CAEP/ACMU 2002 Scientific Abstracts: 45-59

2003 Scientific Abstracts

CJEM 2002;4(2):124-154

045 Use and Yield of Investigations for Alert Patients with Possible Subarachnoid Hemorrhage.
Perry JJ, Stiell IG, Wells GA, Spacek A. Division of Emergency Medicine, University of Ottawa. Ottawa, ON.

OBJECTIVES: There is little evidence to guide investigation to rule out subarachnoid hemorrhage (SAH) in alert ED patients with acute headache. This study evaluated the current use and yield of CT and LP for SAH in ED patients with possible SAH. METHODS: This health records review enrolled patients presenting to a tertiary care university teaching hospital ED if they were >15 years, alert with GCS 15, had no new neurological deficits, and had a complaint of headache, syncope or possible SAH. Outcome measures included: CT use and yield, LP use and yield and length of stay prior to discharge/referral to neurosurgery. Exclusion criteria included: maximal intensity in >1 hour, referrals with SAH, recurrent headaches, head trauma, pain for >14 days, focal neurological deficits, papilledema or decreased level of consciousness. Analysis included: descriptive statistics including 95% CI and ANOVA for length of stay. RESULTS: The 891 patients seen over a 10-month period had these characteristics: mean age 41.9, 66.4% female, 1.1% SAH, 2.6% admitted, 42.2% vomiting, 40.8% transient loss of consciousness, 35.1% CT, and 6.8% LP. Only 9 (2.6%) CT and 2 (2.4%) LPs were positive for SAH. There were no missed cases with CT. There was 1 positive LP without a prior CT and another with a positive CT. There were 144 (11.5%) patients who underwent a normal CT without subsequent LP. The mean length-of-stay for patients without SAH was as follows: 4.0 hours (3.8-4.1) without testing, 5.0 hours (4.7-5.4) with only CT, 7.1 hours (6.3-7.9) with LP (p = 0.001). CONCLUSIONS: This study demonstrated that patients who underwent testing spent much more time in the ED. CT and LP had very low yield suggesting the need for a clinical decision rule to guide physicians in the investigation of acute headache to rule out SAH.

046 Is There Still a Role for Physical Examination of Patients with Minor Head Injury?
Stiell IG, Clement C, Cass D, Rowe BH, Eisenhauer M, Schull M, McKnight RD, MacPhail I, Brison R, Reardon M, Greenberg G, Battram E, for the CCC Study Group. Division of Emergency Medicine, University of Ottawa, Ottawa, ON.

OBJECTIVES: In an era of ubiquitous CT scanning, is there still a role for physical examination of minor head injury patients? This study evaluated the accuracy and reliability of common physical signs. METHODS: This prospective cohort study was conducted in 10 tertiary care EDs and involved adults with loss of consciousness, amnesia, or confusion and a GCS score of 13-15. MDs performed a standardized exam for: pupillary size and reaction, lateralizing motor weakness, suspected open skull fracture, basal skull fracture signs, and unreliability due to suspected ethanol/drug intoxication. Where feasible, 2nd physicians performed interobserver assessments. Patients had CT to determine the outcome, clinically important brain injury. Analyses included univariate association, kappa, sensitivity, specificity, adjusted odds ratio by stepwise logistic regression. RESULTS: The 3,121 patients enrolled over 36 months had these characteristics: mean age 38.7, GCS score - 15 79.8%, important brain injury 8.1%, required neurological intervention 1.4%. The Table shows % of brain injury (N = 254) and non-injury (N = 2867) patients with the findings, p-value, kappa, sensitivity, specificity, adjusted odds ratio.

Assessment Injury No injury P-Value Kappa Sens Spec O.R. Abnormal pupils 2.8% 1.1% 0.05 0.66 3% 99% NS Lateralizing weakness 0.8% 1.1% NS 0.66 1% 99% NS Suspected open skull # 11.8% 2.6% 0.001 0.85 12% 97% 3.2 Signs of basal skull # 30.4% 4.7% 0.001 0.76 30% 95% 5.0 Unreliable 2nd Etoh/Drug 18.1% 11.8% 0.01 0.54 18% 88% NS

CONCLUSIONS: Assessment of pupils and motor weakness is not useful in minor head injury patients. The most reliable and accurate physical findings for identifying the risk for brain injury are 'suspected open skull fracture' and 'signs of basal skull fracture' and these should be incorporated into decision rules for the management of minor head injury.

047 What can be Gained from the General Physical Examination of Alert Patients with Potential Cervical Spine Injury?
Stiell IG, Clement C, Worthington JR, Schull M, Eisenhauer M, MacPhail I, Cass D, Rowe BH, Battram E, Bandiera G, Brison R, McKnight RD, for the CCC Study Group. Division of Emergency Medicine, University of Ottawa. Ottawa, ON.

OBJECTIVES: In the assessment of potential C-spine injury patients, what can be gained from the general physical examination? This study evaluated the accuracy and reliability of common physical signs. METHODS: This prospective cohort study was conducted in 10 tertiary care EDs and involved alert (GCS 15) and stable adult trauma patients. MDs performed a standardized exam for: patient position, distracting painful injuries, unreliability due to ethanol/drug intoxication, visible facial injury, visible head injury, motor deficit in extremities, sensory deficit in extremities. 2nd physicians performed interobserver assessments in 150 cases. Patients underwent radiography to determine the outcome, clinically important C-spine injury. Analyses included univariate association, kappa, sensitivity, specificity, odds ratio by multivariate logistic regression. RESULTS: The 8,924 patients enrolled over 36 months had mean age 36.8 and 1.7% had important C-spine injury. The Table shows % of C-spine injury (N = 151) and non-injury (N = 8773) patients with the findings, p-value, kappa, sensitivity, specificity, adjusted odds ratio.

Physical findings Injury No injury P-Value Kappa Sens Spec O.R. Upright position 6% 39% 0.001 0.74 6% 62% NS Distracting injuries 15% 8% 0.001 0.41 15% 92% NS Unreliable 2nd Etoh/Drug 8% 4% 0.05 0.22 8% 96% NS Facial injury 43% 19% 0.001 0.75 43% 81% 1.8 Head injury 48% 20% 0.001 0.76 48% 80% 1.6 Motor deficit 5% 1% 0.001 0.93 5% 99% NS Sensory deficit 6% 2% 0.001 0.60 6% 98% NS

CONCLUSIONS: The findings 'distracting painful injuries' and 'unreliable due to etoh/drug' show poor interobserver agreement. The other 5 findings are reliable but only 'facial injury' and 'head injury' independently predict a higher risk of C-spine injury in alert trauma patients.

048 Success and Complications of Individual Treatment Methods for Paroxysmal Atrial Fibrillation.
Kapur AK, Stiell IG, Wells GA, Brison RJ, Mortensen M. Division of Emergency Medicine, University of Ottawa. Ottawa, ON.

OBJECTIVES: To compare the proportion of paroxysmal atrial fibrillation (PAF) patients who convert to sinus rhythm in the ED with rate control agents (RC), pharmacologic agents (PHARM) or electrical cardioversion (ELEC). To determine the proportion of patients in each group who suffer complications in the ED. METHODS: This 6-month prospective cohort study, conducted at 3 university-affiliated hospital EDs, enrolled all adult patients who presented to the ED with <48 hours of clinically stable PAF. Success was determined by the ED physician's interpretation of the ECG. Complications were determined by review of the patient's ED chart and vital signs. Proportions, with 95% confidence intervals (CI), were compared using chi-square. RESULTS: We enrolled 169 patients; 81 in the RC group, 127 PHARM, 57 ELEC, and 12 received no treatment (some patients received more than 1 treatment). 7 of the untreated patients (58.3%, CI: 32.0%-80.7%) and 4 RC patients (4.9%, CI: 1.9%-12.0%) spontaneously converted. 65 PHARM patients (51.2%, CI: 42.6%-59.7%) and 50 ELEC patients cardioverted (87.7%, CI: 76.8%-93.9%). None of the untreated patients had complications (0.0%, CI: 0.0%-24.3%). 2 RC patients had complications (2.5%, CI: 0.7%-8.6%). 4 PHARM patients had complications (3.1%, CI: 1.2%-7.8%) and 1 of them was admitted (0.8%, CI: 0.1%-4.3%). 9 ELEC patients had complications (15.8%, CI: 8.5%-27.4%) and 1 of them was admitted (1.8%, CI: 0.3%-9.3%). Electrical cardioversion was less successful if preceded by rate control (73.9% vs 97.1%, p = 0.01). Pharmacologic conversion was also less successful if preceded by rate control (73.7% vs 88.1%) but this was not significant (p = 0.10). CONCLUSIONS: Electrical cardioversion was the most successful treatment method. Administration of rate control agents decreased the success of the other treatment methods. Most complications were minor and did not lead to admission. This suggests that primary electrical cardioversion is the optimal ED treatment for PAF.

049 Closed Reduction of Distal Radius Fractures in the Emergency Room: Factors Associated with Orthopedic Intervention.
Skoretz TG, Eisenhauer M, Amir H. London Health Sciences Centre, University of Western Ontario. London, ON.

OBJECTIVE: To describe patient and radiographic characteristics associated with Orthopedic intervention in patients that received closed reduction of a distal radius fracture in the Emergency Room. INTRODUCTION: Closed reduction of a distal radius fracture is a time consuming and laborious procedure. Despite closed reduction in the ER, many patients will go on to further manipulation and/or operative repair by the Orthopedic Surgery service. Discovering factors that predict future Orthopedic intervention may be helpful in the management of this common injury. METHODS: The Emergency Room logbook and billing records were reviewed for all adult patients that underwent a closed reduction of a distal radius fracture by the Emergency Medicine service at London Health Sciences Centre-South Street, a tertiary care centre, in 2000. Hospital charts and presenting wrist radiographs were reviewed. Multivariate analysis was used to calculate predictors of Orthopedic intervention (repeat closed reduction or operative repair). In addition, multiple reviewers assessed initial radiographs to calculate inter-rater reliability in extracting 5 different x-ray variables. RESULTS: A total of 71 distal radius fractures underwent closed reduction by the Emergency Room medical staff at LHSC-South Street. Seventy charts were available for review. Initial radiographs of the injured wrist were available in 56 patients. Analyses showed that patient age (OR = 0.952) and initial dorsal angulation (OR = 0.964) were associated with Orthopedic intervention. Analyses of inter-rater reliability demonstrated fair to excellent reliability in extraction of radiographic variables. CONCLUSION: In the sample of patients reviewed, patient age and initial dorsal angulation were predictive of future Orthopedic intervention. In addition, inter-rater reliability in extracting x-ray data was considered good overall, but variability existed.

050 Isocapnic Hyperpnea Accelerates Ethanol Elimination: a Model.
Preiss D, Sasano H, Vesely A, Petroianu G, Fisher JA. Department of Anesthesia, University Health Network. Toronto, ON.

BACKGROUND: Using the lungs to accelerate ethanol elimination has been limited by concerns about the adverse effects of the hypocapnia accompanying hyperventilation. Based on a simple method to produce isocapnic hyperpnea1 (IH), we re-examined the potential contribution alcohol elimination through the lungs to enhance total body ethanol clearance. We hypothesized that at high ethanol concentrations, isocapnic hyperpnea significantly accelerates elimination, compared to that due to hepatic metabolism alone. METHODS: Using a commercial spreadsheet program, we simulated the elimination of ethanol, based on its distribution over total body water, a blood-air partition coefficient of 2000, and a constant hepatic elimination rate of 15 mg/dL/h. We used the model to predict rates of ethanol elimination for ventilations of 5 and 25 L/min at blood ethanol concentrations of 100 mg/dL (just above the legal driving limit) and 600 mg/dL (near lethal limit for non-tolerant adults). RESULTS: Increasing minute ventilation from 5 to 25 L/min increased the elimination rate of ethanol by 9% at an ethanol concentration of 100 mg/dL, and by 50% at a concentration of 600 mg/dL. CONCLUSION: Our model predicts that IH will contribute significantly to the rate of ethanol elimination at high initial concentrations and may provide a useful adjunct to standard treatment in highly intoxicated patients. We predict that IH will be even more effective in tolerant subjects who present with even higher blood alcohol concentrations.

051 Does Urine Screening for Drugs of Abuse Change the Management of ED Patients?
Eisen JS, Sivilotti MLA, Collier C. Department of Emergency Medicine, Queen's University. Kingston, ON.

BACKGROUND: It is estimated that substance use is a frequent factor in Emergency Department (ED) visits. Qualitative urine testing for drugs of abuse (U-DOA) is frequently ordered, but is limited in its ability to establish the identity, timing or dose of substances used. Although previous retrospective studies have demonstrated these limitations, their study design cannot be used to determine whether U-DOA provides useful information to the ED physician when making patient care decisions. Objective: To isolate and measure the impact of U-DOA on ED patient care. METHODS: All U-DOA ordered in adult patients seen in 2 teaching EDs were eligible; screens that were ordered for victims of trauma or sexual assault were excluded. Prior to reporting the test results to the ED, ordering physicians were phoned by the investigators and queried about their patient care plans before, and then immediately after the results were disclosed. This design isolated the impact of the U-DOA screen on ED patient care decisions. Any changes in plan reported by the physician were compared to a pre-determined set of changes that were considered to be clinically important. RESULTS: To date, 81 U-DOA have been enrolled during a period with approximately 42,000 ED visits. One ED physician reported a change in plan (CT head deferred), but this change was not considered significant according to pre-specified criteria. U-DOA thus led to a clinically important change in management in 0/81 cases (95% CI 0-3.7%). CONCLUSIONS: U-DOA is rarely helpful in guiding patient care decisions in the ED. These results call into question the need for the test in the ED setting.

052 Economic Evaluation of the Potential Impact of the Canadian C-Spine Rule.
Coyle D, Stiell IG, Wells GA, Clement C, for the CCC Study Group. Division of Emergency Medicine, University of Ottawa, Ottawa, ON.

INTRODUCTION: The Canadian C-Spine Rule (CCR) is designed to improve the efficiency of ED management of potential cervical spine injury patients. This economic analysis estimated the potential cost savings to the Canadian health care system with widespread use of the CCR. METHODS: This economic analysis used a probabilistic-based decision analytic model comparing current clinical practice to that assuming 100% uptake of the CCR. Costs savings were assessed from a Canadian health care system perspective. The sensitivity and specificity of the rule was estimated by combining data from the derivation (N = 8,924) and validation (N = 7,017) studies. For our base analysis, current radiography rates were estimated to be 71.6%. Sensitivity analyses assumed rates of 90% and 100%. Cost data were obtained from provincial health care fee schedules, hospital cost accounting systems and, if required, the literature. The probabilistic model employed Monte Carlo simulation that was based on 3,000 replications. We estimated the expected values for potential cost savings and reduction in radiography rates. Results are in Canadian dollars. RESULTS: In our base analysis, the expected value of cost savings with the CCR was $8.54 (95% credibility interval $5.61-$11.91) per alert stable trauma patient. The rule is forecasted to lead to an absolute reduction in radiography of 12.8% (95% CI 8.9-16.9) compared to current rates of 71.6%. The total annual cost savings, assuming a Canadian adult trauma patient population of either 185,000 or 400,000 patients, would be $1.6 million and $3.4 million respectively. Assuming radiography rates of 90% and 100%, the expected annual cost savings were $8.8 million and $11.5 million respectively, based on 400,000 patients per year. CONCLUSIONS: Widespread use of the CCR is expected to lead to cost savings as low as $1.6 million per year or as high as $11.5 million. Future studies should evaluate the potential economic impact of the CCR in other countries.

053 Transient Ischemic Attacks in the Emergency Department: Description and Outcome.
Rowe BH, Yiannakoulias N, Bullard M, Spooner CH, Holroyd BR, Svenson L, Rosychuk R, Schopflocher D. University of Alberta, Edmonton, AB.

OBJECTIVES: Defining the short-term prognosis and risk factors for stroke after transient ischemic attacks (TIA) may provide guidance in determining which patients need rapid ED evaluation. Recent US data suggest the 90-day risk of recurrent TIA (13%) or stroke (11%) are high. This study examines ED presentations of TIA and links data to health care use in the subsequent year. METHODS: All patients presenting to Alberta EDs were eligible for inclusion. Data were derived from a sample of ED patients treated in 17 health regions over 1 year (98/99) with a diagnostic code of TIA (434.x). Data were extracted from the Ambulatory Care Classification System (ACCS) database, consisting of computerized abstracts coded similarly across regions. Diagnostic categories were coded by medical record nosologists using ICD-9 codes for the primary discharge diagnosis. Descriptive statistics and crude presentation rates are reported. RESULTS: Overall, 1.49 million ED visits were recorded in the year; the number of patients with a diagnosis of TIA was 2543 (1.7/1000 ED visits). Overall, 75% of patients were over the age of 65 years; males and females were equally represented. Limited daily or seasonal variation exists; Monday (15.6%) and December (10.7%) numbers were highest. Most patients are discharged (1810; 71%); admission (770; 28%) is higher than the ED average and few leave prior to seeing a physician (<1%). The rate of TIA varies between regions, with the average of 7.5/1000 population. Representation to the ED is common (833; 37%); however, representation with a TIA (236; 10%) or stroke 24 (1%) in the subsequent year was less frequently observed. CONCLUSIONS: These results indicate that TIA is a relatively common presentation to the ED, but that development of recurrent TIA or stroke was lower than expected based on recent US figures. Further evaluation of TIA patients in the ED is urgently required to understand the observed variation and determine predictors of recurrence.

054 Defining 'Irrelevant' CT Findings in Blunt Head Injury Patients.
Atzema C, Mower WR, Hoffman JR, Holmes JF, Killain AJ, Greenwood SD, Shen A. University of California. Los Angeles, CA, USA.

INTRODUCTION: Researchers developing a clinical decision instrument (CDI) for the use of computed tomography (CT) in patients with minor head injury (MHI) must classify certain injuries seen on CT as 'clinically unimportant'. This is necessary to identify which patients actually needed a head CT. This study aims to evaluate the importance of various minor CT findings, based on need for neurosurgical intervention and Glasgow Outcome Scale (GOS) scores. METHODS: NEXUS II is a prospective observational study involving patients at 18 sites who received an emergent head CT scan between April 1999 and December 2000. In this substudy of NEXUS II we prospectively defined a number of CT findings generally considered clinically unimportant, and identified patients at 6 sites for whom the official radiology report included 1 of these findings. Two trained independent abstractors reviewed patient charts to determine presence of neurosurgical intervention or a poor outcome (GOS 3-5). RESULTS: Prevalence of minor CT findings was 1.86% (n 156) among the first 8374 trauma patients in the NEXUS II cohort. Eighty-two patients at the 6 sites met the inclusion criteria, and 11 (13%) patients fared poorly and/or had neurosurgical intervention. Adequate follow-up information was available on 10 of these patients, all of whom had an abnormal GCS at the time of the CT scan. Five of the 7 neurosurgical patients had abnormal coagulation studies. CONCLUSIONS: Clinically unimportant findings are diagnosed in less than 2% of head trauma patients undergoing CT scanning. While an important minority of these patients do have neurosurgery or a poor outcome, this appears to be extremely rare in patients who do not present with an abnormal mental status and/or a coagulopathy. With certain qualifiers, clinicians and developers of a CDI for the use of head CT in MHI patients may safely classify minor CT findings as insignificant.

055 Attitudes and Judgement of Emergency Physicians in the Management of Patients with Acute Headache.
Perry JJ, Stiell IG, Wells GA, Mortensen M, Lesiuk H, Wallace G, Sivilotti M, Kapur A. Division of Emergency Medicine, University of Ottawa, Ottawa, ON.

OBJECTIVE: Currently there is little objective evidence guiding physicians in the investigation acute headache to rule out subarachnoid hemorrhage (SAH). This study assessed emergency physicians (EP) in: 1) their attitudes to not ordering head CT before performing LP, this demonstrates if EPs are willing to use Schull's model, which suggests a LP directly for patients with normal neurological examination, and 2) the accuracy of their judgment for predicting SAH without a decision rule. METHODS: This 1-year prospective cohort study was conducted in 2 tertiary care university EDs. Data was collected for consecutive alert patients with an acute headache and a normal neurological examination. Prior to investigation, MDs recorded the pre-test probability for SAH to the closest decile and comfort in 'performing an LP without obtaining a CT with a 3-point Likert scale. The criterion outcome was SAH as diagnosed by SAH on CT, xanthochromia in the cerebral spinal fluid (CSF), or the presence of red blood cells in the final tube of CSF with positive cerebral angiography. Descriptive statistics and a receiver operating characteristic (ROC) curve with a 95% CI were generated. RESULTS: The 222 enrolled patients had a mean age 43.4 years, 58.1% were female, 9.0% had SAH, 83.2% underwent CT, and 41.9% underwent LP. EPs reported being 'uncomfortable' in performing an LP without first ordering a CT in 54.6% of cases. They were 'very comfortable' in performing an LP without CT in 7.7% of the cases. The area under the ROC curve for the pre-test probability of SAH was 0.85 (95% CI, 0.76, 0.93). There were 3 positive cases with a pre-test probability of <5% and 4 patients with SAH with a pre-test probability of 10%. The remainder had a pre-test probability of over 20%. CONCLUSIONS: EPs were uncomfortable in performing an LP without obtaining a CT. Physicians showed only fair accuracy in predicting SAH and a clinical decision rule may improve the accuracy and efficiency of SAH diagnosis.

056 The Influence of the Emergency Medicine Clinical Teachers' National Certification Level on their Evaluation by Residents.
Steiner IP, Yoon PW, Kelly KD, Donoff MG, Diner BM, Mackey DS, Rowe BH. University of Alberta. Edmonton, AB.

INTRODUCTION: The evaluation of clinical teaching faculty is necessary and using accepted tools it can be valid and reliable. Currently there are no data from the medical education literature concerning specific faculty-related factors relating to teaching performance. This study examines the influence of EM certification status of clinical faculty on the teaching performance scores provided by residents. METHODS: A retrospective analysis of data accumulated between 07/1994-07/2000 on 1st, 2nd and 3rd year Family Medicine residents' evaluations of EM clinical teaching faculty at the University of Alberta was conducted. Resident and teaching faculty related variables were entered anonymously using the ED Scale (Acad Emerg Med 2000;7[9]:1015-21). Credentialing and demographic information on EM teaching faculty was supplemented by data obtained through a 9-question survey; public information resources provided data on some teachers. Descriptive and ANOVA analyses are presented. RESULTS: 562 Family Medicine residents completed EM clinical rotations during the study period and 777/831 (94%) had voluntarily returned anonymous completed evaluation forms. 705/831 (85%) had valid data. 115 clinical teaching faculty members had been evaluated in 4 dispositional domains: Didactic teaching, Clinical teaching, Approachability and Helpfulness for a total of 12,816 individual evaluations. Complete information on 109/115 (95%) EM teaching faculty members was obtained. Univariate analysis on the scores by EM certification level indicated that EM specialists rated statistically highest in the didactic teaching category (p < 0.001), whereas EM certified family physicians rated higher in the approachable and helpful categories (p < 0.001). Physicians without any national certification were rated lowest on all 4 categories. Subgroup analysis revealed superior teaching performance by formally trained teachers in certain evaluation domains. CONCLUSIONS: EM national certification is a positive moderator of teaching performance. The statistically significant differences found between specialist and family physician teaching groups probably have no practical implications.

057 Medical Undergraduate Curriculum International Health Enrichment Project.
Felix J, Bullard M, Hoyano D, Sowa B, Laing L, Baydala L, Fanning A. University of Alberta. Edmonton, AB.

INTRODUCTION: Many recent applicants to Emergency Medicine training programs cite international health (IH) opportunities as 1 reason for their specialty selection. A CAEP International Emergency Medicine Committee has recently been formed. This study attempted to identify the extent of international health (IH) content in a typical medical curriculum, in concert with a proposal to enhance it. METHODS: A manual search of the first 2 years of undergraduate course materials at the University of Alberta was completed by trained research assistants. IH content was coded as: any material consistent with the previously established IH Core Content. IH mentions were not weighted and any written IH content in handouts was included. In parallel, the content of each educational block was surveyed to identify topic areas best suited to IH enrichment. These results were reported to each block Coordinator. Finally 2 of the authors met face-to-face with the major Block Coordinators to discuss implementation. RESULTS: In 2001, Year 1 and 2 contained 11 distinct educational blocks. The number of IH mentions ranged from 2 (Cardiology) to 69 (Infection/Immunity/Inflammation) with a median of 22 (IQR: 11, 29). All (100%) Block Coordinators supported the IH initiative; however, 80% requested assistance in developing teaching materials and concepts. Our presentation to the Undergraduate Curriculum Committee led to the incorporation of IH enrichments into the curriculum beginning in September 2001. CONCLUSIONS: Prior to this survey, IH was not a large component of most medical student block training at this University. There are presently 7 hours of dedicated IH time in the first 2 years of the curriculum with several enrichment areas being developed. Optimizing the amount and type of IH undergraduate enrichment is an ongoing project. Educators in other universities need to repeat this study, and motivated EM educators need to participate in areas of IH teaching.

058 The Development and Evaluation of a Public Access Defibrillation (PAD) Training Program.
Irwin K, Travers A, McDonald S. Division of Emergency Medicine, University of Alberta. Edmonton, AB.

INTRODUCTION: Sudden out of hospital cardiac arrest remains a significant cause of morbidity and mortality. Automatic external defibrillators (AEDs) are safe and effective when used by emergency response personnel, but it is unclear whether this benefit extends to lay responders. The Public Access Defibrillation (PAD) Trial is a multi-centre, randomized trial designed to compare the effectiveness of cardiopulmonary resuscitation (CPR) alone, to CPR and AED use by volunteer lay responders. The purpose of this study is to evaluate student satisfaction with the CPR and AED training program developed for the trial in a major Canadian urban centre. METHODS: We developed a training program to teach CPR in 2 hours and AED use in an additional 2 hours. The instructor to student ratio was between 1:4 and 1:6. At the conclusion of each training session, volunteers were asked to complete an evaluation survey. RESULTS: To date, 771 volunteers have been trained, 647 of whom completed surveys, a response rate of 83.9%. On a scale of 1-5, CPR only students rated their confidence level with rescue breathing, CPR, and foreign body airway obstruction at a mean of 4.07 (SD 0.77) and CPR plus AED students at a mean of 4.29 (SD 0.74). Confidence with AED use was rated at a mean of 4.44 (SD 0.66). When asked for general comments, 7.7% of participants felt the program was rushed and 18.9% felt the practice scenarios were the best component. Overall, 75.5% of lay responders felt the program was useful for someone at their level. CONCLUSIONS: Efficient and effective training programs will be needed if AED use in the community becomes widespread. The authors believe that this training program can form the basis for future programs designed to teach lay rescuers the skills necessary to respond appropriately in a cardiac arrest, including defibrillation.

059 Internet Access to Computer-Based CME in Southeastern Ontario: Are Physicians and Hospitals Ready?
Sampsel K. Queen's University. Kingston, ON.

BACKGROUND: The use of computer-based technology in medical teaching has increased exponentially. One area that has potential for the application of these technologies is the provision of online Continuing Medical Education (CME) programs to rural and remote areas. However, access to programs that involve interactive graphics and video may be limited by the local computer hardware or speed of internet connection. Prior to implementing a series of computer-based CME learning modules we wanted to assess the computer resources available to hospitals and physicians in rural and remote areas of southeastern Ontario. METHODS: A series of hospital site visits and surveys were conducted within the Queen's University CME catchment area. During site visits, the investigators used the local hospital computer facilities to access learning modules from the Queen's University server. The ease of access and practical performance of the modules were assessed. Further, physicians at 2 sites were asked to complete a survey about their use of home computers for educational purposes. RESULTS: All of the learning modules tested from the sites could be operated by some means (over the internet, downloaded from the internet or via a CD-ROM) at all of the locations evaluated. Current use of computers for educational purposes by physicians either at home or at the local hospital varied by location and physician. The majority of survey respondents reported current use and interest in future online CME-accredited applications. CONCLUSIONS: Internet access to multimedia learning modules by physicians in southeastern Ontario is currently feasible and has potential for widespread use with minimal upgrades to existing infrastructure. Additionally, a majority of physicians are currently using computers and the internet for educational purposes and show interest in online CME initiatives.