CAEP/ACMU 2002 Scientific Abstracts: 15-29

2003 Scientific Abstracts

CJEM 2002;4(2):124-154

015 The Reliability of the Canadian Emergency Department Triage and Acuity Scale in the Prehospital Setting: Interrater Agreement between Paramedics and Nurses.
Murray MJ, Bondy S. Royal Victoria Hospital. Barrie, ON.

OBJECTIVE: To determine the rate of interobserver reliability of the Canadian Triage and Acuity Scale (CTAS) between paramedics and emergency department triage nurses. METHODS: Two hundred and ten paramedics were trained on the use of the CTAS in an 8-hour didactic course. They applied the scale to every patient transferred to the 7 area hospital emergency departments participating during the 4-week study period. The paramedic CTAS assignment was done on arrival to hospital and compared to the triage nurse on arrival in the ED. The triage nurse score was taken as the gold standard. Scores were not revealed by the paramedic or the RN. The rate of agreement was determined between the groups of raters using k statistics and overall correlation using Pearson's rho. RESULTS: There were 1636 patients transferred to hospital during the study period. Of those 1437 had CTAS scores assigned by both the paramedic on arrival and by the triage nurse in the ED. The distribution of CTAS scores and mean scores were the same for both groups of raters. The probability of agreement between the 2 observers on a given patient was 0.599 and the overall agreement within 1 level was 96%. Overall correlation (using Pearson's rho) between the 2 scores was 0.62 (95% Cl 0.59 to 0.65). The overall chance corrected agreement k using quadratic weights was 0.61 (95% Cl 0.56 to 0.66). Further analysis showed meaningful differences between hospitals in terms of degree of agreement. Observed levels of agreement from 1 centre to another showed the overall correlation between the 2 sets of raters ranging from a high of 0.70 to a low of 0.47. CONCLUSIONS: The observed rate of agreement between the 2 raters was significantly greater than by chance alone and consistently in the moderate to substantial range. This suggests that paramedics understand and can apply the CTAS scale to patients similar to nurses.

016 How Accurate and Reliable is Examination of the Neck in Alert and Stable Trauma Patients?
Stiell IG, McKnight RD, Clement C, Brison R, Lesiuk H, Wells GA, Greenberg G, Reardon M, Cass D, Schull M, Morrison L, Eisenhauer M, for the CCC Study Group. Division of Emergency Medicine, University of Ottawa. Ottawa, ON.

OBJECTIVES: Many physicians are reluctant to examine the neck of alert and stable trauma patients. This study assessed the accuracy and reliability of physical examination of the neck. METHODS: This prospective cohort study was conducted in 10 tertiary care EDs and involved alert (GCS 15) and stable adult trauma patients at risk for neck injury. Physicians loosened the neck collar and performed a standardized clinical exam for midline tenderness, postero-lateral tenderness, deformity, active rotation to 45 degrees, and active flexion. Where feasible, 2nd physicians performed interobserver assessments. Patients then underwent radiography to determine the outcome criterion, clinically important C-spine injury. Data analyses included univariate association, kappa, sensitivity, specificity, odds ratio by stepwise logistic regression. RESULTS: The 8,924 patients had these characteristics: important C-spine injury 1.7%; mean age 36.8 years; postero-lateral tenderness 65.5%; midline tenderness 57.8%; deformity 1.3%; able to rotate neck 55.5%; able to flex neck 52.9%. This Table shows % of injury and non-injury patients with findings, p-value, kappa coefficient, sensitivity, specificity, adjusted odds ratio.

Assessment Injury No injury P-Value Kappa Sens Spec O.R. No midline tenderness 13.9% 42.7% 0.001 0.78 86% 43% 0.4 No posterolat tenderness 48.7% 34.2% 0.001 0.32 51% 34% NS No deformity 96.1% 98.8% 0.05 N/A 4% 99% NS Able to rotate 4.0% 56.4% 0.001 0.67 96% 56% 0.07 Able to flex 1.3% 53.8% 0.001 0.63 99% 53% 0.05

CONCLUSIONS: The most reliable and discriminating neck findings for identifying patients at low risk for cervical spine injury are 'ability to actively flex', 'ability to actively rotate the neck', and 'absence of midline tenderness'. Guidelines or decision rules for the management C-spine injury should incorporate these physical findings.

017 Effect of Socioeconomic Status on Pre-Hospital Transport Delays of Patients with Chest Pain.
Govindarajan A, Schull M. Institute for Clinical Evaluative Sciences, Department of Emergency Services, Sunnybrook & Women's College Health Sciences Centre, University of Toronto, Toronto, ON.

OBJECTIVE: Socioeconomic status (SES) is an important determinant of health, but its impact on pre-hospital care has not been widely studied. This study sought to determine whether SES was associated with pre-hospital transport delays for patients with chest pain. METHODS: A retrospective study of patients with chest pain transported by ambulance in Toronto, Canada from January to December 1999 was conducted. The primary outcome measure was the 90th percentile for System Response Interval (SRI), with secondary outcomes being 90th percentile Transport interval, On-scene interval and Total pre-hospital interval (TPHI). The primary dependent variable was SES, defined by the median income for each patient's postal region. Other covariates studied by quantile regression analysis included age, gender, dispatch and return priority, time of day, day of week, type of paramedic crew and percent of highrise dwellings in the region. RESULTS: 4896 patients transported by ambulance met inclusion criteria. The median age was 70, and 50.2% were female. The median income was $19,215. 90th percentile SRI and TPHI were 11 min and 49 min respectively. In univariate analyses, high SES patients had lower mean case severity (p < 0.01) and similar dispatch priorities (p = 0.2), yet were more likely to be transported by an ALS crew (p < 0.01). In multivariate analyses, SES was not significantly associated with any transport intervals. However, age (+50.4s/10yrs; 95% CI 21.0-83.6), female gender (+170.6 s; 95% CI 65.3-273.5) and ALS crews (+351.7 s; 95% CI 263.6-477.2) were associated with delays in TPHI. CONCLUSIONS: SES was not associated with pre-hospital transport intervals for chest pain patients. However, age, gender and ALS crews were associated with delays. Patients from high SES groups were more likely to be transported by an ALS crew, which, in turn, was associated with a 12% increase in total pre-hospital interval.

018 Prospective Validation of the NEXUS Low-Risk Criteria for Cervical Spine Radiography.
Stiell IG, Clement C, Wells GA, Morrison L, Greenberg G, Dreyer J, Holroyd B, Bandiera G, Reardon M, McKnight RD, Brison R, Battram E, for the CCC Study Group. Division of Emergency Medicine, University of Ottawa. Ottawa, ON.

OBJECTIVES: The NEXUS Low-Risk Criteria (NLC) for C-spine radiography in trauma were derived in a 974 patient cohort, validated in a multicentre 34,069 case study, and found to have very high sensitivity. The NLC require radiography unless all 5 low-risk criteria are met. This study prospectively and explicitly evaluated the accuracy, reliability, and acceptability of the NLC in new hospital sites. METHODS: We conducted a prospective cohort study in 9 tertiary care EDs and included all alert (GCS 15) and stable adult trauma patients at risk for neck injury, regardless of whether the physician ordered radiography. More than 350 MDs completed 15-item data forms and interpreted the NLC status for all patients who then underwent radiography to determine the outcome, clinically important C-spine injury. A 2nd MD independently examined 120 patients. Patients were followed by a 14-day telephone interview. Analyses included sensitivity, specificity, kappa coefficient, and descriptive statistics, with 95% CIs. RESULTS: Over 30 months, we enrolled 7,017 patients with these characteristics: mean age 37.5 (range 16-100), male 52.7%, dangerous mechanism 19.5%, arrival by ambulance 62.6%, clinically important C-spine injury 2.0%, unimportant injury 0.5%, internal fixation 0.6%, halo 0.6%. The NLC classified patients for 140 important injuries with sensitivity 91.4% (95% CI 85-96), specificity 33.7% (33-35), and would have required radiography for 66.8%. The kappa value for MD interpretation of the NLC was 0.52 (0.33-0.72). MDs misinterpreted the rule in 3.8% of cases and indicated discomfort applying the rule in 7.1%. Of the 12 important injury cases not identified, 3 required halo fixation and 2 underwent internal fixation; 10 of the 12 were clearly injured by a dangerous mechanism. CONCLUSIONS: These data suggest that the NLC are less sensitive than previously believed, have fair interobserver agreement, and would have little impact on C-spine radiography ordering rates outside of the U.S.

019 Safety and Efficacy of Intravenous Lidocaine During Intubation of Head Injury Patients: a Systematic Review and Meta-Analysis.
Vaillancourt C, Kapur A, Stiell IG, Wells GA. Division of Emergency Medicine, University of Ottawa, Ottawa, ON.

INTRODUCTION: Endotracheal intubation is believed to result in detrimental intra-cranial pressure (ICP) rise and cerebral perfusion pressure (CPP) decline in head injury patients. We sought to determine the safety and efficacy of IV lidocaine in preventing such changes. METHODS: For this systematic review and meta-analysis, we searched 9 electronic databases, 4 trial registries, and 6 scientific Web sites. We performed hand searches and contacted 12 international content experts. We reviewed without restriction all Randomized Controlled Trials reporting IV lidocaine and endotracheal intubation as interventions. Two investigators used standardized forms to review papers for inclusion, quality and data extraction. We used Kappa for inter-observer agreement and Review Manager 4.1 to calculate weighted mean differences (WMD) and 95% Confidence Intervals using random effect model. RESULTS: We electronically identified 331 papers and selected 56/331 for further evaluation (Kappa 0.92). 17 papers from non-electronic sources were also evaluated. We included 55/73 papers in the systematic review (Kappa 0.84). Only 2/55 papers reported ICP measures. One had insufficient information, 1 reported a 12.1 (95% CI 1.4-22.8) decrease in ICP compared to placebo when using 1.5 mg/kg of IV lidocaine 2 min before intubation of patients with brain tumours. We meta-analysed 24/55 papers measuring mean arterial pressure (MAP) with 463 patients, elective surgery 79%, mean dose lidocaine 1.6 mg/kg and mean timing before intubation 1.9 min. We found a WMD of -6.6 mm Hg (95% CI 2.1-11.2) in MAP with lidocaine. CONCLUSIONS: After controlling for other interventions, we found that MAP drops in patients receiving IV lidocaine. Instead of improving CPP, the use of IV lidocaine could be detrimental or at best not useful. There is little or no evidence to support the current use of IV lidocaine during rapid sequence induction of head injury patients. Further studies looking at final neurological outcomes are needed.

020 (Plenary Session) Multicentre Prospective Validation of the Canadian C-Spine Rule.
Stiell IG, Clement C, Wells GA, McKnight RD, Brison R, Worthington JR, Schull M, Eisenhauer M, Rowe BH, MacPhail I, Cass D, Lesiuk H, for the CCC Study Group. Division of Emergency Medicine, University of Ottawa, Ottawa, ON.

OBJECTIVES: The Canadian C-Spine Rule (CCR) for radiography in alert and stable trauma patients was previously derived in a cohort of 8,924 patients. The CCR calls for evaluation of active neck rotation if patients have none of 3 high-risk criteria and at least 1 of 5 low-risk criteria. This study prospectively and explicitly evaluated the accuracy, reliability, and acceptability of the CCR. METHODS: This prospective cohort study was conducted in 9 tertiary care EDs and involved alert (GCS 15) and stable adult trauma patients at risk for neck injury. More than 350 physicians completed 15-item data forms and interpreted the CCR status for all patients who then underwent radiography to determine the outcome, clinically important C-spine injury. Some patients were independently examined by a 2nd MD. Patients were followed by a 14-day telephone interview. Analyses included sensitivity, specificity, kappa coefficient, and descriptive statistics, with 95% CIs. RESULTS: The 7,017 patients enrolled over 30 months had these characteristics: mean age 37.5 (range 16-100), male 52.7%, ambulance arrival 62.6%, clinically important C-spine injury 2.0%, unimportant injury 0.5%, internal fixation 0.6%, halo 0.6%. The CCR classified patients for 140 important injuries with sensitivity 99.3% (95% CI 96-100), specificity 40.4% (39-42), and would have required radiography for 49.9%. The kappa value for MD interpretation of the CCR was 0.66 (0.52-0.81). MDs misclassified the rule in 8.7% of cases, did not evaluate range of motion when indicated in 10.5%, and were comfortable applying the rule in 92.2%. The single case not identified was an ambulatory male without midline tenderness, whose initial radiographs were normal, and who was eventually treated with a hard collar. CONCLUSIONS: The CCR has proven to be an accurate, reliable, and acceptable decision rule. Widespread implementation would lead to more efficient use of immobilization procedures and radiography for alert and stable trauma patients.

021 (Plenary Session) The Validity of Clean-Voided (Bag) Urinalysis (UA) in the Diagnosis of Urinary Tract Infection (UTI) in Nontoilet-Trained Children: A Head-to-Head Comparison with Catheter UA.
McGillivray DL, Kramer MS, Mulrooney ET, Mok E. Montreal Children's Hospital, McGill University. Montreal, QC.

INTRODUCTION: Urine cultures (UC) from clean-voided bag specimens in nontoilet-trained infants and young children are often contaminated. The UA from such specimens is believed to be adequate since it relies on tests for the presence of leukocytes and nitrite rather than on viable bacteria. This belief has not previously been subjected to head-to-head comparison with the UA of simultaneously obtained catheterized (cath) specimens. The study objective was to compare the validity of a clean-voided bag versus cath UA in determing the presence of a UTI based on cath UC. METHOD: We compared the sensitivity (Se) and specificity (Sp) of simultaneous bag and cath UA collected in 311 children presenting to a tertiary-care pediatric ED. A cath UC yielding >=10,000 organisms/ml of single pathogen was used as the gold standard to define UTI. A positive UA was defined as a dipstick positive for leukocyte esterase and/or nitrite. Secondary analysis included the addition of microscopic pyuria (>5wbc/hpf) to define a positive UA. P values are based on the paired (McNemar) chi-squared test. RESULTS: The bag was more Se than the catheter UA in all age groups, 0.80; 95% CI, (0.72, 0.89) versus 0.66 (0.57, 0.76) respectively, (P value < .02). Bag/cath UA in infants ¾90 days had low Se, 0.57 (0.31, 0.83) and 0.36 (0.11, 0.61) respectively, (P value NS). For infants >90 days Se for bag and cath UA were 0.84 (0.76, 0.93) and 0.71 (0.61, 0.82) respectively with a P value < 0.02. Bag/cath Sp for all ages was 0.44 and 0.96. Addition of microscopic pyuria did not alter the bag/cath UA comparison. Se increased to 0.91 and 0.79. CONCLUSION: The bag had a higher Se than the cath in a head-to-head comparison using cath culture as the gold standard. In infants ¾90 days, neither bag nor cath UA is sufficiently sensitive. In low risk infants >90 days, the 9-16% false-negative rate associated with the bag UA may be sufficient to decide initial management.

022 (Plenary Session) Nurses, Patients and Physicians: an Analysis of Causes of Emergency Department Overcrowding.
Schull MJ, Lazier K, Vermeulen M, Mawhinney S, Morrison LJ. Institute for Clinical Evaluative Sciences, Sunnybrook and Women's College Health Sciences Centre, Prehospital Research Group of Toronto Emergency Medical Services, Department of Medicine, University of Toronto, ON; Faculty of Medicine, Dalhousie University. Halifax, NS.

OBJECTIVE: To determine the relationship between physician, nursing and patient factors on emergency department (ED) overcrowding. METHODS: Data were collected on ED overcrowding (defined as ambulance diversion) at 1 hospital in Toronto, Canada, during consecutive 8-hour intervals from January 1 to December 31, 1999 (n = 1095). Using autoregressive integrated moving average methods, the association between overcrowding and nurse-hours, physician on-duty, and admitted patients held in the ED was determined. Covariates included ambulance, walk-in and major trauma patient volume, admitted patient volume, average time for assessment and disposition, time of day and day of week. RESULTS: 37,999 patients were treated in the ED over the study period; 2% were trauma patients, 16% arrived by ambulance and 22% were admitted. ED nurse-hours per interval averaged 60, but varied by three-fold. A mean of 3.2 admitted patients were held in the ED each interval. For admitted patients, the time from registration to admission order (Assessment time) and from admission order to ED departure (Holding time) averaged 5.2 and 3.5 hours respectively. There was no overcrowding during 170 (15.5%) intervals while 17 (1.5%) were overcrowded the entire interval. In multivariate analyses, ED nurse-hours (p = 0.8) and physician on duty (p = 0.06-0.8) were not associated with overcrowding. The number of admitted patients held in the ED (p < 0.001), number admitted per interval (p = 0.04), assessment time (p = 0.008), holding time (p < 0.001) were all associated with overcrowding. Ambulance patients were associated with overcrowding (p < 0.001), but walk-in (p = 0.2) and major trauma patients (p = 0.4) were not. CONCLUSION: Admitted patients held in the ED are significant determinants of overcrowding, while ED physician on duty and nurse-hours are not. A minority of patients is admitted, yet they contribute disproportionately to overcrowding. Reducing the volume of walk-in patients is unlikely to lessen overcrowding.

023 (Plenary Session) Prospective Multicentre Study of Relapse Following Emergency Department Treatment of COPD Exacerbation.
Rowe BH, Kim S, Emerman CE, Cydulka RK, Clark S, Camargo CA Jr. University of Alberta. Edmonton, AB.

OBJECTIVE: Risk of relapse after ED treatment of COPD exacerbations is uncertain. Our objective was to determine the relapse rate and identify risk factors for relapse. METHODS: 29 North American EDs enrolled patients (pts) 24 hrs/day for a median of 2 weeks. Enrolled pts underwent a structured ED interview and telephone interview 2 weeks later. Inclusion criteria were MD diagnosis of COPD, age 55+, and discharge to home. Relapse was defined as an urgent visit to any ED or clinic within 2 weeks of ED discharge. Data analysis used Chi-2, t-test, K-W test, and logistic regression. RESULTS: Of 419 subjects, 160 (38%) were sent home; follow-up was available in 149 (93%). Relapse was 9% at 1 week, and 21% (95% CI, 14%-28%) at 2 weeks. Body mass index (BMI) was higher in pts who relapsed (29.4 vs 26.0, p = 0.02). Pts who relapsed had higher number of ED or urgent clinic visits for COPD exacerbation during the past year (7 vs 4, p = 0.01). Relapse pts were more likely to report activity limitations (none, mild, moderate, severe) in the 24 hours before the ED visit (p = 0.002), while other subjective symptom ratings were not significant (p = 0.06 and p = 0.16). Relapse was associated with initial respiratory rate (26 vs 23, p = 0.003), but not with other objective severity measures such as O2 saturation or initial peak flow (both p > 0.4). Discharge medications did not predict relapse after adjustment for initial respiratory rate. Controlling for age, sex, and number of ED or urgent clinic visits (all NS), significant predictors of relapse were higher BMI (OR, 1.08 per unit; 95% CI, 1.01-1.14), more activity limitation preceding ED visit (OR, 4.0 per unit; 1.5-10.1), and initial respiratory rate (OR, 1.13 per breath/min; 1.02-1.26). CONCLUSION: On multivariate analysis, BMI, activity limitation, and initial respiratory rate predicted COPD relapse. Future research might target interventions, such as tailored outpatient therapy or a lower admission threshold, for this high-risk group.

024 (Plenary Session) Identification of High-Risk Locations of Cardiac Arrest for Optimal Implementation of Public Access Defibrillation (PAD) Programs.
De Maio VJ, Stiell IG, Wells GA, Vaillancourt C, Spaite DW, Nesbitt L, Martin MT, Cousineau D, for the OPALS Group. Department of Emergency Medicine, University of North Carolina. Chapel Hill, NC, U.S.A.

OBJECTIVES: Many agencies are promoting widespread availability of AEDs in public places despite a lack of evidence for the best locations for PAD. We attempt to identify high-risk cardiac arrest locations to guide the optimal distribution of AEDs in our communities. METHODS: This was an analysis of a prospective cohort study of all adult, out-of-hospital cardiac arrests occurring before EMS arrival within the 20 communities of the Ontario Prehospital Advanced Life Support (OPALS) Study. EMS response included firefighter defibrillation, BLS-D and ALS paramedics. Case definitions followed the Utstein guidelines. The place of arrest was identified from a centralized dispatch database. Unique property type codes were identified for each address from the provincial property assessment roll and grouped into 26 location categories. Analysis was descriptive. RESULTS: From 1995-2000, there were 6151 consecutive cardiac arrests occurring at 5401 separate addresses. Private residences comprised 87% of these addresses and the remaining 13% were public locations. The number of addresses with multiple cardiac arrests during the study period include: >2 arrests, 404 addresses; >3 arrests, 123 addresses; >4 arrests, 57 addresses; >5 arrests, 30 addresses. Those sites with an average of 1 arrest per year (>5 from 1995-2000) accounted for only 201 (3.3%) of all cardiac arrests. The number of separate addresses for each of these high-risk location categories include: nursing homes 16, apartments 8, stores/strip mall 3, college 1, office building 1, mobile-home park 1. CONCLUSIONS: Most cardiac arrests occur as isolated events in private residences. We identified few locations within 20 OPALS communities that may be amenable to PAD. Further study will evaluate the utility of providing PAD for each of the location categories. All communities considering public placement of AEDs should similarly identify high-risk sites to guide the rational deployment of these devices.

025 (Plenary Session) Treated Versus Untreated HIV Positive Patients in an Urban Emergency Department.
Grafstein EJ, Kimel G, Hogg RS, Craib KJP, Innes GD, Christenson JM, Sherlock C, Palepu A, O'Shaughnessy MV. Providence Health Care, St. Paul's Hospital, UBC. Vancouver, BC.

BACKGROUND: There are an estimated 9,000 injection drug users of whom approximately 2,000 are HIV positive in Vancouver. Many present to the emergency department (ED) without antiretroviral therapy (ART). OBJECTIVE: To identify sociodemographic characteristics of HIV patients presenting to the emergency department who are not on ART. METHODS: A survey was performed between June 1 and September 30, 2001 at St. Paul's Hospital Emergency Department, an urban, academic, tertiary care centre in Vancouver, Canada. All patients between the ages of 18-65 were screened to determine their HIV status. Consented HIV positive patients also provided a blood sample for CD4 count, viral load, and Hepatitis C antibody status. RESULTS: For the 4 month period we screened 447 patients who admitted to being HIV positive. 323 patients consented and 5 who were found to be HIV negative were withdrawn. CD4 counts were obtained in 300 (94%) and VL was obtained in 292 (92%) patients. 37% of patients were on ART and 63% were not. Of those patients not on ART (n = 200), 53% had been on ART and stopped and 47% had never been on ART. 33% of patients not on ART were injection drug users (IDUs) compared to 25% of patients on ART identified as IDUs. In univariate analyses, gender [OR = 2.0, 95% CI: 1.1, 3.6] aboriginal status [OR = 1.8, 95% CI: 1.0, 3.2], injection drug use [OR = 1.6, 95% CI: 1.0, 2.8], unstable housing [OR = 2.0, 95% CI: 1.2, 3.3], age (mean-ART = 40 vs. mean-no ART = 38; p = 0.009) were significantly associated with lack of ART. In multivariate analysis, unstable housing (p = 0.011) was the only significant predictor of lack of treatment. Mean CD4 count was 310/muL ± 233 in untreated IDUs and 368/muL ± 211 in untreated non-IDUs. CONCLUSION: There is a significant untreated HIV patient population using the emergency department for medical treatment. Stable housing appears to be important to receiving ART. A rapid access clinic may improve the ability to provide ART to untreated HIV patients seeking care in the ED.

026 (Plenary Session) Does Access to a STAT Cardiology Follow-Up Clinic Reduce ED Length of Stay in Patients with Chest Pain?
Christenson J, Clarke T, Innes G, Anis A, McKnight D, Boychuk B, Grafstein E, Thompson C, Rosenberg F, Gin K, Tilley J, Singer J. St. Paul's Hospital, UBC. Vancouver, BC.

OBJECTIVE: Rapid access to outpatient cardiology evaluation may, in some cases, reduce the need for emergency investigations and shorten ED disposition time. Our objective was to determine the impact of a STAT cardiology outpatient clinic on ED length of stay (LOS) for patients presenting with chest pain METHODS: This observational study was performed at 2 urban EDs with similar patient populations, ED staffing, invasive capability, and teaching responsibilities. Both are cardiac referral centres, but 1 has access to a STAT cardiology outpatient clinic (STAT) for urgent follow-up within 1-2 days. Consecutive, consenting patients >24 years old who presented to the ED with chest discomfort over a one-year period were prospectively enrolled. Investigators assigned a 30-day outcome diagnosis of definite acute coronary syndrome (ACS) or no ACS based on pre-defined explicit criteria. Patients discharged with a non-ACS diagnosis and no arrangements for urgent follow-up investigations were classified as "missed ACS." Index visit LOS, disposition, diagnostic test utilization and patient outcomes were ascertained for each case through a structured review of the clinical record. Statistical significance was determined using Wilcoxon Rank Sum Test, t-test or the chi-square statistic. RESULTS: 885 patients were enrolled at the STAT hospital and 936 at the NOSTAT Hospital. Median (IQR) index ED LOS was 4.3 (3.0, 6.4) hours in the STAT group and 4.9 (2.9,8.8) hours in NOSTAT (p < 0.01). Admission rates were 33.3% and 39.4% respectively (p < 0.01). Rates of missed ACS (1.4 vs 1.1%), noninvasive (18.6 vs 16.3%) and invasive testing (17.3 vs 19.7%) were similar. CONCLUSION: ED LOS and admission rate is reduced in a centre with access to a stat cardiology clinic with fewer ETTs, scans and echos during the index visit. These data suggest that a STAT cardiology clinic is effective in reducing index ED utilization in patients with chest pain without increasing the number of patients with missed ACS.

027 Agreement Among Pediatric Health Care Professionals with New Triage Guidelines.
Bergeron S, Gouin S, Bailey B, Amre D, Patel H. Divisions Of Emergency Medicine, Research Institute & Intensive Ambulatory Care Service, Ste-Justine & The Montreal Children's Hospitals. Montreal, QC.

BACKGROUND: Recently, the 5 category Canadian Paediatric Triage and Acuity Scale (PaedCTAS) has been proposed for the triage of pediatric patients coming to an Emergency Department (ED). OBJECTIVE: To compare triage level assignment, using case scenarios, in a pediatric ED between registered nurses (RN) and pediatric emergency physicians (PEP) using PaedCTAS. To compare triage level assignment by RNs and PEPs to a consensus agreement derived from the PaedCTAS. To compare triage level assignment using the PaedCTAS vs previous 4 category triage tool. METHODS: Cross-sectional questionnaire survey sent to all RNs and PEPs working in the ED after 5 months of the PaedCTAS implementation in our ED. The survey included 55 case scenarios providing details of patient's symptoms, signs and mode of arrival. Participants were instructed to assign triage category on each case, using the following scale: resuscitation, emergent, urgent, less urgent, non urgent. Kappa statistics and the mean number (±1 SD) of correct responses were calculated. RESULTS: A response rate of 95% was achieved (29 RNs, 15 PEPs). The kappa level of agreement (±1 SD) amongst the RNs was 0.51 ± 0.02 and was 0.39 ± 0.03 amongst the PEPs (P < 0.001). The mean number of correct responses (±1 SD) for the RNs was 64% ± 27% and for the PEPs was 60% ± 22% (P = 0.31). There were no significant differences by stratifying the RNs and the PEPs by experience level (<10 vs. >10 years) or by the type of shift work (day vs. evening vs. overnight). The same survey conducted a year ago with our previous triage tool, yielded levels of agreement for the RNs of 0.453 ± 0.003 and of 0.419 ± 0.005 for the PEPs. CONCLUSIONS: With the introduction of the PaedCTAS, the level of agreement and accuracy of triage categorisation remained moderate for both RNs and PEPs.

028 Randomized, Double-Blind, Placebo-Controlled Trial of Oral Salbutamol in Outpatient Infants with Acute Viral Bronchiolitis.
Patel H, Gouin S, Platt RW, Smith MBH. Divisions of Ambulatory Care Service, Emergency, Epidemiology & Biostatistics and Pediatrics, McGill University. Montreal, QC, Queen's Universities, Canada & Northern Ireland.

BACKGROUND: Many infants with acute viral bronchiolitis are treated with oral salbutamol. Evidence is lacking to support this widespread practice. OBJECTIVE: To determine if oral salbutamol is effective in reducing the short-term symptom severity of infants with mild to moderate bronchiolitis. METHODS: In this randomized, double-blind trial, previously well infants with first time wheezing were randomized upon discharge from the Emergency Department to receive either salbutamol (SAL) (0.1 mg/kg/dose) TID or placebo (PLAC) TID for 7 days. Daily standardized telephone interviews inquiring about symptom frequency and severity were conducted with caregivers for 14 days. The primary outcome of interest was the time to resolution of symptoms (ROS). Secondary outcomes included time to: normal feeding and sleeping, resolved cough, resolved coryza and quiet breathing. Re-visit and hospital admission rates were also measured. RESULTS: During the study period (winters 1999-2001), 127 infants were enrolled (SAL = 63, PLAC = 64). Baseline demographic features, symptoms and signs were similar between groups. The overall mean age was 4.9 months, 60% were male and 76% positive for respiratory syncytial virus. The mean time (SD) to ROS (days) was similar: SAL = 8.9 (4.0), PLAC = 8.4 (3.7) (p = 0.5). There were no significant group differences in the secondary outcomes for SAL vs PLAC groups respectively: 4.4 vs 3.3 days for normal feeding, 3.0 vs 3.3 days for normal sleeping, 5.9 vs 5.4 days for resolved cough, 3.9 vs 2.7 days for resolved coryza and 4.4 vs 4.9 days for quiet breathing. Health care re-visit and admission rates were similar between groups. CONCLUSIONS: No significant group differences in the short-term symptom resolution in infants with mild-moderate bronchiolitis treated with oral salbutamol versus placebo were found. The widespread practice of oral salbutamol in this patient group is not recommended.

029 Pediatric Intravenous (IV) Insertion in the Emergency Department (ED): Bevel Up or Bevel Down?
Black KJL, Pusic M, Harmidy D, Larson C, McGillivray D. Montreal Children's Hospital. Montreal, QC.

INTRODUCTION: Intravenous catheters are usually inserted bevel up. Bevel down insertion may be superior in small and/or dehydrated children. We seek to determine whether there is a difference in the success rate of IV insertion using these 2 methods. METHODS: We recruited children requiring an IV in the ED where there was time to obtain consent. Patients were randomized to have the first attempt bevel up or bevel down. If the first attempt was unsuccessful, the alternate technique was used on second attempt. Attempts beyond 2 were not tracked. RESULTS: We recruited 400 patients. Data are available from 380 (206 bevel up; 174 bevel down). At least 63 nurses participated (some were unidentified). The nurses participated in the study a median number of 2 times (maximum 36). The success rate on first attempt was 75.7% for bevel up and 58% for bevel down. The success rate on second attempt was 59.6% for bevel up and 42.9% for bevel down. The nurses who participated fewer than or equal to 2 times had a success rate of 82.7% (95% CI: 69.4, 95.9) bevel up and 50% (95 CI: 31.2, 68.8) bevel down. The 12 nurses who attempted bevel down more than 5 times had a success rate of 65% on the first attempt. CONCLUSION: The limitations of this study include a small sample size, the learning curve of a new technique, and a large number of nurses performing a limited number of procedures. While the success with the bevel down technique improved with experience, a larger number of nurses with experience in the technique are needed to determine if it is superior to the established method.