grip strength were determined using SPSS and

MEDCALC.

Results: Overall, 165 patients were enrolled with complete data

collection. The mean age of the subjects was 74 years. 43% of the

subjects were male. 27.1% of males and 11.7% of females tested

below their age and height adjusted grip strength norms. Grip

strength demonstrated poor diagnostic test characteristics with

regards to identifying frail and pre-frail geriatric ED patients.

Diagnostic Test Characteristics of Grip Strength for Females

Sen % (95% CI) Spec % (95% CI) LR+ (95% CI) LR- (95% CI) AUC (95% CI)

1 Fried criterion 12 (-4-27) 83 (73-94) 0.71 (0.17-3.00) 1.06 (0.85-1.31) 0.49 (0.35-0.62)

2 Fried criteria 29 (9-48) 91 (82-99) 3.14 (0.99-9.96) 0.79 (0.59-1.05) 0.47 (0.32-0.63)

3 Fried criteria 11 (-9-32) 84 (74-94) 0.69 (0.10-4.82) 1.06 (0.82-1.37) 0.49 (0.32-0.66)

Diagnostic Test Characteristics of Grip Strength for Males

Sen % (95% CI) Spec % (95% CI) LR+ (95% CI) LR- (95% CI) AUC (95% CI)

1 Fried criterion 21 (0-43) 69 (55-83) 0.69 (0.23-2.08) 1.14 (0.81-1.60) 0.41 (0.25-0.57)

2 Fried criteria 40 (10-70) 74 (61-87) 1.53 (0.62-3.78) 0.81 (0.48-1.39) 0.48 (0.30-0.67)

3 Fried criteria 55 (25-84) 78 (66-90) 2.46 (1.14-5.29) 0.58 (0.30-1.14) 0.44 (0.25-0.63)

Conclusion: Low sensitivities and ROC AUCs indicated that grip

strength poorly detected frailty and pre-frailty in geriatric ED

patients. A brief, effective screening tool for frailty should still be

researched to improve care for geriatric ED patients.

12. Are They Working? The Effects Of UI And Community-

Based Interventions On Thursday Night Binge Drinking

Nicholas J Edwards and Michael Takacs. University of Iowa Carver

College of Medicine, Iowa City, IA

Background: 2011 survey data indicates that 65% of UI students

engage in binge drinking; down from 70% in 2006, but staggering

when compared to 44% of college students nationwide. At this time,

the impact of UI and community-based interventions on this decrease

in self-reported risky drinking is unclear. Nonetheless, emergency

departments (ED) continue to play an important role in injury

surveillance and can capitalize on “teachable moments” during

alcohol-related ED visits.

Objectives: Compare numbers of alcohol-related ED visits before

and after the start of alcohol-interventions (more Friday classes, 21-

Only Ordinance) to determine the efficacy of these programs, with

trends among students and across genders being focal points.

Methods: 18-22 year-olds, who presented to the ETC for alcohol-

related injuries on Thursday nights from Fall 2006 to Spring 2011,

were eligible for this retrospective study. Data were compiled from

patients‟ medical records, and FERPA-approved access to the UI

Provost‟s database determined the patients‟ UI academic status. Non-

students served as controls. Data were analyzed via chi-square and

ANOVA.

Results: On Thursday nights from Fall 2009-Spring 2011, 127

patients presented to the ED for alcohol related-injuries; 76 males

(60%), 51 females (40%), and 78 UI-students (61%) versus 49 non-

students (39%). 25 males presented with violence-related injuries,

compared to 0 females (p<0.0001). A study of semesters before and

after implementation of alcohol-interventions showed a 15% decrease

in Thursday night alcohol-related ED visits following increases in

Friday classes, and a 54% decrease following onset of the 21-Only

Ordinance (p<0.02 when comparing interventions). Among UI-

students, 31% and 53% decreases were seen, respectively (p<0.01

when comparing semesters).

Conclusion: Further research is indicated to effectively study

correlations between alcohol-related ED visits and alcohol-

interventions, as retrospective studies cannot provide direct causation

for observed changes. Observed differences between male and female

incidence and mechanism of injury may warrant future interventions

and educational means that are gender-specific.

13. Short QTc in Emergency Department Patients

Stacey House, Peta-Gay Laird and S. Eliza Halcomb. Washington


Background: A short QTc interval has been shown to predispose

patients to arrhythmias and sudden death. Electrolyte abnormalities,

hyperthermia, and some medications are associated with shortened

QTc. As the importance of short QTc has only recently been

appreciated, there is limited literature describing patients with short

QTc especially in the ED.

Objectives: The study objective was to characterize the ED

population with short QTc.

Methods: This study was a retrospective review of ED patients (pts)

who received an ECG from April - September 2009 at a large

volume, tertiary care center. Inclusion criteria were pts with a

QTc≤390ms. Exclusion criteria included pts with an ECG showing

bradycardia (HR<60bpm), tachycardia (HR>100bpm), QRS>120ms,

or non-sinus rhythm. ED electronic medical records were reviewed

for multiple comorbid conditions, presenting symptoms, electrolyte

abnormalities, medications, and disposition.

Results: 13,494 pts received ECGs during the six month period. Of

these, 281 had a QTc≤390ms (2%, 95%CI 1.8-2.3%). 136 were

excluded, leaving 145 eligible pts. Of these, 108 (75%) had a QTc

380-390ms, 26 (18%) had a QTc 370-379ms, and 10 (7%) had a

QTc≤369ms. These pts were 39±2 years old and were predominantly

male (71%, 95%CI 63-78%). Hypertension (22%), psychiatric

conditions (17%), and drug abuse (22%) were the most common

comorbidities. The most common symptoms were chest pain (56%),

shortness of breath (40%), and dizziness (19%). 18% (95%CI 10-

25%) had abnormal serum potassium, and 13% (95%CI 6-19%) had

abnormal serum calcium. 4% (95CI 1-7%) were hyperthermic. Only

3% (95%CI 1-5%) were on home medications which shortened QTc

interval including <1% on digoxin, the most commonly described

cause of medication-induced short QTc. 70% (95%CI 63-78%) were

discharged from the ED. There were no significant differences among

the different length QTc groups with regards to comorbidities,

symptoms, electrolyte abnormalities, QTc shortening medications, or

disposition.

Conclusion: Shortened QTc occurs in 1-2% of ED pts with <0.1%

having a QTc<369ms. Even though hypercalcemia, hyperthermia,

and digoxin therapy are commonly reported causes of shortened QTc,

a very small portion of ED pts with shortened QTc had these

findings. As the majority of these pts are discharged from the ED,

further studies are needed to determine the cardiac event rates in ED

pts with shortened QTc.

14. Data Based on All-terrain Vehicle (ATV) Crash Site Informs

Rural Health and Safety Policy

Gerene M Denning, Kari Harland, Kevin Kremer, Charles Jennissen

and Christopher Buresh. University of Iowa, Iowa City, IA

Background: Every year, U.S. ATV crashes result in over 500

deaths, 130,000 ED visits, and $4 billion in lost life and healthcare

costs. One in three victims are under the age of 16. Because the vast

majority of ATV crashes occur in or near rural communities, they

represent a serious threat to rural health and safety.

Objectives: The objectives of this project were to compare Iowa

ATV crashes by crash location, and to develop public policy

recommendations based on these results.

Methods: Data for these studies were generated from our Iowa ATV

Injury Surveillance Database (2002-2009). Proportions were

compared using the chi-square test. Injury severity scores for on and

off-road crashes were compared using the Mann-Whitney test.

Results: Females (23%) and children under sixteen (32%) were a

higher percentage of on-road crash victims as compared to crashes in

Off-Highway Vehicle (OHV) parks (females, 8%; children 10%; p <

0.05). There were also significantly higher proportions of on-road

(17%) and off-road (15%) crashes that involved passengers, when

compared to crashes in the parks (3.8%, p < 0.05). Monitoring and

enforcement of helmet requirements in the parks appeared to increase

helmet use (91%) relative to other sites (on-road, 13%; off-road,

25%; p < 0.0001); Iowa does not currently have a statewide helmet

law. On-road crashes were 8-fold more likely to involve a collision

with another vehicle relative to off-road crashes. On-road fatalities

averaged two per year, whereas a single fatality was recorded in the

parks over the 8-year period. Injury severity scores were higher for

on-road crashes relative to off-road locations (p < 0.0001), and

victims from on-road crashes were 3 times more likely to suffer

traumatic brain injury relative to off-road victims.

Conclusion: Iowa law allows cities and counties to designate

streets/roads for general ATV use; however, our data indicate that on-

road ATV crashes pose a serious injury risk and traffic safety hazard.

Based on these findings, we would strongly advise policy makers

against increasing ATV road use. Conversely, enforcement of OHV

park regulations, including no passenger rules and required helmet

use, appears to promote safer behaviors and better outcomes.

Expanding safe, controlled places for recreational riding would be a

potential way to reduce ATV-related deaths and injuries.

15. A Comparison of Two Hospital Electronic Medical Record

Systems and Their Effects on the Relationship Between Physician

Charting and Patient Contact

John Shabosky, Jonathan dela Cruz and Matthew Albrecht.

Southern Illinois University School of Medicine, Springfield, IL

Background: Recent health care reform has placed an emphasis on

the electronic health record (EHR). With the advent of the EHR it is

common to see ED providers spending more time in front of

computers documenting and away from patients. Finding strategies to

decrease provider interaction with computers and increase time with

patients may lead to improved patient outcomes and satisfaction.

Computerized charting adjuncts, such as voice recognition software,

have been marketed as ways to improve provider efficiency and

patient contact.

Objectives: We present here observational data comparing two

separate ED sites, one where computerized charting is done by

conventional techniques and one that is assisted with voice

recognition dictation, and their effects on physican charting and

patient contact.

Methods: A prospective observational quality initiative was

conducted at two teaching hospitals located less than 1 mile from

each other. One site primarily uses conventional computerized

charting while the other uses voice recognition dictation. Four trained

quality assistants observed ED physicians for 180 minutes during

shifts. The tasks each physician performed were noted and logged in

30 second intervals. Tasks listed were identified from a

predetermined standardized list presented at observer training. A total

of 4140 minutes were logged. Time allocated to charting and that

allocated to direct patient care were then compared between sites.

Results: ED physicians spent 28.6% of their time charting using

conventional techniques vs 25.7% using voice recognition dictation

(p=0.4349). Time allocated to direct patient care was found to be

22.8% with conventional charting vs 25.1% using dictation (p=4887).

In total, ED physicians using conventional charting techniques spent

668/2340 minutes charting. ED physicians using voice recognition

dictation spent 333/1800 minutes dictating and an additional

129.5/1800 minutes reviewing or correcting their dictations.

Conclusion: The use of voice recognition assisted dictation rather

than conventional techniques did not significantly change the amount

of time physicians spent charting or with direct patient care.

Although voice recognition dictation decreased initial input time of

documenting data, a considerable amount of time was required to

review and correct these dictations.

16. A Mobile Lightly-embalmed Cadaver Lab: A Possible Model

For Training Rural Providers

Wesley Zeger1, Paul Travis2, Michael Wadman1, Carol Lomneth1,

Sara Keim1 and Stephanie Vandermuelen1. 1UNMC, Omaha, NE; 2Creighton University, Omaha, NE

Background: In Nebraska, 80% of emergency departments have

annual visits less than 10,000, the predominance are in rural settings.

General practitioners working in rural emergency medicine

departments have reported low confidence in several emergency

medicine skills. Current staffing patterns include using midlevels as

the primary provider with non-emergency medicine trained

physicians as back-up. Lightly-embalmed cadaver labs are used for

resident‟s procedural training.

Objectives: To describe the impact of a lightly-embalmed cadaver

workshop on physician assistant‟s (PA) reported level of confidence

in selected emergency medicine procedures.

Methods: An emergency medicine procedure lab was offered at the

Nebraska Association of Physician Assistants annual conference.

Each lab consisted of a 2 hour hand‟s on session teaching

endotracheal intubation techniques, tube thoracostomy, intraosseous

access, and arthrocentesis of the knee, shoulder, ankle, and wrist to

PA‟s. IRB approved surveys were distributed pre-lab and a post-lab

survey was distributed after lab completion. Baseline demographic

experience was collected. Pre- and post-lab procedural confidence

was rated on a 6-point likert scale (1-6) with p values calculated

using the Wilcoxon Signed-Rank Test.

Results: 26 PA‟s participated in the course. All completed a pre and

post-lab assessment. No PA had done any one procedure more than 5

times in their career. Pre-lab modes of confidence level were ≤ 3 for

each procedure. Post-lab modes were ≥ 4 for each procedure except

arthrocentesis of the ankle and wrist. However, post lab assessments

of procedural confidence improvement was statistically significantly

for all procedures with p values < 0.05.

Conclusion: Midlevel provider‟s level of confidence improved for

emergent procedures after completion of a procedure lab using

lightly-embalmed cadavers. A mobile cadaver lab would be

beneficial to train rural providers with minimal experience.

17. Utilization Of Computed Tomography In Blunt Trauma:

When Is Thoracic And Lumbar Imaging Warranted?

Aalap Mehta, Laurie Byrne, Vicki Moran and Eric Armbrecht. St.

Louis University, St. Louis, MO

Background: Computed tomography (CT) is becoming the standard

of care for evaluating blunt trauma patients. Some clinicians argue

that all level I and II trauma patients should undergo whole-body

imaging even with a glascow coma score (GCS) of 15 and no clinical

evidence for spinal injury. Insufficient evidence exists to support

routine use of thoracic and lumbar CT in blunt trauma.

Objectives: To explore the association between available clinical

indicators and thoracolumbar fracture (TLfx) in the trauma setting

and determine if utilization of thoracolumbar imaging can be

modified.

Methods: This retrospective study included all level I/II blunt trauma

patients with spine fracture and GCS of 13+ presenting to St. Louis

University Hospital in 2009. The positive predictive values (PPV) for

TLfx was determined independently for clinical indicators (no back

pain and no other injury) and their combination. In addition, the

association between TLfx and cervical spine fracture (CSfx) was

estimated by phi coefficient of association. Subtypes of non-spinal

injuries (e.g., lower extremity, upper extremity, intrathoracic) were

assessed by descriptive statistics.

Results: Of the 216 adult patients with complete registry data records

included in this study, 72.2% had TLfx. The PPVs (and 95%

confidence interval) for clinical indicators of no back pain and no

other injury were 0.58 (0.34, 0.47) and 0.60 (0.47, 0.72), respectively.

The PPV for the combination of information about back pain or

injury was 0.63 (0.54, 0.71), indicating 63% of cases with no back

pain or no injury had a TLfx per CT. Of the 87 cases with CSfx, 38

(or 44%) also had TLfx. By comparison, 91% of the 129 cases

without CSfx had TLfx. The phi coefficient between TLfx and CSfx

was 0.52 (p < 0.001), indicating a weak positive association.

Intrathoracic and upper extremity were the two most common injury

subtypes associated with TLfx.

Conclusion: In this study of trauma patients with GCS 13+, having

no back pain was unreliable in ruling out TLfx for 59% of patients.

The overlap between TLfx and CSfx was relatively weak and

unrelated to known clinical factors, such as no back pain. This study

did not reveal back pain or injury as reliable clinical indicators to

rule-out TLfx. The study provides no evidence against the routine use

of thoracic and lumbar CT in blunt trauma patients.

18. Changing Presentation Rates For Mtbi (Concussion) And

Changing Imaging Rates

Han Huang1, Nick Echevarria1, David Milzman1, Carla Tilchin1 and

Ronny Song2. 1Georgetown University School of Medicine,

Bethesda, MD; 2Georgetown University, Bethesda, MD

Background: : Minor traumatic brain injury (mTBI or concussion)

has seen changes in resources devoted to education, and awareness as

well as structured limitations on athletic concerns. Few studies to

date have attempted to determine whether, increased occurrence is

related to change in injury patterns or improvements in physician

awareness and diagnosis.

Objectives: : To determine if mTBI rates are increasing faster than

all trauma and whether detection is related to better diagnosis or

increased occurrence including the use of advanced imaging rates

related to any possible increase in detection and utility.

Methods: the Emergency Department and Trauma Center records

were analyzed at ED and Trauma Centers in 2 metropolitan areas for

the past decade 2000-2010. Trauma registries and the AZYXXI

database (Microsoft; Redmond,WA) were analyzed for trauma

admits, and mTBI rates and treatment interventions including use of

radiographic study and dispositions. IRB approval and data analysis

was obtained and performed, respectively.

Results: : A 10 year study found rapid rise in past 5 year with

number of concussions which increased by 140% compared to ED

and Trauma patients increased only by 23.9%; p< 0.02.

(Figure 1) There were also increases in use of CT for concussion:

25.8% with less than 2% of mTBI having a positive finding on Head

CT and none requiring neurosurgical intervention.

Both number of concussions and admitted concussions experienced

the same rate of rise as number of concussions and equal AUC.

Conclusion: There has been an effective impact on mTBI

presentation and admission to our trauma centers in the past five

years. CT increased in use with no improved treatment intervention.

Future studies will need to determine utility of admit compared to

outpatient observation and neuropsychiatric intervention for isolated

mTBI.

19. Validity of the Triage Risk Screening Tool (TRST) and

Identification of Seniors at Risk (ISAR) Instrument As Predictors

for Mortality, ED Revisits, Hospital Admission, Nursing Home

Admission, and Functional Decline in Cognitively Normal and

Cognitively Impaired Geriatric ED Patients

Dan Feng, Sophia Li and Christopher R Carpenter. Washington

University School of Medicine, St Louis, MO

Background: ED revisit and post-ED hospitalization, nursing home

(NH) admission, and functional decline are key challenges for

improving geriatric medical care and quality of life. The Triage Risk

Screening Tool (TRST) and Identification of Seniors at Risk (ISAR)

were developed as prognostic tools to predict suboptimal post-ED

geriatric outcomes. These have only been validated in the regions

where they were derived, and the NIH has recommended further

research to confirm their ED applicability. In addition, TRST and

ISAR are not specifically validated for cognitively impaired

individuals, who comprise a majority of geriatric ED visits.

Objectives: To test the predictive validity of TRST and ISAR for

mortality, ED revisit, hospitalization, NH admission, and functional

decline at 30 days post ED in geriatric ED patients with 1) no

cognitive impairment and 2) suspected cognitive impairment.

Methods: This was a prospective, observational cohort study of all

consenting ED patients age 65 and older in a private, urban, academic

hospital between June 1 and July 31, 2011. Within a larger RCT,

trained geriatric technicians administered the Older American

Resources and Services Activities of Daily Living (OARS-ADL)

scale, Short Blessed Test (SBT) for dementia, TRST, and ISAR. At

30 days post enrollment, mortality, ED revisit, hospitalization, NH

admission, functional decline (a ≥3-point decline on OARS-ADL),

and the composite outcome were measured via telephone follow-up.

Participants were excluded at follow-up if they had received a

cognitive intervention used in the larger RCT. ROC curves with area

under the curve (AUC) and likelihood ratios were calculated for the

predictive validity of TRST and ISAR in individuals with no

evidence (SBT score≤4) and evidence (SBT>4) of cognitive

impairment.

Results: Participants (N=168) had a mean age of 74, were 43.1%

male, and 62% African-American. TRST and ISAR stratified 81%

and 79% at high risk for composite outcome (score>2). TRST and

ISAR had AUCs of 0.64 and 0.70 for composite outcome in all

participants at 30 days, exhibiting poor and moderate validity,

respectively. ISAR had moderate predictive validity for composite

outcome in patients with no cognitive impairment (-LR = 0.20,

N=25).

Conclusion: ISAR has some validity for suboptimal outcomes in

geriatric ED patients with no cognitive impairment. Further study is

necessary to verify precision.

20. Diagnostic Accuracy of Various Health Literacy Screening

Tools in the Emergency Department

Andrew Melson, Christopher Carpenter and Richard Griffey.

Washington University in St. Louis School of Medicine, Saint Louis,

MO

Background: Health literacy is an important determinant of health

outcomes that concerns how well a patient can obtain, process and

understand health information needed to make appropriate health

decisions. Inadequate health literacy has been linked to poor

medication adherence, increased, longer hospital stays and greater

emergency department (ED) utilization. A recent systematic review

of health literacy and ED outcomes identified only one study using

more than one screening tool. We are not aware of any studies

comparing the diagnostic accuracy of various screening tools in the

ED setting.

Objectives: We compare the diagnostic accuracy of commonly used

health literacy screening tools in ED patients.

Methods: We performed a prospective, observational convenience

sample study of adult ED patients presenting from March - July 2011

to an urban, academic ED with 97,000 annual visits. Exclusion

criteria included: patients with aphasia, known dementia, mental

retardation, inability to communicate, non-English speaking or too ill

to interview as determined by physicians. We screened participants

using the short versions of the Test of Functional Health Literacy in

Adults (S-TOHFLA) and the Rapid Estimation of Adult Literacy in

Medicine (REALM-R), the Newest Vital Sign (NVS) and a panel of

3 single item literacy screens (SILS) used in prior studies. Results for

S-TOFHLA were dichotomized, combining marginal and low health

literacy strata. Three separate Likert-style SILS questions were asked

such as: How confident are you filling out medical forms by

yourself? Primary outcome measures were screening test

characteristics, comparing each with the S-TOFHLA as the criterion

standard, based primarily on its wide use for this purpose.

Results: 262 patients participated. Participants were 55% female,

31% white, 68% black and 1% other race, with an average age of

43.8 years. The S-TOFHLA, REALM-R and NVS identified 20.2%

49.6% and 75.6% respectively as having inadequate or marginal

health literacy.

Conclusion: In ED patients, when compared to the S-TOFHLA, the

NVS and SILS3 had the highest sensitivity (100%) and specificity

(95%) respectively in identifying low health literacy. The importance

of these test characteristics depends on the goals in performing health

literacy screening and must be balanced against other considerations

for screening in the ED such as feasibility and usability.

Diagnostic Accuracy of Screening Tools Compared to S-TOFHLA

Sensitivity

95% Confidence

Interval

Specificity 95% Confidence

Interval

Positive Likelihood

Ratio

95% Confidence

Interval

Negative Likelihood

Ratio

95% Confidence

Interval

REALM-

R 85% 72-93 59% 52-66 2.1 1.7-2.5 0.25 0.13-0.5

NVS 100% 92-100 31% 25-37 1.4 1.3-1.6 0 0

SILS1 33% 21-47 86% 80-90 2.3 1.4-3.8 0.8 0.65-0.95

SILS2 51% 37-65 81% 75-86 2.7 1.8-3.9 0.6 0.46-0.80

SILS3 32% 20-46 95% 91-97 6.1 3.0-12.2 0.7 0.60-0.86

21. "What Did You Say?” Noise: Does It Distract From Patient

Care In The Emergency Department?

Laurie E Byrne, Peter Anaradian and Preeti Dalawari. St. Louis

University, St. Louis, MO

Background: Research in critical care units have shown that noise

exposure contributes to increased levels of stress and sleep

deprivation in patients. Noise has also shown to negatively impact

staff by increasing levels of stress and interfering with patient care.

The Environmental Protection Agency (EPA) recommends that

hospital noise levels should not exceed 40 decibels (dB). Previous

studies indicate that noise levels in the emergency department (ED)

have consistently exceeded this level. However, no studies evaluated

both ED staff and patients on the affects of noise on their care.

Objectives: The purpose of this study was to evaluate patient and

staff perceptions of noise exposure and quality of care in the ED.

Methods: The study was a cross sectional survey of a convenience

sample of ED patients and staff at an academic tertiary center during

three standard 8 hour ED shifts (day, evening, and overnight). The

questionnaire asked about perception of noise level, potential sources

of noise, and how it affected the quality of care using a 10-point

rating scale. A dosimeter was used to measure the noise level at the

time the questionnaires were distributed. Independent t-test was used

to evaluate differences in perception between staff and patients;

ANOVA was used to evaluate differences among shifts.

Results: In this study, 106 people participated; 57% were patients.

There was no difference in the perception of overall noise level

between patients and staff or by shift. Each group reported the noise

level to be moderately loud (5 out of 10). Both groups thought the

noise level interfered with patient care, but not to a significant degree

(3 out of 10). Both groups cited voices from people‟s conversations

and intercom use as a leading contributor to noise. The perception of

the telephone contributing to the noise level was reported by staff but

not by patients (p=0.001). There was a significant difference in noise

level among shifts with the evening shift noise level higher at an

average dosimeter reading of 80 dB (p value < 0.05).

Conclusion: The emergency department noise level was consistently

above the EPA‟s recommended noise level. However, both patients

and staff did not perceive any significant impact in care.

22. Undiagnosed Mental Illness in Children and Adolescents in

the Emergency Department

Yanika Wolfe and Dane M. Doctor. Rosalind Franklin

University/Chicago Medical School, North Chicago, IL

Background: Many patients present to the emergency department

with undiagnosed psychiatric illness that may cause or exacerbate

their presenting complaint. Pediatric and adolescent mental health

concerns are also particularly unaddressed, even though they

represent a key risk factor for later psychiatric problems. Early

diagnosis of these illnesses may improve treatment and referral for

patients with these problems.

Objectives: The objective of this study was to identify unsuspected

psychiatric illness in child and adolescent patients presenting to the

emergency department with non-psychiatric related complaints.

Methods: This IRB approved study involved enrolling a convenience

sample of 100 patients from a level I inner city teaching emergency

department, which sees 60,000 patients per year. The validated

interview tool, M.I.N.I. KID (MINI International Neuropsychiatric

Interview for Children and Adolescents) was administered to English

speaking patients between the ages of 12-17 presenting to the

emergency department with non-psychiatric complaints. Written

consent was required from both the patient (minor) and

parent/guardian. All consenting patients were given the MINI

Neuropsychiatric interview in the emergency department. Once

completed, the researcher scored the results. If the patient tested

positive for any disease modules, the researcher informed the

attending physician.

Results: A total of 40 patients were enrolled. The enrolled patient

body was 52.5% African American, 47.5% Hispanic, and 55%

Female. Overall, 40% of patients tested positive for one or more

undiagnosed mental illness. Of those that did test positive for

psychiatric illness based on the results of the MINI, the majority

62.5% had only one psychiatric illness. The most frequently

identified disorders were Oppositional Defiant Disorder (10%),

(Hypo)Manic Episodes (7.5%), ADHD (7.5%) and Hypomanic

Symptoms (25.0%). Only one patient was classified by the MINI as a

suicide risk. The physician and mental health crisis worker were

notified and the patient was given a suicide resource pamphlet.

Conclusion: This study gives strength to the argument that there is

significant undiagnosed psychiatric illness in young patients

presenting to the emergency department. Additionally, the notion that

the ED may be a good place to identify undiagnosed mental health

illnesses was also reinforced.

23. A Comparison of Diversion and No Diversion and the Effect

on patient Safety and Outcomes in the Emergency Department

Eman Spaulding, Laurie Byrne, Eric Armbrecht and Collin

Jackson. Saint Louis University, Saint Louis, MO

Background: Diversion is a controversial topic in emergency

medicine that produces debate on institution-specific and regional-

level policy. Our literature review revealed no prior studies on the

association between diversion and overall quality of care.

Objectives: The Emergency Department (ED) at Saint Louis

University, as well as all EDs in the region, adopted a new regional

zero diversion policy, effective Oct 2009. In this study we examine

how ED performance measures, including left without treatment

(LWOT), left without being seen (LWBS), left against medical

advice (AMA), deaths, and the average length of stay, changed after

the new policy.

Methods: We selected a six-month period (April through Sept)

before and after the zero diversion policy change to limit effect of

seasonal variation. A two-sided z-ratio was used to test the difference

between hospital-option and zero diversion policy periods for

LWOT, LWBS, AMA, deaths, and admission rate. Mean monthly

length of stay (in minutes) was assessed by a t-test for independent

samples.

Results: The total ED census during the two periods was

approximately the same. During the hospital-option period, diversion

was activated for an average of 7.0 hours per month. LWOT and

LWBS rates were 19.4% (p < 0.001) and 18.2% (p = 0.002) lower,

respectively, during zero diversion. There were no differences in

observed AMA (p = 0.183) or death rates (p = 0.653). Inpatient

admission rate was 4.4% higher during zero diversion (p = 0.009).

Diversion Policy Period

Hospital-option

(n = 18,108)

Zero

(n = 18,698)

Rates (per 1,000 Census)

P

LWOT

70.8 57.1 < 0.001

LWBS

28.7 23.5 0.002

AMA

13.3 11.7 0.183

Deaths

3.5 3.2 0.653

Inpatient

Admission 280.59 292.87 0.009

Length of Stay (minutes, mean + sd)

Admitted

334 + 11.0 329 + 11.8 0.496

Discharged

242 + 9.0 228 + 8.0 0.015

While there was no significant difference in average monthly length

of stay for admitted patients, discharged patients had faster treatment

times during zero diversion (228 + 8.0 minutes) versus hospital-

option (242 + 9.0 minutes), p = 0.015.

Conclusion: Adopting a zero diversion policy was not associated

with increased rates of death, AMA or overall ED length of stay. Our

results revealed improvements in key performance measures,

including rates of patients leaving without being seen or treated, and

decreased length of stay for discharged patients.

24. Impact Of Presence Of Third Molars On Mandible Fractures

Following Facial Trauma

David Milzman1, David Weiner2 and Ryan Murray1. 1Georgetown

University School of Medicine, Washington, DC; 2Georgetown

University School of Medicine, Bethesda, MD

Background: Facial trauma is a common cause of Mandible fracture.

The majority are young men, and the mechanism of injury is often

due to assault, vehicular accident, or falls.

Objectives: To determine if the presence of third molars particularly,

impacted teeth create a increased risk for mandible fracture compared

to persons with an already extracted third molar due to ossification

and stronger mandible in that region.

Methods: Retrospective analysis of four years of consecutive

presentations of mandible fractures to the emergency and trauma

center was performed. Radiographic analysis by expert reviewers

confirmed the presence and location of fractures and third molars as

well as the angulation of the third molar.

Results: A total of 569 patients were evaluated with 34 excluded due

to incomplete data. The mean age of patients was 29.6 (95% CI: 26.7

to 31.5) with 87% male, 71.5% AA and 12.1% Caucasian were

included. 312 Pts were admitted for immediate fixation (54.8%).

82.4% had third molars present, with 53% impacted and 47% non-

impacted. 95.9% (513) sent for evaluation had a fracture, with 82%

requiring operative repair and fixation. 62.4% of pts underwent

ORIF, 52.4% were fitted with arch bars, and 36% also required

extraction.

Sensitivity of third molars predicting angle fractures was 88.31%. An

odds ratio of 2.4 was calculated for the presence of impacted third

molars and mandible angle fractures (95% CI: 1.664-3.448). An odds

ratio of 3.6 was calculated or presence of all impacted and non-

impacted third molars and mandible angle fractures (95% CI: 2.52-

5.347)

Conclusion: The presence of a third molar increases the likelihood

of a mandible angle fracture following trauma. The presence of an

impacted third molar results in the leading point for a fracture site.

Strong recommendations for prophylactic removal of third molars

may be indicated for all student and professional athletes alike who

participate in contact sports.

Oral Presentation Session 2

11:00am-12:00pm

25. Mild Cognitive Impairment: A Pilot Study To Evaluate The

Montreal Cognitive Assessment Screening Tool For Use In Urban

Aging African Americans Who Present To The Emergency

Department

Kanika A Turner and Christopher R Carpenter. Washington


Background: Mild cognitive impairment (MCI) is a transitional state

between normal aging and dementia with preserved activities of daily

living. Detecting MCI in aging adults who present to the Emergency

Department (ED) is critical for prevention and treatment of

dementing illnesses. Additionally, disparities in cognitive

impairments exist between aging African Americans (AA) and

Caucasian Americans (CA). The Montreal Cognitive Assessment

(MoCA) is a screening tool used to detect MCI.

Objectives: To evaluate and compare the diagnostic accuracy

between AA and CA of the MoCA in an ED setting for detection of

MCI.

Methods: This was a cross sectional, consecutive sampling study.

Eligible subjects were consenting English-speaking community

dwelling patients over age 65. Exclusion was based on ED physician

judgment, caregiver‟s refusal, or residence >30 miles from hospital.

Trained researchers administered the Brief Alzheimer‟s Screen

(BAS), Short Blessed Test (SBT), AD8, and MoCA. MCI was

defined as a MoCA score <26. Chi-square analyses were performed

with MoCA scores. Diagnostic accuracy of the BAS, SBT, and AD8

to detect MoCA-defined MCI was assessed using SPSS.

Results: We enrolled 165 patients: 61% AA, mean age 74 years,

39% with < 12th grade education, and 57% female. MCI was

detected in 85% of patients who completed the MoCA with 97%

MCI incidence in AA and 66% in CA.

Conclusion: The MoCA is not an ideal MCI-screening instrument in

the ED. The incidence of MCI as judged by the MoCA is

unacceptably high and likely an epiphenomenon reflective of the

difficulty of administering the test in ED settings, particularly for

AA, but also for CA. The incidence of MCI should not be >50% in

either ethnic group.

Diagnostic Test Characteristics of BAS, SBT, and cAD8 using MoCA as gold standard

Sensitivity

(95% CI)

Specificity

(95% CI)

Positive

Likelihood

(95% CI)

Negative

Likelihood

Ratio (95%)

AUC-All

(95% CI)

AUC-AA

(95% CI)

AUC-CA

(95% CI)

BAS,

n=128 85 (63-96) 61 (57-63) 2.2 (1.5-2.6) 0.25 (0.06-0.65)

0.781

(0.676-

0.887)

0.906

(0.797-

1.00)

0.676

(0.524-

0.828)

SBT,

n=127 90 (69-98) 45 (41-47) 1.6 (1.2-1.8) 0.22 (0.04-0.77)

0.697

(0.599-

0.794)

0.837

(0.697-

0.977)

0.559

(0.403-

0.714)

cAD8

, n=61 67 (38-88) 49 (42-54) 1.3 (0.65-1.9) 0.68 (0.22-1.5)

0.557

(0.387-

0.726)

N/A

0.508

(0.305-

0.710)

26. Cardioprotection by Endogenous Fibroblast Growth Factor

2 in Cardiac Ischemia-Reperfusion Injury In Vivo

Stacey L House, Carla Weinheimer, Attila Kovacs and David

Ornitz. Washington University in St. Louis, St. Louis, MO

Background: Fibroblast growth factor 2 (FGF2) has been shown to

be cardioprotective in many in vitro and ex vivo models of cardiac

ischemia. Limited data is available on the ability of FGF2 to protect

the heart in vivo.

Objectives: The objective of this study was to determine the

cardioprotective efficacy of endogenous FGF2 in a closed chest

model of regional cardiac ischemia-reperfusion (IR) injury.

Methods: Mice with a targeted ablation of the Fgf2 gene (Fgf2

knockout) and wildtype controls were subjected to a closed chest

model of regional cardiac IR injury to assess the cardioprotective

efficacy of endogenous FGF2. In this model, mice were subjected to

90 minutes of occlusion of the left anterior descending artery

followed by reperfusion for 7 days. Transthoracic echocardiography

was performed on post-ischemic day 1 and day 7 to assess for cardiac

function (ejection fraction) and myocardial infarct size (wall motion

abnormalities). Histological analysis of myocyte cross-sectional area

and vessel density and size was performed.

Results: Mice with a targeted ablation of the Fgf2 gene do not show

any abnormalities in cardiac morphometry or function. When

subjected to closed chest regional cardiac IR injury, Fgf2 knockout

mice had significantly increased myocardial infarct size as measured

by echocardiography compared to wildtype mice at both 1 day and 7

days post-IR injury (p<0.05). In addition, Fgf2 knockout animals

showed significantly worsened cardiac function at 1 day and 7 days

post-IR injury (p<0.05). Myocyte cross-sectional area in the peri-

infarct area showed no difference between Fgf2 knockout and

wildtype mice suggesting no difference in post-ischemic cardiac

hypertrophy. Fgf2 knockout mice have normal vessel density

compared to wildtype controls in the non-injured state. After cardiac

IR injury, Fgf2 knockout hearts showed significantly decreased

vessel density and increased vessel diameter compared to wildtype

controls (p<0.05) suggesting a defect in vascular remodeling in the

Fgf2 knockout mice after IR injury.

Conclusion: Endogenous FGF2 improves cardiac function, reduces

myocardial infarct size, and mediates vascular remodeling after

cardiac IR injury. These data show the cardioprotective potential of

endogenous FGF2 in a clinically relevant, in vivo, closed chest

regional cardiac ischemia-reperfusion model which mimics acute

myocardial infarction.

27. The Correlation between Health Literacy and Numeracy in




MO

Background: Although health numeracy is often considered a subset

or domain of health literacy, very little research has been done

showing a direct relationship between the two.

Objectives: To explore the correlation between health literacy and

numeracy in an emergency department (ED) setting.

Methods: We performed a prospective, observational convenience

sample study of adult ED patients presenting from March - July 2011

to an urban, academic ED with 97,000 annual visits. We enrolled 262

patients with sub-acute illness. Measurements of numeracy and

health literacy consisted of 4 validated questions and 3 commonly-

used screening tools (Short Test of Functional Health Literacy in

Adults (S-TOFHLA), Rapid Estimate of Adult Literacy in Medicine-

Revised (REALM-R), and Newest Vital Sign (NVS)) respectively.

Results: Numeracy performance was universally poor, with 11/262

subjects (4.2%, 95% CI 2.3,7.5) correctly answering all questions,

and a mean proportion of correct responses of 36.8%. Proportions of

low or marginal health literacy as determined by the 3 screening tools

varied significantly (S-TOHFLA: 20.2%, REALM-R: 49.6% , NVS:

75.6%, n=262 for all). However, correlation of each with health

numeracy was low-to-moderate (S-TOFHLA: 0.416, REALM-R:

0.363, NVS: 0.499. p<0.001).

Conclusion: We observed varying degrees of health literacy but

near-universal poor performance on numeracy testing. Correlations

between numeracy and health literacy were low to moderate. Insofar

as numeracy is considered a subset of health literacy, our results

suggest that commonly used health literacy screening tools in ED-

based studies inadequately evaluate and overestimate numeracy. This

suggests the need for separate numeracy screening. Providers should

be sensitive to potential numeracy deficits among those who may

otherwise have normal health literacy.

28. Cost-Benefit Analysis of Specialized Screeners in the

Emergency Department and of Memory and Aging Project

Satellite Intervention

Charlene W Lai1 and Christopher R Carpenter2. 1Saint Louis

University School of Medicine, St. Louis, MO; 2Washington

University School of Medicine in St. Louis, St. Louis, MO

Background: Cognitive dysfunction is an expensive diagnosis that is

increasing in the United States. The lack of health care providers able

to correctly diagnose dementia and delirium creates a missed

opportunity to decrease costs and slow disease progression.

Objectives: The purpose of this study is to evaluate the costs and

benefits of training screeners to detect cognitive dysfunction in older

adults in the Emergency Department (ED) and the subsequent referral

to the Memory and Aging Project Satellite (MAPS).

Methods: In a blinded, randomized controlled study at one urban

academic medical center, geriatric screeners collected patients‟

responses to the Short Blessed Test (SBT). Consenting subjects were

English-speaking adults > 65 years who lived within 30 miles of

Saint Louis, MO. Subjects were excluded if they were deemed too ill

to participate by the attending physician, institutionalized, and for

those with cognitive impairment, lacked caregiver consent.

Abnormally scoring subjects were referred to MAPS, a free

community resource that offers an in- home safety assessment,

memory testing, caregiver counseling, and physician referrals. An

abnormal result was defined as a score> 4 on the SBT. Followup

phone calls to patients were made at a 1-month interval. Costs of ED

visits, hospitalization, and institutionalization were found using the

Medicare Expenditure Panel Survey, Healthcare Cost and Utilization

Project, and National Health Expenditure Database. A decision

analytic approach was used to analyze the data. One dimensional

microsimulation and sensitivity analysis were used to test the

robustness of the model and to identify critical uncertainties in the

parameters.

Results: The prevalence of cognitive dysfunction in adults>65 in the

ED was 52.8%. Assuming a 20% improvement in patient outcomes,

screening and MAPS referral were shown to reduce the cost of

patient care by $410, on average. A 40% improvement in outcomes

would reduce the cost by $714, and a 10% improvement by $105.

Conclusion: Preliminary analysis indicates that screening and MAPS

referral reduces cost of patient care. This study has several

limitations. First, this study was conducted at a single urban academic

medical center; results may not be generalizable to populations that

differ significantly from the one studied. Second, cost data found was

not specific to the hospital where the study was conducted.

29. Ultrasound Simulation Training: Location of Central Venous

Catheter Guide Wire Position

Melissa Thomas1, Charles Schmier2 and Michael Wadman1. 1University of Nebraska Medical Center, Omaha, NE; 2University of

Arizona Medical Center, Tucson, AZ

Background: Placement of a central venous catheter (CVC) is an

important procedure commonly performed by Emergency Physicians

(EPs). The technique of using ultrasound (US) to confirm that a guide

wire is positioned in the internal jugular vein (IJ) prior to dilation and

canulation has been described. To our knowledge however, no study

has used a control group of guide wires incorrectly positioned in the

carotid artery (CA) when assessing the effectiveness of this

technique.

Objectives: Determine the accuracy of EPs in detecting the location

of a CVC guide wire with the use of ultrasound on a CVC training

model.

Methods: Single blinded cross-sectional study. Prior to study

participant engagement, a CVC guide wire was positioned in either

the IJ or CA of a Blue Phantom(TM) head and torso model designed

for US guided CVC simulation training. Subjects were blinded to the

position of the guide wire. Each participant used a high frequency

linear probe with a Sonosite M-Turbo(TM) US system to detect the

location of the guide wire. Study participants were tested twice, once

with the guide wire in the IJ and once with it placed in the CA.

Sensitivity and specificity were summarized using descriptive

statistics with the associated 95% confidence intervals.

Results: A total of 46 US examinations were performed by 23 EPs

with varying levels of experience; 14 first year residents, 4 second

year residents, 4 third year residents, and one attending participated.

The guide wire was positioned in the IJ for 23 examinations and in

the CA for 23 examinations. The guide wire location was correctly

identified in 43 of the 46 examinations. Correctly localizing the guide

wire as positioned in the IJ (occurred 21 of 23 attempts) was

considered as a true positive, correctly localizing the guide wire as

positioned in the CA (occurred 22 of 23 attempts) was considered as

a true negative. EPs use of US yielded a sensitivity of 91% (CI 70,

98), specificity of 96% (CI 76, 99), positive predictive value of 96%

(CI 75, 99), and negative predictive value of 92% (CI 72, 99).

Conclusion: EPs performed well in the use of US to localize guide

wire position on a CVC training model.

30. Application of Lean Principles of the Toyota Production

System Lead to Greatly Improved Door to Needle Times

Matthew Rudy1, Andria L Ford1, Jennifer A. Williams2, Naim

Khoury1, Tomoko Sampson1, Craig McCammon2, Shawn O'Connor1,

Jin-Moo Lee1 and Peter Panagos1. 1Washington University, Saint

Louis, MO; 2Barnes Jewish Hospital, Saint Louis, MO

Background: Recent analysis has shown that less than a third of

patients treated with intravenous tissue plasminogen activator (tPA)

had door-to-needle times (DTN) within the „Golden Hour‟

recommended by current guidelines. It has been suggested that

shorter DTN is associated with improved outcomes and lower in-

hospital mortality.

Objectives: To apply Toyota Lean manufacturing principles to

improve ED DTN in acute ischemic stroke (AIS) patients receiving

IV tPA.

Methods: In March 2011, a prospective analysis of all AIS patients

presenting to the ED were treated employing Lean manufacturing

principles to improve tPA DTN. Lean techniques such as value-

stream mapping, just-in-time delivery, workplace organization,

reduction of systemic wastes, use of workers for quality improvement

and ongoing process refinement formed the basis of modifications.

Since 2004 detailed data has been kept on all patients given tPA,

including times of symptom onset, ED presentation, and tPA therapy,

adverse outcomes and discharge location. Statistical analysis was

performed to evaluate for reduction in DTN, adverse outcomes and

discharge destination. Data was available for four months post VSA.

A control group was selected with all tPA patients that presented

during the four months immediately prior to the process change. In

addition a four-month period exactly one year prior to the process

change was chosen for comparison to account for any seasonal

variation.

Results: In the post intervention group, 37 patients received tPA with

a mean DTN of 37 minutes (95% CI 28-52). Intracerebral

hemorrhage (ICH) was seen in 2/37 patients. In the four months prior

to change, 28 patients were treated with tPA, mean DTN of 64

minutes (95% CI, 51 -77), ICH seen in 4/28 patients. One-year prior,

14 patients were treated with tPA, mean DTN 59 minutes (95% CI,

51 - 67), ICH noted in 2/14 patients. There was a significant

reduction in DTN comparing the post VSA group to both other

groups, p=0.001, p=0.011 respectively. No statistically significant

difference in occurrence of ICH was observed. Discharge location

data was evaluated categorically, with no significant difference

observed.

Conclusion: Lean-manufacturing principles utilized in the treatment

of AIS can significantly improve DTN without significantly

compromising safety or favorable discharge location.

Lightning Oral Presentation Session 2

1:40pm-3:00pm

31. Impact Of Teaching Life Saving Procedures To First Year

Medical Students

Michael Ybarra, Ryan Murray, David Weiner and David

Milzman. Georgetown University School of Medicine, Bethesda, MD

Background: : A fear of first year medical students involves a

scenario where they are looked to for help in a medical emergency.

\While students may have learned about the life saving effects of

epinephrine in anaphylaxis, they may be unaware of how to

administer an epinephrine auto injector.

Objectives: The purpose of our “Introduction to Life Saving

Procedures” course for the first year medical students is to provide

basic knowledge and practical skills such as taking a pulse, assessing

respirations, caring for a choking victim, using an automatic

defibrillator, and an epinephrine auto injector.

Methods: A core curriculum was developed for first year medical

students and offered electively for one three hour session. A pre-

session survey was given to students to assess for prior medical

experience and knowledge of these potentially life saving sills. The

same survey was given one week after the session.

Results: The pre-session survey confirmed our suspicion that most

students had little knowledge of important, potentially life saving

skills. Only 20% of respondents correctly stated how to assess a

patient‟s respirations and 24% could correctly state the number of

chest compressions needed in cardiac arrest. Sixty-two percent of

respondents listed one or more appropriate critical actions items if

witness to a motor vehicle collision. None of the respondents

correctly stated the three-step method for using an epinephrine auto

injector.

The post-session survey showed significant improvement. There was

a statistically significant improvement in the number of students able

to describe the method for using an epinephrine auto injector (91% of

respondents, p < 0.001). There was also significant improvement in

the correct responses to the number of chest compressions needed in

cardiac arrest and critical action items if witness to a motor vehicle

collision (p values < 0.001 and = 0.007).

Conclusion: First year medical students had a low level of

knowledge and skills required of healthcare providers prior to a

course “Introduction to Life Saving Procedures.” There was

statistically significant improvement in nearly all categories.

Although there was no documented use in life=saving situation future

studies will track the actual value of this course.

32. Association of Falls with Sarcopenia and Frailty in Older

Adults Presenting to The Emergency Department

Denis T.K. Balaban, Steven Abboud, BS, Stephanie Chang, BS, Dan

Feng, BS, Grant M. Fischer, BS, Jessie Hu, BS, Charlene Lai, BA,

Sophia Li, BS, Owais Nadeem, Ross Passo, Taylor Real, Kanika

Taylor, BS, Lila Wahidi, Christopher R. Carpenter, MD, MS.

Washington University in St. Louis, St. Louis, MO

Objectives: Falls are an increasing and preventable source of injury

in older adults presenting to the emergency department (ED). There

exists a scarcity of independent ED-validated falls risk factors.

Identification of risk factors may lead to effective and resource-

efficient falls prevention programs. This study‟s objective is to

investigate the association of falls one month after an ED visit with

grip strength and Deficit Accumulation Index (DAI) score.

Methods: In a prospective observational study at one urban

academic, university-affiliated medical center, trained geriatric

technicians (GTs) measured grip strength, administered the DAI, and

obtained patients‟ falls history as part of a larger study examining

cognitive dysfunction in ED patients 65 or older. One month

following an ED visit, GTs contacted participants by phone to

identify subsequent falls. Association of grip strength and DAI with

one-month fall incidence was measured using Spearman‟s rho for

non-parametric data.

Results: The prevalence of low grip strength, defined as below age,

sex, and height norms, among 38 participants with complete follow-

up was 24%; falls were self-reported in 11%. Using Spearman‟s rho,

no significant correlation was identified between 1-month falls and

grip strength (females: rs = -0.142, p>0.4; males: rs = 0.000, p>0.90)

or between 1-month falls and DAI score (females: rs = 0.107, p>0.60;

males: rs = 0.336, p>0.10).

Conclusions: There exists a minimal association of 1-month falls

with grip strength and sarcopenia. However, due to follow-up

limitations in determining one-month falls, the number of reported

falls was most likely underestimated. The study can be improved by

giving participants a falls calendar, as used in other falls studies,

which would improve follow-up and recollection of falls.

33. Impact Of Airline Flight On Professional Athletes Following

Minor Traumatic Brain Injury (mtbi) In Terms Of Total Games

Missed Due To Injury

David Milzman1, Jeremy Altman2, Matt Milzman2, Chris Fleury2 and

Carla Tilchin3. 1Georgetown University School of Medicine,

Bethesda, MD; 2Georgetown University, Bethesda, DC; 3Bates

College, Bethesda, ME

Background: Air travel may be associated with unmeasured

neurophysiological changes in an injured brain that may impact post-

concussion recovery.

Objectives: To determine if air travel within 6-12 hours of

concussion is associated with increased recovery time in professional

ice hockey players (NHL)

Methods: Prospective cohort study of all active-roster National

Hockey League players during the 2010-2011 seasons

Review of all NHL injuries and games missed based on team website

and confirmed with NHL accounts via website.

Results: : During the 2010-2011 hockey season, 101 players

experienced a concussion. Of these, 39 (39%) flew within 12 hours of

the incident injury. The average distance flown was 1060 miles and

all were in a pressurized cabin. However, the median number of

games missed for head-injured NHL players who traveled by air

immediately after concussion, 6.5 (IQR 3-18), was significantly

higher than the median number missed for those who did not travel

by air (5: IQR 3-12; p <0.01); a 30% increased missed number of

games.

Conclusion: While other confounding factors must also be

considered, early air travel post concussion is associated with

significantly longer recovery times in professional ice hockey

players.

34. Can Ambulances Be Triaged To Urgent Care Centers Based

On Chief Complaint?

Tina Khosla, Joseph Delucia, Ting Zhang and William Terrin. St.

Louis University Hospital, St. Louis, MO

Background: Overcrowding and long waits are well known to the

emergency department. This study was designed to help create a

more efficient practice where people can be served their health care

needs in a faster fashion and help reduce the patient load in the

emergency department.

Objectives: This study focused on developing a system for

Emergency Medical Services (EMS) to take patients to an

appropriate place, whether it is to an emergency department (ED) or

an urgent care center based on their chief complaint.

Methods: This study was a retrospective study looking at medical

records acquired in the ED at St. Louis University Hospital. We used

the records of patients that were brought in by ground EMS. We

excluded all special populations, including pediatric, incarcerated,

pregnant, patients older than 90, and patients with cognitive

impairment. We looked at the chief complaint and the disposition of

the patient to see if the chief complaint can be safely triaged to urgent

care centers. We determined that a chief complaint can be considered

safe if there was a 95% discharge rate with minimal intervention

which is defined as history and physical, lab work and plain films.

Results: We analyzed 9,620 records after exclusions and grouped

them by chief complaint. We included chief complaints if there were

greater than 7 of the same chief complaint. We found 10 chief

complaints that were discharged with a rate greater than 95%. We

then took those 10 chief complaints and investigated what treatment

was completed in the emergency department. Patients with the chief

complaint of toothache, insect bite, and needle stick exposure were

discharged 97%, 95%, 100% respectively with minimal intervention.

Conclusion: EMS can likely safely triage patients to urgent care

centers if they have a chief complaint of toothache, insect bite and

needle stick exposure. This study was intended to be the beginning of

an investigation to start the triage system of EMS to urgent care

centers instead of coming straight to an ED to help provide patients

with faster more appropriate care and secondarily decreasing

overcrowding in the ED. Further studies can break down EMS

gestalt, age, sex, vital signs for triaging purposes.

35. A Cost Benefit Analysis Of Ultrasound Programs For

Central Venous Cannulation

Daniel L Theodoro. Washington University School of Medicine in St.

Louis, St. Louis, MO

Background: Ultrasound (US) guidance for assistance of central

venous cannulation (CVC) has widespread acceptance in teaching

hospitals. Survey data suggests that penetration of US technology

may lag in other hospitals. Barriers might include cost, re-

imbursement and physician acceptance.

Objectives: To perform a cost-benefit analysis comparing

Emergency Departments (ED) with US programs to those without US

programs (ED LM) from the perspective of the provider. The

provider perspective was chosen to inform purchasers who may cite

cost and re-imbursement issues as primary barriers.

Methods: We created a Markov decision model (TreeAge Pro 2009

Healthcare Suite, Williamstown, MA) to estimate the cost benefit of

an ED US program compared to ED LM. Through literature review

adverse event data was obtained on pneumothorax, central line

associate blood stream infections (CLABSI), and catheter related

thrombosis. Vascular complications (e.g. hematoma) were not

included since little evidence suggests they have clinical

consequences. Cost data regarding equipment, time-savings, and

complications were obtained from the literature. Deterministic

sensitivity analyses and Monte Carlo simulation for 10,000 samples

were conducted to account for the uncertainty in our model.

Results: The expected cost benefit to the ED US program was $455

compared to the ED LM program with a cost of $886. There was a

cost benefit to the ED US program until a threshold value of $1223

meaning that if the cost per ultrasound guided central line exceeded

this, a non-ultrasound guided program would be more beneficial.

There was greater cost benefit with the ED US program across all

probabilities of adverse events. The ED US program dominated the

ED LM program across all costs of CLABSI. The cost benefit of the

ED US was more sensitive to changes in the cost of thrombosis and

pneumothorax than CLABSI. Probabilistic sensitivity analysis also

confirmed a cost benefit to the ED US program ($515 compared to

$952). Tracker variables in our Monte Carlo model suggested that

while a greater proportion of CLABSI may occur in the ED US

program, the cost is offset by fewer thrombotic complications.

Conclusion: From the perspective of the provider, an US assisted

program has more cost-benefit than a LM program. Greater cost

savings may be realized avoiding thrombotic complications than

infectious complications.

36. Airway Management at a Regional Trauma Center: An

Analysis of Resident Experience

Jordan Sullivan and James McClay. University of Nebraska

Medical Center, Omaha, NE

Background: Competency in emergency airway management is

essential to the practice of emergency medicine.

Objectives: To determine emergency medicine resident airway

management methods and success rates at a regional trauma center by

post-graduate year (PGY) to compare to published benchmarks.

Methods: The Nebraska Medical Center (NMC) ED is a level I

regional trauma center treating 50,000 patients annually. The data

repository was queried to identify patients with emergency airway

management from 2006 through 2010. Record for patients with

emergency airway management (intubation) seen during the months

of October, November, and December were manually reviewed to

determine the operator, number of attempts, success or failure, and

devices used. These months were chosen to represent mid-year

resident skill levels. This was an IRB approved study.

Results: The NMC ED encountered a monthly average of 18.25

cases requiring emergency airway management during the study

period. Emergency medicine residents performed 72% of all initial

intubation attempts. The first operator was successful in 90% of cases

overall with 80% (± 4.5% over the years studied) on the first attempt.

Success rates on the first attempt were as follows: PGY 1 = 50%,

PGY 2 = 76%, PGY 3 = 84%, and attending physician = 84%.

Success rates by the first operator were as follows: PGY 1 = 50%,

PGY 2 = 87%, PGY 3 = 95%, and attending physician = 97%. There

was a 100% increase in the use of Video Laryngoscopes from 2006-

2010. Success rates with Video Laryngoscope were the same as with

standard laryngoscope.

Conclusion: Published benchmarks indicate that NMC resident

success rates are slightly below the North American benchmarks

(Sagarin et al. 2005). Success rates on initial intubation attempts

increased significantly over the 3 years of residency. Senior residents

(PGY3) obtained success rates nearly identical with attending

physicians. The increased use of video laryngoscopes did not have an

impact on intubation success rates. Intubation success was

determined most directly by experience level, not device. This single

center study demonstrates the success of airway management by

emergency medicine residents at the NMC. Sagarin MJ, et al.,

Airway management by US and Canadian emergency medicine

residents: a multicenter analysis of more than 6,000 endotracheal

intubation attempts, Ann Emerg Med, 2005, 46(4):328-336.

37. A Comparison of 3 Forms of Procedural Sedation for the

Reduction of Dislocated Total Hip Arthroplasty

Scott Burdette, Jonathan dela Cruz, Donald Sullivan, Eric

Varboncouer, Daniel O'Keefe, Joe Milbrandt, Myto Duong, Steven

Scaife, David Griffen and Khaled Saleh. Southern Illinois

University School of Medicine, Springfield, IL

Background: Hip dislocations post total hip arthroplasty (TAH) are

a common complaint seen in the emergency department (ED).

Patients who present to the ED most often require closed reduction

under procedural sedation as their initial form of treatment.

Procedural sedation for prosthetic hip reduction commonly involves

the use of an opiate/benzodiazepine combination (O/BZD),

etomidate, or propofol. All three forms of procedural sedation have

been documented as safe to be utilized in an ED setting, however

little has been studied comparing the effectiveness of these agents in

the reduction of dislocated hip prostheses.

Objectives: A retrospective review comparing TAH reduction

outcomes and complications with the use of O/BZD, etomidate, or

propofol as sedation agents.

Methods: A retrospective chart review was performed on 198

patients presenting to 2 academic EDs identified by CPT codes for

THA dislocations. They were subsequently grouped by sedation

modality. Primary outcomes measured included reduction

complications with skin injury, failure of reduction, neurovascular

injury, or fracture. Secondary outcomes measured included sedation

complications regarding airway compromise, utilization of a reversal

agent, inability to achieve sedation, and time to recover. These

outcomes were than analyzed using chi-square and ANOVA.

Results: 8.7% of propofol sedated patients (n=70) had reduction

complications, with 7.3% having sedation complications. 24.7% of

etomidate sedated patients (n=77) had reduction complications with

11.7% having sedation complications. 28.9% of O/BZD sedated

patients (n=55) had reduction complications, with 21.2% having

sedation complications. There were significantly less reduction

complications with propofol compared to the other agents (p=0.011).

Propofol, etomidate, and O/BZD had mean recovery times of 25.1,

30.8, and 44.4 minutes. Propofol had a significantly decreased

recovery time when compared to O/BZD (p=0.05).

Conclusion: Propofol, etomidate, and O/BZD are commonly used

agents in the sedation of TAH reductions in the emergency

department. In this small study, patients who received propofol had a

trend towards reduced complication rates and improved recovery

times. The use of propofol may lead to improved patient outcomes

and throughput given these results.

38. Knowledge of Alcohol Impairment in Boaters

Maria L Scarbrough and Preeti Dalawari. St. Louis University, St.

Louis, MO

Background: Alcohol is a factor in at least 60% of boating related

fatalities. Prior literature has shown that 30-40% of the participants

drank alcohol while boating, and they seldom knew the laws or

dangers associated with alcohol ingestion while boating.

Objectives: To our knowledge, this is the first study to directly

approach boaters at the dock to assess participants‟ knowledge

regarding alcohol impairment while boating.

Methods: This was a cross sectional survey of a convenience sample

of boaters aged 21 and older at 4 lakes in Illinois during July 2011.

Participants were asked to fill out an 8-question survey covering

knowledge about alcohol use and boating. Chi square analysis was

used to assess knowledge differences by demographic variables, as

well as boat ownership and seating position. Kruskal-Wallis assessed

differences by education level.

Results: 210 people participated. The majority of participants

correctly answered 4 of the 5 knowledge questions, including

84%correctly reporting the watercraft blood alcohol legal limit. 76%

admitted drinking alcohol while boating. 81% erroneously believed

that it was more dangerous for the driver to be intoxicated than the

passenger (N=194). There were no differences in knowledge by

gender, education, boat ownership or seating position. Participants

older than 40 years of age were more likely to know that being

intoxicated makes one 10 times more likely to drown (p<0.05).

Younger participants (age 21-40) were significantly more likely to

report drinking while boating compared to older participants

(p<0.05). Older participants were also more likely to own a boat and

be drivers (p<0.05).

Conclusion: A majority of participants imbibe while boating despite

a basic understanding of the dangers in doing so. Public health

officials may benefit from focusing education on the younger age

group of boaters to help decrease alcohol related morbidity and

mortality.

39. Got Wheels?--Adolescent Exposure to ATVs and Their

Driving Practices

Charles A Jennissen1, Denning Gerene1, Hoogerwerf Pam1, Peck

Jeffrey2 and Wetgen Kristel1. 1University of Iowa Hospitals and

Clinics, Iowa City, IA; 2U.S. Army Corps of Engineers, Iowa City,

IA

Background: All-terrain vehicle (ATV)-related injuries have almost

tripled in the past decade and residents in rural communities suffer

the brunt of this problem. More children die each year in the United

States from ATVs than from bicycle crashes. However, the degree of

adolescent exposure to ATVs is currently unknown. Education is

considered an essential element of improving ATV safety, but many

children receive little or no instruction.

Objectives: (1) Determine adolescent exposure to ATVs and their

operating practices. (2) Educate and help adolescents understand the

key principles for safely operating ATVs.

Methods: A community-based multi-disciplinary ATV task force

was formed and an educational program was developed highlighting

our ten “Safety Tips for ATV Riders” (STARS). The program was

presented at schools targeting 12-15 year olds. An audience response

system was utilized to obtain demographic information, determine

ATV exposure and safety knowledge, and assess knowledge

acquisition.

Results: A total of 2,200 students in 13 Eastern Iowa schools

received the ATV safety educational intervention. 78% reported

riding on an ATV at least a few times a year and nearly 30% stated

they ride an ATV at least once a week. Of those who reported having

been on an ATV in the past, 92% had ridden with more than one

person and 77% had been on a public road with an ATV. Nearly two-

thirds of those riding ATVs reported they never or almost never wear

a helmet. 57% of those with riding exposure had been in an ATV

crash (rolled over, fallen off, or hit something). On the three

knowledge questions, pre-intervention percent correct were 52%,

27% and 46%. This increased to 93%, 80% and 79% correct post-

intervention. 44% said that they were likely or very likely to use the

ATV safety tips they had learned during the intervention, while 36%

said they were unlikely or very unlikely to do so.

Conclusion: Adolescents in Eastern Iowa have a high exposure to

ATV riding. Most practice unsafe behaviors while riding ATVs and

the majority of adolescents exposed to ATVs have experienced a

crash. Most youth in the study demonstrated a deficiency in some

ATV safety knowledge. However, our classroom educational

intervention was able to increase short-term ATV safety knowledge

and a significant proportion of participants felt they would use the

safety information presented.

40. Feasibility of Using Health Literacy Screening Tools in an

Urban Emergency Department



MO

Background: Health literacy is an important determinant of health

outcomes. Deficits have been linked to poor medication adherence

and greater emergency department (ED) utilization. Validated

screening tools have been developed for general use, but health care

providers do not routinely perform such screening. One possible

reason is the amount of time and effort such assessments can require,

especially in the ED, where significant time pressures are the norm.

Lengthy screening tests not only take more time to administer but

also increase the potential for confounding interruptions.

Objectives: In a separate analysis of health literacy screening tools

we found the short versions of the Test of Functional Health Literacy

in Adults (S-TOHFLA), the Rapid Estimation of Adult Literacy in

Medicine (REALM-R), and the Newest Vital Sign (NVS) to identify

20%, 50% and 76% of ED patients as having low health literacy

respectively. In the present analysis, we aimed to assess the

feasibility of using these health literacy screening tools in the ED,

focusing on relative time burden and test interruptions.

Methods: We performed a prospective observational study of a

convenience sample of adult patients presenting during March and

April 2011 to an urban, academic ED with 97,000 annual visits.

Exclusion criteria included: patients with aphasia, known dementia,

mental retardation, non-English speaking or too ill to interview. We

screened participants using the S-TOHFLA, the REALM-R and the

NVS while documenting start and stop times as well as whether any

interruptions took place during test administration.

Results: In total, 249 patients were enrolled. Among participants,

54% were female, 31% white, 67% black and 2% other race, with an

average age of 43.5 years. On average, the S-TOHFLA took 5.84 (+/-

0.17) minutes to administer, while the NVS and REALM-R took 2.82

(+/- 0.17) and 0.64 (+/- 0.08) minutes, respectively. The S-TOHFLA,

NVS and REALM-R tests were interrupted 10.4%, 6.4% and 0% of

the time respectively.

Conclusion: The S-TOFHLA took on average, 3.02 minutes and 5.2

minutes longer than the NVS and REALM-R respectively. The S-

TOFHLA and the NVS were interrupted 10.4% and 6.4% of the time

respectively, with no interruptions of REALM-R. The S-TOFHLA,

often used as a criterion standard, identifies a lower proportion of ED

patients as having low health literacy but is lengthier and subject to

interruption.

41. Frequency and Mortality of Non-Contiguous Spine Fractures

with CT Scan Use

Vijai Chauhan1, Neelaysh Vukkadala2, Howard Place1, Laura

Sicking1, Lauren Segelhorst1, Eric Armbrecht2, Camelia Guild2 and

Preeti Dalawari1. 1Saint Louis University SOM, Saint Louis, MO; 2Saint Louis University, Saint Louis, MO

Background: : Spine fractures are common in trauma patients. Non-

contiguous spine fracture frequency in published studies is variable

(1.6%-16.7%). The published data on the diagnosis of spine fractures

commonly uses plain radiography as the imaging tool, but there are

limited studies using computed tomography (CT) scan.

Objectives: The purpose of this study was to assess the incidence of

non-contiguous spine fractures and the location pattern of these

fractures in trauma patients who underwent CT scan imaging and, to

assess the relationship between non-contiguous fractures and

mortality.

Methods: : This was a retrospective chart review of trauma patients

admitted between 2005-2010 at a Level 1 trauma center. All patients

with spinal fractures were identified through the trauma registry.

Demographics, vertebral injury, mortality, and time to diagnosis were

recorded. Delay in diagnosis, defined as greater than 60 minutes, was

based upon the time delay between the first and second spine

fractures being reported to the emergency department physician. Chi-

square analysis was used to determine a difference in mortality

between contiguous and non-contiguous fractures. Logistic

regression analysis was used to examine the association between non-

contiguous spine fractures and mortality after adjusting for potential

confounders.

Results: There were 2,222 cases of spine fractures of which 381

(17%) were non-contiguous; while our annual incidence ranged from

16% to 19% for the time period studied. The mortality rate for non-

contiguous spine fracture cases was 8.9% versus 5.5% for contiguous

cases (p= .011). Compared with contiguous spine fractures, patients

with a non-contiguous spine fracture had significantly higher odds for

mortality (aOR= 1.73, 95% CI 1.15-2.62). Of the 364 patients who

had a complete scan, the distribution of regional spine fracture

patterns were, cervical and thoracic (27.6%), thoracic and lumbar

(25.4.%), cervical, thoracic and lumbar (14.0 %), and cervical and

lumbar (12.2%). Neither fracture pattern nor a delay in diagnosis was

significantly associated with mortality.

Conclusion: According to our regional data, of those trauma patients

with spine fractures, approximately 1 in 5 will have non-contiguous

fractures. Non-contiguous spine fractures are associated with a higher

mortality rate.

42. Self-rated Health As A Predictor Of Emergency Department

Recidivism And Functional Decline Among Geriatric Patients

Stephanie K Chang1 and Christopher R Carpenter2. 1St. Louis

University, St. Louis, MO; 2Washington University in St. Louis, St.

Louis, MO

Background: Numerous cohort studies have found poor self-rated

health (SRH) to be a significant risk factor for mortality and

healthcare utilization. SRH assesses self-perceived health status

through a single, categorical question, and is associated with

mortality after adjustment for co-morbidities and functional status.

Objectives: To assess the prognostic accuracy of SRH for functional

decline and ED recidivism among geriatric patients, and to examine

how cognitive impairment influences the predictive value of SRH.

Methods: This study was a secondary analysis of data from a

randomized controlled trial, conducted within one urban academic

medical center in St. Louis, Missouri. Eligible patients were

community-dwelling individuals 65 years of age and older, who

presented to the study site ED between June 1, 2011 and July 31,

2011. Enrollment occurred through a consecutive sampling, with the

following exclusion criteria: residence outside of a 30-mile radius

from the study site, inability to speak English, physician judgment of

critical illness, and subject or caregiver refusal. SRH was assessed

through a single question from the Quality of Life in Alzheimer‟s

Disease subject report, and the Short Blessed Test was utilized for

cognitive screening. Information concerning ED recidivism and

functional decline was collected by telephone, at 1 and 3 months

following the index visit.

Results: As of July 14, 2011, 168 subjects have been enrolled, and

52 have provided 1-month follow-up data. 25 of these subjects were

cognitively normal, and 27 were cognitively impaired. For the

outcome of ED recidivism, sensitivity and specificity of poor/fair

SRH was 65% (95% CI 53-77) and 33% (24-43) for cognitively

normal patients, and 83% (42-99) and 33% (22-38) for cognitively

impaired patients. For the outcome of functional decline, sensitivity

and specificity of poor/fair SRH was 67% (45-87) and 42% (20-62)

for cognitively normal patients, and 83% (60-97) and 40% (22-51)

for cognitively impaired patients.

Conclusion: Preliminary analyses show that poor/fair SRH does not

significantly predict ED recidivism or functional decline, among

cognitively impaired or cognitively normal subjects. Thus, SRH

would not be a useful triaging tool for the ED. Significant limitations

include a lack of external validity, and reliance on patient self-report

during follow-up.

43. Stroke Volume Changes in ED Patients with Shock

Undergoing Serial Passive Leg Raising and Fluid Challenges

Stephanie Charshafian1, Ashley Janssen1, Christopher Holthaus1,

Brian Fuller1, Kevin Williams1, Enyo Ablordeppey1, Brian

Wessman1, Daniel Theodoro1, Ronald Chang1, Jennifer Williams2,

Thomas Ahrens2 and Richard Hotchkiss1. 1Washington University in

St Louis, St Louis, MO; 2Barnes-Jewish Hospital, St Louis, MO

Background: Stroke volume index changes with passive leg raising

have been shown to predict volume responsiveness.

Objectives: To estimate the positive predictive value (PPV) of

Passive Leg Raising (PLR) compared to 500ml saline boluses in ED

patients with shock.

Methods: This is a subset analysis of adult ED patients prospectively

randomized to fluid optimization (FO) in the ED between Aug 2010-

Aug 2011(ClinTrials ID: NCT01128413). The study is IRB approved

with informed consent and being conducted at an academic ED with

90,000 visits/yr. Inclusion criteria are vasopressor use, or SBP ≤90 or

MAP ≤65 after ≥20ml/kg IV fluids, or lactate ≥2.5 mmol/L.

Exclusion criteria are pulse oximetry <90% or inability to do PLR.

FO consists of non-invasive bioreactance monitoring of stroke

volume (Cheetah NICOM®) and PLR testing. Patients deemed

volume responsive (VR) receive a 500ml saline bolus if the PLR

percent change (%Δ) in stroke volume index (SVI) or cardiac index is

≥15%. PLR is repeated immediately after each bolus with repeat

boluses if ≥15%. If <15%, fluids are saline locked and PLR done

every 30 minutes. SVI changes are calculated as:

%ΔSVI=(Maximum challenge SVI-Average baseline SVI)/Average

baseline SVI. Paired Students t-Test and descriptive analysis were

performed (Microsoft® Excel).

Results: 7 patients (4 male) with a median age of 60 yrs (range 42-

87) underwent 69 PLRs. 40 of 69 (58%) PLRs were VR and received

fluid boluses. The median %ΔSVI are as follows: bolus 10% (IQR 1-

22), pre-bolus PLR 32% (IQR 24-39), and post-bolus 26% (IQR 11-

36). The pre-& post PLR %ΔSVI were statistically different when

compared to the bolus %ΔSVI (both p ≤ 0.01). The PPV of pre-&

post bolus %ΔSVI were 38% and 22% respectively. 10/40 (25%)

bolus events resulted in a negative bolus %ΔSVI.

Conclusion: In this small subset analysis, pre-& post PLR SVI

changes demonstrated suboptimal PPV when compared to fluid

challenges. More study is needed in ED patients and quantitative

incorporation of SVI changes with fluid boluses may be additionally

useful in guiding fluid administration.

44. Seeking a Functional Definition of Drug-Seeking Behavior

Benjamin Scallon, Mark Graber, Azeemuddin Ahmed, Kari Harland

and Gerene Denning. University of Iowa, Iowa City, IA.

Background. The 2005 National Institute on Drug Abuse (NIDA)

Research Report on prescription drug abuse and addiction estimated

that a startling 48 million Americans have used prescription

medication for illicit, nonmedical purposes. Approximately 80-90%

of misused prescription drugs are legally obtained through the

healthcare system, most often via emergency departments (ED).

Using an open-ended question, the top five drug-seeking criteria

listed by EM physicians were “multiple visits,” “multiple allergies,”

“asking for a drug by name,” “abnormal behavior” and “high-risk

complaint.”

Objective. The goal of this study was to determine whether top

criteria were consistent using a different survey method and if these

criteria or foils impacted decision-making.

Methods. ED physicians (n = 56) were randomized into three groups.

Each group was asked to evaluate three patient scenarios. Scenarios

between groups varied in detail. Participants scored the likelihood

that the patient was drug-seeking (10 pt scale) and indicated the

amount of drugs they would prescribe. Physicians also ranked their

top 5 out of 25 listed characteristics of drug-seeking behavior.

Results. Patient 1 mean scores for baseline history, history plus

multiple drug allergies, and history plus allergies and requesting a

specific drug were 4.3, 5.2, and 6.5 (overall p = 0.0023). Patient 2

mean scores for baseline history, history plus smoking/bad dentition,

and history plus smoking/bad dentition and prison tattoos were 5.8,

6.5, and 5.2 (overall p = 0.0949). Patient 3 mean scores for baseline

history, history plus stating Vicodin is ineffective, and history plus

Vicodin comment and white-collar occupation were 3.8, 5.1, and 4.9

(overall p = 0.2379). For patient 1, the length of the drug

prescription (days) exhibited a weak negative correlation with the

score given for the likelihood of being a drug seeker (r = -0.24). The

top five criteria chosen were “lying,” “multiple prescribers,” “history

of drug abuse,” “acting” and “the Iowa Prescription Monitoring

Program.”

Conclusions. The scenario portion suggests that ED physicians make

judgments based on commonly accepted drug-seeking criteria and

are, generally, unbiased against potential foils. Both survey methods

provide insights into physician decision-making, however, prompting

them with a list results in different selections.

45. Disposition Variability For Patients with Chest Pain Among

Emergency Department Physicians

David J Gresback and Michael D Zwank. Regions Hospital, Saint

Paul, MN

Background: Chest pain is a common presenting complaint to the

emergency department (ED) with high rates of hospitalization. There

is a high degree of variability in the management of these patients

including ultimate disposition.

Objectives: As a quality measure, we sought to examine the

variability of disposition among different emergency department

physicians in an effort to understand differences between practicing

pattern and as a baseline for further quality improvement initiatives.

Methods: In this retrospective chart review at an urban academic

emergency department, all visits with chief complaint of chest pain

from March 2011 to June 2011 were reviewed (n=1168). The charts

were examined with a one month follow-up looking at: disposition,

repeat visits, repeat hospitalizations and outcomes of interest. All

providers with less than 10 chest pain visits were excluded from

review. Outcomes of interest were defined as: unstable angina,

STEMI or NSTEMI, coronary artery bypass graft, percutaneous

coronary intervention or death. Acuity rate was calculated as

outcomes of interest divided by total chest pain patient visits. Acuity

admission index was calculated as acuity rate over admission rate.

Results: 31 out of 36 physician met inclusion criteria of at least 10

chest pain patient visits (mean=38). Mean admission rate was 0.55

(range 0.31-0.79). Outcomes of interest were seen in 77 patient visits

(7%) with 2 missed outcomes (one cardiac, one non-cardiac). No

provider had more than one missed outcome. Mean acuity admission

index was 0.15 (SD 0.10; range 0.0-0.37). No providers with lower

than the mean acuity admission index had a missed outcome. Five

providers had an acuity admission index more than one standard

deviation below the mean. Among these providers, 128 patients were

admitted with no outcomes of interest.

Conclusion: The acuity admission index may be a way to stratify

providers practice patterns in regards to disposition while accounting

for the acuity of patients seen. Only 1 cardiac outcome was missed

among 1168 patient visits. Our hospital will be instituting a low-risk

chest pain protocol which likely will lead to fewer admissions of low-

risk patients. This data set suggests that several providers and many

patients may benefit from such a protocol. The data set only included

three months of patient visits and may be limited by

this.

Poster Presentations

3:00pm-4:20pm

46. Characterization Of On-road ATV Crashes In Iowa From

2002-2009

Kevin Kremer, Gerene Denning, PhD and Christopher Buresh,

MD. University of Iowa, Iowa City, IA

Background: All-terrain vehicle (ATV) crashes result in over 500

fatalities each year and produce similar mortality rates and higher

rates of head and neck trauma as compared to motorcycles. A study

in Ohio showed worse outcomes for individuals involved in on-road

ATV crashes relative to crash victims at recreational parks. Iowa law

allows counties and cities to designate roads for ATV use; however,

the potential impact of increased on-road ATV use has not been

investigated.

Objectives: To determine demographics and crash mechanisms for

Iowa‟s on-road ATV crashes, and to develop public policy

recommendations based on these results.

Methods: The Iowa Department of Transportation (DOT) records

data for all ATV crashes on Iowa roads and highways including GPS

Coordinates of the location of the crash. GPS coordinates were

mapped in ArcGIS 10.0 using the Universal Transverse Mercator

coordinate system in zone 15N. Qualitative analysis of Iowa DOT

crash data was performed to characterize on-road crashes.

Results: There were 246 on-road ATV crashes reported by the Iowa

DOT from 2002 to 2009. Of these crashes, 78% of victims were male

(20% female, 2% unknown), 66% were 16 years old or older (22%

<16 years old, 13% unknown), and 13% involved passengers. 57% of

on-road crashes were collisions; 65% of those collisions involved

another vehicle. Mapping showed that on-road crashes happen in

both urban and rural areas.

Conclusion: Although it is illegal to carry passengers on ATVs in

Iowa, over 1 in 10 on-road crashes involved a passenger. It is also

illegal to ride ATVs on public roads; however, there were 246 on-

road crashes during the study period. Over 33% of these crashes

involved a collision with another vehicle, thus posing a general traffic

hazard. The number of on-road crashes in Iowa is alarming and some

occur at a significant distance from trauma centers. Based on our

findings, we would strongly recommend against counties and cities

designating roads and streets for ATV recreational use. Future

projects will include continuing crash surveillance and educational

efforts to inform the public about the dangers of on-road ATV use.

47. Differences In Perception About Access To Care Between

Patients Who Choose An Urban Academic Emergency

Department Over A Community-based Student-run Free Clinic

For Non-urgent Care

Matthew Dettmer1, Cerrone Cohen2, Edward Jauch3, Kit N Simpson3,

Brenda Walker3, Wanda Gonsalves3, Kathryn Koval3, Joshua Gray3

and Steven Saef3. 1Washington University Medical Center/Barnes-

Jewish Hospital, St. Louis, MO; 2UC Davis Health System,

Sacramento, CA; 3Medical University of South Carolina, Charleston,

SC

Background: Uninsured patients often choose the Emergency

Department (ED) over other suitable venues for non-urgent care.

Understanding patient preferences and obstacles to non-urgent care

can improve access to care.

Objectives: Characterize differences in perception about access to

non-urgent care by uninsured patients who present to an urban

academic ED vs. a community-based student-run free clinic (FC).

Methods: We compared responses of uninsured patients with non-

urgent complaints presenting to an urban academic level I

trauma/tertiary care ED with those of a FC using a prospective,

anonymous survey. Survey items evaluated patients' perceptions

about access to care which might explain their choice of venue. ED

patients with Emergency Severity Index (ESI) categories 4 or 5 and

selected category 3 patients (ambulatory, normal mental status, skin

warm and dry, no signs or symptoms of vital organ compromise)

were deemed non-urgent. All patients presenting to the FC were

deemed non-urgent. The study instrument was a 10 item survey

addressing Desirability of a FC over the ED (DFE); Transportation

Status (Access to a Car); Perceived Quality of Care; Usual Place of

Care; Importance of Cost; Self-Perceived Level of Illness (SPLOI);

distance to ED or FC, and patient demographics. All items were

answered on a 5-point Likert Scale. Scores from like items

addressing similar concerns were combined. A convenience sample

of 100 patients was obtained from each site. Comparisons were made

using Student‟s t-Test. Logistic regression was used to adjust for the

effect of significant variables, demographics, and distance on the

response to the item about DFE.

Results: Differences were noted between the ED and FC patients for

items regarding Cost (ED mean 4.31, FC mean 3.68; p=0.03) with

ED patients showing less concern about cost; Transportation (ED

mean 7.00, FC mean 8.01; p=0.003) with ED patients showing

greater concern about access to a car; and SPLOI (ED mean 2.87, FC

mean 3.40; p=0.01) with ED patients perceiving themselves as more

ill. No difference was noted between the groups regarding DFE after

adjustment (p=0.68)

Conclusion: Non-urgent, uninsured patients presenting to the ED

showed less concern about the cost of care, greater concern about

transportation, and felt themselves to be more ill than those

presenting to a FC. No difference was noted between the groups

regarding DFE after adjustment.

48. Preliminary Report On Factors Associated With Inadequate

Or Uninterpretable Cervical Spine Radiographs And Need For

Ct In Cervical Spine Trauma.

Richard Griffey, Betty Chen and Steven Katz. Barnes-

Jewish/Washington University in St. Louis, Saint Louis, MO

Background: Though cervical spine CT (CSCT) comprises an

increasing proportion of initial cervical spine (c-spine) imaging in

trauma, patients at low to moderate risk of injury often undergo

radiography (xrays) as the initial imaging modality. Initial screening

with CSCT in trauma has been demonstrated only to be cost-effective

for patients meeting specific high-risk criteria who are undergoing

concomitant head CT. For patients not meeting these criteria,

identification of patients likely to have inadequate or uninterpretable

c-spine xrays, requiring subsequent CT would aid in an evidence-

based approach in determining initial imaging modality and improve

upon imaging efficiency.

Objectives: To identify risk factors associated with inadequate

evaluation with xrays as a first step in further distinguishing which

patients would benefit from primary CT.

Methods: Setting: Academic, urban, level 1 trauma center with

87,000 visits. Participants: Trauma patients >18 years old with c-

spine xrays followed by CSCT in the ED. Design: Retrospective

observational study from March 2008-2010. We performed explicit

chart review of an electronic medical record for comorbidities,

medications and other features likely to result in inadequate xrays,

and noted the reasons for performing CT.

Results: Among 8752 visits with c-spine imaging, there were 4838

with CT, and 616 with xrays and CT. The latter had a mean age of 46

were 55% male and 52% black. Common mechanisms were motor

vehicle collision (282) and fall (177) and assault (50) with

Emergency Severity Index scores of 3 (358) and 2 (195). Arrival was

by ambulance in 405(65%). 5.7% of patients had chronic neck pain

or prior c-spine surgery. 5.7% of patients also had arthritis or bone

disease. 10% of patients were taking a steroid or a medication for

osteoporosis, and 9.4% were either unable to cooperate or had an

upper extremity injury. CT after xray was most often performed for

inadequate xrays (53%), degenerative disease (36%), and

malalignment (25%).

Conclusion: This preliminary review identifies chronic neck pain,

prior c-spine surgery, arthritis, osteoporosis, steroid use, and

behavioral issues as potential risk factors for inadequate or

uninterpretable c-spine xrays. Further study in a larger cohort of

control patients is underway to determine whether significant

differences warrant development of a clinical decision rule.

49. All Terrain Vehicle (ATV) Crash Fatality Surveillance

through Press Clippings

Gretchen McCall and Charles Jennissen, MD. University of Iowa,

Iowa City, IA

Background: ATV crashes are a growing source of injuries and

deaths, particularly in rural communities. Every year, ATV crashes

result in over 700 deaths and more than 130,000 ED visits. ATV

injury surveillance is extremely challenging and crash data must be

collected from many sources. Newspaper reports are an untapped

resource to investigate the factors and variables surrounding ATV

crashes.

Objective: The objective of this study was to use press clippings for

nine states (IA, IL, KS, MN, MO, ND, NE, and SD) as a source for

studying fatal ATV crashes.

Methods: A retrospective study of 2009 and 2010 ATV press

clippings was performed and clippings for fatal crashes were

identified. Descriptive analyses were done for demographics and

crash mechanisms. The number of press clippings for fatal and non-

fatal crashes was compared using the Mann-Whitney test.

Results: Press clippings captured over 90% of state fatalities as

reported by the Consumer Product Safety Commission (CPSC); and

the number of press clippings for fatal crashes was significantly

higher than for non-fatal crashes (median 2.0 vs. 1.0). Demographic

variables (e.g., gender) were well documented (93-100%). ATV-

related fatalities were 84% males and 16% of victims were children

under 16 years of age. Approximately 1 in 4 victims (24%) were

wearing a helmet. Documentation of crash circumstances (e.g.,

surface type) was variable (20-97%). The majority of crashes

occurred at dusk/dark (52%). More than 1 in 10 fatal crashes

involved vehicle-vehicle collisions (15%) or being pinned by the

vehicle (11%). Vehicle-related parameters (e.g., vehicle model) were

poorly documented (12-30%). Annual fatality rates were higher than

the overall average of 1.0 deaths/100,000 rural population for MN

(1.2), MO (1.3), NE (1.4), and ND (1.4). Rates for IL (1.0) and WI

(0.9) were at or near the average, and IA (0.6), KS (0.8), and SD (0.6)

were below average. There did not appear to be an association

between mortality rate and number of ATV laws.

Conclusions: Press clippings are a valuable resource for ATV

fatality surveillance because they comprehensively capture fatalities

in multiple states and they provide information not readily available

from other sources. They also contribute additional insights as part of

our integrated ATV surveillance database.

50. A Quality Curriculum: A Novel Approach To Addressing

The ACGME Core Competencies

Jonathan dela Cruz, Antonio Cummings, James Waymack, David

Griffen and Christopher McDowell. Southern Illinois University

School of Medicine, Springfield, IL

Background: Of the ACGME core competencies, application of

practice-based learning and improvement, and systems-based practice

have been difficult to assess in emergency medicine (EM) residency

curriculum. ABEM has now required attestation to a quality

improvement (QI) activity for continued certification. It is important

that EM residents are fluent in their core competencies and are

exposed to QI principles.

Objectives: We present here a formalized curriculum in quality to

assess resident understanding of ACGME core competencies while

providing them with a skill set in QI.

Methods: A class of 6 EM residents participated in a 3 part lecture

series on QI principles during core didactics. Using a previous

hospital QI project as a model, the residents learned the application of

statistical process control. Residents then became members of an

interdisciplinary QI project team intervening on the reversal of

coagulopathic ICH. Each resident was required to advance different

areas of the project. Their progress was tracked through periodic

meetings with the QI project leader and time was allotted during core

conferences for them to present their tasks. Presentations included

basic science didactics on the coagulation cascade, literature reviews

on current treatments, and a focused audit of the year‟s previous ICH

data. Understanding of the ACGME core competencies was

evaluated by core faculty during resident presentations and during

their meetings with the QI project team leader who also was a core

faculty member.

Results: All residents engaged in the process and showed an

improved understanding of the ACGME core competencies and QI

principles. This knowledge was demonstrated through their

presentation of didactic lectures, integration with an interdisciplinary

QI project team, and successful implementation of a new treatment

protocol. The QI project continues to be monitored and the outcomes

of the process changes are to be followed longitudinally.

Conclusion: A quality curriculum surrounding resident involvement

in a QI project seems feasible and promising. Involvement in a QI

project enhanced understanding of ACGME core competencies.

Further observation of resident project involvement and data

collection of QI project outcomes need to be performed to fully

assess the potential this curriculum has on resident education.

51. Emergency Department Interruptions in the Age of

Electronic Health Records

Matthew Albrecht, Jonathan dela Cruz and John Shabosky.

Southern Illinois University School of Medicine, Springfield, IL

Background: Interruptions of clinical care in the emergency

department (ED) have been correlated with increased medical errors

and decreased patient satisfaction. Studies have also shown that most

interruptions happen during physician documentation. With the

advent of the electronic health record and computerized

documentation, ED physicians now spend much of their clinical time

in front of computers and are more susceptible to interruptions. Voice

recognition dictation adjuncts to computerized charting boast

increased provider efficiency, however, little is known about how

data input of computerized documentation affects physician

interruptions.

Objectives: We present here observational interruptions data

comparing two separate ED sites, one that uses computerized

charting by conventional techniques and one assisted by voice

recognition dictation technology.

Methods: A prospective observational quality initiative was

conducted at two teaching hospital EDs located less than 1 mile from

each other. One site primarily uses conventional computerized

charting while the other uses voice recognition dictation

computerized charting. Four trained observers followed ED

physicians for 180 minutes during shifts. The tasks each ED

physician performed were noted and logged in 30 second intervals.

Tasks listed were selected from a predetermined standardized list

presented at observer training. Tasks were also noted as either

completed or placed in queue after a change in task occurred. A total

of 4140 minutes were logged. Interruptions were noted when a

change in task occurred with the previous task being placed in queue.

Data was then compared between sites.

Results: ED physicians averaged 5.33 interruptions/hour with

conventional computerized charting compared to 3.47

interruptions/hour with assisted voice recognition dictation

(p=0.0165).

Conclusion: Computerized charting assisted with voice recognition

dictation significantly decreased total per hour interruptions when

compared to conventional techniques. Charting with voice

recognition dictation has the potential to decrease interruptions in the

ED allowing for more efficient workflow and improved patient care.

52. Ct Scanning Practice In Minor Pediatric Head Injury At A

Community Emergency Department

Myto Duong, Varshita Pande and Joseph Milbrandt. Southern

Illinois University, Springfield, IL

Background: Pediatric head injury (HI) is responsible for >7400

deaths, 60,000 admissions and 600,000 emergency department (ED)

visits annually. Over 50% of minor pediatric HI will get a head CT

scan. Head CT scans has doubled between 1995 and 2005.

Objectives: The objective of our study was to determine the overall

rate of head CT use in children with minor HI and to evaluate the

appropriateness of head CT use based on Kuppermann et al

recommendations in 2009.

Methods: A retrospective chart review was performed for patients

<18 years old presenting to the ED with a HI in 2008 and 2009.

Patients were identified using ICD codes. Information collected

included age, gender, mechanism of injury, clinical findings, imaging

studies on initial presentation, any clinically significant HI finding on

head CT, number of repeat head CT related to initial injury with a

limit of 1 month post-injury.

Results: A total of 654 charts were reviewed. 383 (59%) patients had

a head CT scan. Out of 654 HI, 352 were minor and 165 (47%) had a

CT scan. Of these 165 head CT scans, 123 met criteria for a scan.

Only 10 of the 123 (8%) had abnormalities. 42 of the 352 (12%)

minor HI had a scan when they did not meet criteria (all were

negative except 2 -neither required any intervention). We identified

62 (18%) HI with no scan but did meet criteria for a head CT scan.

Conclusion: Even before head CT scanning guidelines for minor

pediatric HI were available, the overall rate of head CT use in

children with minor HI (47%) in our community ED was below the

national average for adult ED but high compared to pediatric EDs in

the United States. The percentage of pediatric patients with minor HI

who met criterias for the head CT scan was 53% but only 35% of the

minor HI who met criteria had a CT scan. Eighteen percent of

patients with minor HI met criteria for a head CT scan but did not

have one. Although there are other urgent cares and ED in our

community, our hospital is the only children‟s hospital in the

community who would admit patients with HI complications. Based

on return visits data to our hospital, none of these patients required

further evaluation or hospitalization. Although the algorithm

previously suggested for CT scan utilization was designed to

decrease pediatric head CT scanning, the algorithm identified a large

number of patients who had negative CT findings. In addition, we

identified overutilization of head CT scans in 12% of minor pediatric

HI in our ED.

53. Comparison Of Interpreters In Emergency Medicine: Video

Conference Vs. In-person

Yanika Wolfe1, Leslie Zun2, LaVonne Downey3 and Trena Burke4. 1Rosalind Franklin University/Chicago Medical School, North

Chicago, IL; 2Mount Sinai Hospital Emergency Department,

Chicago, IL; 3Roosevelt University, Chicago, IL; 4Mount Sinai

Hospital Emergency Medicine, Chicago, IL

Background: Many studies have shown the benefits of using

professional interpreters for patients with limited English proficiency.

Despite this, interpreters are still underutilized within the ED. This

fact is attributable to the lack of available interpreters, cost and time

constraints. Only a few studies have examined the impact of using

videoconference interpretation method in the ED.

Objectives: The purpose of this study is to compare the effectiveness

of video conference (IVIN-Illinois Video Interpreter Network) and

in-person (LIVE) interpretation methods in ED setting with regards

to patient and staff satisfaction, cost, and throughput times.

Methods: This was an IRB approved, prospective cohort study

consisting of a convenience sample of 100 medically stable Spanish

speaking patients, 18 years and older, presenting to the level 1 trauma

ED of an urban teaching hospital. Each patient was assigned to

receive either IVIN or LIVE interpreter. At the end of treatment,

patient was given a survey which assessed the patient‟s satisfaction of

the communication quality with staff and patient‟s level of

understanding of what was explained. A survey was also given to the

health care provider to assess whether or not language barrier issues

were addressed.

Results: 25 patients were enrolled, 15 in LIVE interpreter and 7 in

IVIN group. Majority of both cohorts listed elementary school as

their highest level of education and was currently unemployed. In

regards to patient‟s satisfaction of the quality of communication with

hospital staff, 93% LIVE interpreter users reported that they were

either very satisfied or somewhat satisfied, compared to 100% of

IVIN users. 80% LIVE interpreter users reported that they could

understand very or mostly easily things that were explained to them,

compared to 71% of IVIN users. Most healthcare providers felt that

language issues were adequately addressed by using the LIVE

interpreter (87%) or IVIN (85%).

Conclusion: This preliminary data suggests that video-conference

interpreters performs as well as in-person interpreters in ED setting

with regards to the patient and provider‟s satisfactions. This

preliminary result warrants further data collection. Potential

differences in throughput times between these two interpretation

methods will also be considered and further analyzed as part of the

second phase of the study.

54. Impact Of The Use Of A Standardized Order Set For

Asthma Patients In The Emergency Department

Daniel D Ofori1, Leslie Zun1 and LaVonne Downey2. 1Rosalind

Franklin University of Medicine and Sciences, North Chicago, IL; 2Roosevelt University, Chicago, IL

Background: Order set use is on the rise. Order sets combine

evidence-based orders for specific diagnosis into concise, easy to use

formats. How beneficial is this in the E.D for asthma patients?

Objectives: To investigate the impact of the use of a standardized

order set list for patients presenting to the E.D with asthma

exacerbation, on treatment throughput time, outcome, length of stay,

cost and patient return to the E.D.

Methods: An IRB-approved randomized chart review was conducted

on patients presenting to the E.D. of a Midwest, inner city, level 1

trauma hospital between December 2003 and June 2011. The study

compared patients for whom an asthma order set was used (users) to

those for whom an asthma order was not used (non-users). The data

was analyzed using SPSS frequency descriptive, one-way anova and

crosstabulations.

Results: 101 patients were enrolled: 52 male and 49 female.

Ethnicities included 91 African-American, 8 Hispanic and 2

unknown. 28 patients were 17 years old or younger, with 73 older

than 17 years. Most patients were brought in by the fire department.

E.D priority ratings were 55 urgent, 23 non-urgent, 20 acute and 1

critical. 62 patients were on publicaid, 28 uninsured/self-pay and 8 on

private insurance. Asthma order sets were used for 34 patients; order

sets were not used for 55 patients; order set use/non-use could not be

verified for 12 patients. 49 patients returned to the E.D within 30

days of discharge. Significant difference between order set users and

non-users were found for: 1) Length of stay: sig value of 0.015 and F

value of 6.164 for 37 patients (13 users vs. 24 non-users) staying for

1 day; 2) Total treatment time: sig value of 0.010 and F value 7.028

for 18 patients (6 users vs. 12 non-users) with 2.5-4 hours, 18 patients

(6 users vs. 12 non-users) with 5-7 hours; 3) Total throughput time:

sig value of 0.014 and F value of 6.342 for 12 patients (3 users vs. 9

non-users) with 2.5-3.5 hours, 19 patients (6 users vs. 13 non-users)

with 5-7 hours; 4)E.D. charges: sig value of 0.001 and F value of

12.948 for 19 patients (all non-users) with $0-$1,000, 16 patients (6

users vs. 10 non-users) with $2,000-$5,000.

Conclusion: The study showed that using a standardized order set for

asthma patients in the E.D. resulted in fewer patients with long

treatment and throughput times, thus expediting patient care delivery.

55. Same Patient. Same Overdose. Different Treatment.

Different Outcome.

Jon B Cole1, Heather Ellsworth2 and Samuel J Stellpflug2. 1Hennepin

Regional Poison Center, Minneapolis, MN; 2Regions Hospital, St.

Paul, MN

Background: Intravenous Fat Emulsion (IFE) is a promising therapy

for Poison-Induced Cardiogenic Shock (PICS). An American College

of Medical Toxicology position statement asserts that IFE is “a

reasonable consideration for therapy, even if the patient is not in

cardiac arrest.”

Objectives: We present a case series of a single patient who

overdosed on two separate occasions with diltiazem (D), metoprolol

(M), and amiodarone (A). She received IFE both times with different

outcomes.

Methods: This is a retrospective review of a 2-case series; the same

patient was the subject in both cases.

Results: Case 1: A 30 yo woman with hypertrophic cardiomyopathy

and an AICD presented with an overdose (OD) of D, M, and A.

Initial vital signs showed BP 89/46 and HR 73. Over 3 hrs the BP and

HR dropped to 64/41 and 70, and she was confused. ECG showed

paced rhythm. Normal saline (NS) 4L IV and 27 mEq IV Ca2+ were

given, and a high dose insulin (HDI) infusion escalated to 10U/kg/hr.

She remained hypotensive and confused. The CVP was 20 and an

Echo showed low EF. IFE (20%) was given as a 100mL bolus and an

infusion of 1.5L over 1 hr. Within 15 min of the bolus the BP was

110/60 and confusion improved. She had no negative sequelae.

Serum levels from the ED were D: 1449 ng/mL (nl 130-190), M: 388

ng/mL (30-300), A: 2.7 mg/L (0.5-2).

Case 2: The same patient presented with an OD of D, M, and A 4

months later. She was treated with NS, but became hypotensive and

suffered a cardiac arrest treated with glucagon and pressors

unsuccessfully. IFE was given with return of spontaneous circulation.

She received HDI at 1U/kg/hr, a Ca2+ infusion, dopamine,

phenylephrine and vasopressin. She improved clinically and was

noted to be alert and following commands. Shortly thereafter she

suffered a second cardiac arrest and died. Post-mortem drug levels

were D: 4,500 ng/mL, M 162 ng/mL, and A: 1.9 mg/L.

Conclusion: Early IFE in the setting of refractory Poison-Induced

Cardiogenic Shock may be preferable to waiting for cardiac arrest. In

case 1 the patient got IFE while declining clinically but had a pulse;

she had rapid improvement and a good outcome. In case 2 IFE was

delayed; though she clearly responded, she ultimately died. In this

patient it appears early IFE was associated with a better outcome. We

recognize that in case 2 the concentration of D was higher than case

1, and pressors were included in the treatment of case 2; both factors

may have affected the outcome.

56. Effect of Protocol Implementation on Emergency

Department Observation Unit Length of Stay and Charges

Adam E Stenger, Robert Poirier and Jennifer Wiler. Washington

University, St. Louis, MO

Background: Emergency Department-based observation units are

becoming increasingly used for the assessment and treatment of

patients who may not require inpatient management or monitoring.

Objectives: To determine if implementation of Emergency

Department Observation Unit (EDOU) care pathways (CP) impacted

EDOU patient length of stay (LOS) and total ED (professional plus

facility) charges.

Methods: In June of 2009, 21 CP were implemented in a 12 bed

EDOU. Data from a 2 week period (12/1-14/2008) 6 months pre-

implementation were retrospectively compared to a 2 week period

(12/1-14/2009) 6 months post-implementation. EDOU LOS and total

charges were compared for all EDOU patients, those admitted to the

hospital, and those discharged from the EDOU. Boarding patients

(ED patients admitted to the hospital waiting in the EDOU for an

inpatient bed) were excluded from the analysis. EDOU LOS and total

charges were analyzed using medians and interquartile ranges (IQ)

(25th and 75th %tiles). Statistical significance was analyzed using

Wilcoxon Rank Sum.

Results: 171 pre-implementation and 192 post-implementation

patient visits met inclusion criteria with 3 visits excluded because of

incomplete billing data. The overall median EDOU patient LOS was

15 minutes shorter after the implementation of CP (658 vs 643 mins;

P=0.89). The LOS of EDOU patients who required inpatient

hospitalization decreased 287 minutes post-implementation (1027 vs

740 mins; P=0.10); whereas those discharged from the EDOU only

decreased 9 minutes (620 vs 611 mins; P=0.74). Median overall

charges for the entire cohort were $755 higher post-CP

implementation ($4,863 vs $5,618; P=0.13); and were $53 higher for

EDOU patients who required inpatient hospitalization ($10,857 vs

$10,910; P=0.74). Total charges decreased $179 for patients who

were discharged from the EDOU ($4,173 vs $4,352; P=0.13).

Conclusion: Implementation of EDOU CP decreased the overall

LOS for EDOU patients. LOS was also decreased for patients those

who required inpatient hospitalization or were discharged from the

EDOU. EDOU CP also increased total ED billing. Future multicenter

research is needed to validate these findings.

57. Retrospective Study of Underage Drinking and Emergency

Department (ED) Visits: Before and After the 21 Ordinance

Christopher R Peterson and Michael Takacs. University of Iowa,

Iowa City, IA

Background: Excessive consumption of alcohol and dangerous

drinking behaviors continue to be a growing concern in Iowa City. A

2009 study reported that 70% of UI students had engaged in high-risk

drinking in the last two weeks as compared to 44% nationally. The

Iowa City Council sought to curtail underage alcohol consumption by

passing the 21-Only Ordinance on 6/1/2010, banning people under 21

from bars after 10:00 pm. There has been much debate in the

community as to the effectiveness of this measure - whether it would

reduce dangerous drinking, or simply shift drinking to house parties

where supervision and police presence would be minimal.

Objectives: The objective of our study was to determine whether the

rate of alcohol-related ED visits among 18-20 year olds decreased

following implementation of the 21-Only Ordinance.

Methods: A retrospective study of 18-20 year olds presenting to the

ED for alcohol-related reasons from 6/1/2009 to 5/31/2011 was

performed. Medical record data were compiled, including age, blood

alcohol content (BAC), date and time of visit, complaint and

diagnosis. Data were analyzed using Pearson‟s chi-square test.

Results: In the year prior to the 21-Only Ordinance, there were 1685

visits to the ED by 18-20 year old patients; 272 of these visits were

for alcohol related reason (16.3/100 patients). In the year following,

there were 206 alcohol visits out of 1608 total visits (12.4/100

patients), suggesting overall decline (23.8%) in alcohol-related visits

among the study population (p<.01).

Alcohol-related ED visits by 18-20 year old UI students decreased

from 8.72% to 6.16% (p<.01).

Alcohol-related visits involving violence decreased from 2.85% of

total visits in the year prior to 1.43% after (p<.01). Similarly, the

proportion of visits involving a mental or emotional condition, such

as depression or suicidal ideations, decreased from 2.20% to 1.06%

(p=.01).

Conclusion: Retrospective studies can reveal trends within a given

population over time, but are unable to provide causation for these

trends. Thus, while this study suggests a significant decline in 18-20

year old alcohol-related visits to the ED in the year after the 21-Only

Ordinance, additional studies are needed to determine the

sustainability of these changes.

58. A Retrospective Review of the Use and Safety of Sedation for

Agitated Patients with Hepatic Encephalopathy in the

Emergency Department

Jason West1 and Vijai Chauhan2. 1Albert Einstein School of

Medicine, Jacobi/Montefiore Hospitals, Bronx, NY; 2Saint Louis


Background: Patients with hepatic encephalopathy may present with

a wide range of alterations in mental status including delirium,

agitation, and aggression. There are no consensus guidelines to

recommend a standard agent for sedation in patients with hepatic

encephalopathy or hepatic failure in the emergency department (ED).

Objectives: We intended to compare and characterize the use of

intravenous midazolam, lorazepam, and haloperidol for the sedation

of agitated patients with hepatic encephalopathy and end-stage liver

disease (ESLD) in the ED.

Methods: This was a retrospective chart review set in a university

hospital ED. The ED database was queried to identify patients

admitted with hepatic encephalopathy 2005-2009, and further chart

review was performed if the patient received sedation for agitation.

We analyzed the adequacy of sedation, adverse events, and

disposition.

Results: Of the 401 patients presenting with hepatic encephalopathy

or ESLD, 8 received sedation for agitation in the ED. 7 patients

recieved lorazepam, and 1 patient received both haloperidol and

lorazepam. One patient recieving both drugs required active airway

management and intubation for respiratory depression. No patients

were reported to have post-sedation hypotension, arrhythmia,

vomiting, or significant Glasgow Coma Scale changes. All patients

were adequately sedated at the time of disposition and were more

likely to require admission to intensive care units.

Conclusion: Agitated patients with hepatic encephalopathy given

lorazepam were adequately sedated but may be at increased risk of

requiring active airway management.

59. A Cost Comparison of Fomepizole and Hemodialysis in the

Treatment of Methanol and Ethylene Glycol Toxicity

Heather Ellsworth, Kristin M Engebretsen, Lisa M Hlavenka, Andy

K Kim, Jon B Cole, Carson R Harris and Samuel J Stellpflug.

Regions Hospital, St. Paul, MN

Background: Fomepizole (F), alone or in combination with

hemodialysis (HD), may be used in the treatment of toxic alcohol

exposures such as methanol (M) and ethylene glycol (EG). There is a

paucity of data regarding the financial cost of each treatment.

Objectives: Using patient charge estimates specific to our institution,

we present an analysis comparing cost effectiveness of F and HD for

treatment of M and EG levels of 50 mg/dL.

Methods: Patient charges associated with treatment of EG and M

exposures in 2010 at our institution were reviewed and averaged with

respect to the cost of the following: F dose, HD session, and daily

rates of a general care (GC) and intensive care unit (ICU) beds. All

other costs were assumed comparable irrespective of treatment

received. Based on available pharmacokinetic (PK) data for M and

EG in the presence of F, the duration of treatment was projected.

Results: The average patient charge for a dose of F was $1,267, HD

session $765, GC bed (daily rate) $915, and ICU bed (daily rate)

$1,524. For an EG or M level of 50 mg/dL treated with HD, the

patient charge would approximate $4,823 (2 doses of F, 1 HD

session, 1 day of hospitalization in the ICU). In contrast, the

estimated cost associated with treatment of an EG level of 50 mg/dL

with F only, based on a t½ of 12.9 h, to an endpoint of <20 mg/dL

was $5,631 (based on a treatment duration of 25.8 h, 3 doses of F, 2

days of hospitalization in a GC bed). Similarly, for a M level of 50

mg/dL treated with F only, with an estimated t½ of 54 h, the

estimated cost was $17,245 (administration of 10 doses of F and 5

days of hospitalization in a GC bed).

Conclusion: Hemodialysis is a more cost effective approach to the

management of methanol and ethylene glycol toxicity than alone if

levels exceed 50 mg/dL. This is especially true for M, which has a

significantly longer t½ than EG. Limitations include not accounting

for the cost of complications related to HD such as vascular injury,

infection, and thrombosis (data suggest these complications are rare).

Another limitation is the failure to account for individual variability

with respect to PK as well as patient weight, which may influence the

number and volume of F doses required. Accounting for these

parameters could make the cost difference between F and HD even

more favorable for HD, considering reports of extremely long EG

and M t½'s treated with F alone.

60. Equestrian Helmet Use in Horse Organization Promotional

Material

Charles A Jennissen1 and Suleimaan Waheed2. 1University of Iowa

Hospitals and Clinics, Iowa City, IA; 2University of Iowa, Iowa City,

IA

Background: Equestrian helmet use is an effective method to

prevent head injuries in horse-related events. However, rates of

protective head gear use while riding or working around horses is still

low. The media can have a great impact on injury prevention both

positively and negatively by their portrayal of protective safety

equipment or lack thereof.

Objectives: To determine the equestrian helmet use by individuals

pictured in horse organization promotional materials.

Methods: Literature was requested from horse organizations through

email and/or mail, with the inquiring investigator posing as a horse

enthusiast. Organizations contacted included national horse agencies,

breed registries and all state equine councils. Photographs in

materials received were reviewed for equestrian helmet use along

with the age and activity of individuals depicted in photographs.

Results: 113 of 335 organizations responded and 95 organizations

sent published material. A total of 2,004 photos with 2,738 people

were evaluated. The highest equestrian helmet use was by children,

and teen helmet use was generally portrayed more frequently than in

adults. The lowest rate were in those that appeared elderly (14.6%).

Helmet use was highest in photos that depicted competition-jumping

(87.9%). Competition-riding and pleasure-riding helmet use was only

30.0% and 34.5%, respectively. Equestrian helmet use was low in all

portrait categories--photos where pictured individuals were formally

posing for the camera. No one who was pictured while working on,

with or while on a horse was shown with an equestrian helmet; nor

was anyone in a parade. Adults riding with children did have a

significantly higher rate of wearing an equestrian helmet than adults

who were pleasure-riding in general (44.2% vs. 23.2%).

Conclusion: Photographs in horse organization literature often show

people not wearing helmets during equine-related activities. Horse

organizations have an excellent opportunity to define injury

prevention practices as normative behavior. One way this may be

accomplished is by portraying people always wearing equestrian

helmets in the photos they use in their published material.

Developing a culture of safe equestrian practices including helmet

use will decrease the number of serious head injuries experienced by

horse enthusiasts.

61. Facilitators of Evidence-Based Pediatric Pain Management

in Emergency Departments: Similarities and Differences Between

Rural and Urban Hospitals

Charles A Jennissen1, Sarah Wente2, Charmaine Kleiber2 and Ryoko

Furukawa2. 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2University of Iowa College of Nursing, Iowa City, IA

Background: Children‟s pain management in the Emergency

Department (ED) remains inadequate. Available evidence-based

practice (EBP) guidelines for pediatric pain management exist, but

are currently under utilized in managing pediatric pain in EDs.

Objectives: To determine the factors that nurses identify as

facilitating the use of EBP in the management and prevention of

pediatric pain in the ED and whether these factors are different for

rural versus urban hospitals.

Methods: All nurses working in hospital EDs in the state of Iowa

were invited to participate in a confidential survey regarding EBP of

pediatric pain treatment and included the question “What would

facilitate the use of EBP pediatric pain management in your ED?”

Qualitative responses were analyzed using Nvivo software to identify

patterns and themes. Researchers reviewed the responses

independently and then discussed the coding, resolving any

discrepancies.

Results: Of 1171 returned surveys, 735 contained responses to the

study question. Data fell into five nodes: knowledge, staff aspects,

hospital system, treatment, and patient/family issues. Knowledge and

staff aspects appear to be key facilitators for EBP in EDs. The

knowledge node revealed several themes including the desire for

specific types of training and education, information sharing, and for

examples of guidelines and policies. Staff aspects included the need

for more collaboration with physicians, and more openness and

motivation to change. Critical access hospital ED nurses more

frequently reported a need for education and guidelines/standing

orders than nurses from larger hospital EDs. Nurses from rural

facilities also reported wanting more exposure to pediatric patients

and asked for processes for the sharing of information from other

facilities, including larger hospitals with pediatric expertise. Nurses

from all hospital sizes reported the need for “proof” of effectiveness

of pain management practices.

Conclusion: Most strategies to increase evidence-based pediatric

pain management in EDs can be utilized in hospitals of all sizes.

However, rural hospitals may benefit more from networking and

information sharing with other hospitals, including examples of

guidelines and standing orders. It will be important all strategies

stress effectiveness and positive impact on the patient.

62. Characterization of Clinical Rotations in Three and Four

Year Emergency Medicine Residency Training Programs

Kenneth D Grosz, Robert Muelleman, Lance Hoffman and Michael

Wadman. University of Nebraska Medical Center, Omaha, NE

Background: Emergency medicine (EM) currently recognizes 3

training formats: PGY 1-3, 2-4, and 1-4. EM program requirements

proscribe that „no less than 50% of the clinical experience take place

under the supervision of emergency medicine faculty‟, that there

must be „at least two months of critical care rotations,‟ and if less

than 16% of all ED encounters are pediatric patients, some pediatric

rotations are required. Little is known about the content of the

remaining rotations in EM programs.

Objectives: To describe the similarities and differences in clinical

rotations between three and four year EM residency programs.

Methods: EM residency programs were identified on the SAEM

website during November, 2010. Information was abstracted from

individual program websites regarding the types and duration of

rotations during residency. Rotations were grouped into EM, critical

care (CC), surgery (surg), medicine (IM), pediatrics (peds), other or

(s)elective clinical categories. The median/interquartile range for the

number of blocks in each category were calculated for PGY 1-3 and

PGY 1-4 programs and compared by Mann-Whitney Rank Sum Test.

Results: We identified 152 programs: 113 PGY 1-3, 35 PGY 1-4 and

4 PGY 2-4. Within the PGY 1-3 programs there were 44 with 39 four

week blocks and 69 with 36 month blocks. Within the 35 PGY 1-4

programs there were 25 with 52 four week blocks and 10 with 48

month blocks. In comparing 52 and 39 block programs, there were

significant differences in EM: 34(32.2, 36) vs 26(24.5, 27.1)

p<0.001, other: 7(5.4,7.8) vs 4(3, 5.4) P<0.001 and (s)elective

4(2,4.5) vs 2(1,2) p<0.001. There were no differences in CC: 4(3,5)

vs 4 (3,4.4) p=0.653, surg: 2.5(1.4,3) vs 2(1.25,3) p=0.389, IM:

1(0.75,2) vs 1(0,1) p=0.115, and peds 0(0,1) vs 0(0,0) p=0.081. In

comparing 48 and 36 block programs, there were significant

differences in EM: 29.5(28, 30) vs 23(22, 24.6) p<0.001, other:

5.4(4,7) vs 3.5(3,4)p<0.001, and (s)elective: 4.25(3,6.5) vs 2(1,2)

p<0.001. There were no differences in CC: 4(3,5) vs 4 (3,4) p=0.988,

surg: 3(2,4.5) vs 2(1.4,3) p=0.054, IM: 2(1,3) vs 1(0,2) p=0.051, and

peds 0(0,1) vs 0(0,1) p=0.685.

Conclusion: Of the additional 13 or 12 blocks in four year programs,

there are an additional 8 or 6.5 EM blocks, 3 or 1.9 other blocks, and

2 or 2.25 elective blocks respectively.

63. Let The Good Times Roll: Computer Modeling to Investigate

Risk of ATV Rollover While Turning

Charles A Jennissen1, Gerene Denning1, John Steffen2, Jonathon

Marsico2, Thomas Schnell2 and Daniel McGehee2. 1University of

Iowa Hospitals and Clinics, Iowa City, IA; 2University of Iowa

College of Engineering, Iowa City, IA

Background: Rollovers are the most common all-terrain vehicle

(ATV) crash mechanism. Most field research of ATV rollovers is

limited due to the risk of subject injury. Computer modeling is a

potential tool to safely investigate ATV crash mechanisms and risk

factors.

Objectives: To explore how various factors might affect the

likelihood of an ATV rollover while turning including velocity,

surface friction, turning radius, passenger and ATV center of gravity,

and wheelbase dimensions

Methods: Vehicle specifications for a convenience sampling of

utility ATVs were compiled. A computerized free body diagram was

constructed of an ATV with passenger(s), and the risk of sliding or

rollover with turning was assessed for multiple parameters while

keeping ATV size specifications constant. The relative rollover risk

of various ATV models was also determined.

Results: Surfaces with higher friction coefficients (i.e. dry pavement)

increase the likelihood of a rollover while turning. Even a typical dirt

trail (friction coefficient of 0.3) would require a 16.4 mph limit to

avoid a slide with an average adult male driver making a 60 ft. radius

turn. A slide may not result in a rollover but will reduce the operators

control over the ATV. The risk of rollover increases significantly

with tighter turns. If the operator simply takes more gradual turns at

higher speeds, roll-overs can be avoided entirely. The minimum

turning radius for most ATVs was around 8 ft. which only allows a

maximum speed of around 10 mph to avoid a rollover on high

friction surfaces. As the combined operator/passenger weight

increases from 85 lbs to 365 lbs, the vehicle speed needs to be

reduced approximately 4 mph in order to prevent a rollover at the

same turning radius. There was a difference, albeit relatively small, in

the speed at which ATVs from different manufacturers will rollover.

Conclusion: Surface friction, total rider mass, velocity and turning

radius are rollover determinants that are terrain and rider decision

dependent. Education of operators, enforcement of strict no passenger

rules, and speed limiters for younger drivers may be important to

affect these factors and prevent rollover crashes. Manufacturers could

engineer better rollover protection by optimizing ATV width and

lowering its center of gravity, and/or producing ATVs with roll bars

and safety belts.

64. A Picture’s Worth a Thousand Words: Utilizing Social

Media to Better Understand ATV Crash Mechanisms

Morgan Price1, Gerene Denning2 and Charles A Jennissen2. 1University of Iowa Emergency Department, Iowa City, IA; 2University of Iowa Hospitals and Clinics, Iowa City, IA

Background: Over the last decade, all terrain vehicle (ATV) crashes,

injuries and deaths have risen more than 400%, with over 800 deaths

and 130,000 ED visits every year. Rollovers have been reported as

the most common mechanism. However, most injury surveillance

sources provide limited data on the sequence of events during an

ATV crash. This limitation provides the rationale to investigate less

traditional sources such as social media sites like YouTube.

Objectives: The study‟s objective was to compile a video library of

ATV crashes and to review these videos in order to achieve insights

regarding the crash mechanisms and contributing factors of ATV

crashes on uphill inclines.

Methods: A retrospective search of videos posted on YouTube

between April 2006 and July 2011 was performed. Videos were

compiled and coded according to occupant, crash, vehicle, and video

parameters. Uphill incline crashes were identified and reviewed

creating a highly detailed account of the crash sequence, moment by

moment, for every vehicle and person involved.

Results: One hundred eighty three ATV crash videos have been

downloaded to date and 52 uphill incline crashes were reviewed.

Almost all ATV operators in the videos were males and 81% were

adults. Helmet use was 73%. All crashes involving adolescents

occurred on adult-sized vehicles. 75% of vehicles were sports ATVs

and 25% were single-person utility ATVs. Major surface types shown

in the videos were dirt (72%), mud (10%), and solid rock (6%).

Overall, forty-three of the uphill crashes (83%) resulted in rollovers,

68% of these rollovers were backwards. A major contributor in the

majority of these crashes was loss of momentum followed by

inappropriate acceleration. A difference between sports and utility

ATVs was noted in which utility ATVs during a slower velocity

backward rollover would veer to the side once the metal rack on the

back hit the ground.

Conclusion: Videos from social media sites are a rich source of ATV

crash mechanism information. Analysis of these videos yields

significant details that are not available through any other data

source. Our ATV crash video library will serve as both an important

educational and research tool.

65. Complications of Extremity Computed Tomography

Angiogram Completed in Emergency Department

Emily Tilzer and Vijai Chauhan. Saint Louis University Hospital,

Saint Louis, MO

Background: Computed Tomography Angiography (CTA) is

increasingly used as a imaging modality for extremity vascular

pathology in patients presenting to the Emergency Department. From

limb trauma to acute arterial blockage, CTA is noninvasive and

frequently immediately available (1). However, the procedure still

requires intravenous contrast, which can cause adverse events, such

as anaphylactoid reactions or acute kidney injury.

Objectives: The objective of this study was to analyze the frequency

of adverse reactions related to CTA studies ordered for Emergency

Department patients.

Methods: This was a retrospective chart review of patients age 18-90

who received a CTA from July 2009 to August 2010 at an academic

medical center. A list of all CTA studies ordered from the Emergency

Department was cross referenced with patient‟s creatinine, admission

status, documented reactions, and time-to and type-of intervention.

Results: This is preliminary study data on 20 of approximately 60

subjects. These 20 patients had no documented adverse reaction to

the intravenous contrast or increase in creatinine.

Conclusion: As a modality that is becoming more common for

evaluation of extremity vascular pathology, CTA did not have an

increase in complications when ordered from the Emergency

Department. Further studies are needed to with larger number of

patient‟s who receive a CTA to detect any possible complications.

66. Safety Depictions on Primetime TV: Lack of Seat belts and

Helmets

David Milzman. Georgetown University School of Medicine,

Bethesda, MD

Background: A 1998 Mich St. U study recorded prime time TV

portrayal of 25% seatbelt usage when actual national usage was 65%

that year.. in 13 years, since the US national usage had inc. to 85%.

Objectives: Compare Primetime TV traffic/safety exposures with

USDOT NHTSA figures and Compare to Past TV representations.

Methods: Researchers watched a total of 53 non-news, non reality-

TV totaling 53 programs across 10 weeks of Spring 2011 primetime

(8-11 PM EST)from the following networks: ABC, CBS, NBC, FOX

and CW. Commercials were excluded. All instances of seat belt

usage (driver and passenger) , helmets (bikes and motorcycle) and

miscellaneous pedestrian and vehicular traffic infractions were also

recorded.

Results: total of 273 of prime time tV was viewed with an overall

rate for proper seat belt usage in 37.6% (95% CI: 32.4-42.9) of

drivers, 22.3% (95% CI:18.5-26.0) passengers. Proper seating and

childseat usage , not noted in original 1998 study was only 14%.

Helmet were used by 15.9% of bicyclists, 70.3%of motorcyclists.

There was 17% rate of Pedestrian and 22% vehicular traffic

violations, also. Overall proper 2011 restraint use was 30.1%

(95%CI: 25.4- 34.6). This figure represent only a 4.2% rise and NS

increase since the prior study. Portrayal of Primetime TV seatbelt

usage rose a 4.8% (p ≤ 0.11) from 1998 to 2011 while actual US

seatbelt use increased a significant 20%.(p ≤ 0.03) helmet use did

increase for both bike by 32% to 15.9% and motorcycle by 20% to

70.3%.

Conclusion: Recent studies have found traffic safety behaviors

continue to increase in Us population; however, major TV network

programs have not incorporated such simple safety changes into

current programming despite prior study into these deficiencies. A

poor example continues to be set.

67. Agreement Between Physician and CT Scan in High Energy

Mechanism Stable Trauma Patients

Michael D Zwank1, Eric A Gross2, Mary J Hughes3, David J Castle3,

Amanda C Miller3, William P Hughes3 and Christopher P Anderson4. 1Regions Hospital, Saint Paul, MN; 2Hennepin County Medical

Center, Minneapolis, MN; 3Michigan State University, East Lansing,

MI; 4Healthpartners Research Foundation, Bloomington, MN

Background: Computed tomography (CT) is a vital adjunct in the

evaluation and care of trauma patients. While its usefulness is

undisputable, this benefit comes with radiation related risk given the

relatively high doses of ionizing radiation that are used. This concern

has generated a debate over the proper role of CT in stable trauma

patients. While several studies have promoted liberal CT use, to date

there has been no well designed prospective study to examine this

practice in this patient population.

Objectives: This study assessed how closely physician assessment

and CT scan results agree in the alert stable patient who has

experienced high energy trauma. Can physicians reliably detect

severe injuries in this select patient population?

Methods: This is a prospective cohort study conducted at three Level

I trauma centers. A convenience sample was enrolled when study

personnel were available. Patients were included if they met the

inclusion criteria: blunt trauma, trauma team activation, Glasgow

Coma Score 15, systolic blood pressure on arrival > 100, age between

18 and 65. Trauma team leaders completed a survey regarding the

reliability of the patient and suspicion of any injury and severe injury

in various body regions (head, neck, chest, abdomen, pelvis and

extremities). The patient‟s chart was later abstracted for outcome and

injuries detected on x-ray or CT. Major injuries were defined a priori.

Results: 150 patients were enrolled. Mean age was 43 (SD=17.6).

Mechanisms of injury were primarily motor vehicle accident and fall.

46% of patients were deemed unreliable mostly because of

intoxication or distracting injury. Among the reliable patients (n=81),

there were 4 major injuries that were not detected by the provider.

The negative predictive value of physician assessment ranged from

0.97 to 1 (CI 0.85 to 1). Sensitivity of physician assessment to the

presence of major injury ranged from 0.67 to 1 (CI 0.09-1).

Conclusion: Clinicians can reliably detect major injuries in alert

stable trauma patients who are deemed reliable. There were only four

major injuries that were missed. None of these injuries required

intervention beyond observation. Attention needs to be given to

patients who are intoxicated or otherwise deemed unreliable and to

patients with significant distracting injuries. These patients may

benefit from increased CT scan utilization.

68. Padding the Slider Transfer Board and Patient Comfort in


Jerome R Walker1, Christopher P Anderson2 and Michael D Zwank1. 1Regions Hospital, Saint Paul, MN; 2Healthpartners Research

Foundation, Bloomington, MN

Background: A slider board (SB) is a rigid thin plastic board that

facilitates the movement of a patient from an emergency department

(ED) gurney to a radiology imaging table such as CT scan or x-ray.

Often patients who have experienced trauma are placed on a SB

immediately on arrival in the ED with the anticipation of needs for

imaging.

Objectives: The primary objective of this study is to compare patient

comfort when using a padded versus an unpadded SB. Secondary

objectives including number of imaging tests ordered and dose of

analgesics.

Methods: This was a randomized controlled trial involving adults

age 18-65 arriving to the ED on pre-hospital EMS backboard who

were expected to be on a SB for greater than 30 minutes. Patients

were excluded if: trauma team activation, pregnant,

hemodynamically unstable, GCS < 14. Patients were randomized to

standard care of slider board versus slider board padded by 3 inch egg

crate overlay foam. Pain scores were measured using visual analog

scale (VAS) measured in centimeters at 0, 30, 60, 90, 120 minutes.

Frequency/dosage of analgesics and number/type of imaging tests

ordered were recorded. Variables were analyzed descriptively with

means, medians, standard deviations and ranges. The outcome of pain

(as measured by VAS) was evaluated for normality using the

Kolmogorov-Smirnov test. The association between pain time and

the use of a padded board was quantified using linear mixed-effects

regression.

Results: 39 patients were enrolled (16 women, 23 men; 18 assigned

to control, 21 padded). Mean age was 42. Mean time on the slider

board was 107 minutes and mean number of imaging studies was 1.7.

Mean pain score in the control group was 6.73 and in the padded

group was 5.45 (p=0.047). Pain ratings diminished in both groups

over time. The time on the slider board, total amount of analgesics

and number of imaging studies ordered was similar in both groups.

Conclusion: Padding the slider board led to decreased discomfort but

not decreased amount of analgesics or number of imaging studies.

The difference in VAS scores is not likely to be clinically significant.

Since the conclusion of this study, our hospital has instituted a policy

of only using the slider board when needed - not placing any patient

on a slider board in anticipation of imaging studies.

69. The Utility of Computed Tomography in the Diagnosis of

Renal Colic in the Emergency Department

Michael D Zwank1, David J Gresback1 and Benjamin M Ho2. 1Regions Hospital, Saint Paul, MN; 2University of Wisconsin,

Madison, WI

Background: Patients with renal colic commonly present to the

emergency department and are usually treated with analgesics,

antiemetics and rehydration. Rarely to these patients require more

acute care or hospitalization. A very common approach to evaluating

patients with suspected renal colic in 2011 is to use computed

tomography (CT) scan which carries a heavy burden in both radiation

exposure and expense.

Objectives: Does CT scan change management, diagnosis or

disposition in patients with suspected renal colic?

Methods: In this observational study, a convenience sample of 35

(ongoing enrollment, goal=100) clinically stable patients between the

age of 18 and 50 with chief complaint of abdominal/back/flank pain

and renal colic as the most likely diagnosis were enrolled. Exclusion

criteria were: history of previous kidney stone, history of chronic

kidney disease (CR >2.0), urinary tract infection, recent CT (<6 mo)

or history of nephrectomy or renal transplant. Pre-CT and Post-CT

surveys were completed by the treating provider. Descriptive

statistics were used.

Results: 35 patients were enrolled in the study to date. The discharge

diagnosis was renal colic in 24 patients (69%). 10 cases had change

of diagnosis from renal colic: 4 muscular back pain, 3 abdominal

pain, 1 ovarian cyst seen on CT, 1 ovarian mass seen on CT, 1

testicular torsion not seen on CT. 4 cases had changed disposition

after CT-scan: 3 were diagnosed with renal colic/ureterolithiasis and

admitted for further care and 1 was taken to the operating room for

surgical management of testicular torsion. 10 patients were given

tamsulosin only after confirmation of ureterolithiasis. In the pre-CT

survey, providers thought that CT scan would/might be useful in 15

cases. In this group, 8/15 cases (53%) resulted in either changed

diagnosis or disposition. Conversely, in cases where no perceived

value would come from CT scan, 0/6 cases (0%) resulted in changed

diagnosis or disposition.

Conclusion: CT scans with high perceived value prior to completion

changed diagnosis or disposition in 53% of these patients while CT

scans with no perceived value did not change diagnosis or

disposition. There were a significant number of diagnosis and

disposition changes after completion of CT. These results are limited

by small patient numbers to date.

70. The True Impact Of A Left Vs. A Right Shift In Assessing A

White Blood Cell Count: Bacterial Viral And The True

Infectious Source

David Milzman1, Anchal Ghai1, Jenika Ferritti-gallon2 and Stephan

Chang1. 1Georgetown University School of Medicine, Bethesda, DC; 2Georgetown University, Washington, DC

Background: The complete blood cell count and differential, have

been used f as a diagnostic tool for acute bacterial infections. it has

always been taught that an increase in WBC accompanied by a

specific increase in neutrophils especially immature neutrophils,

referred to as a left shift, are associated with a bacterial infection. In

contrast an increase in WBC, specifically lymphocytes, referred to as

a right shift, is associated with a viral disease.

Objectives: This study will compare proven viral and bacterial

infections and the finding of right and left WBC shifts with the

respective infectious causation.

Methods: The study was completed at a level 1 trauma center urban

teaching ED with 87,000 annual visits. A retrospective cohort study

of all ED patients presenting between Jan 1 2009 and Jan 1 2011with

a full white blood cell count and differential performed on admission

with necessary supporting medical record info obtained through the

Azyxxi( Smith, M and Microsoft, Redmond, WA) EMR. Viral

disease was confirmed with a positive viral swab and bacterial

infection was confirmed with positive blood culture.

Results: a total of 107 viral infections and 205 bacterial infections

meeting strict criteria were discovered. There was a difference for

age and gender between the two groups with mean age for viral 44.5

and bacterial 62.2 with viral having 65% female and bacterial : 51%

female P 10000 neutrophils was 79% accurate compared to accuracy

for a right shift finding a viral infection was 34%.

Conclusion: Although the total WBC was greater in bacterial VS

viral infection the finding of the "classic" shifts in lymphocyte

predominance for viral infections was not accurate and that of

bacterial infection was found to be a better marker.

71. Pre-Arrest Characteristics and Use of Advance Directives

among Out-of-Hospital Cardiac Arrest Victims

David Milzman1, Erwin Wang2 and Han Huang3. 1Georgetown

University School of Medicine, Bethesda, MD; 2Georgetown

University School of Medicine, Bethesda, DC; 3Georgetown

University School of Medicine, Washington, DC

Background: Several factors have Early recognition of an arrest

improves survival, as every delay in initiating treatment reduces

likelihood of survival (Larsen, 1993) demonstrated to improve CA

survival rates.

Objectives: to determine the true survival to hospital discharge in a

major urban city with a documented less than 5% survival rate from

out-of hospital cardiac arrest and to evaluate the value of

implementing advanced directives from the prehospital side.

Methods: A two year prospective data collection and scene

investigation study of all cardiac arrest victims who presented to a 87,

000 Annual ED visit urban teaching hospital was completed b/w

2009-2010. Utstein criteria and Demographic information including

age, gender, and ethnicity

Medical information:

Location of cardiac arrest

Incidence of pre-existing disease

EMS response time

Presenting cardiac rhythm

Interventions by EMS, family m

Results: Initially, 199 cases were identified and 53 were excluded

according to Utstein criteria: of the 146 included study patients there

was an overall 6/6 % survival to hospital discharge. CA was most

frequently reported from home with a 8.6% survival rate vs. skilled

nursing facility 1.8% survival. P < 0.03. SNF patients were older,

had lower SF-36 scores for independent living and actually had only

2/ 66 with Advanced directives in place.

Conclusion: Advanced directives do not coincide with low

independent functionality in this urban city with very low cardiac

arrest survival even from V Fib. Improvements in education and

acceptance of not only DNR orders but bystander CPR are needed to

improve outcomes and correct expectations.

72. Comparison of Data Collection Using Real Time Observers

to Subsequent Review of Video Data for Airway Management

Research

James Miner, Megan Terrebonne, Robert Reardon and John

McGill. Hennepin County Medical Center, Minneapolis, MN

Background: The optimal method of data collection for clinical

airway research is unknown.

Objectives: To compare data collected by a real-time observer to

data obtained by subsequent review of video of the same procedure

by a different observer.

Methods: This was a prospective observational study of patients

undergoing endotracheal intubation at an urban level one trauma

center where all emergency intubations are recorded using video

devices from three distinct angles with the cardiac monitor

information recorded alongside these images. Observers at the

bedside collected information regarding vital signs, airway

maneuvers, method of intubation, number of breaths delivered by

bag-valve-mask, number of intubation attempts, the duration of each

maneuver and attempt, and any adverse events including oxygen

saturations <93%. The same procedure was subsequently reviewed

for the same data using the video recordings of the procedure using a

different observer. Data describing the occurrence of hypoxia, the

number of bag-valve-mask breaths given, the number of intubation

attempts, and the time to successful intubation recorded for each

procedure were compared between the real time assessment and the

video assessment. Data were compared using descriptive statistics.

Results: Twenty patients were included. The number of breaths

given by bag-valve mask prior to intubation was different between

the two groups in 8 cases. More breaths were detected by video than

by real time in 6 cases (median difference 6, range 1 to 17). The

device used was recorded the same in both groups (13 laryngoscope,

7 CMAC). The drugs given and the doses were recorded the same in

both groups. The lowest oxygen saturation was recorded the same in

both groups. The number of attempts was the same in both groups.

The time to intubation was recorded the same in 14 cases. In one case

the time to intubation could not be determined from the video. In 4

cases it was longer in the video group (median difference 45 seconds,

range 22 to 95); in 1 case it was longer in the real-time group

(difference 2 minutes).

Conclusion: There were significant discrepancies between the data

collected from real-time observers and from review of video. It is

possible that a combination of video and real-time data collection

may improve research accuracy.

73. Correlation Between Exercise Levels and Medical School

Board Scores

Vijai Chauhan and Sean Cavanaugh. Saint Louis University SOM,

Saint Louis, MO

Background: Medical education is recognized as a stressful

undertaking and coping strategies of students impact their

performance and wellbeing. It is accepted that the demanding

workload often prevents students from a steady exercise schedule,

and as they progress through their medical training, good health

habits and health status decline. A few studies with adolescents have

strongly suggested a positive relationship between physical fitness

and academic achievement, although the causation may be unclear.

However none have examined a relationship between levels of

exercise and academic performance in medical students.

Objectives: This study sought to find a correlation between exercise

levels and academic performance as indicated by student US Medical

Licensing Examination (USMLE) Step 1 test scores.

Methods: This IRB-approved study involved two anonymous

surveys of a midwestern medical school class of 2012. The first

survey was administered at the beginning of 2nd year and the second

survey at beginning of the 3rd year of medical school. Surveys asked

height, weight & exercise practices. The second survey included

specific questions about weekly exercise practices over the preceding

year, and also a 10-digit range of USMLE Step 1 score.

Results: A total of 28 students responded to the second survey, 46%

male, with a mean age of 24.8 and mean BMI of 22.6. Two groups

were designated according to USMLE score range of 226-265 or 186-

225. Those in the lower score group had a higher BMI of 23.5 versus

the higher score group with BMI of 21 (p=0.110). Exercise practices

of these two groups were examined by comparing the self-reported

average number of hours of exercise per week over the previous year,

3.42 for the 186-225 group versus 4.13 for the 226-265 group

(p=0.431). The group that exercised more had a higher incidence of

reporting running/jogging and weight training as their preferred

modes of exercise.

Conclusion: This small study suggests an association between a

higher USMLE Step 1 score with increased exercise activity and

lower BMI, although calculated p-values did not indicate statistical

significance. Both factors suggest a motivated individual. Further

study involving more respondents is necessary to better characterize

the validity of this association.

74. Pain Medication Delivery In The Ed For Extremity

Fractures: Correlation Of Prescribers' And Patients' Gender

And Ethnicity

David Milzman1, Valerie Huckabee1, bill dirkes1, Julie Vieth2 and

collier Wright1. 1Georgetown University School of Medicine,

Washington, DC; 2Georgetown U / Georgetown WHC EM

Residency, Washington, DC

Background: There is great debate on timing of pain medication in

the ED and especially if there may be bias based on patient selection

factors such as age, gender and ethnicity. No study has really

investigated the role of the physician prescriber own demographic

factors in relation to that of the patient.

Objectives: Primary: To determine if bias exists in analgesic

prescribing practices based solely on patients' gender and ethnicity

Secondary: To determine if the gender and ethnicity of the physician

relative to that of the patient influenced pain management

Methods: A 5 year review of patients presenting to an Urban,

Teaching Hospital ED with 80,000 annual visits.

Inclusion criteria: Adult patients with long-bone fractures but without

other distracting diagnoses

Caucasian, African American, Latino or American Indian

Primary Outcome: Administration of analgesia in the ED based on

patient gender and ethnicity.

Secondary Outcome: Gender/ethnicity of prescribing physician and

type of medication

Results: 782 patients met inclusion criteria. Mean age was 50.9

years, 60.7% were female, 191 identified as Caucasian, 562 as

African-American, 95 as Latino/Hispanic

Physician prescriber incidents: 79% male and 55% White, 29%

African American and 14% Asian.

There was no outlier group with regard to physician and patients

when looking at timing of pain medication delivery and narcotic VS

non narcotic medication selection. Although overall ED physician

performance was delayed with mean time to medication > 30 min in

68% of cases without bias and overall, all groups tended to

administer less medication to women VS men and Older > 65 yrs

received less mediation than younger patients without bias based on

physician prescribing.

Conclusion: No observed bias based on patient gender nor ethnicity

No observed bias based on physician gender nor ethnicity

Type of pain medication prescribed and delay to medication delivery

in minutes were independent of the race and gender of patients and

physicians

75. Protein Expression Of M2 Receptor In Atria And Ventricles

Of Sham Rats

Elizabeth M Spartz, Huiyin Tu, T. Paul Tran and Yu-Long Li.

University of Nebraska Medical Center, Omaha, NE

Background: Autonomic dysfunction is being recognized as an

important pathogenic cause of increased morbidity and mortality in

many disease states, including chronic heart failure (CHF) and

diabetes mellitus (DM). The dysfunction is caused by an imbalance

between the sympathetic tone, which of left ventricle, right ventricle,

left atria, and right atria were harvested, homogenized, and protein

levels for M2 receptors were measured using western blotting.

Results: See graph (attached).

Conclusion: Cardiac function is profoundly affected by neural

activation. While activation of the sympathetic system increases heart

rate, contractility and conduction velocity, activation of the

parasympathetic system (PNS) has the opposite effects; PNS is

concerned with rest, conservation, and restoration of energy via

reduction of heart rate and blood pressure. Of the five muscarinic

subtypes, only M2 receptors appear to be clinically relevant in

mammalian cardiac physiology. Although a body of data established

that PNS outflow is reduced in disease states such as CHF and DM, it

is not clear whether the reduction in PNS outflow occurs at the ICG

level or the PNS terminal level. This preliminary study is part of our

larger study to answer the question if the reduction in PNS outflow in

CHF/DM is caused by a dysfunction in ICG or a reduction in M2

receptor at the cardiac tissue. Consistent with data obtained through

other methods, our data suggest that most of the M2 receptors localize

in the cardiac atria in this rodent model.

76. Rates of Selected Procedures and High-Acuity Diagnoses in

Urban and Rural Emergency Departments

James Waymack, Steve Markwell and Ted Clark. Southern Illinois

University, Springfield, IL.

Background: EM workforce studies show relatively low rates of

board certified/residency-trained emergency physicians practicing in

rural EDs. Rural ED rotations for EM residents may lead to increased

numbers of residency-trained EM providers in rural areas, as well as

provide unique training experience. There is concern, however, that

residents trained in rural environments will not get sufficient

procedural experience or patient acuity.

Objectives: To compare the rates of selected procedures and high-

acuity diagnoses at rural and urban EDs in the US.

Methods: Procedures and high-acuity diagnoses were selected based

on ACGME guidelines and were identified in the Nationwide

Emergency Department Sample (NEDS) database by ICD9 Code.

The rates of procedures and diagnoses, reported as a percentage of all

visits, are compared between two categories. The urban category (U)

includes hospitals that are in counties defined as large or small

metropolitan; the rural category (R) includes hospitals that are in

counties defined as metropolitan or non-metropolitan.

Results: Procedure rates are lower for rural EDs. (R%, U%) Fracture

reduction - 0.25, 0.46; chest tube - 0.06, 0.13; cricothyrotomy - 0.01,

0.07; intubation - 0.27, 0.55; lumbar puncture - 0.13, 0.33;

pericardiocentesis - 0.002, 0.007; thoracotomy - 0.002, 0.006. High-

acuity diagnosis rates are lower for rural EDs. (R%, U%) Acute MI -

0.53, 0.68; cardiac arrest - 0.19, 0.24; cardiac dysrhythmia - 3.50,

4.36; pneumothorax - 0.04, 0.05, intracranial bleeding - 0.10, 0.15;

ischemic CVA - 0.73, 0.88; acute appendicitis - 0.19, 0.29; ectopic

pregnancy - 0.02, 0.05; pulmonary embolism - 0.12, 0.19; aortic

aneurysm - 0.13, 0.17; aortic dissection - 0.01, 0.02; testicular torsion

- 0.01, 0.02.

Conclusion: The lower rates of procedures and high-acuity diagnoses

in rural EDs confirms the concern that residents receiving a

substantial portion of their training in rural EDs may not get

sufficient experience in certain procedures or diagnoses. The benefits

of a rural ED rotation must be weighed against the risk of lower

procedure and high-acuity diagnosis rates. The impact of a 1-3 month

rotation in a rural ED on overall procedural competency and clinical

experience cannot, however, be extrapolated, and further study is

required to quantify this effect.

77. Do Alcohol-Related Emergency Department (ED) Visits

Mirror Police Data? A Retrospective Study

Greg Pelc, Michael Takacs and Hans House. University of Iowa,

Iowa City, IA

Background: A 2011 self-reported survey at the University of Iowa

(UI) indicates that 64.5% of UI students engaged in binge drinking in

the past two weeks, exceeding the national average of 44%. The UI

has recently supported a number of programs to address this problem,

including AlcoholEdu, more Friday classes, Red Watch Band

Program, the under 21-Ordinance, and increased late-night

programming. Measures to identify the effectiveness of these

interventions are needed to determine their worth. Police data and

alcohol-related ED visits are two measures for adverse consequences

of alcohol use.

Objectives: The study was designed to examine the relationship

between alcohol-related visits at the UI ED with Iowa City Police

Department (ICPD) and University of Iowa Police Department

(UIPD) records. Does the level of alcohol-related ED visits reflect the

number of alcohol-related incidents documented by police?

Methods: ED medical records for patients 18-22 years of age

presenting between 6:00 pm and 6:00 am were retrospectively

examined from June 2008 to May 2011. Patient data (including age,

date and time of visit, and diagnosis) was compiled for any subject

with an alcohol-related illness or injury. ICPD and UIPD records

were obtained and compiled into categories for common offenses.

Monthly totals for alcohol-related ED visits were then compared to

police data using correlation tests.

Results: From June 2008 to May 2011, there were 1,258 alcohol-

related ED visits. In the same period, the aggregate police data

indicated the following number of charges: 3,335 Public Intoxication

(PI), 2,937 Possession of Alcohol Under Legal Age (PAULA), 1,572

Operating While Intoxicated (OWI), 1,143 Disorderly Conduct (DC),

and 784 Interference with Official Acts (IOA). A weak positive

correlation exists between alcohol-related ED visits and alcohol-

related police charges, with correlation coefficients for ED visits

versus PI, PAULA, and IOA charges of 0.61, 0.55, and 0.51,

respectively.

Conclusion: The weak positive correlation between alcohol-related

ED visits and police charges tracks the general trends of college-age

alcohol abuse, with rises and falls cyclically based on student life in

Iowa City. Both ED and police data are worthwhile measures of

college-age alcohol abuse in Iowa City, as they are not mutually

dependent upon one another.

78. Acute Disaster Response: Lessons Learned from a Small-

scale Event

Kathy Lehman-Huskamp and Anthony Scalzo. Southern Illinois

University, Springfield, IL; Saint Louis University, Saint Louis, MO

Background: In August 2008, the St. Louis area experienced an

incident involving nine individuals who were illegally entering a

waste dumpster at a repackaging facility in East St. Louis, IL. The

men were inadvertently exposed to nitroaniline. Within hours, the

individuals began having symptoms and presented by either private

car or ambulance to hospitals in St. Louis, MO. This event ultimately

resulted in the temporary closing of two Emergency Departments and

one Intensive Care Unit.

Objectives: To illustrate critical lessons learned with disaster

response involving a small-scale event.

Methods: A retrospective analysis was performed on publicly

available records of a real-time event. This project was determined to

be exempt from review of the Institutional Review Board.

Results: Eight significant lessons regarding disaster response were

derived from this experience.

Conclusion: Disaster response plans cannot solely be based on mass

casualty events. Small scale events such as this case study have a

higher probability of occurrence in any given response area.

Consequently, disaster planning must be flexible in its response scale

at both the emergency responder and hospital level.

Medical Student SimWars Competition

Kansas University Medical Center

Jeremy Cook, MS2

Patrick Harper, MS2

Elspeth Pearce, MS2

Julianne Schwerdtfager, MS2

St. Louis University, School of Medicine Team 1

Stephen Gregory, MS4

Sarah Kuehnle, MS3

Stefan Law, MS3

Andrew Jung, MS2

Neil Kalsi, MS3 (alternate)

St. Louis University, School of Medicine Team 2

Cory Cheatham, MS3

Matthew Fellin, MS3

Jeff Scott, MS3

Kamran Hussaini, MS2

Jacinta Robenstine, MS3 (alternate)

Southern Illinois University, School of Medicine

Jennifer Carroll, MS3

Loren Reed, MS3

Matt Albrecht, MS4

Dan O‟Keefe, MS4

Mike O‟Keefe, MS4 (alternate)

Washington University in St. Louis, School of Medicine Team 1

Rob Klemisch, MS2

Akshay Ganju, MS2

Clark Smith, MS4

Sara Manning, MS4

Washington University in St. Louis, School of Medicine Team 2

Austin Wesevich, MS1

Dylan Kluck, MS1

Amelia Lucisano, MS1

Shelley Forbes, MS1

test

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